Why comprehensive heart assessments are being undervalued

A comprehensive heart assessment can look deceptively simple on a billing statement. The appointment may involve a conversation, a physical examination and a clinical decision, yet that visible portion represents only part of the work. Cardiologists also review previous tests, interpret changing symptoms, assess risk, explain uncertainty and coordinate the next stage of care.

Evaluation and management codes are intended to recognise this cognitive and clinical work. When their value is reduced, or when payment models favour procedures over careful assessment, the effect reaches beyond practice revenue. It can influence appointment times, staffing, follow-up systems and the availability of specialists for patients with complex cardiovascular needs.

The issue has been especially prominent in the United States, where Medicare physician fee schedule changes have prompted campaigns such as Campaign for Patient Access. Australian patients and clinicians face a different reimbursement system through Medicare and the Medicare Benefits Schedule, but the underlying concern is familiar: a payment structure that undervalues judgement can weaken access to thorough care.

What evaluation and management codes cover

Evaluation and management, or E/M, codes describe the work involved in assessing a patient and deciding how care should proceed. They generally reflect the complexity of the medical decision, the information reviewed, the risks considered and the amount of coordination required. They are distinct from procedure codes for interventions such as catheterisation, ablation or device implantation.

A heart assessment may involve several layers of reasoning. A cardiologist might compare an old echocardiogram with a new one, distinguish exertional angina from reflux, review medication interactions, consider kidney function and determine whether a patient needs urgent hospital assessment. Much of this work happens away from the examination room and cannot be reduced to the number of minutes spent speaking with the patient.

The code therefore represents professional expertise rather than a simple unit of time. A short review can be highly complex, while a longer appointment may involve a relatively straightforward decision. Payment policy that treats every consultation as interchangeable risks missing that distinction.

Why heart care depends on detailed assessment

Cardiovascular symptoms are often ambiguous. Breathlessness can relate to heart failure, lung disease, anaemia or reduced fitness. Dizziness may arise from an arrhythmia, medication, dehydration or a neurological condition. Chest discomfort can signal an acute emergency, a stable coronary condition or a problem outside the cardiovascular system.

A careful assessment helps a clinician decide what must happen now and what can safely wait. It may prevent an unnecessary scan, identify a patient who needs same-day treatment or reveal that a familiar diagnosis no longer explains the symptoms. These decisions protect patients from both under-treatment and avoidable investigations.

The assessment also establishes a baseline for ongoing care. A patient with atrial fibrillation, inherited heart disease or heart failure may need repeated reviews of symptoms, rhythm, blood pressure, renal function, medicines and lifestyle factors. A rushed consultation can leave important changes undocumented and make later deterioration harder to recognise.

How fee reductions distort clinical priorities

When E/M payments fall while procedural services remain comparatively attractive, practices can face pressure to increase volume or prioritise billable interventions. That pressure may be subtle. It can appear as shorter consultation slots, fewer nurse-supported follow-ups, delayed telephone reviews or reduced time for communication with general practitioners.

This is particularly serious in cardiology because many valuable decisions do not produce an immediate procedure. Adjusting a diuretic, explaining anticoagulation, managing blood pressure or deciding that an invasive test is unnecessary can prevent hospitalisation. Yet a payment system focused on procedures may assign less financial weight to these preventive and diagnostic choices.

Cuts can also affect the viability of smaller specialist services. A cardiology practice in regional New South Wales, Queensland or Western Australia may already operate with high travel, recruitment and technology costs. If consultation-based care is repeatedly discounted, maintaining outreach clinics and telehealth support becomes more difficult.

The Australian context is different but relevant

Australia does not use the United States’ CPT and Medicare physician fee schedule in the same way. Doctors work within the MBS, private billing arrangements, hospital contracts and funding rules set by state and territory systems. Still, the question of how a thorough consultation is valued remains important for Australian patients and providers.

Bulk billing pressures, gap fees and specialist availability shape access in cities such as Melbourne, Sydney and Brisbane, while rural and remote communities can face long waits or substantial travel to see a cardiologist. A patient from regional Queensland may need to take a day off work and travel several hours for an appointment. If consultation funding does not support adequate clinical time, that journey may result in an assessment that feels too brief for the complexity involved.

Australian practice also depends on coordinated care. Cardiologists communicate with GPs, pharmacists, cardiac rehabilitation teams and hospital services. During periods such as summer heat in Adelaide or prolonged travel distances across the Northern Territory, medication management and early recognition of deterioration can be especially important. A sustainable funding model must account for these practical realities rather than valuing isolated services in a vacuum.

The hidden work behind a single consultation

Before a patient arrives, the cardiology team may gather referral information, check previous imaging, reconcile medicines and identify missing pathology results. During the appointment, the clinician listens for patterns, assesses risk, explains options and makes a plan that the patient can realistically follow. Afterward, the practice may prepare correspondence, arrange testing and communicate with other healthcare professionals.

Complex cases also require shared decision-making. A patient may need to weigh anticoagulation against bleeding risk, choose between monitoring and an invasive test, or understand why surgery is not currently appropriate. Clear communication is a clinical intervention in its own right, especially when fear or health literacy concerns affect adherence.

These activities are easy to overlook because they are distributed across people and time. The patient may remember a 30-minute consultation, while the care team has spent hours assembling the evidence and managing the consequences. E/M valuation should reflect the complete episode of professional work.

What a fair valuation should recognise

A stronger approach would reward the quality and complexity of assessment rather than encouraging a narrow focus on procedures. It would recognise that careful diagnosis, prevention and treatment planning can reduce emergency presentations and improve the use of hospital resources.

Practical indicators of a properly valued consultation include:

• Time spent reviewing records, imaging, pathology and medication history.
• Complexity of risk assessment and the consequences of clinical decisions.
• Coordination with GPs, hospitals, pharmacists and allied health professionals.
• Communication that supports informed consent, adherence and self-management.
• Follow-up planning for chronic or changing cardiovascular conditions.

Patients and clinicians can help make this work visible by documenting the decisions involved in complex assessments and describing how access affects real care. In the United States, public advocacy campaigns have used patient stories and professional evidence to challenge fee reductions. Australian organisations can draw on the same principle when discussing MBS reviews, private billing and specialist capacity.

Protecting access to comprehensive cardiology

The strongest argument for fair E/M payment is clinical rather than financial. A consultation that identifies worsening heart failure, prevents an unsafe medicine combination or reassures a patient that invasive testing is unnecessary has a measurable effect on health outcomes. Its value cannot be judged solely by whether a procedure follows.

Policy discussions should include patients, cardiologists, GPs, practice nurses, hospital administrators and rural health services. They should examine appointment availability, waiting times, referral patterns and the effect of funding changes on underserved communities. In Australia, that means considering both metropolitan demand and the realities of outreach services in places far from major teaching hospitals.

Support for patient-access advocacy helps keep these effects in public view. People who want to contribute to efforts protecting cardiovascular care can support the campaign, while clinicians can share evidence about consultation complexity, staffing and the consequences of reduced access.

A comprehensive heart assessment is a safeguard, not an administrative luxury. Patients can speak with their GP about timely referral, ask how follow-up will be arranged and report barriers to care through relevant health services. Clinicians and community advocates can continue documenting what happens when complex judgement is undervalued, so reimbursement decisions reflect the care patients actually need.