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Governor's Newsletter, Summer 1999

From the Governor's Desk

Scott Peck started his book, The Road Less Traveled, with the words, "Life is difficult." To paraphrase Dr. Peck, "Medicine is difficult." As internists, we are increasingly being pressured to see more patients for less money. The increase in phone calls and paperwork is growing faster than kudzu. Coding for our services has become a game of "shooting bullets." In the midst of this storm, you find yourself on the phone on hold with an insurance clerk trying to precertify a patient for an MRI and having to listen to the voice message, "your call is very important to us." At times, I feel as though I am in trench warfare, the only difference being that at the end of the day instead of retiring to the barracks, I need to go home and strive to be a good father and a good husband, as well.

I wish the inaugural newsletter contained in it the magic formula for solving all these complex struggles and difficulties. Unfortunately, it bears no such fruit from the Garden of Eden. My experience does lead me to the conclusion that there is healing power in sharing and communicating our experiences. My hope is that this newsletter can be a communication tool that will help bring us closer together so we are more a community than just an organization. Coming together as an informed, unified and engaged body will be our strongest weapon in the long run to defend our profession and fight for the health interests of our patients.

Perhaps no issue in the practice of medicine challenges the need to be informed and engaged more than the issue of evaluation and management (E&M) codes. Our feature article this quarter is on this issue which was written by Dr. Bill Grow, a practicing internist in Valdosta and co-chair of our Health and Public Policy Committee. He recently attended a meeting with the Medical Director of our Medicare carrier on coding, and discovered things about coding that were both enlightening and frightening. After reading the article, I think you will conclude that his concerns need to be all of our concerns.

Beware - E&M Audits in Progress

On Thursday, March 10, 1999, at the invitation of Dr. Frederick Maner, Medical Director for the Part B Medicare carrier for Georgia, five physicians representing the Georgia Chapter of the American College of Physicians, the Georgia OB-GYN Chapter, the Georgia Academy of Family Physicians, and the Medical Association of Georgia met at the carrier's office in Savannah for six hours. The main thrust of the meeting was to introduce us to the carrier, its staff, organizational structure and its operation. However, the last two hours of the meeting were devoted to E&M coding.

The carriers are under a strict HCFA guideline to now enforce E&M coding using the 1994 or 1997 guidelines, which are the present standards until, if and when, future revisions are made. We five physicians were given examples of various records, office, hospital, ER, nursing home, ICU care, and asked to compare our assessment of the correct E&M code for those services with the carrier's assessment of the correct code. According to Dr. Maner, whichever guideline, 1994 or 1997, is the most favorable to the physician is the present HCFA policy to the carrier. Under these guidelines, we five representative physicians were startled to find that we almost invariably coded 1 or 2 levels higher than the carrier did using our knowledge of the present guidelines as outlined. This appeared to be mostly due to our lack of knowledge of the specifics of the 1994 and 1997 E&M guidelines. Auditing of physicians' records using these guidelines is presently in progress for compliance.

As a result of an OIG financial audit, HCFA decided to subject claims for E&M services - the most commonly billed - to prepayment review and to begin random review of 1% of all E&M services beginning October 1997. According to Dr. Maner, no other routine audits are being done. Therefore, except for the 1% random review, when you are audited for E&M coding, it is because you have triggered the audit by HCFA screens. Once the audit is completed, if the reviewer determines the medical records substantiate the services, the case will be closed. If the reviewer, however, determines that the carrier paid a certain percentage of the sampled claims in error, the carrier must determine whether the physician knew or should have known that the service was not medically necessary.

To determine that a service was not medically necessary requires evidence that the physician had received some notice. Acceptable notice includes previous denials for the same service, publication in a carrier newsletter and accepted local standards of practice. If the carrier determines with evidence that the physician should have known that the service under review was not necessary or was erroneously coded, the carrier will proceed to comprehensive review and will ask for refund of overpayment which can amount to tens of thousands of dollars, some over $200,000. This must be paid immediately, even if the overpayment is appealed. There is no letter of warning first.

Dr. Maner and his staff of nurse reviewers try to be as fair as possible, but are under strict HCFA guidelines to enforce the 1994 or 1997 guidelines. The message is clear - if it isn't written down, it did not happen and, if it does not meet the 1994 or 1997 E&M guidelines, it will be down coded with the potential for large repayments. We argued that it is not possible that everything you say and do can be written; that much of what you do is by phone,

(i.e., hospital and nursing home patients); that we spend more and more time trying to decide correct billing codes and less on direct patient care; and that this is not a quality of care issue, but a billing issue. We were heard, but were told that their mandate to enforce the guidelines is clear.

So, if you are not already, become knowledgeable of and start using the 1994 or 1997 E&M coding guidelines (available through ACP-ASIM customer service at 1-800-523-1546) and START NOW! Pending action of ACP-ASIM and other organizations trying to modify the E&M guidelines, the Medicare carrier's audits and enforcement will proceed as it.

Annual Chapter Meeting

Chapter Elections

Our state chapter meeting held in Atlanta on March 12-14, was a tremendous success. It was a success not only because of the excellent content of the scientific presentations, but also because of the gathering itself. We had a wonderful mix of medical students, residents, faculty, and practicing physicians, young and old, all gathered for an opportunity of great learning and great discourse. (I'll leave each of you to decide who was young and who was old.)

It was also a special meeting because of the attendance of members of the Leadership Council of the Georgia Society of Internal Medicine. These people included: Glenn Carter who was the current President of the Georgia Society of Internal Medicine; Bill Grow, member of the GSIM/Executive Council; Rose Briglevich, Secretary of the GSIM; and Harry Dorsey, former President of the GSIM. As an organization, the Georgia Society of Internal Medicine has done much to promote the interests of internists and their patients in the state of Georgia. It is a tribute to their leadership that we have been able to so smoothly merge the two organizations together.

We owe a tremendous debt of gratitude to Vince Nicolais who was Program Chair of this meeting, as well as the meetings in the two previous years, and also to Louis Riley who was the Program Chair of the Associates' meeting.

At our chapter meeting, we accepted the Nominating Committee's recommendation for new officers and Governor's Council.

These include the following:

Vice President, Glenn Carter, MD
Secretary, Ruth-Marie Fincher, MD
Treasurer, Jeffrey Bell, MD

Council Members:

Joel Todino, MD
Jacquelyn Fincher, MD
Janice Herbert-Carter, MD
Bill Grow, MD
Louis Riley, MD

Chapter Committee Chairpeople:

Educational Program, Guillermo Umpierrez, MD
Associates Program, Louis Riley, MD
Health and Public Policy, Evan Weisman, MD, and Bill Grow, MD
Membership and Fellowship, Vince Nicolais, MD, FACP
Nominations Committee, Mark Silverman, MD, FACP
Diversity Committee, Kenny Frontin, MD, FACP
Women's Committee, Teresa Clark, MD

If you have an interest in working or serving on any of these committees, please contact either the chairperson or me.

News from the Official College Representative (OCR)

Our CR this year was our own Dr. Robert Copeland, who has also recently finished serving as Chairman of the Board of Regents. In his presentation at the town meeting, Dr. Copeland indicated that the merger of the two organizations, the ACP and the ASIM, had gone better than expected and continues to have a very strong impact for the internists around the country. He particularly spoke on the issue of the Political Action Committee (PAC). Prior to the merger, the ASIM did have a PAC. As part of the merger, it was agreed that the ASIM PAC would be dissolved. Many members feel we should form a new PAC for the new organization ACP-ASIM, but this is proving to be very controversial. After Dr. Copeland briefed our members on the pros and cons of the political action committee, the attendees of the meeting gave a strong endorsement from the Georgia Chapter in support of a PAC. The Board of Regents will be making a final decision about whether to form a PAC in the early part of next year and will continue to gather opinions of the Colleges' members in the meantime.

Associates Program

Under Dr. Louis Riley's direction, we had an outstanding Associates Competition Program this year with great representation from all of our state's residency programs in internal medicine. The winners of the Associate Program are as follows:

Clinical Vignette:

First Place - Guillermo Pineda - Medical College of Georgia

Second Place - Antoinette Thaxton-Brooks - Morehouse School of Medicine

Third Place - Jason Thompson - Medical College of Georgia

Research:

First Place - Beth Burgess - Emory University School of Medicine

Second Place - Mark Steen - Emory University School of Medicine

Third Place - Brick Acosta - Savannah Memorial Medical Center

Poster:

First Place - Racheal Innis Sheldon - Atlanta Medical

Second Place - Ethan Tolbert - Emory University School of Medicine

Third Place - Adesoji Oderinde - Morehouse School of Medicine

Georgia Chapter Award Winners

The winner of the year's J. Willis Hurst Outstanding Bedside Teacher Award is Dr. William Theodore Browne from Dwight David Eisenhower Army Medical Center. Dr. Browne was recognized for his outstanding teaching abilities as Director of the Internal Medicine Residency Program at Eisenhower.

The winner of the Georgia Laureate Award went to Mark Silverman for his outstanding accomplishments as outgoing Governor of the chapter and for his ongoing work in our chapter activities, especially the development of the Associates Program, the Summer Mentoring Program, and the Internal Medicine classes.

A special new award, the Governor's Award, was given this year to Dr. Robert Copeland by Dr. Mark Silverman on behalf of our chapter for his lifelong dedication to the College and his exemplary leadership skills, not only at the chapter level, but nationally as well.

Next Chapter Scientific Meeting

Make plans to attend our next chapter meeting in beautiful Savannah at the new Westin Hotel on May 19 - 21, 2000.

Annual Session - ACP-ASIM

News Roundup

The Annual Session continues to be the most outstanding educational opportunity in medicine. One member's comments summed it up well when she said, "During the year, I cannot help but get discouraged with all the hassles and burdens that go along with being an internist, but after attending the annual session, I always feel renewed because it refreshes and reinforces the original values, skills and knowledge that led me to internal medicine in the first place."

The biggest news was the induction of Sandra Adamson-Fryhofer, MD, from Atlanta, Georgia as the President-Elect of the ACP-ASIM. Also inducted was the new President, Whitney Addington, MD, from Chicago, Illinois; Munsey Wheby, MD, from Charlottesville, Virginia as Chairperson of the Board of Governors; and David Gullen, MD, from Scottsdale, Arizona as Chairperson of the Board of Regents.

Master Recipients, Fellows and Awards

This year, three Georgia physicians were awarded Mastership of the College. These include the following:

• Virgil Brown, MD, Professor of Medicine, Emory University School of Medicine;
• William Branch, MD, Professor of Medicine, Emory University School of Medicine; and
• Charlie Harrison, MD, Atlanta Internist, former Governor of the Georgia Chapter

Our state and chapter are fortunate to have the leadership of these Masters and our ten other Masters. I believe there are many more potential Masters within our chapter community. I urge you to please help me identify those individuals during my next four years as Governor.

Congratulations to all the new Fellows of the American College of Physicians-American Society of Internal Medicine. This year the Georgia Chapter had 27 recipients. They are:

This year, our chapter continued to be well recognized. We received the Chapter Management Award and one Evergreen Award for the efforts to expand the Summer Mentoring Program under the new state agency, Georgia Physicians Work Force Committee. Dr. Mark Silverman and the Georgia Chapter were also given a special recognition award for the extremely high percentage of medical students that we have as members of the College. We currently have over 80% of the medical students as members of the College, which far exceeds any other chapter.

Annual ACP-ASIM Session

Clinical Themes Project

Each year the college plans to select a clinical theme which identifies a clinical area where there is good scientific information about what is appropriate care but is not being incorporated consistently in clinical practice. This year's theme will be "Inappropriate Antibiotic Prescribing for Upper Respiratory Infections." The goal of the College over the next two years is to see a 90% reduction. It is hoped that activities directed around this clinical theme will occur not only at the national level, but also at the local chapter level. You will be hearing more about this later.

Member Milestones

To become more of a community, we need to communicate with each other what is happening around the state. I would appreciate your contacting either Nancy Brady or me if you hear of news in your local community regarding an internist, whether it be an award, a new physician, a serious illness, or death.

Web News Corner

There is a link to send an e-mail message to the Governor. Dr. Silverman indicates that since its existence, he has not received one e-mail message. I believe that electronic communication has got to become an important link between the Governor and the members.

To encourage you to send e-mail messages, I am offering free registration to our next Georgia Chapter Scientific Meeting to the first individual who sends me an e-mail message. We are also interested in any comments or suggestions you might have for improving our web site.

Meet the New Georgia Chapter ACP-ASIM Executive Assistant

Our new executive assistant is Nancy Brady. Nancy will be replacing Linda Mason. She has worked in the healthcare and pharmaceutical field since 1983, most recently with the Southwest Georgia Area Health Education Center. She presently lives in Newnan, Georgia. Her phone number is (770) 252-1858, and her e-mail address is nbrady@mail3.newnanutilities.org.

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