Letters

Compliance: a lose-lose situation?

To the Editor:

I was disheartened after reading "Seven Steps to Medicare Compliance" [January 2001, page 41]. It now seems that seeing Medicare patients means going to jail -- or at least suffering large fines.

While the idea of self-audits makes sense, in practical terms it's a no-win proposition. If you don't do self-audits, the Office of Inspector General (OIG) will say you should. If you do them and use them as an internal control (i.e., you don't report cases of underbilling or underdocumenting), the OIG will still say you should report the errors -- at least those in Medicare's favor. If you report errors, you are inviting a Medicare audit.

Since the people enforcing the rules are also the ones making them up, once they decide you're guilty they'll find the proof they need. That's what an audit is, isn't it? A study in the Journal of the American Board of Family Practice [2000;13(2): 144-146] showed that even certified coding specialists with at least 12 years of experience who work as trainers can't agree on the level of service or the levels of history, physical examination and medical decision making represented in a progress note. Auditors have incredible flexibility -- and we have no leeway.

It is clear from the article that doing your own audits offers no protection. I hardly think the OIG considering this a "mitigating factor in [its] recommendations to the prosecuting agencies" is any consolation. Rather, it seems to serve as an invitation to the OIG to come in for the feast.

Jaymi S. Meyers, MD
Seneca, S.C.

Author's response:

The recent trend toward "criminalization" of Medicare infractions certainly raises suspicion that government is doing little more than asking physicians to help prosecute compliance violations. In today's enforcement environment, I don't believe physicians fare better by ignoring compliance issues or failing to implement a compliance program. It's a physician's duty to ensure that claims submitted to government health care programs are true and accurate. Criminal punishment, civil penalties or administrative sanctions for violations can be harsh. And, if violations do occur, the compliance program is an effective bargaining tool. Indeed, it measures a physician's good-faith effort to deter, detect and prevent criminal behavior.

The incentive for self-policing is more than the potential for reduced culpability. A well-designed compliance program not only helps physicians submit proper claims and prevent fraud, it also results in a better run practice and higher quality care for patients.

Mark S. Kennedy, JD
Dallas, Texas

Coding group visits

To the Editor:

In "Planning Group Visits for High-Risk Patients" [June 2000, page 33], the authors suggest using 99213 and 99214 to code group visits. We believe the appropriate codes are those suggested by Kent J. Moore in "Answers to Your Questions" [March 2000, page 21]: 99411 or 99412 for preventive group counseling or 99078 for counseling groups of patients with symptoms or established illnesses.

Anthony Cabreira, MD
Jessie Haven, MD
George D. Harris, MD
St. Petersburg, Fla.

Author's response:

The group medical visits discussed in the June article are conceptually different from the group counseling sessions referenced in "Answers to Your Questions." The group medical visits are for symptomatic patients with an established illness, seen in a group setting for evaluation, management and counseling related to their existing condition. Coding of these visits, also known as drop-in medical shared evaluation and management (E/M) services, is the subject of ongoing discussion by the CPT Editorial Panel. The panel appointed a work group to create a proposal describing the various models of group medical visits. Meanwhile, the panel strongly recommends that E/M code 99499, "Unlisted evaluation and management service," be used.

The group counseling codes referenced in March should be used to describe group counseling for preventive purposes (99411 and 99412) or group counseling that is provided in addition to another service rendered by the physician (99078).

Kent J. Moore
Leawood, Kan.

Adapting flow sheets

To the Editor:

I enjoyed the article "Implementing Preventive Care Flow Sheets" [February 2001, page 51] but would like to point out an error in the flow sheet for children from birth to 12 years old. The check boxes in the health guidelines section are all shaded, implying a particular service is not indicated. Certainly we would all agree that nutrition, dental health, physical activity, fluoride, etc., are indicated for patients in at least some of this age range.

Derek Clevidence, MD, PhD
Cottage Grove, Wis.

Author's response:

We train our physicians to use the health guidelines section of the flow sheet as a checklist of items for patient education as they see appropriate, particularly at well-maintenance visits. The boxes are shaded to imply that there is no specific time at which the items are indicated, so they should be handled at the physician's discretion. I encourage those who find the shading confusing to adapt the form as they see fit.

Scott Moser, MD
Wichita, Kan.

Copyright © 2001 by the American Academy of Family Physicians.
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