Letters to the Editor - April 3, 2000.

Indiana share of tobacco fund to go toward health care, not "up in smoke" - What's a level-four visit? One physician explains how he codes and, just as key, how he documents - Embattled doctor's colleague: Dr. Vargo passed regular audits for cost effectiveness and efficiency

Indiana share of tobacco fund to go toward health care, not "up in smoke"

Regarding "Tobacco money going up in smoke" (Editorial, March 13): How very sad, but predictable, that monies from the tobacco settlement will be spent by many states for projects other than health care. These funds will come to the states by virtue of the multitude of health problems caused by tobacco use.

To use them for anything other than smoking cessation and health care is unconscionable.

However, it is exciting to report that not every state has succumbed to the allure of using their part of the settlement for fixing potholes and giving tax breaks.

The just completed 2000 session of the Indiana General Assembly enacted legislation that will not only direct all of Indiana's share of the tobacco settlement to new health care initiatives, but will also set aside a portion of the funds each year into a trust fund that will grow over the years to fund future health care initiatives.

The Indiana State Medical Assn. strongly supported this concept and is gratified that Indiana's share of the tobacco settlement will not be "going up in smoke," but will be used for the better health of our Hoosier citizens.

--Barney R. Maynard, MD Immediate past president Indiana State Medical Assn. Evansville, Ind.

What's a level-four visit? One physician explains how he codes and, just as key, how he documents

Regarding "Feds try new tack in charging doctor with upcoding" (Article, Feb. 21): I read your article with great interest and some trepidation. The trepidation stems from one of the examples cited in the article, specifically, that Patsy Vargo, MD, charged a level-four office visit for a sinus infection.

As a pediatrician, the following example illustrates a typical encounter for me:

A 16-year-old presents with a complaint of "sinus congestion" (chief complaint). In gathering the history of present illness, he indicates that he has been stuffy for five days, has copious nasal discharge that was clear and is now green, is constant and is associated with a frontal headache (five HPI components: location, quality, severity, duration and associated features).

Review of systems reveals that he also has a sore throat but no ear pain, mild cough, no respiratory distress or shortness of breath, mild nausea and loss of appetite, and a low-grade-fever of 100.6 F (at least four ROS elements). A brief review of the patient's chart (before I even entered the room) revealed that he has no significant medical history, and the patient reported never before having a sinus infection and denies being a smoker (pertinent medical and social histories). The above comprises a "detailed" history (and it's not too far from "comprehensive").

Now I examine the patient. He is awake and alert, his vitals were recorded by the nurse (and are normal), his eyes are clear, his ears are clear and tympanic membranes are mobile and translucent, his nasal turbinates are red and edematous, there is a purulent nasal discharge from both nostrils, his pharynx is mildly erythematous without exudate, he has facial tenderness when percussed lightly, his neck is supple without lymphadenopathy, his lungs are clear without wheezes or crackles, his heart has a regular rhythm and no murmur, his abdomen is soft/nontender and he has no hepatosplenomegaly.

On top of this, it is obvious from casual observation that he has no rashes, that his extremities are well perfused and that he is "grossly" neurologically intact. Before you ask ... yes this is the exam I would do for such a patient. This represents at least 12 documented physical findings, which comprise a "detailed" exam.

Now, the fact that I'm about to prescribe amoxicillin for this patient's apparent sinus infection automatically bumps the diagnosis/management to one of moderate complexity. With that, I have met all three criteria (history, exam, medical decision-making) needed for a level-4 visit, assuming my documentation is adequate.

Indeed, because this is an established patient, I really only need two of the three criteria. This patient absolutely should be (and would be) charged a level-4 visit.

Using these relatively simple criteria, most office visits can be legitimately billed as level 4, which seemed to be the case with Dr. Vargo. Clearly, documentation is the key. The example suggested that there may have been inadequate documentation in the charts in questions, but no specific examples were given.

I don't know Dr. Vargo, and my only knowledge of the case is what was stated in the article, but from the example given, I'm certainly not convinced of any wrongdoing.

--Peter D. Smith, MD Milton, Pa.

Embattled doctor's colleague: Dr. Vargo passed regular audits for cost effectiveness and efficiency

Regarding your recent article "Feds try new tack in charging doctor with upcoding," concerning the civil suit the government has filed against Patsy Vargo, MD, I felt as if you were taking the government's side (Article, Feb. 21).

I have known Dr. Vargo for several years and shared some office space with her for two years following her incident at Malmstrom AFB. In her eight years of working at MAFB caring for the retired military population, she was audited every three months. This audit was for cost effectiveness and efficiency.

She was never told she was in error or criticized for her coding or billing practices. In fact, she won the award for being the most efficient MD on more than one occasion. I would think that if she was coding improperly, it would have been pointed out on one of these audits. Instead, the government chose to accuse her of being a criminal and when they found out that would not work, they filed a civil suit.

--Donald R. Joyner, MD Great Falls, Mont.