RE: appt length

[Guest guest]

Kathy,

Thanks for giving us that link....I had heard that Naomi Remen

was going to do that interview, but I missed it. Gotta love

technology, now I can listen to it. I love her books.

Sharon

At 08:24 PM 9/26/2006, you wrote:

Regarding appointment length, I

don't think that you can compare the average office length visit in an

IMP to the average visit with an internist or a family practitioner in a

regular practice.

At least in my practice

1.the patients self select for a practice where they can spend more time

with a physician and often have more problems. Even a URI for some

of my patients can be a bit more complicated than average although I am

always so happy to see just a URI so that I can quickly finish and code a

99213 visit.

I saw a patient today for her yearly exam, but we really dealt with her

hyperlipidemia-followup and review of labs, but lipids also not in

control, hypothyroidism-stable, urge incontinence-followup with

additional advice, new breast lump-requiring mammogram, myalgias and

arthralgias-ongoing but I continue to advise on different treatment

options, hormone replacement requiring medication adjustment. She

also has a history of anxiety that is currently stable, that I reviewed

with her. Now this took me 70 minutes of visit time. In a

regular practice she would have had to come back at least 3 times to deal

with all of those issues and since she lives at least 30 minutes away

that would be an extra 2 hours of travel time for her. Now

someone could say that none of those are really " complex " , but

honestly we didn't just shoot the breeze during the visit. How else

does one code other than with time. 99214 and extended time.

Oh yeah and she has osteopenia and I scheduled a bone density and

reviewed her treatment and renewed medications for everything.

2.How does one figure out complexity and time accurately anyway.

Sometimes explaining something that seems very straight forward to me may

take a long time getting across to the patient. Diabetes is pretty

straightforward until it happens to someone and they have to wrap their

mind around suddenly having an illness and needing to make huge life

changes. I could sure give results, do a quick this is what you

need to do, as well as a quick physical exam and have them out the

door in 20 minutes, but they may not have understood anything, if I

didn't take time to listen, get feedback, get more family and social

history, write down instructions, set up followup appointments and

pertinent referrals etc. That is all important stuff and should be

part of coding for time.

What about someone who is having anxiety about a social or family

situation. How does one decide on that complexity other than with

time?

3. I feel that often my whole visit is counseling and coordination of

care as I listen, give feedback and bits of advice throughout the whole

visit. I don't save the counseling all for the end or the visit and

then measure and divide and subtract. How does a counselor measure

their time counseling? Do they calculate just the time that they

spent talking or do they include listening, and give and take with the

patient.

4. I don't include time in which I am just being social, although I think

that being social in a visit is also therapeutic. I was listening

to a radio program called Speaking of Faith in which a physician by the

name of Naomi Remen discusses the difference between curing and

healing. A good portion involves taking time to listen. She

gives an example of a man with cancer who continued take his chemo

treatments even though they weren't doing any good, just so he could talk

with his doctor weekly. His doctor would only see him if he

was " receiving some sort of treatment " , but it was the actual

visit with the doctor that was keeping the patient going. One can

get a podcast of that program if interested.

http://speakingoffaith.publicradio.org/programs/listeninggenerously/index.shtml

Kathy Broman

Mason City, IA

kmlb2@...

On Tuesday, September 26, 2006, at 03:46 PM, Seto wrote:

Plus even when we do follow the

complicated coding rules, the health plans can unilaterally say they

won't pay anyways. The example of a well visit plus 99213 modifier 25 is

the most obvious example. Reimbursement is not about medical necessity,

it is about playing by the rules of a convoluted and unfair system where

we physicians are at a disadvantage. Medical necessity should be

determined by the physician, not an administrator.

For the record, I never code based SOLELY on the amount of time I spend

with a patient. However, according to this article from Family Practice

Management

(

http://www.aafp.org/fpm/20030600/27time.html

),

If a physician spends more than 50

percent of a face-to-face visit counseling or coordinating a patient's

care, the physician can code the visit on the basis of time, even if the

history, exam or medical decision-making elements are lacking.

That means a visit of between 25-39 minutes in length, which includes

most return visits for my chronic care patients. I chart the time I start

and the time I end each visit, and if more than half the time is spent

talking about behavioral changes, ways to increase exercise, explaining

their disease process, etc. then it should qualify as a 99214.

Interestingly, when I used to work at Kaiser, I timed myself without

regard to being on time, and found that I averaged 20 minutes per visit.

Unfortunately, I was only allotted 15 minutes per visit so I was

consistently behind by 45-60 minutes at the end of a half day.

Seto

South Pasadena, CA

OK, so I’ll get off my soapbox in a second.

No, I don’t typically code a 99214 for a cold (although I certainly can

get the documentation to be there for it), and I realize that the powers

that be have determined that medical necessity is the key. My argument is

not that I code that way, but that I should not have to worry about it in

the first place. Let’s say someone comes in and we talk about their URI

and I ask briefly how their back pain is and if they are exercising and

have stopped smoking. Generally, this should be a 99214, but instead of

documenting everything, I decide to “code for time.” Oops, no longer is

it about medical necessity, it’s about documentation. So now we are stuck

in this limbo where if we document too much, we are committing fraud

because it is not medically necessary, but if we don’t document

everything, we are told it never happened. This is the reason we have to

go to coding class after coding class only to leave scratching our heads.

It’s a crooked system where the one’s with the money can decide what they

want and shift reality to focus on that. I believe that my time with my

patient is valuable, and I shouldn’t have to justify it based on the

perception of medical necessity. Worried about me overcoding? Look at my

schedule to see if I saw5 patients/hrand coded 99214 for all of them. I

think you’ll find that much easier than searching charts looking to

justify necessity.

Re: RE:

appt length

Yes, but the problem is if we

eliminate the medical necessity part, what would stop fraud & abuse

of the CPT coding? Then all docs would have to do is write one sentence:

" I spent 45 minutes, over 50% on counseling re: . . . " and

nothing else. I agree it is important & helpful to spend the extra

time, but it is just not codable & reimbursable right now in and of

itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible

Family Care 'Modern medicine the old-fashioned way' This e-mail and

attachments may contain information which is confidential and is only for

the named addressee. If you have received this email in error,

please notify the sender immediately and delete it from your

computer.

<br>

<br>

<br>

<div>No virus found in this incoming message.</div>

<div>Checked by AVG Free Edition.</div>

<div>Version: 7.0.405 / Virus Database: 268.12.8/455 - Release

Date: 9/22/2006</div>

</blockquote></x-html>

No virus found in this outgoing message.

Checked by AVG Free Edition.

Version: 7.0.405 / Virus Database: 268.12.8/455 - Release Date: 9/22/2006

[Guest guest]

Kathy,

Thanks for giving us that link....I had heard that Naomi Remen

was going to do that interview, but I missed it. Gotta love

technology, now I can listen to it. I love her books.

Sharon

At 08:24 PM 9/26/2006, you wrote:

Regarding appointment length, I

don't think that you can compare the average office length visit in an

IMP to the average visit with an internist or a family practitioner in a

regular practice.

At least in my practice

1.the patients self select for a practice where they can spend more time

with a physician and often have more problems. Even a URI for some

of my patients can be a bit more complicated than average although I am

always so happy to see just a URI so that I can quickly finish and code a

99213 visit.

I saw a patient today for her yearly exam, but we really dealt with her

hyperlipidemia-followup and review of labs, but lipids also not in

control, hypothyroidism-stable, urge incontinence-followup with

additional advice, new breast lump-requiring mammogram, myalgias and

arthralgias-ongoing but I continue to advise on different treatment

options, hormone replacement requiring medication adjustment. She

also has a history of anxiety that is currently stable, that I reviewed

with her. Now this took me 70 minutes of visit time. In a

regular practice she would have had to come back at least 3 times to deal

with all of those issues and since she lives at least 30 minutes away

that would be an extra 2 hours of travel time for her. Now

someone could say that none of those are really " complex " , but

honestly we didn't just shoot the breeze during the visit. How else

does one code other than with time. 99214 and extended time.

Oh yeah and she has osteopenia and I scheduled a bone density and

reviewed her treatment and renewed medications for everything.

2.How does one figure out complexity and time accurately anyway.

Sometimes explaining something that seems very straight forward to me may

take a long time getting across to the patient. Diabetes is pretty

straightforward until it happens to someone and they have to wrap their

mind around suddenly having an illness and needing to make huge life

changes. I could sure give results, do a quick this is what you

need to do, as well as a quick physical exam and have them out the

door in 20 minutes, but they may not have understood anything, if I

didn't take time to listen, get feedback, get more family and social

history, write down instructions, set up followup appointments and

pertinent referrals etc. That is all important stuff and should be

part of coding for time.

What about someone who is having anxiety about a social or family

situation. How does one decide on that complexity other than with

time?

3. I feel that often my whole visit is counseling and coordination of

care as I listen, give feedback and bits of advice throughout the whole

visit. I don't save the counseling all for the end or the visit and

then measure and divide and subtract. How does a counselor measure

their time counseling? Do they calculate just the time that they

spent talking or do they include listening, and give and take with the

patient.

4. I don't include time in which I am just being social, although I think

that being social in a visit is also therapeutic. I was listening

to a radio program called Speaking of Faith in which a physician by the

name of Naomi Remen discusses the difference between curing and

healing. A good portion involves taking time to listen. She

gives an example of a man with cancer who continued take his chemo

treatments even though they weren't doing any good, just so he could talk

with his doctor weekly. His doctor would only see him if he

was " receiving some sort of treatment " , but it was the actual

visit with the doctor that was keeping the patient going. One can

get a podcast of that program if interested.

http://speakingoffaith.publicradio.org/programs/listeninggenerously/index.shtml

Kathy Broman

Mason City, IA

kmlb2@...

On Tuesday, September 26, 2006, at 03:46 PM, Seto wrote:

Plus even when we do follow the

complicated coding rules, the health plans can unilaterally say they

won't pay anyways. The example of a well visit plus 99213 modifier 25 is

the most obvious example. Reimbursement is not about medical necessity,

it is about playing by the rules of a convoluted and unfair system where

we physicians are at a disadvantage. Medical necessity should be

determined by the physician, not an administrator.

For the record, I never code based SOLELY on the amount of time I spend

with a patient. However, according to this article from Family Practice

Management

(

http://www.aafp.org/fpm/20030600/27time.html

),

If a physician spends more than 50

percent of a face-to-face visit counseling or coordinating a patient's

care, the physician can code the visit on the basis of time, even if the

history, exam or medical decision-making elements are lacking.

That means a visit of between 25-39 minutes in length, which includes

most return visits for my chronic care patients. I chart the time I start

and the time I end each visit, and if more than half the time is spent

talking about behavioral changes, ways to increase exercise, explaining

their disease process, etc. then it should qualify as a 99214.

Interestingly, when I used to work at Kaiser, I timed myself without

regard to being on time, and found that I averaged 20 minutes per visit.

Unfortunately, I was only allotted 15 minutes per visit so I was

consistently behind by 45-60 minutes at the end of a half day.

Seto

South Pasadena, CA

OK, so I’ll get off my soapbox in a second.

No, I don’t typically code a 99214 for a cold (although I certainly can

get the documentation to be there for it), and I realize that the powers

that be have determined that medical necessity is the key. My argument is

not that I code that way, but that I should not have to worry about it in

the first place. Let’s say someone comes in and we talk about their URI

and I ask briefly how their back pain is and if they are exercising and

have stopped smoking. Generally, this should be a 99214, but instead of

documenting everything, I decide to “code for time.” Oops, no longer is

it about medical necessity, it’s about documentation. So now we are stuck

in this limbo where if we document too much, we are committing fraud

because it is not medically necessary, but if we don’t document

everything, we are told it never happened. This is the reason we have to

go to coding class after coding class only to leave scratching our heads.

It’s a crooked system where the one’s with the money can decide what they

want and shift reality to focus on that. I believe that my time with my

patient is valuable, and I shouldn’t have to justify it based on the

perception of medical necessity. Worried about me overcoding? Look at my

schedule to see if I saw5 patients/hrand coded 99214 for all of them. I

think you’ll find that much easier than searching charts looking to

justify necessity.

Re: RE:

appt length

Yes, but the problem is if we

eliminate the medical necessity part, what would stop fraud & abuse

of the CPT coding? Then all docs would have to do is write one sentence:

" I spent 45 minutes, over 50% on counseling re: . . . " and

nothing else. I agree it is important & helpful to spend the extra

time, but it is just not codable & reimbursable right now in and of

itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible

Family Care 'Modern medicine the old-fashioned way' This e-mail and

attachments may contain information which is confidential and is only for

the named addressee. If you have received this email in error,

please notify the sender immediately and delete it from your

computer.

<br>

<br>

<br>

<div>No virus found in this incoming message.</div>

<div>Checked by AVG Free Edition.</div>

<div>Version: 7.0.405 / Virus Database: 268.12.8/455 - Release

Date: 9/22/2006</div>

</blockquote></x-html>

No virus found in this outgoing message.

Checked by AVG Free Edition.

Version: 7.0.405 / Virus Database: 268.12.8/455 - Release Date: 9/22/2006

[Guest guest]

I would code as a 99214 with 25 &

extended visit (or possibly preventive plus extended, I assume that can be

done?). I would not have tried to cover the preventive as well with all of

those acute issues. To me, that is just too much to cover in one visit. The

human mind just can not focus & absorb that much info. Trying to code a

preventive plus 99214/99215 plus extended will likely get everything rejected.

Re:

RE: appt length

Yes, but

the problem is if we eliminate the medical necessity part, what would stop

fraud & abuse of the CPT coding? Then all docs would have to do is write

one sentence: " I spent 45 minutes, over 50% on counseling re: . . . "

and nothing else. I agree it is important & helpful to spend the extra

time, but it is just not codable & reimbursable right now in and of itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care

'Modern medicine the old-fashioned way' This e-mail and attachments may contain

information which is confidential and is only for the named

addressee. If you have received this email in error, please notify

the sender immediately and delete it from your computer.

[Guest guest]

I would code as a 99214 with 25 &

extended visit (or possibly preventive plus extended, I assume that can be

done?). I would not have tried to cover the preventive as well with all of

those acute issues. To me, that is just too much to cover in one visit. The

human mind just can not focus & absorb that much info. Trying to code a

preventive plus 99214/99215 plus extended will likely get everything rejected.

Re:

RE: appt length

Yes, but

the problem is if we eliminate the medical necessity part, what would stop

fraud & abuse of the CPT coding? Then all docs would have to do is write

one sentence: " I spent 45 minutes, over 50% on counseling re: . . . "

and nothing else. I agree it is important & helpful to spend the extra

time, but it is just not codable & reimbursable right now in and of itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care

'Modern medicine the old-fashioned way' This e-mail and attachments may contain

information which is confidential and is only for the named

addressee. If you have received this email in error, please notify

the sender immediately and delete it from your computer.

[Guest guest]

I would code as a 99214 with 25 &

extended visit (or possibly preventive plus extended, I assume that can be

done?). I would not have tried to cover the preventive as well with all of

those acute issues. To me, that is just too much to cover in one visit. The

human mind just can not focus & absorb that much info. Trying to code a

preventive plus 99214/99215 plus extended will likely get everything rejected.

Re:

RE: appt length

Yes, but

the problem is if we eliminate the medical necessity part, what would stop

fraud & abuse of the CPT coding? Then all docs would have to do is write

one sentence: " I spent 45 minutes, over 50% on counseling re: . . . "

and nothing else. I agree it is important & helpful to spend the extra

time, but it is just not codable & reimbursable right now in and of itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care

'Modern medicine the old-fashioned way' This e-mail and attachments may contain

information which is confidential and is only for the named

addressee. If you have received this email in error, please notify

the sender immediately and delete it from your computer.

[Guest guest]

All of this talk about appt length brings

up a good question: I wonder which is more effective in achieving better

outcomes (that is open to interpretation what those “outcomes” would

be), one long “do everything” visit of 60 – 70 minutes or

several 15 – 25 minute follow-up visits? I personally think people

just tune out after about 25 or 30 minutes. An example is with academic studying.

We typically recall the first and last things we heard or read but much less of

everything in between. That is why studying in short blocks is almost

always better than one long marathon “cram” session. I wonder

if this same thing translates to office visits, and if it has ever been

studied? Are we really being better docs by spending 60 – 70 minutes

with a patient or are multiple short follow ups actually better (not

necessarily just income-wise)?

Re:

RE: appt length

Yes, but

the problem is if we eliminate the medical necessity part, what would stop

fraud & abuse of the CPT coding? Then all docs would have to do is write

one sentence: " I spent 45 minutes, over 50% on counseling re: . . . "

and nothing else. I agree it is important & helpful to spend the extra

time, but it is just not codable & reimbursable right now in and of itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care

'Modern medicine the old-fashioned way' This e-mail and attachments may contain

information which is confidential and is only for the named

addressee. If you have received this email in error, please notify

the sender immediately and delete it from your computer.

[Guest guest]

those are great questions! spending time with someone may be therapeutic in and of itself. we want to make a significant difference, and we must balance that with efficiency, and prevent burn-out. how much time correlates with that which carries over after the patient leaves, and encourages them to remain actively engaged in their care on a daily basis? is that even accomplished by seeing patients in the office? if so, what specific factors, including length of the encounter, promote that? is there some threshhold time period? is there some maximum time period, beyond which there is no demonstrable change in outcome? what tools and their combinations promote a demonstrable change in outcome? is there a particular way to approach patients which makes a difference? are there key words or phrases? is there some particular body

language? of course there are! as gary reminds us, remember interviewing class? we think that the IMP style works better. five extra minutes makes a difference in malpractice rates. we can measure outcomes in terms of ED visits, changes in blood pressure, changes in HbA1C, all objective indicators, but here might be an opportunity to demonstrate more. how do residency programs, kaiser, multi-specialty clinics, all come up with "you have thus-and-so amount of time to see a patient, and you have to see this many patients per day"? i believe that that is in fact based on hard data-- financial data, not patient outcomes! it's based on a model we don't use.i see a study-- to develop a validated tool, perhaps based on the sf-36, to qualify and quantify parameters and traits which truly make a difference in

outcome, both from the doctor's and patient's perspectives. maybe this has already been done. if so, where is it? if not, sounds like a job for the IOM and/or AAFP. get some graduate level psych students to do this at several university teaching hospital resident clinics. we can think all we want, and practice accordingly, which is what we're doing. nonetheless, i think this can be part of evidence-based medicine. it's not touchy-feely, it's making a difference in our lives and the lives of our patients. LL Brock DO wrote: All of this talk about appt length brings up a good question: I wonder which is more effective in achieving better outcomes (that is open to interpretation what those “outcomes” would be), one long “do everything” visit of 60 – 70 minutes or several 15 – 25 minute follow-up visits? I personally think people just tune out after about 25 or 30 minutes. An example is with academic studying. We typically recall the first and last things we heard or read but much less of everything in between. That is why studying in short blocks is almost always better than one long marathon “cram” session. I wonder if this same thing

translates to office visits, and if it has ever been studied? Are we really being better docs by spending 60 – 70 minutes with a patient or are multiple short follow ups actually better (not necessarily just income-wise)? Re: RE: appt length Yes, but the problem is if we eliminate the medical necessity part, what would stop fraud & abuse of the CPT coding? Then all docs would have to do is write one sentence: "I spent 45 minutes, over 50% on counseling re: . . . " and nothing else. I agree it is important & helpful to spend the extra time, but it is just not codable & reimbursable right now in

and of itself.> --Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the sender immediately and delete it from your computer.

All-new Yahoo! Mail - Fire up a more powerful email and get things done faster.

[Guest guest]

Optimal appt length.  Regarding attention span I have seen studies (by the Navy)that show that lectures work best during the first 18 minutes and after that people lose their attention. I do plan to make my talks more interactive with lots of Q/A in the future which keep folks involved. I see medical visits as more of a Q/A interactive session that purely me lecturing a patient  so I think > 18 minutes works well.  However, I do think that if we go through several complex issues and order many tests etc.. we could get to a saturation point where it is simply too overwhelming for the patient.On the other hand, it is nice to realize (with enough time) that all 7 complaints are anxiety related or fall under a different diagnosis rather than treating each separately in short appointments. Most patients love the longer visits.Pamela All of this talk about appt length brings up a good question: I wonder which is more effective in achieving better outcomes (that is open to interpretation what those “outcomes” would be), one long “do everything” visit of 60 – 70 minutes or several 15 – 25 minute follow-up visits?  I personally think people just tune out after about 25 or 30 minutes.  An example is with academic studying.  We typically recall the first and last things we heard or read but much less of everything in between.  That is why studying in short blocks is almost always better than one long marathon “cram” session.  I wonder if this same thing translates to office visits, and if it has ever been studied?  Are we really being better docs by spending 60 – 70 minutes with a patient or are multiple short follow ups actually better (not necessarily just income-wise)?  Re: RE: appt length   Yes, but the problem is if we eliminate the medical necessity part, what would stop fraud & abuse of the CPT coding? Then all docs would have to do is write one sentence: "I spent 45 minutes, over 50% on counseling re: . . . " and nothing else. I agree it is important & helpful to spend the extra time, but it is just not codable & reimbursable right now in and of itself. >   -- Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee.  If you have received this email in error, please notify the sender immediately and delete it from your computer.