Re-clarified clarification on PCEHR item numbers

by Charles Wright on April 28, 2012

My constant, rigorous quest for understanding in the matter of what has become known around here as the Plibersek Uncertainty Principle (PUP), seems at last to be bearing fruit.

Essentially, the Plibersek Uncertainty Principle, which arose from Health Minister Tanya Plibersek’s address outlining “additional support” in the form of MBS consultation items for clinicians creating or adding to a shared health summary, states that no two properties of a ministerial statement, such as meaning and intention, can be known simultaneously.

As I pointed out recently, the meaning of the minister’s statement that “I want to confirm that the use of the longer consultation items will be seen as appropriate by the Medicare Australia Practitioner Review Process and the Professional Services Review in circumstances where there is clear evidence of patient complexity and there is documentation of a substantial patient history” was interpreted by the RACGP for instance, as an undertaking that doctors could claim a payment, prompting its president, Professor Claire Jackson, to “warmly welcome” the news.

Subsequently, however, the minister indicated that her intention, revealed in an interview with the ABC’s AM program, was actually the opposite of what most people – but not the AMA – had believed. “The idea that [doctors] would, during a longer consultation, be paid extra for recording that information in a computer program that many of them are already using,” she told the program, “is probably not the best use of extra health funds.”

At that point, the warm welcome turned bitterly cold, as GPs surmised that they had been, as the colloquial expression puts it, “sold a PUP”.

Having spent the past couple of weeks wallowing around in confusion, you can imagine my relief to have been thrown a lifeline of enlightenment, in the form of another statement by the RACGP, which takes the form of a clarification of the minister’s clarification. You will find the second, or auxiliary clarification here.

In many ways it is a delightful document, which we suggest is probably best delivered in the context of being tucked into bed with a glass of warm milk, and having a caring person – a nanny or Mummy perhaps – reading it to you as a bedtime story.

As you nod gently off to sleep, you will hear a number of “clarification cases”, such as the following:

James is an 18 year old student and lives at home with his caring family, who have registered him for a PCEHR. He has no sexual partners, is on no medication and has no significant past medical history (PMH). He asks you to prepare a shared health summary for him for him.
Q: Can I charge a B?
A: No.
You tell James that Medicare would not regard this as a clinically relevant service and that he would not receive a rebate if you prepared a Shared Health Summary for him.

Just as your anxiety begins to rise, Nanny (or Mummy), will then calm you with the tale of Case 2:

James goes on holiday to Thailand some weeks later. He has unprotected casual sex and develops a purulent discharge. On return home he consults a community-health run STI clinic, which run some tests and tell him he has gonorrhoea and prescribe treatment.
Personally Controlled Electronic Health Records (PCEHRs) and the use of item numbers in general practice
He sees you the following week with swollen painful joints, which have severely interrupted his football training. You diagnose Rieter’s Syndrome and are considering referral to a rheumatologist but you have no details of his results or treatment.
You say you will have to ring around to sort this out and request that he return on the following day. The tests might have to be repeated if state health is not contactable.
James is annoyed and asks if a shared health summary wouldn’t have been of use. He asks if you can now create one when he comes back to assist with effectively sharing his care between community health, local pathology providers, your practice and the rheumatologist. You suggest to James that when he attends consultations with other health care professionals involved in his care, that he let them know he has a PCEHR so they can view the shared health summary and add event summarises if they have also upgraded their software.
Q: Can I charge a B if this takes < 20 minutes or a C if this takes 20 – 40 minutes?
A: Yes – James has asked you to co-ordinate his ongoing care, and the service is both clinically relevant and very important in reducing duplication and minimising fragmentation of care.
If it takes 20-40 minutes it can be billed as a Level C, as the consultation is complex, involving assessment of a number of organ systems, and includes significant counselling and education components.

I think I can safely leave you in the arms of certainty, while I go off to play with the dog.

{ 1 comment }

Anon April 28, 2012 at 12:03 pm

I can’t claim a lot of insight in this area, but I have some opinions.

My opinion is that what the Minister is trying to say is that the existing RACGP guidelines require record keeping in a number of situations. Those guidelines also include creating summarisations at points in time. That work is already included to some extent in the allowable claims for MBS (I haven’t looked in detail so I can’t say whether it’s included 100% or partially included, but clearly its happening today, so it is what it is).

So, in a pre-PCEHR world, if a patient comes in for a visit, as part of that treatment you are obliged to create some records. The time to do so is claimable on MBS today.

In a pre-PCEHR world, if a patient comes to you and asks you to co-ordinate their care, you might have to ring around a bunch of other providers to get the information you need. Under the RACGP guidelines you need to keep records of that – you don’t just get the information, think about it for a while, and then forget it (and I can’t believe that any clinician would do that). You write some sort of summary. That work is claimable on MBS today.

So, in the new PCEHR world, the same remains true. The Minister is trying to say that she doesn’t believe that changing that documentation from being stored on your local system to being uploaded to PCEHR creates a meaningful increase in time. But the actual creation of the underlying records clearly does take time, and is claimable today.

I personally suspect there is some level of “flex” in there – clearly there are clinical interactions that are on the border of a B v’s a C, and there is always some level of discretion about which they are. It seems to me that perhaps there is another 5% hiding in here, and maybe that tips a few more consults into a C.

But having said that, the government is in a tight budget position. They don’t want to create a new funding problem – they don’t want a perception that there is a brand new clinical consultation type which is purely “create me a shared health summary” and that lots of people are going to rush out and do that.

My view is that the health system doesn’t actually have spare capacity. If suddenly people start turning up to their doctor purely to get shared health summaries where previously they wouldn’t have come in to their doctor, then what other care isn’t getting done whilst this happens? It’s not plausible this is going to happen, and the govt doesn’t want people thinking it is.

I can see that people are tying themselves in knots trying to give signals that the govt is actually paying for this work today, without having to come out and say “of course this work is funded.” That is life in govt unfortunately.

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