Sunday, March 24, 2013

Another Surreal Moment in Modern Medicine

A few months ago my office manager, Debbie, informed me that it was time for my annual "coding audit". This is where my employer sends in a hired gun to determine if my choices of office codes for billing purposes are correctly done. Did I document enough to support a 99214? Did I code too many 99212s when my documentation should have been higher, and thus my reimbursement better? The audit is based on Medicare-guidelines, although the ten charts pulled were of patients of all ages and insurance types. Doctors generally approach these sessions with the same dread we felt getting our report cards in grade school.

The tiny blond that came in to discuss my results refused to sit down next to me. It was distracting and intimidating. Since I'm 5'10" it was also infuriating to have this schoolmarm personality towering over me while she explained why she'd flunked me. Seven out of ten charts did not pass her muster. Two of the explanations made sense - one was "overcoded" - not enough documentation to support the 99213 I'd coded and the other the opposite. Six charts were "complete physical exams" (CPE) done on healthy non-Medicare patients. Since Medicare does not pay for preventive exams why were they pulled for a Medicare audit? It got stranger. She told me that I'd flunked because there was no "chief complaint" on the physical form. What? There shouldn't BE a chief complaint for someone who is having a physical. In fact, by definition, there shouldn't be one because it is a preventive service. No amount of discussion would dissuade the woman that she was wrong. I didn't have immediate access to my own specialty society's information on the subject:
The comprehensive history and examination performed during a preventive medicine encounter are not the same as the comprehensive history and exam that are required for certain problem-oriented E/M codes (99201-99350) and defined in Medicare’s Documentation Guidelines for Evaluation & Management Services. In fact, the documentation guidelines don’t apply to preventive medicine services. The history associated with preventive medicine services is not problem-oriented and does not involve a chief complaint or history of present illness.
I gave up arguing, signed the form under written protest and she left. 

Here is the kicker--a week ago one of the people whose chart was audited called to tell us she received all her money back on her physical! She thought it was a mistake and  was upset. She argued with Debbie and insisted that my office take back the money saying "But Dr. Nieder did all that work and spent the time with me." 

I am furious. This suggests to those six patients that I did something wrong. Ironically, this means my employer is out hundreds of dollars for work they paid me for and that should rightfully have been reimbursed. Jawdropping in it's lunacy. Can anyone wonder why the concierge movement is such an attractive, viable alternative to this?


Wednesday, March 13, 2013

Care-less Care and Telemedicine

One of my irritations with fast track care, especially Kroger's Little Clinics, is the overuse of antibiotics. Living in Louisville, where allergies are king, a simple cold often turns into two weeks of miserably clogged sinuses from increased swelling in already perennially irritated mucous membranes.  A few days ago a new version of "careless care" appeared on my radar. Teladoc advertises itself as the first and largest telehealth provider in the US. Some insurance companies and employers pay for their members to utilize the service. This particular patient used it three times in six months, each time receiving and antibiotic for a "sinus" infection, despite the fact that each time she'd only had symptoms for four or five days. She finally came to see me because the medication the teledocs gave never seemed to help. Go figure.

We spent some time talking about the difference between viral infections and bacterial ones, and discussing the problem with bacterial resistance due to the overuse of antibiotics. She promised to see me with her next episode and appeared rueful that she'd not come in sooner with the previous episodes.

The fact that telemedicine can lead to the overuse of antibiotics has been studied[1]. I was unable to find any studies evaluating overprescribing in Urgent Care Centers so I can only relate my own experience. The ERs and the NP staffed Walgreen clinics in my area do a much better job than the Kroger "Little Clinics" where antibiotic prescribing seems to be more ubiquitous than high fructose corn syrup. 

As telemedicine and other forms of convenient care increase, the fragmentation of healthcare does the same. Did I get any patient information from the Teladoc physician? No, of course not. Almost never do I get documents from the Walgreens/Kroger/Walmart nurse practitioner. I can't fight the convenience and know that as more and more patients have difficulties conveniently getting in to see their primary care doctors, this will only get worse. It is imperative that these groups communicate with patients' physicians. The question is, do I have an imperative to educate the Board Certified Physician who works for Teladoc? And why do I suspect he/she might not appreciate that? The answer is, I need my healthcare system to allow me to use telemedicine to treat my own patients at their convenience.

1. Ateev Mehrotra, MD; Suzanne Paone, DHA; G. Daniel Martich, MD; Steven M. Albert, PhD; Grant J. Shevchik, MD JAMA Intern Med. 2013;173(1): 72-74.doi:10.1001/2013.jamainternmed.305

Sunday, March 3, 2013

Are Doctors the Ultimate Engaged Patients?

My nose and sinuses feel like they are about to explode. I am moving into the third week of this and it's getting old. At first I thought that my cold had morphed into allergies but now it is apparent that two viral loads in a row have slammed me, both affecting my upper respiratory tract. If a patient walked into my office as miserable as I am right now my advice would include a steroid dose pack to shrink the swelling, some decongestants, lots of fluid and rest. Since it has been going on for so long if the patient insisted I would probably toss an antibiotic in there as well though it is clear (to me) this is not a bacterial infection. I am using a multi-symptom nighttime OTC cocktail along with a topical antihistamine at night and a decongestant with a expectorant during the day. I have no fever and there is nothing to suggest a bacterial component.

Reflecting on my illness, it occurs to me that one of the reasons doctors are uncomfortable taking care of doctors is that we are the ultimate e-patient. We are participatory, we understand the underlying disease processes and we often waver between allowing the treating doctor to be in charge and taking charge. We want to be partners in our healthcare because we have the training for it and yet hesitate because that's not the way it's done. It brings to mind a moment in my first pregnancy (in eastern KY) when my nurse midwife told me to skip the hospital prenatal courses because I needed to be a patient, not a doctor, and the classes would thrust me into a difficult role in such a small community. I remember feeling relief and feeling good about "only" being a patient. 

Those times when I have needed to be a patient my choices in physicians have assured me that I would be a partner in my healthcare decisions. Most doctors find taking care of other doctors, or their family members, challenging. This can be both self-inflicted and patient-generated. As patients become more engaged in their healthcare perhaps taking care of our own kind will become less anxiety-producing. We will feel confident that no one is "only a patient" because all patients will be partners if they so choose.