Anaesthetic Consultants,
Subang Jaya Medical Centre.
04 February, 2002.

Dr. Peter Ng,
Chairman,
New CDM Review Committee 2001,
Subang Jaya Medical Centre.

Dear Dr. Ng,

Re: Proposals for the CDM Review from the Anaesthetic Consultants

After consultation among the anaesthetic consultants, we are proposing the following changes to be made to the CDM.

1.      Across the Board Increase
The last major increase was in the financial year 1993 that was implemented in July 1992. From that last major increase to now (i.e. 1992 to 2001), the CPI has increased 37.9 %. As the doctors’ fees have been increased by 7.7 % during those years (after adjusting for the 1 % increase to compensate for the transfer of the credit card charges to the doctors), this means that the doctors’ fees have lagged behind inflation by 28.0 %. Hence, we propose an across-the-board increase of 28 % on the current CDM unit price.

As this is a considerable increase, we propose that this be implemented in 2 or 3 installments perhaps spread out over 6 to 12 months.

2.      Adjustment of Codes in Current CDM
We have found that the anaesthetically related codes are generally reasonable after the presumed increase of 28 % (see Appendix I for the list of codes that we deliberated on).

Our only request is for an increase of the unit price for central venous catheterization (code 9199) to RM 50.00 as the current rates are much too low considering the duration of the procedure, the various risks of complications involved and the need for post-procedure monitoring and care.

3.      Addition of New Codes Not Found in the Current CDM
We feel that there is a need for the addition of the following codes to make the current CDM more complete and hence reduce the need for the use of the 9999 or Miscellaneous code.

a.       Patient Controlled Analgesia (PCA)
With the introduction of this new service, there is clearly a need for this code. In general, the PCA will last for 48 to 72 hours and the anaesthetist is responsible for the safe and efficient delivery of this therapy for the whole duration. We propose a unit price of RM 35.00.

b.      Epidural in Labour
Currently, these procedures are linked to the delivery charge of the obstetrician. There are three major problems with this approach.

                     i.            The difficulty or problems in performing the epidural have absolutely no relationship with the delivery process.

                   ii.            There is, at best, only a tenuous link between the time of delivery and the time of performance of the epidural, which may very well be at rather unsociable hours.

                  iii.            We will then solve the problem of what to charge if the patient subsequently delivers by LSCS. There is absolutely no reason to be paid the equivalent of a major consultation if the patient has an LSCS. An epidural was performed on the patient and that is what the patient should pay for, not anything else.

We therefore propose a new code for epidurals for patients in labour. This code should be treated as an independent procedure and hence should not be linked with the obstetrician’s charges in any way. The proposed unit price is RM 60.00

c.       Anaesthesia for Procedures where the Procedurist is Not Charging a “Normal” Procedure Code (e.g. in Radiology)
Many procedures, especially the radiological procedures, do not have a corresponding procedure code. There is a clear need for a code for the anaesthetist to charge appropriately in these cases. We suggest that 2 codes be introduced.

                     i.            One code is for preoperative assessment, induction, reversal and recovery with a Unit Price of RM30, and

                   ii.            Another code is a time-based code that is calculated based on the duration of the anaesthetic. The Unit Price should be RM12.50 per 15 minutes or part thereof.

d.      Minimum Anaesthetic Fee
Last but not least, is the introduction of a minimum anaesthetic professional fee. This is deemed necessary by us because there are several procedures where the anaesthetic professional fee is unreasonably low. Examples would include, but are not exclusive to,

                     i.            Tarsal Cyst, Extirpation of (6754),

                   ii.            Postpartum Haemorrhage Requiring Special Procedure (374), and

                  iii.            Circumcision of Person Under 4 Weeks of Age (4319).

While the anaesthetic risks in these cases are no less than in other cases, they are often in fact of higher risk anaesthetically. Taking the three examples mentioned above,

                     i.            Extirpation of tarsal cyst is generally done in the outpatient clinic unless it is a child who is too young to fully co-operate with the surgeon. Being a paediatric case, it is obviously anaesthetically more difficult.

                   ii.            Code 374 is basically used for Manual Removal of Placenta in patients with postpartum haemorrhage. While procedurally very simple, anaesthetically, the case could be very challenging and prove to be a very high-risk case. Patients may have a full stomach and some may be cardiovascularly collapsed from massive haemorrhage.

                  iii.            The last example involves an anaesthetic for a patient under 4 weeks of age, not a case we would relish under any circumstances. The margin of safety is extremely thin in these cases and leaves no room for errors.

The Malaysian Medical Association Schedule of Fees also recommends a minimum anaesthetic fee that holds true regardless of the surgical fee. This was RM 210 in 1997. We strongly feel that this would be a more equitable fee structure as there are certain anaesthetic processes that need to be done for each anaesthetic however simple the surgical procedure may be.

We, therefore, strongly propose a minimum anaesthetic fee that would be imposed whenever the total anaesthetic fee, when calculated as a percentage of the surgical fee, is less than this minimum anaesthetic fee. For the sake of simplicity in implementation, we propose that this be set at a flat rate of RM 200.00. We feel that the use of a unit price in this situation would make it very complicated.

4.      Automatic Yearly Review of All Doctor’s Fees
To avoid the need for the repeated setting up of committees with its attendant delays and also to avoid the big increases in our fees with each such review, we further propose that the CDM fees be automatically increased on a yearly basis according to the increase in the Consumer Price Index as published by the Malaysian Department of Statistics.

We hope that the committee will deliberate upon and ultimately accept our proposals.

Signed,