Forms do not keep patients out of hospitals

Over one year ago my office implemented an EHR (electronic health record). I’ve not done a note on paper since.

Last week, a Transition of Care (TOC) document was placed on my desk with a sticky note stating: “Dr. Nieder please fill out this form so we can bill a 99496 for your visit with Mrs. Jones yesterday.”

I pick up two sheets of paper with multiple questions including:

  • discharge Medications: (list)
  • present Medications: (list)
  • diagnostic tests reviewed/disposition (list)
  • disease/illness education (discussion documentation)
  • home health/community services discussion/referrals: (list)
  • establishment or re-establishment of referral orders for community resources: (list)
  • discussion with other health care providers: (list)
  • assessment and support of treatment regimen adherence: (discussion documentation)
  • appointments coordinated with: (list)
  • education for self-management, independent living and activities of daily living: (discussion documentation)

Please remember, I am now on an EHR. So I am expected to document electronically first then manually fill out forms. I have no discharge summary yet from the hospital.  The medications when she left the hospital state “resume pre-admission meds.” In order for me to list what tests she had I log in to the hospital portal and look them all up. Some of them have been scanned into my EHR, some not. She had a straight forward admission for a small bowel obstruction. She declined to keep the surgeon’s appointment as she was told there was nothing he could do for her.

A TOC visit is paid at a higher rate than other visits if the patient does not return to the hospital in the following 30 days. Hence, we hold the billing until that time. My understanding of the purpose of this new code is to improve coordination of care as a patient transitions from the hospital to home. Coordination would imply that there are other individuals involved and thus there is improved communication between us.

However my staff and I bear the brunt of gathering information (which is what we normally do anyway, so I guess it’s nice because now we get paid for it).

At what point will it become incumbent upon the hospital to send me the necessary information for treating the patient now that he/she is home again? How does it follow that improving care means the primary care doctor fills out even more forms, ultimately reducing the time spent with the patient?

The form will not keep the patient out of the hospital. Communication can keep the patient out of the hospital. True coordination of care might keep the patient out of the hospital. More busy work for the patient’s primary care doctor will not. Since the order of the day is using hospitalists, it is imperative that we improve our communication systems at the time of discharge and before the patient is seen again in the primary care office. Systems must stop thinking that one more form is going to save the patient. Especially another form on my back.

Kathy Nieder is a family physician who blogs at Family Practice 2.0.

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  • Margalit Gur-Arie

    Dr. Nieder, the items you listed bear an eerie resemblance to patient centered medical home requirements, but as far as I know, these are not all necessarily required for billing a TCM code. So I am wondering if something else is afoot….

    • KANieder

      I don’t think so. The form was not much different than this one developed by the AAFP:

      • Margalit Gur-Arie

        I that case, the form is just a checklist for possible services. If you document these things in the EHR anyway, then that should be sufficient to justify the claim. It may be that your biller likes to have the form filled out to make things easier in case of audit, but as far as I know, and I may be wrong, CMS is not requiring a specific paper form outside the EMR.
        BTW, you can still bill the higher code even if the patient is readmitted, whether within 30 days from the first discharge or 30 days from the second discharge, even if those are overlapping. The only instance where you cannot bill it is if the patient dies within the 30 day period, or if someone else billed it already (my bet is that hospitals will set things up to bill for these codes themselves eventually, maybe in the parking lot or across the street or something…).

        • Stefani D

          The transitional codes do not require separate documentation. There just has to be evidence of non-face to face services provided by the physician or a qualified provider during the 30 days following discharge from a hospital or SNF. For 496, need evidence of complex contact within 2 days of discharge and face to face within 7 days.

        • KANieder

          I like the parking lot idea. The problem, as the hosp saw it, is that our usual form in the EHR wasn’t complex enough to answer questions like “did you have a home health referral”, so if your EHR didn’t document (and I guess ours didn’t) the right questions we had to supplement it. Our EHR isn’t capable of making fast templates for the docs.

  • Suzi Q 38

    My doctor had to do the same thing. Fill out a mountain of forms.
    I don’t know how to pay him back for helping me.
    He did ask me: “Why do I have to fill out this referral?”
    My answer: “Because you are my doctor, and have been for the last 12 years.”
    I didn’t realize that this meant a lot more paperwork for him alone to fill out, as his receptionists were probably not familiar with the medical terminology enough to do so.
    I hope that they were able to help him at least with part of the paperwork.

    I do feel bad, but I needed cervical spine surgery. My main neurologist didn’t want me to get a second opinion, so he refused to write the referral. I needed a second opinion, so the only physician I had to turn to was my PCP.

    • guest

      “I don’t know how to pay him back for helping me.”

      Fruit basket, thank you note, bringing in lunch for the office staff, a nice plant for the office…

      There are a ton of ways that someone who’s not totally self-involved, and who has a little imagination can think of to thank a hard-working doc who has bent over backwards to help them.

      • Suzi Q 38

        Thanks, Good idea.
        I have done that once or twice, and my gestures were met with:” Why did you do that?”
        I don’t know if he did not think that he was deserving of it, or what, LOL.
        Once I stopped my the store and bought everyone something really simple, like a huge tray of premium tangerines. I noticed that he did not share them and they were in his office. I guess he liked the gesture after all.

        I bought a gift card and gave a thank you note for another surgeon, as he called me personally on the phone and corresponded by email. He was not my official surgeon, but a friend of the family.

        I have not thought of bringing in lunch for the staff, but what a great idea.

        Thank you!

      • meyati

        I dropped off a few dozen fresh-home-made cookies. 1 bag for the receptionists, 1 for the nurses, and one for him. I think that he decided that I had the hots for him. He stayed as far away from me, as I would from a rattlesnake. I have skin cancer that wasn’t caught in time. he asked how that was. I said something like., Well I’m Irish, we have a high rate of skin cancer. He jumped and said- I don’t want to hear any more of ‘Us” and “We”. That is inappropriate. I said- in a loud voice-Irish-Irish like Ireland Irish. Lots of skin cancer.

        I’m 71 years old, wear supportive shoes, USMC socks for the extra padding, no cosmetics, baggy cargo pants for dog treats, baggy tank tops in summer or T-shirts-then part of my nose is gone, and thick glasses. Part of my lip was removed, and it gives me a permanent frown. I do wear a bright scrunchy for my tired pony tail. I don’t think that is a description of a cougar. My language is modest, without any innuendos.

        I had a little note with the cookies that said, Thank you for your care-and signed my name.

  • guest

    I think most people these days are running on fumes and inclined to forget that their doctors are really people. It doesn’t help that we have a healthcare system that encourages people to have expectations of their doctors that generally speaking could only be fulfilled by some sort of machine.

    • KANieder

      I appreciate all of your comments. Most days I feel more like a data entry clerk than a machine though, LOL.

  • bill10526

    Dr. Neider is showing the 1984 falacy. In Orwell’s fantastic novel a man is under continuous surveillance by the police. But such a program can not apply to all citizens because at least half of the population would be observers.

    The level of documentation – forms – in medicine is driven more by fear of lawyers than benefits to patients. Corporations have to provide a hugely expensive to calculate ratio of their CEO salaries to the median wage of their employees . Its idiotic and driven by an idiotic populous.

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