More on the Shrink's Notes...

Please see my post on Clinical Psychiatry News and yesterday's post What's in a Note? along with the reader comments. 

One reader asked why it's weird to want to see your shrink's notes and why shrinks refuse to show them on the grounds that they may distress the patients.  Another reader asked why doctors write "patient denies" as though they don't believe the patient.  These are both great questions worthy of their own post.

Why don't psychiatrists like to show patients their notes?  Are they really going to "harm" the patient?  There are a few reasons why a psychiatrist may not want to show a patient her notes.  Here is my list of thoughts as bullet points. Please feel free to add to it.

• Doctor-speak can be cold and clinical and the shrink may worry that the patient's feelings will be hurt.  It can all be quite distancing and who wants to be viewed through the eyes of doctor-speak?
• The doctor may have things in his notes that the patient views differently.  For example, a patient may be angry that the psychiatrist does not believe him that martians monitor his movements with special cameras inside his body and may want it removed from the chart that he has  "delusions."  I could come up with many more examples.
• The shrink may be concerned that the patient will misinterpret things he's said and be upset by them.  
• The shrink may be embarrassed that he has lousy notes.
• Shrink talk can be rather detailed and insulting.  The mental status exam includes a description of the patient-- the patient may feel very hurt to know his doctor saw him as "unkempt" or noticed he was unshaven, or "malodorous" or that he appeared agitated or anxious.  These are descriptive and therefore useful from a clinical standpoint, but they can also be read as insulting and the patient may feel injured, or put the psychiatrist in an awkward spot if he demands something be changed when the psychiatrist doesn't agree. More importantly, reading something uncomplimentary may damage the relationship.  People want their shrinks (particularly their therapists) to think well of them, and how do you continue to have a warm and fuzzy relationship with someone who has written that you smell bad? 
• The shrink may worry that the patient will sue him or file a complaint.
• The patient may want things taken out of the record even if they agree they are true.
• I think mostly it's about avoiding confrontation, but tell me if I'm wrong.

Psychiatrists are taught to report things in a specific way, and doctor-speak has it's own nuances that don't match everyday English.  There is the 'chief complain'-- oh but saying someone is complaining is pejorative, it's like saying they whine!  We think of it as a problem list, but 'complaint' is the medical term.  Similarly with "denies," though I've heard others say that it sounds like we don't believe the patient, and I've come to avoid the term, except if I don't believe the patient, and then I may say why: "denies depression but sobs throughout the session and looks miserable."   

Tell me what you think.

Just One More Question....

Thanks to Peter for bringing this article to my attention.

Have I ever mentioned that I hate forms? Oh, it's not just Medicare forms, it's all medical forms.
In private practice, there's not much paperwork. I see patients and I jot down a note for their charts. Sometimes I type a formal evaluation for their primary care doctor. Sometimes I need to fill out treatment plans or preauthorization forms for medications or forms for disability insurances. And these things are a pain in the neck, but most days there are no forms. I see patients, I turn off the phone, and I'm with them fully.

In the clinics where I've worked, the notes go on forms. There are simple questions to be filled out, nothing that exciting, but it pulls my attention. There's a line for the date. Oh, I do that anyway. Diagnosis. Usually I know that. Time I started. Oh, who cares? Usually I'm talking with the patient and realize I forgot that. I turn to look at the clock and record the time. First zap away from the patient. Age: ? I look at their birthdate. I subtract from the current date to get the year. Why do I have to calculate the age of every patient I see everytime I see them? There are computer labels on every page with the date of birth. If someone wants to know, why can't they do the math? Medical Diagnoses and Medications: I look that up. Date of last physical: ? I look that up or ask the patient. If it's been a while, I tell them to have a check up: Maybe that's useful, but every patient, every visit? I check the box that says they aren't suicidal and that I've discussed the risks and benefits of the medications and how often they come for therapy and what the goals are and if they are getting labs done. I update the medications on the log sheet and in the electronic record. I send a letter to their primary care doc listing their current psych meds: this is required even if their current doc is at the same hospital and can access the updated medications on the EPR. Time ended? I glance at the clock and record it. Duration of appointment: ....Oy, someone else can't subtract the minutes? I've taken to writing 17.3 minutes. Oh, and in there, there was lots of time to hear about the patient's life.

Okay, I'm ranting, but I felt vindicated when Peter sent us all Teresa Brown, R.N.'s article in the NYTimes Well Blog, "Caring for the Chart or for the Patient." Nurse Brown writes:

Because that’s my real concern: the effect on patients of incessant record-keeping. Each of these individual initiatives has merit and is worthwhile, but together they become a mishmash of confusing and oppressive paperwork.

I Don't Know What to Charge!

I got a letter today from a patient asking me to explain why I've billed him roughly $4.50 more than Medicare allows. He included a statement from...?Medicare or it's administrators saying that this lower amount is the Medicare-allowed amount and that if his doctor charged more, a refund is due.

Every year, in December, I try to figure out the Medicare fees. Mostly I call a shrink friend who is in the same jurisdiction who is also a non-participating Medicare provider, which is different then someone who "opts out." I have to charge the Medicare amount, but it's always this funny challenge to figure it out just how much that is. At one point, I couldn't even figure out where I practice---in Maryland there are two districts, 01 and 99, and my office appeared to be located in neither. So now I think I know where I am (no one else I asked was completely certain either). For the record, it's not easy to find the fees, they vary by district and by procedure and by whether you are a facility or non-facility, participating, or non-participating, and there is the limiting fee and caps, and it gets mailed to me as a CD that doesn't open, and it's not on a website that I can find and the psychiatric society doesn't always have any better luck, and some of my friends are "participating" and have different fees, and most have "opted out" and one just can't deal so he doesn't charge any Medicare patient any fee and he doesn't submit...easier to work for free.

Okay, so every year for the past couple of years, Medicare is cutting fees by 21% or 24%. But at some point, Congress changes their minds and undoes the cut, so I've taken to keeping my fees the same, with the idea that it will be easier to reimburse patients (or credit their accounts) then it will be to tell patients that I was wrong to drop my fees and they now owe me money. And every year, Congress votes, after a period of ranting and uncertainty, to undo the fee cut. This year, Congress seems to vote to delay the cut multiple times every few weeks. I called a friend, he got a similar letter from a patient. The tone of the letters imply that we are purposely overcharging or willfully committing Medicare fraud.

The executive director of our state medical society got pulled in. He sent out a newsletter from the Medicare folks. It states:

On April 15, 2010, President Obama signed into law
the “Continuing Extension Act of 2010.” This law
extends through May 31, 2010, the zero percent
update to the Medicare physician fee schedule
(MPFS) that was in effect for claims with dates of
service January 1, 2010 through March 31,
2010. The law is retroactive to April 1, 2010.
Consequently, effective immediately, claims with
dates of service April 1, 2010 and later, which were
being held by Medicare contractors, have been
released for processing and payment. Please keep in
mind that the statutory payment floors still apply and,
therefore, clean electronic claims cannot be paid
before 14 calendar days after the date they are
received by Medicare contractors (29 calendar days
for clean paper claims).

Given the uncertainty regarding MPFS claims with
dates of service June 1, 2010, and later, please
watch your listservs and your contractor‟s website for
more information.

So Medicare is saying there is no decrease, at least not for the next 2 weeks, at which point we can again try to figure out what to charge. But CMS is telling patients that the fees we are charging are illegally high. Whistle blowers and Medicare fraud publicity and fines, leave me wishing it was easy for everyone to simply know the correct fees.

Can Medicare Make ME Crazy?

I've moved. You know that. The new office is terrific, shabby chic walls and all.
So I'm working on the whole change-of-address thing. I've notified the post office, the bank, sent a zillion notices out. I've notified my malpractice insurance agent so many times that he called to tell me he changed my address weeks ago and I keep notifying him. I called the Controlled Dangerous Substance folks in my state. It costs $50 to notify them of a change of address. What gives with that. And the DEA...no forms, I tried emailing, I guess I'll send a real letter. The hospital gave me a local number, but it's out of service.
And Medicare: have I mentioned the 221 downloadable forms and how to change your address you have to fill out the 27 page enrollment form? I did? I guess I did.
Did I mention that I'm a non-participating Medicare provider? I don't want to 'enroll.' I finally tackled the form, figuring it would have a box at the end where I could check off that I'm not a participating provider....since I have not 'opted out' ...I'm actually participating by not participating. Try explaining this all to a distressed patient.

I surrender. Tomorrow, I'll try calling. I will no longer be blogging. I anticipate the next year of my life will be on hold.

If you have any answers, by all means....

Forwarding Address

I moved my office yesterday. As fate would have it, the final piece of mail I received at my old address was a notice from Medicare informing me that I needed to update them if there were any changes in my practice, for example, a change of address. It told me where to go (on the internet, that is).

Okay, so in case you're wondering, Medicare has 221 downloadable forms on their website.

If I understand the directions right (and do feel free to help me out here) CMS-8551 is the form for me:

Additional Information Physicians can apply for enrollment in the Medicare Program or make a change in their enrollment information using either: 1. Have a National Plan and Provider Enumeration System (NPPES) User ID and password to use Internet-based PECOS. • For security reasons, passwords should be changed periodically, at least once a year. • For information on how to change a password, go to the NPPES Application Help page and select the “Reset Password Page” on the NPPES Application Help page. 2. Go to PECOS to complete, review, and submit the electronic enrollment application via PECOS. 3. Print, sign, and date the two-page Certification Statement and mail it with all supporting paper documentation to the Medicare contractor within seven days of the electronic submission. NOTE: A Medicare contractor will not process an Internet enrollment application without the signed and dated two-page Certification Statement and the required supporting documentation. In addition, the effective date of filing an enrollment application is the date the Medicare contractor receives the signed two-page Certification Statement that is associated with the Internet submission. Physicians who are enrolled in the Medicare Program, but have not submitted the CMS-855I since 2003, are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or the CMS-855I) as an initial application when reporting a change for the first time. If a physician has any questions about reporting a change, the physician should contact his or her designated Medicare contractor in advance of submitting the CMS-855I.
(Note, I deleted the Medicare web addresses from the body of the text I copied)

Okay, so 221 downloadable forms, and the form for change of address is the CMS-8551. No prob, I'm on it. PECOS. What are PECOS? I know what pesos are, but PECOS? So form CMS-8551, downloaded for my change of address is 27 pages long. What would it take to get Medicare to have 222 downloadable forms, with the 222nd form being a one-page change of address form.

Please Print Legibly

I'm not much for paperwork. In fact, I hate it.

In my private practice, I give people directions on the phone: how to get to my office, where to park, what to bring, what to do about their health insurance, yadayadayada.... It's a lot of information. I don't have forms, except for an Authorization to Obtain/Release Psychiatric Information, and I give people a single sheet of Office Policies with my cancellation policy and how to reach me: cell phone, home phone.

No other forms, and a few times I've wished I had an emergency contact or some piece of information I didn't have at my fingertips. So I'm moving this month and I'm re-thinking my professional life. Mostly, I've funneled my anxiety into the decor--I'm now on my 5th and 6th quarts of sample paint. Why does taupe look purple when you put it on the wall?

Oh yeah, I was talking about forms. So I'm going to try sending out a few sheets of information before the first appointment: directions, where to park, what to expect, what to bring, and a form requesting some basic contact info. I've been wondering what other people do, and so I've been surfing other shrinks' websites to see what they do: a lot of them have their forms up, some even have their fees listed. This is interesting.

So the forms thing also gets interesting. Some people have really extensive, all-inclusive, no-issue-left-unaddressed forms. One doc asks people to circle the name of any psychotropic they've ever been on, and he lists the name of every psychiatric medication. Here's the list:

Abilify diazepam metamphetamine Rozeram Adderall divalproex sodium Methylin Serax alprazolam doxepin methylphenidate Serentil Ambien Effexor mirtazapine Seroquel amitriptyline Elavil Moban sertraline amoxapine escitralopram Modafanil Serzone amphetamine Eskalith molindone Sinequan Anafranil fluoxetine Nardil Stelazine Antabuse fluphenazine Navane Strattera Asendin flurazepam nefazodone Surmontil atenolol fluvoxamine Neurontin Tegretol Ativan Focalin Norpramin temazepam atomoxetine gabapentin nortriptyline Tenormin Aventyl Geodon olanzapine thioridazine bupropion Halcion Orap thiothixene Buspar Haldol oxazepam Thorazine buspirone haloperidol Pamelor Tofranil carbamazepine imipramine Parnate Topamax Carbatrol Inderal paroxetine topiramate Celexa Klonopin Paxil Tranxene Centrax Lamictal pemoline tranylcypromine chlordiazepoxide lamotrigine perphenazine trazodone chlorpromazine Lexapro phenelzine triazolam citalopram Librium Pimozide trifluoperazine clomipramine lithium prazepam Trilafon clonazepam Lithobid Prolixin trimipramine clorazepate Lithonate Primidone Valium clozapine Lithotabs propranolol valproic acid Clozaril lorazepam protriptyline venlafaxine Concerta loxapine Provigil Vivactil Cylert Loxitane Prozac Wellbutrin Dalmane ludiomil quetiapine Xanax Depakene Lunesta Remeron ziprasidone Depakote Luvox Restoril Zoloft desipramine maprotiline Risperdal zopiclone Desyrel Mellaril risperidone Zydis Dexedrine mesoridazine Ritalin Zyprexa dextroamphetamine Metadate

Just in case you were interested.

Other shrinks have fewer forms, but still post some very interesting stuff. One has photos of herself in a red leather skirt on an analyst's couch (I thought it was an ad for a TV show about a psychiatrist!), another includes his resume and mentions he was an Eagle Scout.

Okay, so tell me if you have a shrinky website, I'd love to look at it. And since I've always just asked people questions and never asked them to fill out forms, tell me how you feel about forms, both from the doc's point of view, and also from the patient's perspective. Thank you!

Oy, the Ravens, they aren't doing so well. I think they got the wrong forms.

You Have to Fill This Form Out

Oh my, whose idea was it to mandate that psychiatrists need to fill out certain forms? I work in a clinic where people often walk in with disability forms. I don't know them, how do I know they're disabled? Maybe my great interventions will cure them and they can go back to work. "But I need the form tomorrow, doc, or I can't get my check." I filled one out the other day, feeling rather pressured-- it was on someone I was seeing for the second time, and the first time she'd sat there angry and hadn't spoken. So I put in my best guess at diagnosis, but you know, they all ask for the dates of disability, with a maximum of 12 months, and how would I know this??? That crystal ball, didn't I leave it in the top drawer? The patient became agitated, she needed the form for tomorrow or she'd lose her check. I had 4 patients who'd shown up simultaneously, and she'd also brought poetry to show me. She was getting agitated, I was telling her the therapist needed to do these forms, she was saying she'd lose her check if she didn't have it by tomorrow (now how can that be and why was that my problem? at 4 pm no less). I scrawled "unclear" for the dates of disability and she was livid. Oy. Maybe I should have just written a year, she was homeless in a shelter and hadn't worked in a zillion, and she had some mental illness where she was angry, irritable, sullen, and refusing to give information one day and effusive with poetry to share on another. I wish I just hadn't felt so cornered.

Oh, but then there's my favorite form the psychiatrist "HAS" to fill out. The payee form. My patient (a homeless woman with multiple medical problems and a fondness for crack cocaine and malt liquor) wants to be her own payee---she doesn't like that her daughter currently doles out the dough.

"You gotta fill the form out," she says.

"I don't do those forms, " I say.

"They say my psychiatrist has to fill the form out."

Whose bright Idea was that, I have no clue if people can manage their money. Plenty of folks I know with psychiatric disorders manage their finances fine. And plenty of folks I know without psychiatric disorders are financial disasters. I don't follow these people around to see how they manage, I see them for 20 minutes in a clinic to ask how their mood is and if they're having and hallucinations or side effects. I suppose if any ever had command auditory hallucinations to turn over their family trust funds to me personally, I might consider it.

"I don't know if you can manage your money I say." She stares at me. "Do you know if I can manage my money? I never said you need a payee in the first place. Go find who ever said you need a payee and have them say you don't."

"My psychiatrist has to fill it out," she insists.

No, your psychiatrist doesn't.

Oh here, read this: CLICK