Letters

Electronic transmissions: HIPAA's definition

To the Editor:

After reading "What You Need to Know About HIPAA Now" [March 2001, page 43], I was a little confused by some of the details of the new transactions and privacy and security regulations. Although the regulations protect information in any form, the definition of the covered entity is "any provider that transmits electronically," thus implying that those who don't transmit electronically are not covered entities.

What is electronic transmission? Does it include faxing and/or calling the ER for information about last night's patient visit? If the new regulations apply to oral communications, does this potentially make life more difficult for the doctor? If physicians don't use any form of electronic transmission, do only the old standards apply?

Terence R. Mahoney, MD
Daytona Beach, Fla.

Author's response:

The first drafts of the privacy and security rules seemed to apply only to personal health information in electronic form. However, the standards' framers and the many people who commented felt this might encourage some entities to try to avoid HIPAA by "going paper." The final drafts made the standards more consistent with the basic principle, which is protection against unwanted disclosure of a person's health information, regardless of its form.

A physician or practice becomes subject to all HIPAA rules by dint of transmitting health information electronically using any one or more of the "covered transactions" (i.e., the basic claims and eligibility forms used for third-party payment). However, the rules also state that health care providers who do not transmit patient data electronically "become covered by this rule when other entities, such as a billing service or hospital, transmit standard electronic transactions on their behalf." For all practical purposes, this means all physicians and practices are covered by HIPAA.

Covered entities must abide by the HIPAA rules, which protect personal health information in your practice in any form. This includes faxes, paper documents and even oral communications. (Need I point out that the great majority of privacy breaches take the form of gossip?) In my opinion, there aren't any loopholes.

You are correct in suggesting that complying with the rules will make life somewhat more difficult for most physicians' practices, at least in the short term. However, putting basic security measures in place will dramatically reduce your risk of accidental disclosures of confidential patient information and allow you and your patients to sleep better at night!

David C. Kibbe, MD
Chapel Hill, N.C.

Call me doctor, please

To the Editor:

Family Practice Management (FPM) would be greatly enhanced if the word "provider" was banned from print and replaced with the title of the medical professional the article is discussing. I am a physician, I did not graduate from provider school, I do not have a provider license and the American Association of Providership does not certify me.

Will my fellow colleagues join me in not only displaying a high degree of professionalism in their conversation and writings, but also in insisting we be addressed as physicians or doctors?

Gregory K. Terpstra, DO
Potosi, Mo.

Editor's response:

FPM uses "provider" to refer to nonphysician health care providers - for instance, in the phrase "midlevel providers" - and to groups of (pardon the expression) health care providers that include individuals from more than one profession, as in the sentence, "Our clinic has 20 providers, 15 of whom are family physicians." It is our policy not to use the term as a synonym for "physician."

Life as a "free-range physician"

To the Editor:

I read "14 Alternative Practice Styles" [February 2001, page 33] with interest and wondered where I could get more information about practicing as a "free-range physician." It seems like you'd need more than a car, laptop and cell phone. How do free-range physicians handle billing and malpractice insurance? How does a call schedule work? How do they promote themselves to the patient community?

Barbara Weber, MD
Sheboygan Falls, Wis.

Author's response:

You'll need to submit your own charges and arrange your own malpractice insurance. You could field all of your own telephone calls after hours but refer patients needing immediate care to a local urgent care center, ER or hospitalist. A call group that covers each other's vacations would allow you some time away. I have known some doctors who use a local "ask-a-nurse" as their first-line call coverage and then take the calls that exceed the ability of the ask-a-nurse service. You might decide to find a partner to go into free-range practice with you.

To build your patient base, you should promote yourself like other physicians in private practice. Consider the phone book, print ads, billboards and radio spots. Word-of-mouth and physician/nurse referrals will remain important sources of new patients. Long-term relation-ships with facilities such as nursing homes will also generate significant patient volume.

James M. Giovino, MD
Janesville, Wis.

Medicare angst

To the Editor:

I understand your indignation about public advertisement of electron beam tomography [Editor's Page, March 2001, page 10]. But where is your indignation for the administrative/fiscal equivalent of "dumbing down" when Medicare reimbursement is not only considered the gold standard and the index for other payers, but its rules also dictate how a physician should practice?

Consider the following answer to a coding and documentation question in the March 2001 issue that asked which prolonged services code should be used: "99354. This is determined by subtracting the time that CPT indicates is typically associated with the level of office visit you provided from the time you actually spent in face-to-face contact with the patient. The CPT manual says a 99213 typically involves 15 minutes of face to-face time. Subtracting 15 from 70 leaves 55 minutes. Prolonged services code 99354 accounts for the first hour of direct patient contact 'beyond the usual service,' according to CPT. It may be used to report prolonged service of 30 minutes to one hour and should be submitted with the office visit code. If the prolonged service exceeded one hour, you could also submit 99355."

Say what? Is this what we studied medicine to be doing? Is this how we must spend our time? All this effort so Medicare can reimburse - when it does - a mere pittance for our efforts, send our patients to "spy" on us as part of Medicare's anti-fraud campaign and over-regulate us with mind-numbing schemes as the answer above attests to?

Save the angst for the right party! I wish the profession could develop whatever it takes to challenge Medicare reimbursement and rules.

Oguchi H. Nkwocha, MD
Monterey, Calif.

Coding observation stays

To the Editor:

In "Answers to Your Questions" [Coding & Documentation, February 2001, page 14], the author advised physicians to use CPT code 99499, "Unlisted evaluation and management service," to code the second day of a three-day observation stay. I recommend using codes 99212-99215 instead. The reimbursement for 99212 would be roughly equal to that for 99499, but using codes 99213, 99214 or 99215 would generate higher reimbursement. A source at the Health Care Financing Administration's (HCFA) regional office in Dallas prompted me to start recommending this approach to my clients about seven years ago. Medicare carriers expect to see these codes used on the second day of a three-day observation stay and will even pay for three separate visits. We almost never have this questioned by any carrier.

Don Self
Whitehouse, Texas

Author's response:

I based my advice on information from the AMA, which owns and maintains CPT. The AMA's CPT Assistant newsletter addressed the issue in April 1996.

Mr. Self is correct that Medicare requires a different coding convention. According to section 15504.B of the Medicare Carriers Manual, "In the rare circumstance when a patient is held in observation status for more than two calendar dates, the physician must bill subsequent services furnished before the date of discharge using the outpatient/office visit codes."

Unfortunately, we cannot guarantee that all third-party payers will agree with this or any other coding recommendation, including Mr. Self's. The best approach for practices is always to check with their local Medicare carrier and the other payers they submit claims to. The differences between payers can be significant.

Kent J. Moore
AAFP
Leawood, Kan.

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