In the current expensive fee for service medical remuneration systemthe item number or the CMS Procedure Code is of major importance, for without a number to attached to a bill for medical services, there will be no payment from the insurance company private or government.
In my December 2017 blog, “No Malpractice Insurance for Elective Lumbar Fusion for Low Back Pain,” I wrote about the way medical malpractice insurance companies were responding to that marketplace and the problems of unsuccessful surgical procedures.
Now government agencies in Australia are going the next step and are removing the procedure codes for services deemed to be ineffective or unnecessary.
In its statement of April 29, 2018[i], the Department of Health of the Australian Government announced changes to the spine surgery schedule eliminating intradiscal injection of chymopapain and spinal manipulation performed in the operating theatre, and items for spinal fusion must not be claimed for treatment of uncomplicated axial chronic lower back pain. Also, perhaps in part to the dramatic increase in knee MRIs, they are restricting the ability of primary care providers from ordering knee MRIs in patients over fifty years of age.
Indeed, spinal fusion for idiopathic back pain is no longer in widespread use, as surgery for this syndrome without a specific diagnosis has no basis.
I remember the days when at the end of a non-spinal procedure, the spine was manipulated “just for good measure” or “while we are here” under that general anesthesia.
One can assume that primary care providers will no longer order knee MRIs and surgeons will stop spinal manipulations under anesthesia.
The majority of health care providers only order tests and perform procedures that are properly indicated, are in the patient’s best interest, and are effective.
Thus, while there will be an expected reduction of inappropriate and ineffective tests and procedures, government departments in countries with some form of universal health are removing procedure codes and therefore removing the associated rewards in a fee for service system,and reducing the cost of their health care.
In my opinion the cost and efficiency of the health care in the U.S. will not improve significantly until there are changes in the fee for service system.
-Anthony Dwyer, M.D.
(The opinions stated in this blog are those of the author Dr. Anthony Dwyer and not necessarily those of the American College of Spine Surgery).
ICD-10-CM Diagnosis and