Letters
Discouraging cover
To the Editor:
I received the February issue of Family Practice Management today and was so discouraged by the cover illustration that I chose to throw the issue away.
Someone must have a shallow view of God to think that he would be so indecisive in handing down his law through Moses -- as if he gave us multiple choices. I hope you'll be more selective in the future.
Terry Weston, MD
Mansfield, Ohio
Editor's note:
I'm sorry you found the illustration offensive. I assure you that it does not reflect a "shallow view of God," nor was it intended to ascribe to him human decision-making skills. In fact, the illustration wasn't meant to depict the handing down of the Mosaic law in any literal sense. It was intended to evoke (and alter) that image to depict the confusion physicians feel when faced with competing "commandments" in the form of various clinical policies, each offered as the last word on how to deliver care. We hope you continue to find Family Practice Management useful despite your disappointment with this illustration.
Ambulatory-only care
To the Editor:
In the debate over the implications of the hospitalist movement for family physicians ("What the Hospitalist Movement Means to Family Physicians," November/December 1998), one point has been overlooked: An ambulatory-only practice may not be in our patients' best interests.
Without the inpatient experience and the interaction with specialist colleagues, real continuing medical education will decline. How can this be replaced? Lectures in a darkened hotel ballroom will not keep me abreast of changing approaches to the management of, for example, ischemic heart disease -- therapies that will carry over into my office practice. The longer we are away from inpatient medicine, the more likely we will lose the ability to recognize truly ill patients.
Without the inpatient experience, we will truly be indistinguishable from midlevel providers. The choice of hospital-only versus ambulatory-only care is about more than personal satisfaction or economics; it is about the quality of care we will provide for our patients.
John R. McConaghy, MD
Toledo, Ohio
Coding challenge
To the Editor:
We are concerned about your response to the question on prolonged labor and a C-section ("Coding & Documentation," September 1998). A physician in our group wishes to bill following your recommendation, but we don't believe the recommendation follows CPT guidelines.
According to CPT, delivery includes admission to the hospital and the admission history and physical. So, the physician should not also bill an initial hospital service (99223) as the answer suggested. Delivery is not a time-based code; the time involved in delivery, including labor, is inherent in the service. And the prolonged service code is not billed with a service that doesn't have a defined time. Therefore, the article's recommendation to bill the prolonged service code with the delivery code is also inappropriate.
We believe the correct codes would be 59425 (antepartum care), 59514 with modifier -80 (assisting at the C-section) and 59430 (postpartum care).
Nancy Knepp
Peoria, Ill.
Author's response:
As you noted, according to CPT, "Delivery services include admission to the hospital, the admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean delivery." However, CPT goes on to state that "medical problems complicating labor and delivery management may require additional resources and should be identified by utilizing the codes in the Medicine and Evaluation and Management (E/M) Services section in addition to codes for maternity care."
The labor in question involved abnormalities in the fetal heart rate that required the physician's continued presence at the hospital. We believe this situation qualifies as a medical problem complicating labor and delivery management that requires additional resources, and thus it should be identified using E/M codes.
While CPT leaves room for differing interpretations on this point, we continue to believe that our interpretation is a reasonable one. However, we can't guarantee that third-party payers will accept the recommended coding.
Kent J. Moore
AAFP
Kansas City, Mo.
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