Letters

Stumbling blocks to open access

To the Editor:

I enjoyed Dr. John Giannone's article in the January 2003 issue ["Open Access as an Alternative to Patient Combat," page 65]. We've adopted open access but have encountered some stumbling blocks. First, how do we get patients to accept the new model? Although we offer assurances that appointments will be open (and they are), a lot of people still want to schedule appointments. Second, how do we get buy-in from all of our providers?

Tiffany J.G. Lehner, DO
Sparta, Wis.

Author's response:

As with any change, there has to be transition. It's been two years since we implemented open access, and we still have quite a bit of transition ahead of us. It takes time for patients to trust that they will get in when they call. You and your staff must stick firmly to two rules: 1. Do today's work today. 2. Protect tomorrow at all costs. Your reception staff has to kindly, yet firmly, "bring them in today." Unfortunately, I have a three-week backlog for scheduled visits, so patients can be seen today - or in three weeks. Most choose today. Patients know they can get in any day they call. Staff know that by protecting tomorrow at today's expense, they may actually get home on time tomorrow. I think there is even a little pride when we're less than 50 percent booked at the start of the day. So, hang in there with your patients, and the transition will happen.

Invite those colleagues who want to get onboard and leave the rest alone. They will get tired of having their lunch eaten. This is a difficult concept for doctors and others to accept. Show them it works, and then help them catch up. But be careful about acute visits for their patients. All your hard work with backlog will be for naught if you try to provide open access to your patients and urgent care to your colleagues' patients. Remember, open access is counterintuitive, but it works.

A nice touch

To the Editor:

"Keeping the Human Touch" by Dr. Frank H. Boehm [April 2003, page 66] is a very timely article that every doctor should read. Many of my patients who have seen another doctor have told me that he or she never touched them. I make it a point to touch each patient, especially in the area of the complaint, even though it might not be necessary to make a diagnosis or initiate treatment. On some occasions, the touch might be the most important element of the encounter.

Richard E. Hunton, MD
Greenwood, S.C.

Clarification

Several readers have written to FPM questioning the advice given by Kent J. Moore in "Coding Hospital Admissions From Other Sites of Service" [February 2003, page 19]. The article suggests that if a physician sees a patient in the office on a given day and then admits the patient to the hospital that same day, the physician can bill both the office visit (99201-99215) and the admit (99221-99223) as long as he or she waits to visit the patient in the hospital on the following date.

Some said this advice seems to contradict CPT, which says, "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service ... all evaluation and management (E/M) services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission." Their understanding of this passage is that if the physician does an office visit and admits the patient on the same day, then the office visit is considered part of the initial hospital care and is not separately billable, regardless of the date of service of the initial hospital visit.

Recognizing CPT's distinction between initial hospital care and admission is the first step to understanding the CPT passage in question. The initial hospital care codes [99221-99223] are "used to report the first hospital inpatient encounter with the patient by the admitting physician," according to CPT, and the descriptors for these codes state, "Initial hospital care, per day," not "Hospital admission."

According to staff at the Centers for Medicare & Medicaid Services, if the date of the initial hospital care coincides with the date of the admission, all related E/M services provided on that day are considered part of the initial hospital care, so only the initial hospital care codes should be submitted. This is because initial hospital care codes are "per day" services. That is, they encompass all of the related services that day. If the physician does not see the patient in the hospital on the date of the admission, services provided on the date of the admission should be billed using the E/M code that reflects the location in which they were delivered, such as 99201-99215. Then, if the physician sees the patient in the hospital on the date following the admission, an initial hospital care code can also be submitted (see the table).

CPT's guidance would be clearer if the passage were revised to include the words in brackets below: "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service ... all evaluation and management (E/M) services provided by that physician in conjunction with that admission are considered part of the initial hospital care when [the initial hospital care is] performed on the same date as the admission."

Advantages of shared care

To the Editor:

I have been "Sharing Maternity Care" [March 2003, page 37] for nearly two years, providing prenatal care to my patients and having their babies delivered by an obstetrician. It began as a response to hospital politics, but then rising malpractice rates made it prohibitive for me to deliver babies. I've found this arrangement satisfactory for my patients and me. Developing a relationship with one doctor helps a patient feel more comfortable asking questions. Instead of seeing multiple doctors, as is common in many large ob/gyn practices, most patients see me for the vast majority of their prenatal visits. After about 26 weeks, the patient sees the obstetrician for an ultrasound and exam. If there are signs of complications at any time, the obstetrician takes over the patient's care. Otherwise, I see the patient through 36 weeks or until labor begins.

I note the level of service incurred at each visit so that if I relinquish care before 36 weeks, I can total the charges and submit a claim. If I see the patient more than 36 weeks, I charge my usual prenatal-care fee. I'd encourage other physicians, particularly those wanting to "ease out" of obstetrics, to consider the shared care model.

Debbie Heck, MD
Muncie, Ind.

Corrections

The spreadsheet in "Evaluating Health Plans: Finding the Keepers" [April 2003, page 47] contains an error. The instructions for calculating days in A/R should read: "Divide the total A/R by the average daily charge. The average daily charge can be determined by dividing annual gross charges by 365."

In the January 2003 issue, Kent J. Moore's "Coding & Documentation" article [page 17] incorrectly stated that a hospital discharge and a nursing home admission could not be coded together on the same date unless the physician saw the patient at both locations on the same date. In fact, these services can be coded together on the same date even when the work of the nursing-home admission is done in the hospital during the course of a hospital discharge. In the guidelines preceding the comprehensive nursing facility assessment codes, CPT states that "comprehensive assessments may be performed at one or more sites in the assessment process: the hospital, observation unit, office, nursing facility, domiciliary/non-nursing facility or patient's home." Of course, the physician still needs to perform the key components of the nursing facility admission (i.e., comprehensive history, comprehensive exam and medical decision making of moderate to high complexity), even if the service is done in the hospital.