CDM Review

• Introduction
• Contents
• Proposal
• Comments

Introduction

Any way, I have asked Elaine to extend the dateline for us. This she has done but asks that we be as quick as possible.

As not all of you managed to read my proposals fully, I have decided to put it up here for everyone to read and comment.

(NB:- The numbering is rather messed up and I don't have the time to correct it. Therefore, you'll have to refer to each section by their titles.)

Contents

After some discussion among the anaesthetists, the following are the points that we would like to bring up for further consideration.

1. Codes in Current CDM, Now Omitted

Several codes that were present in the current CDM have been omitted from the new CDM. These include
1. Endotracheal Intubation

All the old codes for endotracheal intubation have been replaced by codes 13857, 13870, 130879 and 13882. However, these new codes appear to assume that endotracheal intubation is always followed by subsequent ventilation and management in Intensive Care Unit (ICU) which is not necessarily true in every case.
We propose that there should be two codes for endotracheal intubation.
1. One for intubation which was not particularly difficult, and
2. Another for intubation which was more difficult than normal, perhaps requiring special procedures or equipment such as the flexible fibreoptic laryngoscope.

1. for cases intubated and subsequently transferred to another hospital,
2. where the patient expired, or,
3. where intubation was only for suctioning.

1. Regional Blocks

While many new codes have been added, the deletion of the current codes for major regional blocks (748 and 752) leaves something to be desired as there will be no code for blocks done other than for post-operative pain relief or therapeutic reasons. Specifically, there is no code for regional blocks done purely for pain relief not related to surgery. Perhaps these two codes should be reinstated.
2. Miscellaneous Codes Commonly Used in the Wards/ICU

1. 895: Umbilical vein catheterisation
2. 897: Umbilical artery catheterisation
3. 899: Scalp vein catheterisation
4. 907: Blood, by femoral or external jugular vein puncture
5. 917: Restoration of cardiac rhythm by electrical stimulation
6. 927: Insertion of intravenous line-percutaneous
7. 929: Insertion of intravenous line-by open exposure
8. 932: Intravenous - infusion or injection of a substance
9. 934: Intraarterial - infusion or injection of a substance
10. 954: Venesection

1. Relevancy of Codes in New CDM

There are many new codes for regional and field blocks but we note that many of these codes have minimal application. We question the rationale for this when many more relevant codes have not been included.
There is, also, disagreement on the implementation of "package charges" such as those mentioned in codes 13870 and 13873. Each individual case is different and it would be most inequitable to charge everyone the same regardless of how difficult the case is. It is best for the physician to charge for each procedure performed so that the complexity of the case is reflected in the charge. If the physician feels that the total charge would then be too high, he is at freedom to charge at lower Code Classes, such as code D or code E, or even to omit some codes if he is so inclined.
2. Proposed New Codes Not in Either Current or New CDM
1. Cardio-Pulmonary Resuscitation (CPR)

While there is now a code for CPR in newborns (245), this was mainly meant for use by Paediatricians who were called in to standby in patients undergoing lower segment Caesarean section (LSCS). There is no corresponding CPR code for use in adults. This is necessary as CPR obviously entails much more time, energy and risk than in the usual consultations or visits. Further, such calls often occur in the wee hours of the morning.
2. Patient Controlled Analgesia (PCA)

There should be a code for this as once this has been initiated, the anaesthetist concerned will be responsible for it and it normally lasts about 48 hours. While post-operative pain relief using epidural and spinal has a new code, there is none for PCA and this anomaly should be addressed.
3. Epidural in Patients in Labour

Currently, these procedures are linked to the delivery charge of the obstetrician. There are three major problems with this approach.
1. The difficulty or problems in performing the epidural have absolutely no relationship with the delivery process.
2. 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.
3. 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.
4. Anaesthesia and Sedation for Radiological Procedures

There is often no corresponding operator's fee by which the anaesthetic fee can be based on. Hence, we propose that two new codes be introduced.
1. There should be a base fee to account for preoperative assessment, induction, reversal and recovery, and
2. An additional fee based on the duration of the anaesthetic.
The same codes could then be used for any procedures (not just radiological) where there is no corresponding operator's fee.
5. Pain Service Procedures

1. Epidural/spinal catheter with,
1. Tunnelling and external port,
2. Implanted port, e.g. Porta-a-cath, or
3. Reservoir devices,
2. Subcutaneous local anaesthetic and/or steroid injections for pain, and
3. Low Power Laser therapy to painful areas by medical practitioner.

1. Introduction of Minimum Anaesthetic Professional 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,
1. Tarsal Cyst, Extirpation of (6754),
2. Postpartum Haemorrhage Requiring Special Procedure (374), and
3. Circumcision of Person Under 4 Weeks of Age (4319).

1. 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.
2. 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.
3. The last example involves an anaesthetic for a patient under 4 weeks of age, not a case I would relish under any circumstances. The margin of safety is extremely thin in these cases and leaves no room for errors.

Proposal

You may have other ideas to add or you may have a different opinion of what changes are needed.

I will then try to incorporate the views of all of you or we will make a vote first on those matters where there are divergent views.
 
 

Comments From GASBoard

                 The main sticking point amongst the more senior members appear to be my proposal
                 for a minimum anaesthetic fee. I feel quite strongly that we should press for this as it is
                 both logical and fair to have such a scheme.

                 Many other hospitals have something similar including the Kuantan Specialist
                 Hospital. Their minimum is about RM 200 although the exact figure is variable from
                 patient to patient.

                 The MMA Fee Schedule also suggests this scheme. In the latest edition (Third
                 Edition), on page 29, the minimum anaesthetic fee is RM 210 regardless of the
                 surgical fee and even for the more complex porcedures, the anaesthetic fee varies
                 from about 35.4 % to 62.6 %.

                 As you can see, our 35 % is nothing to shout about. Even Assunta used to give 40 %
                 to anaesthetists a few years ago, although the figure may be different now.
                 Furthermore, they could also charge for the preanaesthetic consultation (I can't
                 remember for sure, but I think it was about RM 35 to RM 50).

                 Pertaining to the charge for radiological procedures, the scheme suggested is the best
                 I could think of. It is admittedly rather complicated and if any of you can come up
                 with a simpler and still equitable system, that would be great.
 

CDM review
                From: gasbach
                 Date: Feb 6 1999

                 EPIDURALS
                 My suggestions
                 1.A fixed epidural fee,but with the usual A to D scales ie eg Rm350 at A and
                 correspondingly less for B,C,D.Thus broadly,it follows the present costs,to placate
                 some quarters worried about we overcharging.
                 But we have the liberty to account for our difficulties.if LSCS occurs,nothing to do
                 with epidural charge.
                 2.Radiology
                 Similar principle to above.Scale for A at RM500.
                 (some procedures scary,adgust downwards if piece of cake)
                 3.Pain procedures;as I understand most of these are listed in the `Australian Book`
                 which the hospital is following.Except for the few listed in the newsletter.
                 4minimum fees;agreed;but how do we go about diplomatically.
                 suggest;point out unrealistic examples(as listed),an emergency consult is already
                 RM130,minimum time involved for care is 1 hour( preop assessement,anaesthetic
                 time,recovery care),Singapore practice-minimum S$150(2 yrs ago)
                 5 Unrelated matter:when surgeon goes in second time usually he feels guilty a bit and
                 may not feel like charging a proper ammount.The second anaesthetist is
                 penalised.Any suggestions?
                 6 Generally I agree with the rest of the suggestions