Letters

Payment for care plan oversight

To the Editor:

I appreciated "Billing for nursing home work" [Coding & Documentation, July/August 2002, page 22]. I think it is crucially important for physicians providing care for nursing home patients to be adequately reimbursed for their services, or soon they will be out of business. You are right that one cannot bill Medicare for care plan oversight for nursing home patients. However, I think these services can be recapped in the subsequent monthly progress note, demonstrating a greater level of recorded history and medical decision making. For example, describing in the note that since the last visit the patient developed fever and dysuria, a urinalysis and culture were ordered and treatment was instituted could legitimately raise the visit from a 99311 to a 99312.

Steven Zweig, MD
Columbia, Mo.

Author's response:

I agree that it is important for physicians providing care for nursing facility patients to be adequately reimbursed for their services and that developments between visits with these patients may affect the level of service rendered during subsequent encounters. Using your example, a patient who develops fever and dysuria may necessitate a more extensive history and exam to ascertain their status and impact on the patient. The patient may also require a more complex medical decision making process that accounts for an increased number of diagnoses and management options, more data (e.g., from the urinalysis and culture) to be reviewed and greater risk to the patient. Any or all of these may result in a higher level of service than would have been the case otherwise.

That said, I would caution against automatically upcoding nursing faci-lity visits to account for work done between visits, especially if that work is not documented in connection with the visit in question. That type of automatic upcoding could invite an audit that may ultimately prove very costly.

Kent J. Moore
Leawood, Kan.

"Don't worry, Mrs. Fitzbee. As soon as I find the correct Medicare guidelines, that splinter is out of here!"

The cost of translation

To the Editor:

I enjoyed reading "Achieving a More Minority-Friendly Practice" [June 2002, page 39]. As a physician who is often called on to translate, I wish we could do a better job of making translation available. However, it's not that simple. It's not right to hire staff members based on their ethnicity and language abilities when they may not be the best-qualified candidates. This can actually hurt patient care for everyone, including minority patients. How can a private practice afford to provide professional translation when its cost far exceeds the reimbursement for the visit? Medicine is a business; if we spend more on translation than we can recoup for the visit, we will be out of business! Unless there is a life-threatening emergency, adult patients need to be empowered to take responsibility for their medical care.

Sarita Salzberg, MD
Columbus, Ohio

Author's response:

I sympathize with the physician's need to negotiate good patient care with limited resources for interpretation and translation in patients' native languages. However, many health care organizations have found that the relatively small investment of a few extra dollars to improve the flow of communication on the front end can add up to thousands in savings in the long run. Clear communication can actually shorten patient visits, eliminate extra diagnostic work and strengthen the physician-patient relationship in a powerful way, leading to improved compliance and outcomes. A proactive approach also reduces liability ­ an even greater expense than interpretation and translation. If hiring qualified and competent staff who are bilingual is not feasible, telephone interpretation services are a cost-efficient option. The Office of Civil Rights recognizes telephone interpretation services as evidence that a practice has made a reasonable effort to accommodate limited English proficiency patients to comply with Title XI of the Civil Rights Act of 1964.

Amy Glenn-Vega, MBA, MHA, RHEd
Fayetteville, N.C.