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Editor's Correspondence
March 28, 2005

Unreimbursed Services in Primary Care

Arch Intern Med. 2005;165(6):702-703. doi:10.1001/archinte.165.6.702-b

In “Resuscitating Advance Directives,” Lo and Steinbrook1 write, “Furthermore, physicians who discuss advance care planning can bill for their time using evaluation and management codes and documenting the time spent counseling the patient.” Would that it were as fair in practice as it sounds in theory. There are 2 problems with this statement.

In most circumstances no reimbursement is collected for counseling regarding advance directives. Most patients for whom a physician would spend time counseling on advance directives are also seeing that physician for evaluation and management of medical illnesses, generally the very conditions which bring end-of-life discussions to the fore. Thus, a patient for whom advance directive counseling is pertinent will also require assessment and management of, for example, his or her congestive heart failure, diabetes, and nausea. The billing for this patient maximizes out at $99 214 for the medical care, and no additional reimbursement is available for the advance directive counseling. In practice I have never been reimbursed for advance directive counseling. I know of no patients who are willing to come one day for evaluation and management of their medical conditions and then return a few days later for a separate counseling session about advance directives. Thus, the Medicare payment structure is designed such that many of the services provided by primary care physicians remain unreimbursed. (I have informally calculated that about 30% of the services I provide are not reimbursed, either because more than 3 chronic problems are addressed at 1 visit or evaluation and management services are provided in addition to another service such as counseling or a preventive medicine examination.)

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