Home Letters ED-hospitalist handoffs

ED-hospitalist handoffs

August 2014

Published in the August 2014 issue of Today’s Hospitalist

I found the June commentary “Call me maybe?” by Mary Frances Barthel, MD, to be well thought-out.

However, as a clinician, I was appalled to read that some hospitalists still risk writing “tuck-in” orders for patients without seeing them. I can just hear the plaintiff’s lawyer now: “Doctor, would you explain for the jury just how you can write orders for a patient you have never seen?”

And as a CPT consultant, I am surprised at how fiscally short-sighted writing such orders are. If a patient is admitted with only tuck-in orders, billing an initial hospital visit code (99221-99223) for that date of admission would be fraudulent. But if hospitalists bill an initial visit the next day, most payers would deny that claim. Why? Because an initial visit should be billed only on the day of admission.

Once the emergency physician thinks admission is warranted, it is the hospitalist who, after taking a good history and doing the appropriate physical, should decide among inpatient admission, outpatient observation or discharge home with follow-up. It will be the hospitalist, not the emergency physician, who has to face case management in the morning and defend the admission decision.

While I agree that ED physicians should answer hospitalists’ questions, hospitalists should respect emergency physicians’ time constraints. I urge my colleagues to establish a committee of hospitalists and emergency physicians to work out the details of a good ED-hospitalist hand-off “and to never write “tuck-in” orders without seeing the patient within the hour.

Pam Bensen, MD, MS
Buffalo Junction, Va.

Dr. Barthel responds:
I completely agree with Dr. Bensen’s comments about tuck-in orders. Our hospitalist group has advocated for a revision to the medical staff bylaws that would prohibit this type of behavior, and our ED physicians have appealed to the medical executive committee with similar concerns. Unfortunately, there continue to be admitting physicians (outside of our program) who wait until the next day to evaluate their patients in person.