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Rhode Island Internist

December, 1996

In this issue:

PRESIDENT'S MESSAGE - Mitchell Pressman, MD
ASIM Remains the Internist's Advocate

I was reminded of the strength of our organization; its tremendous leadership; the resources available to us; and the willingness of the American Society of Internal Medicine's (ASIM) to listen to its membership; while attending the Society's 40th Anniversary Annual Meeting--held in Chicago Oct. 10- 13. ASIM remains a well-recognized and well-respected grass-roots organization. ASIM speaks just for internists. In contrast, the American Medical Association is unable to speak for all our needs. Along with your membership, ASIM needs your participation to keep its voice loud and clear. The needs of surgeons, gynecologists, radiologists, etc., are different from the needs of internists and their patients. This was one of the messages that rang out at the meeting.

Dr. Shook Highlights ASIM's Plans

In his address to the House of Delegates, incoming ASIM president, M. Boyd Shook, MD, discussed the Society's strategic direction for the coming year. ASIM plans to:

  • Help internists provide better quality care with the Effective Medical Management Self- Assessment Program (EMM-SAP). This program will measure clinical, organ-based knowledge to improve patient satisfaction, increase practice productivity, and help you to gain a competitive advantage in the medical marketplace. ASIM members will receive a $50 rebate on the already-low EMM-SAP subscription price of $450. Watch for more information in this newsletter and ASIM publications--including the new Today's Internist magazine, which debuts with the January/February issue.
  • Increase ASIM advocacy for the practicing internist--especially in the managed care arena.
  • Strengthen component societies and increase membership with the new Trustee Advisory Program. ASIM Trustee Cecil B. Wilson, MD, will maintain close contact with RISIM as our Board liaison; members can contact him through ASIM or via E-mail at asimwilson@mem.po.com.
  • Promote the value of internal medicine--and ASIM in particular--to gain the respect internists justly deserve.

Finally, Dr. Ejnes was outstanding in his presentation during the two optional program sessions titled "Internists in Cyberspace: Here's How"--which was given in front of a standing room audience. He led the delegation through a tour of the Internet using the new Physicians' Online (POL) software. This software will be directly linked to the World Wide Web and will be much faster and easier to use. In the format of Chicago's famous movie critics Siskel and Ebert, Dr. Ejnes got "2 thumbs up!"

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Why You Should Choose ASIM - Yul Ejnes, MD, RISIM President-Elect

This year's ASIM Annual Meeting in Chicago overflowed with programs designed to address the needs of internists, as well as to help state component leaders support their members. This was in addition to the House of Delegates session, where delegates discussed resolutions on managed care, legislative reform, Medicare and residency training, to name a few.

For ASIM and RISIM to continue to work for practicing physicians in Rhode Island, its membership must grow. All internists benefit from ASIM's advocacy efforts, but only some of them pay for those efforts through dues (apologies to Bud Kahn, MD, a past president of the medical society, for adapting one of his lines).

We need to grow both locally and nationally for several reasons. With more dues-paying members, RISIM will serve you better with frequent and timely communications; additional general meetings and educational programs; and an enhanced ability to respond rapidly to events that affect you. On the national level, the implications are equally great and are summarized in Dr. Pressman's article.

How You Can Help

How can you make the best of--and help us to develop further--the valuable resources that ASIM and RISIM provide? Make your colleagues and residents aware of what ASIM and RISIM have done, are doing, and will do, and encourage them to add their support through membership. Many of you have partners in your groups who are not ASIM members. Please share this issue of The Rhode Island Internist--as well as other RISIM/ASIM resources--and tell them why it is important to join the Society. Those of you who work closely with residents and fellows also should make them aware of RISIM/ASIM and our support of physicians-in-training. We've enclosed an application with this newsletter to help you with this effort.

ASIM's House of Delegates voted to maintain dues at $280, and RISIM dues also will remain $40 (Membership in both organizations is free to IM residents and fellows). To put things into perspective, note that annual dues for ASIM/RISIM cost the equivalent of about six or seven Level 3 office visits, and two or three hospital admissions. Given the vast support that membership provides you, the cost to join is nominal; in most cases it pays for itself when you consider the increased reimbursements that result from our educational programs and advocacy efforts with the government insurers!

Calling All Volunteers

Another way to support RISIM/ASIM is to donate your time. We always can use your assistance with ideas for meeting topics, issues requiring RISIM/ASIM's attention, and other ways that we can give you a competitive advantage. Also, we're always in need of your active participation, whether you can attend meetings with insurers, make phone calls or serve on the RISIM Council. If you are interested, please contact Dr. Pressman at (401) 435-5533 or via E-mail: Mitchell_Pressman@brown.edu.

Finally, you also can help your dues go further by helping RISIM develop its electronic communication capability. It costs several hundred dollars and takes a week for RISIM to get a general mailing out to the membership. The same can be accomplished in 20 minutes--at nearly no cost--by using E-mail. All RISIM members have free access to E-mail through POL. I strongly urge all of you to get online, and send us your E-mail addresses at http://users.aol.com/yde/html/RISIM.html. If you need software for POL, you can get it free by calling (800) 332-0009.

How strongly do I feel about this? Enough to make the following offer: If, after you receive the POL software and are unable to set it up yourself or find someone to do it for you, call me at (401) 946-6200; if I can't help you over the phone, I personally will go to your home or office and do it myself!

RISIM--small in numbers, operating without a staff, and on a very limited budget--has made its presence known in ASIM through its award-winning newsletter; its successful efforts to change the policies of local insurers; and its innovative use of the Internet to communicate with members via its Web page.

With your increased support we can do even more.

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RISIM Council Huddles with Medicare Medical Director - Dennis S. Krauss, MD, Editor

On Oct. 30, the RISIM Council met with Parker Staples, MD, medical director for Rhode Island Medicare, in Dr. Pressman's office. The meeting provided a forum for the Council to discuss of a number of recent issues of importantance to you--especially coding.

Dr. Staples addressed several questions about exams for preventive services--including what was formerly considered an annual exam. He stated that physicians do not need to submit -25 modifier on Medicare bills. Providers should continue to get patients to confirm in writing that they understand that purely preventive services are not covered. At times, this might involve one portion of the services submitted to Medicare, although we agreed that few internists provide split bills. The local Medicare carrier has a beneficiary advisory committee, and it was suggested that they continue to deal with the problem of providing information about non-coverage to Medicare beneficiaries.

Dr. Staples felt that Rhode Island physicians' submission of current procedural terminology (CPT) office codes are consistent with national averages. In general, outliers who use the highest CPT codes exclusively are the most likely to be reviewed. He plans to get more data on this issue from the Health Care Financing Administration (HCFA).

RISIM councilors raised the laboratory tests issue as a result of a recent mailing from a local private laboratory mailing concerning automated profiles. Dr. Staples noted that the new regulations require established necessity for individual tests, but details of reviewing this difficult type of determination need to be worked out.

Dr. Staples noted that by the year 2000, there will be fewer national Medicare claims transactions centers, but he still foresees a role for local carriers--such as ours--in providing input to solve local problems. He also said there would be a continued push for managed care companies to compete for Medicare beneficiaries--in the short run trying to select the healthiest beneficiaries. For now, review of such plans will probably be outside of HCFA's review system.

If you would like a copy of the 1992 Medicare memo on annual preventive exams, please contact Dr. Pressman by fax at (401) 431-2556.

How You Should Bill for a Partially Preventive Service - Brett Baker, ASIM Third-Party Relations Specialist

A preventive service is noncovered and nonreimbursable by Medicare, and includes a comprehensive systems review; a comprehensive or interval past, family and social history; and a comprehensive assessment or history of pertinent risk factors.

When you address a particular problem during the preventive medicine service, you will report two codes, one for the preventive medicine service and one for whatever level of E/M service you used to address the particular problem identified during that service. For Medicare patients, bill your Medicare carrier the level of E/M service rendered to evaluate and manage the medical problem that was discovered during the preventive visit. Internists first should assess the correct level of service CPT code to describe the portion of the visit devoted to the treatment of symptoms and/or diagnosed conditions (e.g., hypertension or fatigue). This code (e.g., office visit CPT code) describes the portion of the visit for which Medicare covers and reimburses physicians. Limiting charges apply to the covered visit code.

Select the second code from the preventive medicine CPT coding series to describe those preventive E/M services performed in the absence of complaints (CPT codes 99381-99404). The patient is responsible for payment of the noncovered charges associated with the preventive CPT code, and no limiting charges apply.

HCFA states that the physician may charge the beneficiary (for the noncovered remainder of the routine physical) the amount that the physician's current established charge for the routine physical exceeds the current established charge for the covered visit. Therefore, bill the patient for the preventive service, determining the amount by subtracting your regular fee for the other E/M service (that which you bill to Medicare) from your regular fee for the preventive visit. The patient is responsible for any screening procedures or laboratory services, and no limiting charges apply because Medicare does not cover these services.

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View From the Rhode Island Hill
Managed Care Dominates 1996 General Assembly Activities -Steven DeToy

The 1996 session of the Rhode Island General Assembly will go into the history books as the longest session ever. The General Assembly considered more than 140 pieces of health care legislation this session. Not surprisingly, the bulk of these bills dealt with managed care.

At the top of the list for physicians, other providers, consumers, insurance companies, regulators and employers was 96 H-8172 Sub A3, "The Health Care Accessibility and Quality Insurance Act," introduced by Rep. George Zainyeh (D-35, Warwick). The Zainyeh bill already has become a national model because it requires all insurance companies to disclose a wide variety of data about their plans to provide consumers with the information they need to make informed decisions regarding health plans and understanding their health care coverage.

The bill outlaws "gag" clauses; requires the Department of Health to standardize definitions for commonly used terms; and mandates for disclosure of information that pertains to second opinions, prior or ongoing authorization, reimbursement and policies for access to care in an emergency room. Insurers also must provide information about disclosure of capitation agreements, provider incentives and any aspect of the plan that may put the consumer at financial risk.

In the sections that deal with providers, plans are required to publish lists of all participating providers by office location, specialty and any other information deemed in the public interest by the Rhode Island Department of Health (RIDOH).

The other major piece of legislation that swallowed much time and effort this year would criminalize assisted suicide. The bill passed despite opposition centering around the potential ramifications the bill has on a physician's decision-making process.

The Rhode Island Medical Society (RIMS) will continue to oppose any legislation that would hamper a patient's ability to access appropriate medical care.

The major disappointment of this session came from CVS, the Rhode Island-based pharmacy chain. In 1995, CVS marshaled a "single line" prescription form bill through the General Assembly that made it more difficult for physicians to prescribe nongeneric products. CVS initially was opposed to a bill that would have mandated the use of Food and Drug Administration standards for drug substitution, but agreed to compromise language that allowed the bill to move through the General Assembly. However, in an arrogant move, CVS reneged on its support and had the bill killed in the last days of the session.

The majority of patient- and physician-oriented legislation is put together by the RIMS's Public Laws Committee. Representing internal medicine on the committee for the past two years are John Pell, MD, and RISIM members: J. Jeffreys Bandola, MD, of Wakefield; Allen Dennison, MD, of Barrington; RISIM President-Elect Yul Ejnes, MD, of Cranston; and Anthony Kazlauskas, MD, of Warwick.

A list of legislation the General Assembly passed--and the bills authors--that may be of interest to RISIM members is available. Please contact Dr. Pressman by fax at (401) 431-2556.

Steven DeToy is a lobbyist for the Rhode Island Medical Society.

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RISIM Welcomes New Members:

Nelson J. Chu, MD, of East Greenwich
James P. Crowley, MD, of Providence
Patrick Raphael Daly, MD, of Narragansett
Suh Dong Hahn, MD, of Pawtucket
Steven M. Kempner, MD, of Providence


Mitchell Pressman, MD
450 Veterans Memorial Pkwy
Building 6
East Providence, RI 02914
(401) 435-5533
E-mail: Mitchell_Pressman@brown.edu

Yul Ejnes, MD
Renaissance Medical, Ltd.
75 Sockanossett Cross Road
Cranston, RI 02920
(401) 946-6200
E-mail: Yul_Ejnes@brown.edu

Immediate Past President
Sewell Kahn, MD
250E Centerville Road
Warwick, RI 02886
(401) 739-7380
FAX: (401) 737-7558

Membership Chair
Paul McKenney, MD
470 Tollgate Rd.
Warwick, RI 02886
(401) 738-6544

Newsletter Editor
Dennis Krauss, MD
49 Seekonk Street
Providence, RI 02906
(401) 351-7103
FAX:(401) 751-6179

Meeting-Program Coordinator
Harold H. Horwitz, MD
49 Seekonk Street
Providence, RI 02906
(401) 351-2280

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