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.
