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Implementing the ‘medical model’ in your practice

August 8, 2012

Edited by Chuck Brownlow, O.D., Medical Records consultant

There has been a lot said and much written lately about the “medical model” of eye care delivery. Of course I’ve listened and read much on the subject, but I must admit I’m a little confused. As I pondered whether there actually is a difference between a “medical model” for eye care and a “non-medical model” or a “routine model,” I decided to think about other health care providers and whether I could detect a swing in their mode of operation into some new “medical model.” Somewhat to my surprise, I have seen a change in health care delivery, so I’ll review that with you to see if it may shed light on this concentration on the appropriateness of the “medical model.”

The influence of coding

Local physicians seem to change the way they deliver care after they sell their practices to large regional clinics. I’ve noticed they spend more time asking questions, many of which don’t seem to be at all related to the reason I’m in their office, with the questions often almost scripted.

This is much different than the older “model” used by the same physicians, so I’m thinking maybe this is part of the new “medical model.” I’ve even had physicians, nurses, advance practice nurses, physician assistants, and other personnel apologize during the case history, even making comments such as “I’m sorry for all these questions, but our certified professional coders say we’ll get in trouble if we don’t ask at least four questions in this section.” Mmmm. Maybe this is what they’re talking about when they refer to the “medical model.”

The influence of EHRs

In my visits to those same health care providers I’ve noticed they don’t spend much time actually looking at me or even touching me… Their hands and eyes are pretty much devoted to “hunt and peck,” typing lots of words and numbers into a keyboard, while looking back and forth, fingers to monitor, very much like that dog that played piano on the old Muppets TV show.

I even interrupted a doctor one time as he was struggling with data entry to ask him if he had noticed I had developed a tendency to drag one foot while walking, or that one side of my face doesn’t seem to move any more when I smile or talk, or that the “whites of my eyes” seemed pretty yellow lately. Needless to say, he took a real good look at me right away before returning to his data entry, this time accompanied by some mumbling about “health care would be a lot better if we didn’t have to pay attention to the lousy patients.”

I’ve even spoken with health care providers who are very excited about their clinics’ new electronic medical records. One doctor swung the monitor around so I could see the red flags on the screen indicating he could not grade as high as he wanted unless he went back and did at least two more tests… The computer even told him which tests to do. I thought that was up to the doctor’s professional judgment, based on my needs. Don’t worry, though, he did go back and do the extra tests, so his coding choices were fine. Mmmmm. Maybe this is what they’re talking about when they refer to the “medical model.”

The influence of local coverage determinations, software, CE

I overheard a colleague discussing her protocols for dealing with primary open-angle glaucoma. It seems she discovered the local coverage determination for her Medicare carrier included lists of procedure codes that are paid when billed with the diagnosis code for open-angle glaucoma.

She was very excited about this because it meant she could do four, five, even six different procedures each time her glaucoma patients came in for their quarterly check-ups. She was giddy in describing the positive impact on her gross and net revenues.

Mmmmmmm. The “medical model,” I’ll bet.

The influence of audits by Medicare, other insurers

Over the past several months I’ve learned of quite a few optometrists being audited by Medicare and other insurers. Some have been surprised auditors are checking to be sure the care provided for the patient is related to the reason for visit recorded at the top of the chart and the resulting diagnoses recorded at the bottom of the chart.

Some of the auditors demand repayment for office visits and/or procedures that are coded improperly, with no clear relationship between the content of the record and the Current Procedural Terminology (CPT© American Medical Association) definitions for the chosen codes.

I’ve spoken with doctors who are shocked to learn that it is their own professional judgment that should determine which questions are asked of each patient, which tests are provided for each patient, and how frequently the patient is re-examined.

The influence of well-developed protocols for the provision of care, accurate coding

My consideration of these several observations relative to the “medical model” for the provision of care has brought me to the following conclusion: the “medical model” really has not changed at all.

Patient care, doctors’ records of the care provided, Medicare and insurance claims for those services, reimbursements for those services, and ultimately, the outcome of insurers’ audits of the care provided are and always have been best served when providers follow several key caveats:

  • All case history questions, all care provided, all diagnoses and management options recorded for every patient visit must be based on the needs of the patient that day, as expressed in the reason for the visit (chief complaint, presenting problem, doctor’s order for return to the office, symptoms, etc.).
  • All information related to the patient’s case (history/ exam/ medical decision-making/ management options/ orders/ additional testing) must be carefully recorded in the medical record.
  • Each medical record must be signed (in pen or, in EHRs, electronically) by the doctor responsible for the care and must bear the legible identity of the doctor (typed/ printed/ stamped).
  • All CPT codes (office visit, surgery, procedures) are chosen by comparing the contents of the medical record with the CPT definitions for the related codes.
  • All claims are submitted based on national rules (CPT and ICD-9) and on forms or electronically, complying with the rules of the patient’s insurer.

Now that is a “medical model” all health care providers can live with!

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