Letters

E/M coding: Everything old is new again

To the Editor:

The proposed revision of the evaluation and management (E/M) codes described in "An Update on the E/M Codes and Documentation Guidelines" [May 2003, page 14] reminded me of the time when there were booklets for different specialties that gave examples of the different coding levels because words such as "expanded problem focused" did not by themselves convey the intended meaning. I understand the motive to make E/M coding easier, but what is proposed will mark a step back to a time when examples were woefully inadequate.

Robert Ireland Jr., MD
Tuscaloosa, Ala.

Keeping hospitals afloat

To the Editor:

I'm intrigued by "Seven Ways to Help Your Hospital Stay in Business" [May 2003, page 27] because of my concern that as physicians do less and less hospital work they will see these issues as irrelevant to everyday practice. As a family physician and full-time hospitalist, I'd like to offer the following comments:

• I disagree that physicians have an incentive to prolong hospital stays. They simply have no direct incentive to do the extra work, such as follow-up rounding in the afternoon, that would facilitate an earlier discharge. Unless the patient needs critical care, physicians usually get one charge per day.
• Hospitals do bear the burden of a denial. But because days are denied less frequently than stays, it's in a hospital's financial interest to prolong a "per diem" so that it may charge for more "in-between" days, which have lower costs and better net revenue.
• We do need to change the prevailing mind-set about what acute-care hospitals are for, but it will take quite a while for everyone to accept decisions such as directly admitting a frail, elderly patient to a skilled nursing facility. Right now, Medicare won't pay for it, patients and family resist it and physicians are concerned that it's poor medical care.
• In principle, not "including the kitchen sink" is a good philosophy, but our present system resists an elective admission or the rapid approval of an intensive service. The quick alternative is to perform certain tests and procedures while patients are in the hospital.
• I believe it's still not mainstream to attribute the same level of importance to cost that is attributed to patient care.
• I see patients admitted from the office who don't need inpatient care. I fear this problem will worsen as more primary care physicians stop doing hospital work and become less familiar with what can and cannot be done in the hospital.
• A patient-centered approach often will reduce unnecessary physician intervention. However, it forces physicians to make some difficult decisions about patient care.

Chris Shearer, MD, MPH
Phoenix

Physicians must take charge

To the Editor:

"Seven Ways to Help Your Hospital Stay in Business" was right on target. I'd like to suggest an additional strategy: the family physician must act as the "captain of the ship." As a family physician and medical director of a community hospital, I have seen too many delays in care and discharge that resulted from a physician abdicating his or her role to the subspecialists. At our facility, some patients admitted for chest pain and ruled out for cardiac disease have remained in the hospital for three additional days while the subspecialists performed everything from CT scans to endoscopies. I suggest developing care maps or guidelines that start in the ED and assist the physician in the most expeditious work-up of his or her patients.

Jerry R. Frank, MD
Patchogue, N.Y.

Simplifying with stamps

To the Editor:

As noted in "Making Paper Charts More Efficient" [April 2003, page 51], it's quite a challenge to standardize processes to meet the demands of documentation. In our large residency practice, we use several stamps, including one that documents a no-show and directs follow-up and one that documents tests that were not completed and directs follow-up. The stamp we find most helpful enables us to document that we've reviewed letters and labs and other test results without needing the patient's chart. It looks like this:

Reviewed by: ________________________ Date: ______________________ Letter sent Phoned Repeat/Follow-up in       _____ days/mos/yrs (circle one)     Discuss at next visit

The chart still needs to be pulled to file the result, but it does not need to be taken out of circulation, which is of great benefit to our staff.

Richard M. Rayner, MD
Harrisburg, Pa.

Reducing risk with consultations

To the Editor:

The article "Seven Reasons Family Doctors Get Sued and How to Reduce Your Risk" by Dr. Richard Roberts [March 2003, page 29] included useful information. However, waiting to consult until after three visits "because it's as good a number as any" is an invitation to disaster. Uncertainty is integral to primary care and must always trigger an assessment of risk in order to determine how urgently a diagnosis must be pursued. I have recently been consulted about two malpractice cases in which immediate consultation would likely have avoided horrendous outcomes.

Peter Goodwin, MD
Portland, Ore.

Author's response:

Even an astute clinician concludes a number of patient visits with only a tentative or working diagnosis and a request that the patient return after additional time, further testing or empiric therapy, following which a more definitive diagnosis can be determined. Of course there are situations where immediate consultation is warranted. Conversely, consultations that are made too hastily also raise liability risk for negligent referral, given their cascade of potentially harmful effects (e.g., unnecessary surgery that goes awry). Every day we must make clinical judgments about the urgency of a problem. My point in offering the "rule of three" was to urge clinicians to set a threshold for themselves and consider consultation, if only with their practice partner, for patients with nonurgent problems that continue to be a diagnostic dilemma after several visits.