Letters

Coding controversy

To the Editor:

I enjoyed "An Update on the E/M Codes and Documentation Guidelines" [May 2003, page 14] by Kent Moore, but it induced a panic attack. I have read various versions of the vignettes proposed to help describe each level of service, and they seem capricious, arbitrary and very subjective. I don't think I could ever use them to justify coding a higher level, as any auditor could have a different opinion that I would have no way to objectively dispute. Although the current guidelines are far from perfect, I have learned to use them to objectively support my coding. I hope they remain unchanged until I can retire out of this mess.

Everest A. Whited, MD
Pflugerville, Texas

Author's response:

The AAFP shares your concerns. The Academy believes that, like you, family physicians have adapted to the current evaluation and management (E/M) codes and the associated documentation guidelines for E/M services. Also, like you, the Academy questions the proposed dependence on brief clinical examples to guide coding. Such examples may make choosing E/M codes more intuitive for physicians, but the Academy believes they will provide precious little defense in an audit situation. The AAFP also has doubts about the ability of clinical examples to ensure work equivalency across specialties under the resource-based relative value scale (RBRVS).

The Academy and other national specialty societies have communicated these concerns to the AMA CPT Editorial Panel and have urged the Panel, as a prerequisite to implementation, to get in writing from the Centers for Medicare & Medicaid Services (CMS) a commitment to 1) accept the new code descriptors for Medicare and Medicaid and not create its own coding system for E/M services and 2) officially indicate what, if any, set of documentation guidelines it will use based on these new code descriptors. In the meantime, if the Panel continues in its present direction, the Academy does plan to participate in developing the clinical examples and would also plan to assist in reviewing draft proposals for the new code descriptors so that the results are as useful to family physicians as possible.

EMRs aren't for everyone

To the Editor:

I have yet to see one unfavorable thing written about electronic medical records (EMRs) in FPM. This disturbs me because, with rare exception, all the people I know who have taken the plunge into EMRs hate it. It increases charting time by hours a day, increases costs as outlined in "Implementing an EMR System: One Clinic's Experience" [May 2003, page 37] and looks like an overall bad idea for most, except those committed to new technology. Do you have an article coming out on the downside of EMRs? I don't think so.

Don Brown, MD
Cary, N.C.

Editor's response:

We would welcome the opportunity to review manuscripts written by physicians who want to share what they've learned from their positive or negative EMR experiences. Please send manuscript submissions to omaresh@aafp.org.

Change attitudes; save hospitals

To the Editor:

In "Seven Ways to Help Your Hospital Stay in Business"[May 2003, page 27], Dr. Kathryn Stewart describes what I've been trying to tell other physicians for years. Unfortunately, physicians still have no incentive to change their approaches to hospital care and, as Robert Edsall points out in his editorial ["Perverse Incentives, Perverted System," May 2003, page 11], we have a long way to go before incentives actually align.

Another problem is patients' dependency on hospital care. Most of us run a service-oriented business with our patients as "clients." We are focused on serving these people because we care about them and because our livelihoods depend on it. If we delay tests, send patients home earlier and make better use of outpatient care, many of our patients feel our care is poor and move on to competing physicians. I've seen many patients cling to their normal saline IV as if it's their lifeline, and they're upset when switched to oral pills and prepared for discharge. As much as I try to use my best bedside manner to explain these things, I still feel my "clients" are not happy with me.

To change this mind-set, we need to educate the American public as much as or more than we do physicians. Patients need to get over the idea that every headache needs an MRI, every bad cold needs an antibiotic and that bypass surgery is a panacea. What a refreshing change to have patients who are motivated to leave acute care, willing to receive certain services as outpatients and who do not want every test available just because their insurance covers it.

Richard Allen, MD
Boston