The Happy Hospitalist

Dementia Quotes, Sayings and Stories That Will Make You Laugh!

2013-05-19T23:24:00.000-05:00

Over the years I've had some pretty fascinating, interesting and humorous conversations with dementia patients. Behind all that agitation and confusion that can make hospitalization for demented people so complicated and full of risk is the innocence of dementia itself. Dementia is a child like state of innocence that separates the patient's reality from ours. It is that skewed reality that drives both the pain and humor of dementia.

Take for example the demented old lady with multiple medical problems. She's brushing her teeth with the help of staff. She's laughing and giggling and then blurts out from nowhere, "I don't know what I'm doing, but if I spit on you it's going to kill you!" The innocence of it all. I asked my facebook readers to share their funny stories and experiences they have had with their demented patients and they didn't disappoint. Dementia can be sad and sweet at the same time. By definition, dementia robs one of their ability to understand and comprehend the world around them. They live in their own reality. Some demented people become angry. Some become paranoid. Some become sweet and funny. Below is a collection of quotes, stories and sayings my readers have experienced from patients with dementia. Feel free to add your own. In addition, make sure to "Like" my facebook page for The Happy Hospitalist if you want to experience a whole lot of humor and occasionally crappy serious stuff too. Over 3,500 followers agree. Without further delay, here is some good old fashion dementia humor!

"The nurses are trying to poison me and the rats here are huge." My response: "No sir, they're trying to poison the guy down the hall and I just got off the phone with the exterminator. He'll be here soon with a rat trap. Now, do you think you can take the medication this nurse has here in sealed packaging? Your blood pressure is too high."
I once helped an alcoholic going through withdrawal feed the "kitten under his bed" milk. Got a small dish of milk, put it under the bed. He said the meowing stopped and he could lay down. If you can't beat crazy, join them.
I was wearing a yellow isolation gown... Heard from the room, "Hey you. Yeah you. Big bird"
One of my first days as a new nurse on an Alzheimer's unit we were in the dining room and an elderly gentleman walked up to a table of female patients, says "Hello ladies" and proceeds to whip out his penis and urinate all over the table.
A patient told the dayshift that nightshift was making beer at the foot of his bed. We were emptying his Foley!
The most common one was the patient from down the hall in an angry indignant voice, "What kind of hotel IS this!" We felt compelled to come up with something amusing to share.
This patient kept coming out of his room and wondering in the hall. We placed a square of tape on the floor and told him he could not go past this area and he would come out of his room, staying inside that square and lean out over the tape on the floor to look around. He never went past it. That was cute.
After shuffling an old lady to the bedside commode she says, "It's been a long time since I had a young man take my pants down."
""Are you Jewish, because I only want a Jewish doctor". As luck would have it there were no Jewish doctors around. I know, right? And in NEW YORK of all places! We sent in the Korean ER doc and she never knew the difference!
I'm a speech pathologist and I was trying so hard to get a little old guy to eat. He grabbed my hand to stop me and said, "Can't you see I'm trying to die here?" He actually did pass away a couple of days later.
Old man lying in bed looking out the window at night said, "I'm waiting for them to come and take me to my home planet". He died that night so maybe it wasn't dementia. Another patient shared the super secret code to all of the nuclear weapons in the world: zero-zero-zero.
"Call 911! This bitch is trying to kill me!" I was doing a neuro check: Q2 hrs as ordered by a completely clueless resident.
An elderly female patient with dementia was going to MRI and got agitated when transportation arrived. She refused to go and kept asking for Dr. Bright Eyes. When I figured out who she was talking about, one of our doctors with the prettiest eyes, I asked him to see her and she calmed right down and was able to get the MRI. The nickname stuck with me.
I had a 91yo WWII Vet at the VA tell me that he was going to "take me to fist city" because he was unhappy with the quality of his breakfast.
Little man sitting at bedside with towel folded square on top of head. When I asked why, he stated it was to keep the kangaroos away. I asked how it was working and he said he hadn't seen one yet. We're in Georgia. There's no high population of kangaroos at our facility to begin with.
I suddenly hear someone on the intercom saying, "Bob, Bob, Why won't you talk to me........" The conversation was one-sided and she became more angry and was clearly confused. It seems our confused patient dialed the hospital three number password for the hospital intercom and thought her son was on the other end. Eight floors and about a ten minute search we found her and shut her phone off. Im sure everyone in the building thought it was funny.
Kept asking who that man was. When we said her husband she said, "No ma'am, my husband is a good looking guy. That old man ain't my husband."
"Somebody needs to get out there and feed that owl. He's gonna starve out there!" Regarding the plastic owl on the roofline to keep the pigeons away. We kept telling him it was not real. He was not convinced!
My dear grandmother was a bit of a terror at times with her dementia, but once she said so sweetly, "I don't know who you are but thank you for coming to visit me."
The old lady that told her family that the night shift nurses tortured and killed puppies. The family believed her enough to ask staff about it.
One who screamed we were going to drown her in the river every time we would transfer her from bed to chair, took one look at me and said, "Dirty squaw". I'm Mi'kmaq first nations. Most of my colleagues didn't even know. Or the one who would wave at the lady in the mirror every time and then tell me she was such a lovely lady, that one.
I've been known to park an imaginary goat for a guy to keep him happy and in bed and was tipped with coins made of poop.
"I don't know who you are but you sure are pretty!" Elderly guy, slightly demented but you can tell he was a ladies man and is still a charmer. My moms patient "With boobs like that who am I to argue with you!" Good point man. Now do your therapy.
While suctioning a lady she spit at me and said "Scram, skunk!" But I guess I would do the same with someone shoving something down my nose.
I had a resident walk up to me in nothing but pantyhose and ask, "Excuse me, do I seem overwhelming queer to you?"
A CNA called me to help get a demented patient off the toilet. She refused to move. I said, "You can't just stay here all night." She shot right back, "I most certainly can." Gotta admit, she had a point. Started to wonder which one of us was the confused one. I told her technically she was right, but it wouldn't be optimal for her to stay there all night. She pondered the word "optimal," decided I must be right, got up and got into bed.
My aunt remembered me as a five year old, did not understand I was an adult. She also thought she was running the nursing home where she lived.
A man once took out his tray from his bedside table and shit in it. The same man also gave everyone spy names and codes. He was bat shit crazy! Each day with him you cried and laughed.
In the middle of the night, call bell rang. When CNA answered, the man said "Come quick, and bring a big banana!"
I was doing a home health setup on an elderly man. I was talking to a family member when the patient comes in and puts on a Sinatra record, strips completely naked and starts dancing with the DME tech who was about 350 lbs. The family was horrified, but I wish I had a camera for that.
"I don't know about that. I've got a Pap smear machine." He said in response to the nurse asking if he wore a CPAP for his apnea.
I had a 92 year old patient flip me off with both hands with such a flourish she would have won an Oscar!
As I was wheeling past her room for the 100th time that day she told me there hay girl goes with that lawn mower again. She said those to the CNA which happened to be my sister, Sheri. Earlier in the day the patient was getting mad at me while I was trying to assess her. Sheri ce in and the woman looked at her badge and said "you better listen to her she is the sheriff" needless to say the name stuck with her throughout nursing school.
Me: Mrs. Dementia, how are you feeling today? Mrs. Dementia: I'm feeling like I wanna kick your ass! Nurse: Now Mrs. Dementia, you shouldn't say that her, she's pregnant. Mrs. Dementia: Shame on you!
Patient admitted with respiratory issues also seeing spiders and bugs all over his room. When RT walked into the room for the breathing treatment he shouted "Oh good, the exterminators are here!" Yeah it was quite a time trying to convince him the updraft was not bug spray!
My dad had a sweet dementia. He was engaged to every female caretaker. He also spoke to our deceased mother on a regular basis and told us what it was like where she is!
Little lady in restraints turned her mantra of "Please help me, please help me!" into a nursery rhyme ditty that continued for most of my 12-hr shift.
I was talking to the family member of a patient with dementia who was on a stretcher in the ER lying nearly flat under a bunch of blankets. I talk with my hands and as I was making an open hand gesture, something came through the air in an arc from the vicinity of the patients head and landed in my hand. I knew right away what it was and started to laugh as I ran to the sink. The horrified family member who also had an inkling of what is was asked, "Momma what did you just do?" A voice came from somewhere in the blankets, " I spit."
I got told the CT surgeon and I would make a cute couple. She was way demented!
The one who refused to go to sleep because I was trying to get my filthy hands on her husband. She kept calling 911 until the phone service was ahem, removed, from her bedside.
"I have diverticulitis in my toes"
I measure how long my patient has been demented by their answer to the question: "Who's the president?" One patient answered "Richard Nixon". You know instantly he's not demented....he's schizophrenic.
"Will you come home with me?"

If you happen to think of your own dementia quotes or stories, feel free to leave them in the comments below for others to enjoy.

2-Midnight Rule: Medicare's New 2013 Inpatient Hospital Payment Policy Explained (CMS 1599-P).

2013-05-06T01:26:00.001-05:00

Hospitalists have risen to the challenge of only providing medically reasonable and necessary inpatient hospital care under the rules of three-midnight medicine. They have refused to delay patient discharges just so patients could enjoy high quality care in the nursing home of their choice that is paid for by our Medicare National Bank. They are willing to accept discharge to home and face the music of bad patient satisfaction survey scores filled out by angry family members who are upset their hospitalist wouldn't commit Medicare fraud to get grandma to a Medicare paid nursing home for the next 100 days so she could avoid selling her assets and enter Medicaid without a fight. Nope. Hospitalists everywhere are taking the ethical road and accepting their bad scores in defeat, knowing their ethics matter more than Medicare rules and regulations.

I tip my hat to all my fellow hospitalists who refuse to commit Medicare fraud in the interest of patient satisfaction. It just doesn't happen, ever. We are an honest breed. I know all my fellow brethren follow this wholesome practice style and have never even considered holding on to a patient just-one-more-day to qualify them for their three midnight stay in the hospital. And for that, we are going to be rewarded by Medicare. Hold on to your seats. Medicare just gave us a bombshell that promises to change how we practice medicine forever. They're calling it the 2-midnight rule (and 1-midnight rule too). The 2-midnight rule changes everything and we owe it to ourselves to get educated. We need to understand the importance of chart documentation requirements we will be asked to comply with starting October 1st, 2013. Read this whole article and then read it again and pass it on to all your hospitalist friends so they too can increase their value to hospitals. As hospital funding takes us on a race to the bottom, we must learn how to maximize our calorie intake at ObamaCare's Budget Buffet or we too will end up in the hospital as an observation admission for acute exacerbation of too-angry-for-discharge.

I have now been a hospitalist for ten years. A consistently frustrating job in my role as physician is my requirement to determine whether a patient should be admitted as inpatient or observation status. If you are a Medicare patient or a family member of a Medicare patient admitted to the hospital, you should always ask during your admission evaluation whether the order is being written for inpatient or observation. Don't ever assume that being admitted into the hospital means you are inpatient. If you have no idea what inpatient vs observation status means, you're not alone, but you owe it to yourself to understand. Medicare has an excellent patient resource to help explain all the important financial implications. I encourage all Medicare patients and their family to click this link and save the pdf file for quick review.

Medicare Part A rules apply if the physician writes an order for inpatient but Medicare Part B rules apply if the physician writes an order for observation. Observation is considered outpatient. That means all the copays, deductibles and coverage inclusions or exclusions are determined by what order the physician has written. Patients without supplemental insurance will get a bill for 20% of all charges incurred during an observation hospital stay because Medicare Part B only covers 80% of allowed outpatient Medicare charges. Patients without Medicare Part B will get a bill for full price. This mostly affects veterans who have Medicare Part A coverage but choose not to pay for Medicare Part B coverage due to their VA benefits. Most of these folks say they want to stay in their local hospital because they say, "I have Medicare". Most have no idea that not paying for Medicare Part B means they aren't covered for observation stays at their local hospital unless the VA is willing to pay for that care. I wouldn't count on that.

Most patients pay for Medicare Part B. Most patients have a supplemental policy too, so the issue is a non issue, except for payment of home medications administered in the hospital. The biggest problem occurs when physicians write an order for observation status and don't tell patients their routine self administered home medications will not be paid for by their Medicare insurance if the hospital provides these pills for them. Patients also have an obligation to educate themselves about the rules of their plan. Because Medicare will not pay, neither will a patient's supplemental policy. That means the hospital will send their patient a very large bill for the $25 dollar Tylenol given for their observation stay for headache, thus causing them another trip to the ER and observation admission for chest pain when they get their $2,000 bill three weeks after discharge. Since this $25 Tylenol is not covered under insurance, the patient gets no benefit of the insurance discount. In addition, I would not always count on Medicare Part D picking up the tab. They may, under certain circumstances, but I wouldn't consider that option reliable. Grandma gets to pay full price for that $25 pain pill. Oops, sorry about that, right?

I have a personal rule to notify every patient I admit observation status into the hospital of this hole in their Medicare coverage so I can give them the opportunity to either provide their home medications for my hospital to verify and administer by the nurse or to hold all their routine home medications until their expected less than 48 hour observation stay has been completed. Sometimes doctors may even look the other way while recommending patients take their own pills without telling anyone. Universally, patients are grateful for my discussion. Unfortunately, this uncompensated time isn't paid for and doesn't affect patient satisfaction scores. That only applies to inpatients. It is a freebie for my time out of respect for my patient's sanity. Unfortunately, I am the exception to the rule. Nobody explains this rule to patients so they can understand the implications to their financial health. I have stopped counting how many times I have heard angry patients describe their bills for several thousand dollars they received three weeks after a 24 hour stay in the hospital. It's a good thing their anger doesn't count for patient satisfaction scores. Maybe that's why nobody takes the time to care.

Determining inpatient or observation status is complex. Medicare says physicians must write an inpatient order for hospitals to get paid for inpatient care (Medicare Part A rules), but having a physician write the order does not guarantee Medicare will pay. Medicare wants it both ways. They require the order but refuse to accept the order as law. So my question becomes, why require a physician order if the order has no teeth? Why not develop a different process that provides experts with the opportunity make the decision. I have no idea why physician input is even relevent. Physicians aren't trained to know this stuff. We are guessing 100% of the time. That's right folks, physicians are not trained to know all the details required for Medicare to pay or deny an inpatient stay. So we guess, every time. All of us. It's irrational, I know. Most hospitals have utilization review experts that scour the patient chart for information to determine whether my order for inpatient or observation status was correct, but this rarely happens in real time. If I get it right, nothing happens. If I get it wrong, I am often asked to consider writing an order to change the status, which may affect patient coverage for self administered medications already provided. Oops, sorry about that, right? It's a shameful way to treat patients.

What are physicians thinking about on admission? In addition to evaluation and stabilization, the medical plan from the start often revolves around methods to quickly and safely get the patient discharged to the next appropriate level of care. That may mean physicians provide an intensity of service much higher than would be expected for the patient's number-of-wrinkles/age ratio. That may mean an aggressively documented thought process to include one-in-a-million-doc types of conditions that would make any residency director put on their pimping caps with an excitement only a morning report can provide. This process defines skilled nursing facility (SNF) driven medicine all across this country. EMTALA is the leaky faucet and "sniffs" are the plumber. The moment patients are admitted to a hospital, the astute hospitalist is already formulating a plan to get free front row tickets in the too-weak-to-pee-on-my-own section of the the three-midnight-road-rally paid for by the Medicare National Bank.

Hospitalists are writing orders and aggressively documenting their grave concerns about acute exacerbation of too-old-to-answer-a-question-without-telling-a-story as a reason to meet inpatient criteria and writing essays about why inpatient status is required to qualify for a three midnight hospitel stay and early disposition to the land of skilled nurses in a nursing home. It happens everywhere in this country, except on my service and in my hospital. Trust me. I refuse to play that atrocious game. My patients whom I admit with acute exacerbation of too-old-to-go-home and life threatening cases of upset-son-is-demanding-admission only get exactly what they need and not a thing more. They don't get medically reasonable and necessary intravenous fluids running at 150 cc/hour for 72 hours because their baseline creatinine is 1.223. They do not get medically reasonable and necessary every 4 hour neuro checks for 72 hours because they're pinky toe is numb without explanation after being stepped on by a farm animal. They won't get that MRI on day three, making sure to wait until agressive hydration has been achieved and they definitely won't get the blood cultures that require inpatient monitoring to rule out sepsis as a contribution to their three year battle with perma-supine syndrome. No. Sir. Ree. My patients don't get any of that medically reasonable and necessary care to get them qualified for their three midnight stay and a golden ticket to the palace in the Sniffdom of their choice provided for under medically reasonable and necessary Medicare benefits paid for by IOUs to the Canadian, British and Chinese governments.

Are you confused yet? Well, things are about to change, again. Many Medicare carriers determine appropriateness of inpatient status by using a combination of diagnosis and intensity of service to determine whether inpatient criteria has been met. For example, diagnoses such as back pain, chest pain, pain in my ass, weakness, syncope and abdominal pain won't get you qualified for inpatient status unless you have a really good hospitalist with extra fellowship training treating exacerbation of needthreemidnightitis as a Medicare approved major complication and comorbidity. When I write the wrong order, lots of paper work must happen for the hospital to get paid. Even I have to retroactively change my billing to match the hospital status or my physician claims will get denied. Most doctors aren't trained on any of this stuff.

On April 26th, 2013, the Centers for Medicare & Medicaid Services (CMS) issued an assortment of proposed rule changes to update 2014 Medicare payment under the Inpatient Prospective Payment System (IPPS) to be applied to discharges on or after October 1st, 2013. Comments on these proposed rule changes will be accepted through June 25th, 2013 with a final ruling to be issued August 1st, 2013. The proposed rule change (CMS-1599-P, RIN 0938-AR53 ) will be published in the Federal Registrar on May 10th, 2013, but can be found here at this time with my focus here on pages 657-678. It's a fascinating look into the mind of Medicare madness. It has huge implications on how we practice medicine as a hospitalist and what we will be asked to document in the chart. It adds another layer of complexity to our role as documenteurs. This CMS fact sheet gives a summary of the proposed rules change. The bolded words are stressed by me.

Admission and Medical Review Criteria for Inpatient Services.
In the proposed rule, CMS clarifies its longstanding policy on how Medicare contractors review inpatient admissions for payment purposes. Under this proposed rule, CMS is proposing that hospital inpatient admissions spanning at least two midnights (that is, at least more than one Medicare utilization day), will presumptively qualify as appropriate for payment under Medicare Part A. Conversely, hospital inpatient admissions spanning less than two midnights (that is, less than one Medicare utilization day) will presumptively be inappropriate for payment under Medicare Part A.

This presumption may be overcome by documentation in the medical record supporting the admitting physician’s expectation that the beneficiary would need care spanning at least two midnights and an unforeseen circumstance results in a shorter beneficiary stay than the physician’s expectation. Physicians must support their expectation, and accordingly their order for admission, through clear and complete medical documentation. This proposed policy would address longstanding concerns from hospitals that they need more guidance on when a patient is appropriately treated and paid by Medicare as an inpatient. At the same time the proposed change would help beneficiaries who in recent years have been having longer stays as outpatients because of hospital uncertainties about payment if they admit the patient to the hospital.

Let me give you a little background about why Medicare is making some changes. Medicare is bankrupt. As a result, they have a program in place to retroactively take back money paid to hospitals for services they may determine not to be medically necessary and appropriate. Much of the recovery has focused on inpatient hospital stays of short duration. Hospitals responded by approaching physicians with recommendations to admit patients as observation status instead of inpatient status or apply observation status to patients already admitted as inpatient in an effort to avoid denial of payment from Medicare. Hospitals want to get paid. Medicare doesn't want to pay. Do you see the problem here?

As a result, many Medicare beneficiaries have experienced longer and more expensive stays in the hospital with higher Medicare Part B financial obligations during observation stays. Since 2006, the number of cases of Medicare beneficiaries experiencing greater than 48 hours of observation has increased from 3% in 2006 to 8% in 2011. This proposed rule is an attempt to help doctors and hospitals write inpatient orders, with a confidence that they will not be denied, if documentation continues to support physician expectations of greater than 2 days in the hospital providing medically reasonable and necessary care. Of course, even by their own admission, abuse potential is great and will be monitored. I have reviewed the proposed rule change, as it currently resides, on pages 657-678 of the current document. If you've gotten this far, you are obviously interested in this stuff so I encourage you to review it for yourself as well. It has a great potential to change how we practice and document as hospitalists for the simple fact that great hospitalists with additional fellowship training in documenting-smoke-and-mirrors can make anything look medically reasonable and necessary. The abuse potential they fear is going to hit Medicare financing straight in the noggin. Just look at the three midnight rule. Patients who are alive, but not really, get shipped off everyday to skilled nursing facilities after their 3-midnight hospital stay for acute exacerbation of frozen body syndrome because they can. Let's take a look at the proposed changes, shall we?

For the first time, as far as I can tell, CMS is telling hospitals and physicians that length of treatment will determine whether patients qualify for inpatient or observation status. The proposed rule is directing carriers to presume hospital inpatient admissions are reasonable and necessary if they cross two midnights and the hospital services are medically necessary and appropriate. Page 657 of the government document details the proposed rule change, with the following statement:

Policy Proposal on Admission and Medical Review Criteria for Hospital Inpatient Services under Medicare Part A

Before this proposed rule change, the only requirements for inpatient status were a physician (or other qualified practitioner) order and medical necessity. On page 661 of this document, stakeholders recommended redefining the parameters to include a beneficiary's length of stay at the hospital. Here is the current documentation on pages 661-662. Pay special attention to section between the blue arrows I have highlighted at the end:

There you have it folks. For the first time, Medicare is going to define length of a hospital stay as reasonable and necessary based on how long patients are in the hospital or are even just expected to be in the hospital. How is this proposed rule change going to be applied in real life? Fast forward to page 663 and the proposed rules change gets even juicier. It describes how Medicare's external review contractors will be required to act:

I think this single paragraph on the proposed rule change is going to transform how hospitalists document in the chart. Medicare has defined for us exactly what is reasonable and necessary for inpatient care. The answer is two midnights. The way I see it, the 2-midnight rule is now our value mandate as a practicing specialty. We have been given the two-midnight rule and I guarantee to all that is true in this world, this is going to be the Bible for hospitalist medicine. Hospitalists that can document a yellow brick road straight to the top of Two Midnight Mountain are going to see their value to administrators explode as diagnosis related groups (DRGs) are the drug of choice for hospitals addicted to Medicare dollars.

External review contractors are now required to presume the threshold of reasonable and necessary for 2-midnight stays. Experienced hospitalists have an amazing ability to provide documentation supporting medically necessary care to anything that barely breaths, barely moves or barely speaks in our chronically alive, but not really patients admitted for medically necessary and reasonable nursing home care. Everything great hospitalists do is medically necessary because their documentation says so. Great hospitalists are worth their weight in gold for this very reason. External review contractors will never be able to show abuse of the 2-midnight presumption by hospitalist groups with great documentations skills. This. Is What. Hospitalists. Do. For. A. Living. Hospitalists are documentation experts. They play that game better than anyone. Hospital systems aren't going to subsidize hospitalists $140,000 per year per hospitalist for nothing. For all intents and purposes, hospitalists are documentation whores and hospitals are their pimps.

How do hospital inpatient payments currently get denied? Page 668-669 provides a nice summary. In a nutshell, payments made in error by CMS are more frequently associated with short stay procedural inpatient claims that should have been provided on a hospital outpatient basis, which I believe is the driving force behind this proposed rule change:

How bad have the errors been? Continuing on with page 669:

In Medicare's eyes, the errors are due to procedures, not little old grandpa admitted with acute exacerbation of too-unsteady-to-ballroom-dance and have nothing to do with hospitalist patients who also get three inpatient midnights for a primary diagnosis of too-wrinkled-to-smile. As a hospitalist, I am not admitting observation patients who just had an EGD or heart catheterization. I am admitting my 98 year old grandmothers who's family can't take care of them anymore so they drop them off at the emergency room for us to handle instead of placing them in a nursing home because they refuse to sell off her assets to qualify for Medicaid instead of planning for the future and purchasing long term care insurance policies.

These are patients where hospitalists with exceptional documentation skills can make anything medically reasonable and necessary and show value under the 2-midnight rule where no value previously existed. This documentation is important because Medicare clearly says on page 671 that a physician order for inpatient shall not by itself make a patient qualified. The medical necessity review rule continues as follows:

In other words, just because the physician writes an order for inpatient, it doesn't mean the inpatient status is automatically correct. This gets me back to my original issue. If the physician order isn't the law, then why have the requirement in the first place. Why not bypass the physician and have a process in place that allows people trained in the determination of inpatient vs outpatient make the determination. Why not allow hospital utilization review experts to make determinations on a retrospective basis and get rid of all the errors we have to deal with under this process. I would love to write an order for "Hospital bed: status per utilization review team" and have Medicare pay for all charges up to that moment in time regardless of the status of the patient. That would make patients happy.

In addition to the physician order, medical necessity reviews will continue as described in the medical review criteria for all hospital services and the inpatient hospital admission guidelines. Pages 672-675 are the four most important pages and every hospitalist should read them and learn them, with special emphasis on the bottom of page 673 through the top of page 675. These three pages are going to transform how we document our social admits who are too-old-to-breath-in-the-upright-position so they can get qualified for three midnights under a diagnosis of need-two-on-the-way-to-three-midnightitis :

It's all about documentation people. Clear as day, Medicare is going to focus on patients who are being billed inpatient who do not stay more than 2 midnights. They may continue to audit the rest, but they are not going to focus their energies on that population unless they find an attempt to game the system (as if somehow the 3-midnight SNF rule is not being gamed). Great hospitalists could get any patient who is admitted with a diagnosis of patient-becomes-invisible-due-to malnutrition-and-old-age-when-they-turn-sideways-but-they-have-no-other-medical-problems qualified for a ten day hospital stay with reasonable and necessary medical care. I hate to tell Medicare the bad news, but from where I'm sitting in the peanut gallery, the entire country is gaming the Medicare system. It's-All-One-Giant-Game. The 3 midnight rule is already a farce. We now have the 2-midnight rule too! Hurray! Oh, and the 1-midnight-rule too! Yeah!

Medicare's rule change has just given hospitalists the social admit green light to write inpatient orders on all their patients with acute exacerbations of too-demented-to-care-about-paying-for-a-nursing-home-but-the-daughter-wants-the-farmland. Why do I say this? Because Medicare clearly states they are going to use physician documentation of the "reasonable basis for the expectation of a stay crossing 2-midnights" that will justify the medical necessity of the inpatient admission. If this isn't an entry into the Inpatient Social Admit Marathon, then you're not reading what I'm reading. Social admits ALWAYS take longer than two midnights to disposition out of the hospital. If a hospitalist states on admission that they think their admission for too-slothy-to-support-themselves is going to be in the hospital longer than two midnights, all they need to do is document their supporting reasons. They state that clear as day:

"The judgement of the physician and the physician's order for inpatient admission should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs and the risk of an adverse event."

Every social admit a hospitalist is asked to admit into the hospital could qualify for inpatient based on the expectation of the process taking longer than two midnights to provide an appropriate discharge to the community (especially at really crappy hospitals) and documenting their judgement of risk for an adverse event if they are not discharged to a nursing facility. They way I see it, Medicare is telling me I can qualify my 98 year old patient who is too-weak-to-hyperventilate as inpatient status by simply writing the following statement:

It is my medical judgement that Mrs Smith presents as a great danger to herself if not continuously monitored in a 24 hour care setting. Due to ___________________ (write anything reasonable that doesn't seem related to patient or family convenience) I do not expect Mrs Smith to be discharged in less than two midnights.

What are the reasons social admits always take longer than two midnights to discharge? Just off the top of my head, here are some reasons:

It's the weekend and everyone knows nursing homes don't accept new SNF patients on the weekend.
It's a holiday. See above.
The patient is homeless and can't find their Medicare card.
The patient is drunk. It takes two days to safely get them sober.
The patient refuses to be discharged and files an appeal. You get two midnights right there.
It takes two midnights to get the psychiatrist to see the patient to tell you they can't make their own decisions.
Any patient admitted after 6 pm by the night hospitalist isn't going to get discharged before 6 pm the next day. That's because they'll be done rounding at 9 am and all the tests won't get done until the afternoon and that means another midnight waiting for test results.
The powers of attorney won't return your phone calls.
It takes two midnights for families to choose a nursing home.
Families demand 12 consultants to prove grandma is just old and weak.
There is no access to clinic records on weekends.
Home medications can't be verified until after the patient is already discharged.
Physical therapists are too busy to see them on day one. Bam! You got another midnight.
The powers of attorney is crazy themselves.
~~The patient won't talk to you or~~ You won't talk to them because they are too hard of hearing.

How can hospitalists encourage compliance with the 2-midnight inpatient rule that is really nothing more than a gateway to 3-midnight Heaven ? Try these methods:

Tell families to go home and don't answer their cell phone for two midnights. Don't call me. I'll call you.
Tell families to tell the hospitalist grandpa was hallucinating this morning, although nobody saw it. Make sure to refuse the CT of the head your hospitalist will order. Delirium will buy you a midnight, maybe two.
Order a cardiac stress test after the patient has has their morning coffee. Oops. Sorry about that. I guess they'll have to wait another midnight to get their test.
Place them on telemetry. Note the one beat run of VT, but forget to call for a cardiology consult until late in the day on a Friday night.
If you admit a patient on Friday, just forget to request clinic records until Saturday. That buys you the weekend while you wait for their clinic to open on Monday. It's not safe to discharge the patient without a complete picture of their health.
Order lots of lab tests. Don't follow up on them until the next day. Regardless of what the labs show, order an advanced imaging test, but don't follow up on the results until the next day. Bam. Two midnights.
Just order a bone marrow biopsy on a weekend to prove grandma doesn't have a case of disseminated it-just-doesn't-matter. Nobody does bone marrow biopsies on weekends. Cancel the bone marrow biopsy on Monday after confirming the patient's case of it-just-doesn't-matter.

I'm fascinated by this proposed rule on several levels. All those patients who are too weak to go home have just found themselves a way into the golden palace of a skilled nursing facility (SNF) paid for by Medicare, otherwise known as a free nursing home. As I interpret this proposed ruling, hospitalists can write an order for inpatient status and document their expectation of longer than 2-midnights in the hospital by documenting their on going concerns to rule out stroke, rule out sepsis and rule out acute exacerbation of old age, regardless of their intensity of service, and support that documentation with further concerns about adverse events, comorbid conditions and severity of signs and symptoms and their patient qualifies for inpatient status because CMS will presume them to qualify as appropriate.

Just wait until the general public gets a hold of this change. No longer do they need to worry about caring for grandma at home. Just bring them to the adult humane society (aka the ER), get them their two midnights on the way to the mandatory three SNF midnights and it's a Friday night SNF party at the fancy nursing home with skilled nurses. Once hospitalists get past that second midnight with inpatient status while ruling out occult bacteremia in the absence of fever, absence of leukocytosis and the absence of standard of care, they can easily get their third SNF midnight by documenting their need to confirm acute exacerbation of needs-three-midnights-and-a-place-to-live-upon-discharge.

Alternatively, I'm fascinated by all the acute drug overdose patients who require ventilator support in the ICU that are admitted at 1 am and are discharged by 3 pm. Apparently, they aren't in the hospital long enough to be admitted inpatient if the hospitalist believes they can be discharged before the following night. Apparently, they are only being observed on the ventilator to determine whether or not to actually turn the ventilator on. Being sick on the ventilator for less than one midnight just doesn't cut it anymore. If you want to qualify your critically ill drug overdose for inpatient, you'd best consider telling the family to go home and get more drugs to double the suicide dose so the hospitalist doesn't extubate them too soon from life support. It's a matter of life or 2-midnights.

However, If hospitalists document their confidence in their excellent care team and can get their critically ill patient discharged in less than two midnights, their hospital may be punished. They should instead consider providing suboptimal care, generate an iatrogenic critical medication error or two and delay the discharge past the second midnight to verify payment under inpatient status. Or maybe they should just delay their discharge for another midnight so their clearly obvious inpatient care gets paid for as an inpatient and not the less funded observation rate.

Yes folks, Medicare gave hospitalists the 3-midnight rule. Now they are preparing to give hospitalists the 2-midnight and 1-midnight rules. On October 1st, 2013, how hospitalists document their social admits will provide a great opportunity for them to show value where none previously existed. Turn that observation frown upside down and give your 108 year old with a mild case of too-old-to-calculate-her-age-based-on-her-date-of-birth a golden ticket to inpatient status and one small midnight away from the dream SNF of her choice. You owe it to her. She's 108 years old and you're not.

Medicaid Pay Increase For Hospitalists Confirmed For 2013-2014.

2013-04-24T00:49:00.001-05:00

Are hospitalists going to get a Medicaid pay raise for 2013 and 2014? The answer is yes, hospitalists qualify for Medicaid parity (with Medicare) as required by the Affordable Care Act (ACA). For many states, Medicaid pays physicians and other providers a fraction of Medicare rates. Legislation signed as part of the ACA mandates Medicaid rates to equal 100% of Part B Medicare rates in calendar year (CY) 2013 and 2014. That means if you haven't already seen increased rates, and you are a qualified physician providing qualfied primary care services, you will get increased Medicaid payments retroactively applied to January 1st, 2013.

When folks think of primary care, most likely think of the outpatient clinics for pediatrics, family medicine and internal medicine physicians. But that's not how ObamaCare defines a primary care specialty. That's right people, hospitalists, pediatric cardiologists and a whole lot of other practicing physicians now qualify as providers of primary care under ACA rules.

I was first alerted to this stunning CY 2013 and 2014 increase in Medicaid payments for hospitalists after reading an article from The Hospitalist titled Afordable Care Act (ACA) Provision Carries Pay Raise For Some Hospitalists. Joshua Bowell, the Society of Hospital Medicine's senior manager of government relations, discusses the rules and how they apply to hospitalists. It's a great article and I encourage all hospitalists to click the link above, read it and forward it to their billing company to make sure all necessary paperwork has been filed to qualify for increased Medicaid payments and retroactive Medicaid payment increases that are required to start on January 1st, 2013.

What are the specifics of this law? You can read the Fall 2011 rule abstract that implements section 1202 of the Affordable Care Act (ACA) here. I have taken the liberty of publishing it below for your review:

Title: Payments for Primary Care Services Under the Medicaid Program (CMS-2370-P)

Abstract: This proposed rule would implement section 1202 of the Affordable Care Act that requires payment by State Medicaid agencies of at least the Medicare rates in effect in calendar years (CYs) 2013 and 2014 for primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. This rule would implement the statutory payment provisions uniformly across all States. Specifically, this proposed rule would define, for purposes of enhanced Federal match, eligible primary care providers and identify eligible primary care services, as well as specify how the enhanced payment should be calculated. This proposed rule would also provide general guidelines for implementing the enhanced payment for managed care services.

So how does a hospitalist and a pediatric cardiologist qualify for primary care under the proposed rule above? Great question. To understand the answer, one must understand how the rule defines the qualified physician providing the qualified primary care service. I did a little digging to find out how. Do you know how hard it is to find all this stuff? The November 6, 2012 Federal Registrar published the final ruling (with a minor correction published December 14th, 2012) titled RIN 0938-AQ63 as it applies to the regulation mandating Medicaid parity with Medicare Part B payments for qualified primary care physicians. Here is the lead summary paragraph of the final ruling:

How does this final ruling define a physician delivering a primary care service? According to the Federal Registrar, the November 6th, 2012 final ruling amends several sections of the Social Security Act, specifically, 1902(a)(13), 1902(jj), 1932(f), and 1905(dd). Effective March 20th, 2010, section 1902(jj) of the Social Security Act now defines a primary care service as follows:

There you have it folks. ObamaCare has defined, through amendment of the Social Security Act, exactly what primary care services are. It is the delivery of evaluation and management services to title XVIII beneficiaries. Title XVIII is Medicare. It appears to me that any physician that submits payment for a qualified E&M charge is submitting a service for a primary care service. What are the E&M codes eligible to receive higher Medicaid payments? Evaluation and Management codes 99201-99499 of the Healthcare Common Procedure Coding System (HCPCS) and vaccine administration codes 90460, 90461, 90471, 90472, 90473 and 90474 have been lawfully determined to qualify for Medicaid parity payments in CY 2013 and 2014.

As a hospitalist, that means most E&M charges qualify for higher Medicaid payments. All initial hospital codes, subsequent care codes, critical care codes, observation codes, and same day admit/discharge codes are included by law. Yes folks, my critical care is considered primary care. And my emergency room codes? If I see a patient in the emergency room and decide not to admit them, my emergency department E&M code is considered a primary care service. Sorry ER doctor, even though you submit the same code, you do not get parity under this law. But why? For many ER doctors, they are the Medicaid patient's primary care provider through dozens of ER visits a year. If any doctor is the primary care doctor for a Medicaid patient, it's the ER physician because no primary care doctor will see them! Why can't they get paid the higher rate?

Does any physician who submits an E/M code get parity payments for their primary care service? Can a urologist get paid Medicaid parity for their office visits? Can a general surgeon get Medicaid parity for their cholecystectomy? The answer is no. Why can a pediatric cardiologist get Medicaid parity but a general surgeon can not? The answer lies in how ObamaCare defines an eligible physician. Return back to the summary statement above and you'll see the physician must have a specialty designation of family medicine, pediatric medicine or general internal medicine. A urologist and general surgeon does not meet that requirement. But how does a pediatric cardiologist make the cut?

The answer lies in this law's interpretation. After the proposed rule was published in May, 2012, one hundred and seventy-seven comments were received. Some of those comments reviewed below helped clarify the who is an eligible physician question. Read this section thoroughly to fully understand who qualifies and who doesn't. Click on the picture to take you directly to the Federal Registrar paragraph contained within.

And that folks is how a pediatric cardiologist gets a Medicaid pay increase for their E&M services in CY 2013 and 2014. The interpretation of this law adds 44 additional specialty designations to the qualifying list for Medicaid parity. What is the gist of the argument? A pediatric cardiologist is trained in the specialty designation of pediatric medicine and thus qualifies for Medicaid fee increases to match Medicare payment rates for 2013 and 2014. The law says if a physician is recognized by the American Board of Physician Specialities (ABPS), the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) as a specialist or subspecialist within the primary care categories, they receive Medicaid parity for their E/M charges.

What if the physician is not certified by any of these boards? The law allows for Medicaid pay raises if 60% of the codes billed in the calendar year of enrollment were for qualified primary care services that has been defined above. I suspect the 60% applies to the absolute number of codes submitted and not 60% of the total RVU value for the calendar year. If the answer is absolute codes, then almost any qualifying physician could qualify by virtue of submitting at least two E&M codes for every non E&M procedure code done in the procedure suite. That would give them a 66% rate of E&M charges which is above the required 60% threshold. I'm confident most medical subspecialists could clear the 60% threshold with no problem as long as they average at least two E&M charges for every non E&M procedure code they provide on any given day.

What about services provide by nonphysician practitioners? Do nurse practitioners, pharmacists, midwives, certified registered nurse anesthetists or other qualified nonphysician practitioners receive the mandatory increases in Medicaid payments? The answer is only if they are billing under the supervision of an eligible physician. That means the answer is no for independent nonphysician practitioners but yes if they are working with physicians in the qualified specialties listed above. Seems silly, doesn't it? A pediatric cardiologist can spend 80% of their time in the cath lab doing procedures, but if they submit at least 60% of their codes as E&M charges they can get Medicaid parity on their office visits, hospital consults and hospital follow-up codes. But the independently practicing certified nurse midwife administering the flu shot to protect mom and baby cannot.

Oh, and sorry OB/Gyn doctors. You may be the only physician for your patients and provide 100% primary care to 80% of your patient population, but you don't qualify for federal subsidized Medicaid fee increases because you didn't train in pediatric medicine, family medicine or general internal medicine. Maybe you should have been a pediatric cardiologist instead. ObamaCare says they are providing massive amounts of primary care these days, and by primary care, I mean telling the patient to contact their primary care provider to fill out the Family Medical Leave Act paperwork so they can have mom and dad at the bedside while they take Junior to the cath lab.

What about states that don't plan on expanding Medicaid eligibility? That has no bearing on the requirement for eligible physicians providing eligible E&M services to get paid 100% of their Part B Medicare rate on their Medicaid charges for CY 2013 and 2014. Whether states decide to expand Medicaid or not, qualified doctors providing qualified E&M charges get a raise on their Medicaid payment rates.

What happens after 2014? As noted in the Federal Registrar, states are required to report Medicaid participation rates to Congress in anticipation of decisions to continue or discontinue the current federal subsidy for qualifying Medicaid charges. I'm sure that's going to be another political fight. I've asked a few of my colleagues about what they intend to do with Medicaid. All of them say they have no intention of expanding their clinic slots to include a greater proportion of Medicaid patients. My facebook post confirms that. They can easily fill up their clinic with follow-up visits on their current panel of patients with chronic disease. I suspect after these two years are up we're going to see no increase in Medicaid participation. Physicians don't run their business on a two year horizon. Imagine expanding a clinic to include a large influx of Medicaid patients only to try and balance the budget based on unstable Medicare politics and a Medicaid policy that falls off the cliff after CY 2014.

What physician in their right mind would budget that? I'm willing to bet almost none. The quirks of this law are simply mind boggling. Pediatric cardiologists and hospitalists will get Medicaid parity for their ICU work but an independently practicing certified nurse midwife trying to take care of mom and baby as the only provider from conception to birth will not. I don't need to say anything more. Oh yeah, one last thing. How much is this little experiment going to cost? The expected cost to the federal government for this Medicaid parity pay increase is 5.6 billion dollars in calendar year 2013 and 5.745 billion dollars in 2014 (using 2012 constant dollars). What's another 11 billion dollars we don't have matter, right?

Place of Service (POS) CMS List Coding Instructions Revised (CR7631).

2013-04-17T15:48:00.000-05:00

Every physician or other provider encounter requires a place of service (POS) code for proper claims processing. But how should a physician determine their point of service? The Centers for Medicare and Medicaid Services (CMS) put an end to that question once and for all with Change Request 7631. Apparently, there have been too many errors over too many years with physicians and other providers reporting the wrong site of service location.

As far as I can tell, this Change Request 7631 was originally submitted March 29th, 2012 under Transmittal 2435 in the CMS Manual System. Transmittal 2435 was replaced by Transmittal 2561 on September 28th, 2012, which was replaced by Transmittal 2563 on October 11, 2012, which was replaced by transmittal 2613 on December December 14th, 2012, which was finally replaced by Transmittal 2679 on March 29th, 2013 in the CMS Manual System. But we're not done yet folks. CMS says in transmittal 2679 they will discuss place of service for laboratory and pathology services through another change request at a later date. Yes folks, single payer government Medicare efficiency is alive and well.

Transmittal 2679 establishes a national policy for the correct place of service code assignment. CMS has a table of all POS codes that are used by all Medicare contractors, Medicaid and private insurance companies as well. Each POS code is defined as a facility or nonfacility place of service for payment purposes under the Medicare Physician Fee Schedule (MPFS). In the now rescinded December 11, 2009 Transmittal 1873, physicians were instructed to submit their two digit place of service based on their physical location during when providing the service (the service location).

This has now changed. With only two exceptions, the place of service code shall now be the same location the beneficiary received their face-to-face service. In cases where a face-to-face encounter is removed (such as providing the professional component in the interpretation of a diagnostic test) at a distant site, the POS code for the professional component shall be determined by the setting in which the technical component was provided. The two exceptions to this face-to-face provision rule defined in Transmittal 2679 are defined as follows:

"For a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS code 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred"

But don't even think about moving to India or contracting with a bunch of radiologists from India. Medicare will not pay for your service. It says so right in Section 60 of this manual:

Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside the United States. For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist or the U.S. facility that performed the imaging test for any of the services that were performed by the radiologist in India.

Place of service codes carry a number between 01 and 99. They can be divided in to two main categories of payment: facility payment rate and nonfacility payment rate. The settings where point of service codes are paid at the facility rate are

Inpatient hospital (POS code 21)
Emergency room hospital (POS code 23)
Medicare participating ASC (POS code 24)
Skilled Nursing Facility for a Part A resident (POS code 34)
Ambulance on land (POS code 41)
Ambulance on air or water (POS code 42)
Inpatient psychiatric facility (POS code 51)
Community mental health center (POS code 53)
Psychiatric residential treatment center (POS code 56)
Comprehensive inpatient rehabilitation center (POS code 61)

Physician's services are paid at the nonfacility rate at the following point of service locations

Pharmacy (POS code 1)
School (POS code 3)
Homeless shelter (POS code 4)
Prison/Correctional Facility (POS code 9)
Home or private residence of patient (POS code 12)
Assisted living facility (POS code 13)
Group Home (POS code 14)
Mobile Unit (POS code 15)
Temporary lodging (POS code 16)
Walk-in retail health clinic (POS code 17)
Urgent care facility (POS code 20)
Birthing center (POS code 25)
Nursing facility and SNFs to part B residents (POS code 32)
Custodial care facility (POS code 33)
Independent clinic (POS code 49)
Federally qualified health center (POS code 50)
Intermediate health care facility/mentally retarded (POS code 54)
Residential substance abuse treatment facility (POS code 55)
Non-residential abuse treatment facility (POS code 57)
Mass immunization center (POS code 60)
Comprehensive outpatient rehabilitation facility (POS code 62)
End-stage renal disease treatment facility (POS code 65)
State or local health clinic (POS code 71)
Rural health clinic (POS code 72)
Independent laboratory (POS code 81)
Other place of service (POS code 99)

All of the above information has been nicely packaged into an easy to read MLN Matters publication for your quick and easy review, should you wish to proceed. Because most of you don't care, I've taken the liberty of contacting CMS myself for better clarity on POS code 99. They have agreed POS code 99 needs better clarity and have asked The Happy Hospitalist to use his influence to further the data mining expedition known as The Medicare National Bank. In addition to these widely publicized point of service codes, CMS has contracted with The Happy Hospital to help further clarify "other place of service" codes as part of an effort to make the roll out of ICD 10 even more thorough. Here is a list of recently approved point of service codes that will be included on the absolute most final transmittal ever, or at least until the next one is made.

Cardiac arrest anywhere (POS code blue)
Cardiac arrest at a movie theater (POS code Blues Brothers)
GI endoscopy suite (POS code brown)
At an accountant's office (POS tax code)
At a medical coder's office (POS over coding)
At an FBI office (POS secret code)
At a CIA office (POS crack the code)
At Google Maps headquarters (POS zip code)
At the Friday night dance with the elderlies club (POS no code)
At a software convention (POS source code)
At a Department of Defense (POS morse code)
At a lawyers convention (POS code of conduct)
At a convention of conspiracy theorists (POS Da Vinci code)
In a supermarket (POS bar code)
In a childs playground (POS code word)
At war (POS code of honor)
At a boarding school (POS dress code)
At a construction site (POS building code)

Any questions?

Hospital Patient Chart Dropped = More Work For Nurses.

2013-04-03T13:42:00.000-05:00

If I drop a patient's hospital chart, I would never expect someone else to put it back together. I dropped it. I put it back together. I expect the same if I drop a cup of coffee all over the computers at the nurses station. I spilled the coffee, I clean it up. That's just my perspective. That's why I'm surprised to see some nurses come to the rescue of the poor helpless doctor who dropped the patient's chart. "I can clean that up for you", they say. "Just leave it and I will put it back together", say other clerks and nurses. It's almost as if there is a class in nursing school called How To Put Your Doctor's Dropped Patient Chart Back Together With A Smile While Keeping Your Angry Thoughts To Yourself. On second thought, maybe these nurses just figure the doctor will just make things worse.

Is this attitude unique to the nurses? I've never seen another doctor offer to put together a chart that another doctor or another nurse dropped. Oh, let me put that back together for you are words I have never heard another physician speak in my ten years of hurried hospitalist life. To think there are some doctors out there who would not take responsibility for fixing their own patient charts makes me sad to call myself a doctor. It's not something I understand, but then again, I also clean up all my own sharpies after a procedure and would not expect a nurse to do it for me.

Hospital patient charts can come in all shapes and sizes. They can open side-to-side or top-to-bottom. They can be secured with clips or they can be fastened together with ringed binders. They can be large, small, big or small. Most of my charts have ringed binders. Occasionally, I may open the rings to take out an EKG or an x ray report to review with another physician. This is a dangerous time for potentially catastrophic chart annihilation. If the chart is not safely resting in a place far away from the surface edge, I guarantee it will find its way on to the floor in a million pieces. Never leave an open chart unattended. That's just asking for trouble.

I've dropped, bumped, nudged and mishandled hundreds of hospital charts over the years. Only a small percentage actually make it onto the floor in a scattered and disorganized array of lab results, progress notes, orders and nursing documentation that will never be read again. I can tell you with confidence, my heart stops at the instant that chart hits the floor. I think to myself, "Am I about to spend the next ten minutes putting together hundreds of pages of charting that nobody reads anyway?" At the exact moment that chart hits the floor, I am frozen with anticipation from this gravity confirming event.

The worst chart mishaps are those where the chart just falls. I have no explanation why it falls. Nobody is standing near it. Nobody is touching it. It just happens. Bam! Down goes the chart. That's the moment when everyone looks around to see who is to blame and who is expected to put it back together. In the old school world of hospital hierarchy, there was no question about who owned the task of hospital patient chart organizer. It was, of course, the job of the nurse. Today, that expectation lingers with some nurses. For others, not so much, as this nursing someecard below helps to explain. Perhaps, someday, when the entire paper hospital chart is replaced by a fully electronic medical record, chart dropping hazards will disappear. Unfortunately, the job of the nurse will not end there. It will instead be replaced by helpless doctors asking nurses to get lab results and xray reports pulled up in the computer. For reasons that make no sense to me, some doctors can complete medical school, residency and intensive fellowships requiring years of specialized training, but they can't type their user ID and password into a computer to find information vital to their patient's care plan.

Doctors Accepting Medicaid? facebook Says There Are None (Picture).

2013-03-29T15:04:00.000-05:00

Citizens who claim Obamacare is a major victory for patients are going to be greatly disappointed to learn that Obamacare promises to provide health care insurance without health care access. Obamacare promises to massively expand Medicaid. Medicaid is broke. The only places accepting Medicaid these days are hospitals and emergency rooms.   I have been a practicing hospitalist now for ten years. I have seen Medicaid failures first hand. In my community of Lincoln, NE, finding a new doctor to accept Medicaid is nearly impossible. In fact, I have witnessed first hand how difficult it is to get a hospitalized patient of mine with Medicaid to find a primary care physician post hospital stay to establish new patient care. It took over 35 phone calls to over 35 clinics to find one physician's office willing to accept a new Medicaid patients. In fact, one office even required five years worth of records and an interview appointment before they would consider accepting a new Medicaid patient.

That's thirty five calls to physicians before one would accept a new Medicaid patient. ObamaCare promises to massively expand Medicaid and promises to cover some of the expansion with unstable federal money that will surely be held hostage by party politics. Physicians aren't biting. Most physicians can easily fill their schedules with follow up appointments of their other chronic disease patients.   For many doctors' offices, accepting new Medicaid patients are not in their budget or long term business plan. It's not just internists and family medicine physicians that are not accepting new Medicaid patients. It's also our colleagues in the pediatric world. I was recently shown a facebook screen shot of a woman who was looking for a pediatrician for their eight month old child with United Healthcare Share Advantage Medicaid insurance.

This is the same company I have have problems as a hospitalist getting inpatient status approved on patients who have spent less than 24 hours in the hospital (due to our excellent care), but meet inpatient criteria by all objective standards. What I saw was sad, but not shocking. Why should physicians be expected to accept insurance that costs them money every time an appointment is made. I recently wrote a Facebook comment about a physician in my community who said they make $1 for every Medicaid appointment. If they saw four Medicaid patients in an hour, they would only make $4 an hour. They said they don't work for $4 an hour. I am sad for this woman and her child. Their hearts must be broken just trying to find a physician to be her child's doctor. They must think all these great doctors are greedy for not accepting Medicaid. Many people have no idea just how badly Medicaid pays.

It's not the doctor's fault Medicaid pays so poorly that they have to turn away innocent eight month old children in favor of other commercial payers with more reasonable rates.    It's no wonder why so many other citizens are opposed to Obamacare. The idea of universal access to insurance does not equate to universal access to doctors. I think emergency rooms had better get prepared for a rapid rise in new patients with Medicaid insurance but no outpatient doctor willing to see them. Why don't doctors accept Medicaid? Running a doctor's office is a business. Doctors can't treat anyone if they can't pay their bills.    Hugs and thank yous don't pay the office electric bills. The future of Obamacare is here and now, but it's going to get a lot worse by making bad policy worse.

Medical Chart Review Sign As A Marker of Prognosis.

2013-03-28T17:23:00.000-05:00

As a hospitalist, I can say with confidence that taking care of an elderly patient with volumes of medical records is easier than taking care of a young patient with volumes of medical charts to review. I find the medical conditions, the psychosocial issues, the family relationships and the complexity of the medical plan much easier to navigate for our elderly sick than for our young sick population. In general, I find the coping mechanisms of our young and chronically ill patients to be more difficult for health care providers to navigate. Perhaps that has to do with a level of immaturity that only experience can overcome by both.    When young patients get sick, doctors and nurses are often forced outside of their comfort zone of communication.   Young patients with thick charts and frequent health care contacts will be considered complex patients for the rest of their lives.

By definition, any attempt at reviewing their medical records will end in sighs of defeat by doctors and nurses.    Think of it as the chart thickness : age ratio. The thicker the medical chart and the younger the patient, the more likely the patient will be referred to every medical and surgical subspecialty known to man. That's because physician, patient, and family expectations and confidence in the medical plan is inversely proportional to the age and thickness of the medical chart that needs to be reviewed. Most physicians, who are being honest with themselves, will agree. Are you only 22 years old and have a medical chart with only 10 pages to review? Your internist will more than likely attempt to tackle your complex set of circumstances with a combination of confident watchful waiting and routine standard of care evaluations. Are you 22 years old with 14 charts, no diagnosis, a history of seeing 12 subspecialists all saying they have nothing to offer and 42 unanswered questions at 5pm on a Friday afternoon? Than I am confident your internist will deploy this medical chart review sign and send you to the nearest ER to make them your problem.

To better help other health care practitioners understand the big picture, no longer should the astute internist document, "Patient appears older than their stated age", a time honored tradition of stating some patients have lived a hard life. That statement alerts the physician that patient age should not be used for prognostic purposes in this case.    Instead, I recommend the astute physician start documenting, "Patient's chart appears thicker than their stated age". That statement alone alerts other physicians they should plan on canceling their clinic to bath in the sea of pain they have been asked to participate in. If you are young and you have lots of medical records, it's important for you to be aware of the personal emotional toll thick charts take on the physician's psyche.

More is not always better. The thicker your volume of records, the less likely physicians are to tackle your problem and the more likely they are to refer you on to other physicians, thereby creating a positive paperwork feedback loop that can have devastating consequences to your health and prognosis. If you don't believe me and you are this patient I am describing, I am more than willing to refer you on to another physician who can better help you understand the dilemma you find yourself in, as this medical someecard helps to explain.

Drug Therapy Requiring Intensive Monitoring For Toxicity (List) For High Risk Medical Decision Making (MDM) in E/M Explained.

2013-03-21T16:39:00.000-05:00

In addition to history and physical, determining the level of medical decision making (MDM) is necessary to define which CPT® code to correctly submit for payment. The American Medical Association's CPT® manual is the authoritative reference for all CPT® related questions and should be available for all physicians to quickly reference. Evaluation and management (E/M) rules are complex and are often open to interpretation, including the high risk MDM component of "drug therapy requiring intensive monitoring for toxicity". The same data presented to different coding experts or auditors will invariably be interpreted differently. It is up to the physician to thoroughly document their thought processes to reduce the possibility of denial of payment during an audit process. The Happy Hospitalist has archived a series of E/M coding lectures through the years to help doctors better understand this complicated process. While I am not a certified coding expert, I have spent years studying the rules and regulations of evaluation and management medicine. Make sure to review all the lectures and the bedside E/M pocket card (picture shown below) to help you with your clinical practice needs.

The Centers for Medicare and Medicaid Services (CMS) has previously published the Evaluation and Management Services Guide. This publication is mandatory reading for any physician wishing to fully understand E&M coding correctly. On pages 16-21, this document provides detailed information on determining risk in the medical decision component of E/M coding. In addition to the three components (history, physical, medical decision making) of E/M, MDM also has three components, the highest two out of three of which are used to determine the overall level of medical decision making. I will in the future be providing a comprehensive discussion on this process. The discussion here shall be limited to understanding the intensive monitoring for drug toxicity of some drug therapy and how it qualifies for high risk medical decision making.

The third component of medical decision making is the risk of complications, significant morbidity and/or mortality, otherwise known as the risk table. The table of risk is presented on on page 20 with the following clarification:

The table...may be used to assist in determining whether the level of risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk.

If you review this very important table of risk in the management options selected component on the far right, you'll find drug therapy requiring intensive monitoring for toxicity in the high risk category. This publication by CMS is the basis for defining high risk E/M coding for some drug management. Does CMS help us by defining which drugs are considered high risk and which ones are not? Does CMS provide us with an important list to stay in compliance with our documentation supporting high risk drug management?

If you came here looking for an absolutely defined, with out a doubt CMS list of drugs allowed for high risk drug management, it doesn't exist. Even CMS states in their discussion of medical decision making that absolutes do not exist. They only provide clinical examples to help guide the clinician in making a determination of what CPT® code to submit for their E&M charge. Some drugs have been identified by the FDA as having a narrow therapeutic index (NTI) which requires intensive monitoring for toxicity. One reference suggested coders use an NTI drug list as their basis for auditing drug therapy requiring intensive monitoring and to add on other drugs physicians felt were warranted. This is a decent starting point. Many coders don't have the clinical experience to understand when some drugs not on an NTI list are high risk in certain clinical circumstances. I believe the most important take home point for physicians is thorough documentation. Documentation is key to helping auditors understand when drug management is and when it isn't high risk. Every patient is different and some drugs may be considered high risk in some clinical situations but not others.

The variability in different opinions from different coders or auditors has roots in the vague E/M language. Drug therapy requiring intensive monitoring for toxicity is a classic example. How does CMS defined intensive? Is hourly monitoring or daily monitoring or weekly monitoring considered intensive? And how is toxicity defined? Does CMS intend to mean toxic drug levels or toxic surrogate side effects? Do they mean complications of treatment? I believe the answers to all the questions can be yes, if given the correct clinical circumstances. One Medicare health administrator, Palmetto GBO, states that cytotoxic chemotherapy is always considered high risk when blood cell counts are used as the surrogate for toxicity. That says to me that drug levels by themselves are not necessary to qualify for high risk drug therapy with intensive monitoring for toxicity. And as far as intensive? What if the CBC isn't ordered until a week after the dose of chemo. Does that meet the threshold for intensive monitoring? Apparently so. This Medicare health administrator provided the following table at the link above with the following clarification. This is the only example on the internet I could find actually presenting a potential list of drugs to be considered for high risk on the E/M risk table.

"The table below lists examples of drugs that may need to have drug levels monitored for toxicity. This is not an all exclusive list. On medical review, to consider therapy with one of these drugs as a high risk management option, we would expect to see documentation in the medical record of drug levels obtained at appropriate intervals."

Even their explanation is vague as they choose not to define "appropriate intervals" for drug levels. My take home point from this list of drugs is we should treat it just as we do using critical care codes CPT® 99291 and CPT® 99292. Just because someone is in the ICU does not mean you can bill critical care and you can bill critical care even if someone is not in the ICU. Just because the drug is on this list does not mean prescribing it qualifies for high risk and just because a drug is not on this list does not mean it isn't considered high risk. Again, I believe documentation is the key to the helping the auditor understand the thought process. This is one more example of how EHR documentation is becoming more about billing and coding for non physician third party payers and less about what is important for communicating a patient's condition to other members of the medical team. Unfortunately, this level of documentation takes time and that time is taken away from face-to-face communication with the patient, another unintended consequence of E/M rules and regulations.

Let's consider warfarin therapy for discussion. Is Coumadin considered drug therapy requiring intensive monitoring for toxicity? As a hospitalist, I take care of a lot of patients on anticoagulation. I believe the answer is yes. Do I directly measure warfarin levels? No I do not, but I do not believe such a lab exists for routine clinical use. The measurement of PT/INR is the clinician's tool for making medical decisions on warfarin therapy. Does the lack of an actual measurement of a drug level exclude Coumadin from the high risk category of MDM? I could find no reference to CMS rules stating only drugs with actual drug level management qualified for drug therapy requiring intensive monitoring for toxicity. Again, I believe aggressive physician documentation is key to help nonphysician auditors understand clinical risk. CMS rules clearly state their intent is to identify conditions which define a high level of risk of significant complications, morbidity and/or mortality.

In the hospital setting, Coumadin use will almost always meet this standard. The potential for excess anticoagulation or under anticoagulation due to drug-drug interactions, under absorption, changes in diet and the constant adjustment in dosing of the medication has the potential to create thrombosis or bleeding complications with catastrophic results. In addition, daily monitoring of Coumadin would most certainly meet the threshold for intensive monitoring. Is there a cut off for how often Coumadin should be monitored to meet the threshold for intenisive monitoring? I don't think a defined time period has ever been established. I think any hospitalized patient on warfarin requiring frequent monitoring (perhaps identified by the hospital's safety protocols) would define Coumadin as high risk drug management because hospitalized patients on Coumadin risk significant morbidity and mortality. If Coumadin use in the hospital is denied by an auditor for not being drug therapy requiring intensive monitoring for toxicity, then I think all drugs should be.

Take the example of chemotherapuetic agents used in cancer. Most certainly these drugs would be considered high risk. But do we actually measure drug levels? Frequently, this type of drug therapy is monitored with electrolyte panels and complete blood counts due to the high risk of electrolyte disturbances, renal failure and bone marrow toxicity from these agents. The Medicare administrator stated above categorically stated cytotoxic chemotherapy was high risk. As I indicated above, if lab data isn't drawn until a week after therapy, does that mean cancer chemotherapy drugs are excluded from meeting the threshold of drug therapy requiring intensive monitoring for toxicity? The Medicare administrator implies no in their discussion linked above. Is it possible to only monitor lab a week after administering a drug and for it to be considered intensive monitoring. It appears so. If chemotherapy agents are excluded from high risk drug management, then I think all drugs should be.

Let us consider a heparin drip. This continuous intravenous medication has a high risk of creating bleeding complications if not monitored with frequent blood draws, often every six hours when first initiated. The monitoring of heparin involves checking partial thromboplastin times (PTTs) or factor Xa levels. Does the failure to monitor actual heparin levels mean this medication cannot be considered drug therapy requiring intensive monitoring for toxicity? If a heparin drip is not considered drug therapy requiring intensive monitoring for toxicity, then no drug should be. The same goes for an insulin drip, amiodarone drip, lasix drip and any other continuous infusion that requires monitoring of a surrogate marker (telemetry, laboratory, radiology).

The list can go on and on. Many drugs may be considered high risk in some clinical situations but not others. How about insulin management in the hospital? We don't measure actual insulin levels, but we do measure glucose to determine whether our insulin dosing is appropriate. Would all hospitalized patients on subcutaneous insulin be considered high risk drug management requiring intensive monitoring for toxicity? One could make an argument that many hospitalized patients are at risk for frequent changes in diet, NPO status, malabsorption, changes in metabolism and many other clinical scenarios that would significantly increase the risk of experiencing complications, morbidity and/or mortality, especially for elderly patients with multiple comorbid conditions.

This is why I think aggressive physician documentation on thought process and analysis of the data is important. In many circumstances, subcutaneous insulin, I believe, deserves to meet the threshold for drug therapy requiring intensive monitoring for toxicity. Is the patient NPO? Do they have an ileus? Are they starting tube feeds? Are they in renal failure? Do they have fever, infection or cardiac issues that are significantly affecting stable blood sugar management and increasing the patient's risk of hyper or hypoglycemic events? Then I believe even subcutaneous insulin should meet the threshold for drug therapy requiring intensive monitoring for toxicity. If insulin management for patient's in these clinical situations do not meet the threshold for high risk drug management, then no medications should.

At the end of this discussion, it should be readily apparent to all that no one list fits all for drugs that can be included in the high risk therapy profile. Because of the failure of CMS to provide clear guidance, I believe the physician has been given a grey area for which thorough documentation will allow work we do every day to be considered high risk and subsequently provide a higher level of E/M coding a payment. The key is for physicians to provide enough documentation for auditors to understand why high risk is present and why the visit meets the criteria of the highest level of medical decision making. If you look closely on my E/M pocket card below, you'll find drug thereapy requiring intensive monitoring for toxicity as one of the reminders to consider high risk for your daily E/M charges.

Click image for high definition view

PCA Morphine Dosage Protocol For Severe Pain Management In the Hospital.

2013-03-18T12:12:00.000-05:00

PCA morphine is a common method used to achieve pain control in the hospital setting. PCA stands for patient controlled analgesia. This therapy usually involves intravenous opiate therapy. Intravenous opiate management should be taken seriously by hospital nurses and doctors as too much medication can result in a life threatening iatrogenic drug overdose. In most situations, patients will respond rapidly to Narcan, the antidote in opiate overdoses. This complication happens everyday in the hospital, even during optimal monitoring conditions. Many foreseeable and unforeseeable variables are responsible. In fact, IV opiate management is even considered high risk drug management for physicians trying to calculate their medical decision making on their daily hospital E/M codes.

Many hospitals have standard protocols for initiating PCA morphine or other intravenous opiates. In addition to morphine, intravenous hydromorphone (Dilaudid) and fentanyl are other common medications used to achieve pain control. All intravenous opiates that should be prescribed with caution. How does a physician choose one medication over another? Considerations include patient preference and experience, physician preference and experience, patient drug allergy profiles, hospital wholesale costs and availability, trial and error for patient response and side effect profiles are just some of the most common reasons to choose one intravenous PCA opiate over the other.

Why is PCA morphine dangerous? Too much medication can cause patients to stop breathing. Opiates, often inappropriately referred to as narcotics by doctors and nurses, suppress the central nervous system's respiratory drive and increases the risk of life threatening apnea. This is the cause of death in a heroin overdose. This is the cause of death in the epidemic of prescription opiate drug overdoses heard about on the news. Many PCA morphine order sets require continuous oxygen saturation monitoring and frequent documentation of respiratory rate as safety mechanisms. This is to protect the patient from experiencing prolonged hypoxemia as a result of too much sedation when no family is available at the bedside.

How does the PCA morphine protocol work? The intravenous medication is placed inside a special pump secured to an IV pole. The pump is set to deliver medication through a patient's IV at the rate based on the physician's order. Doctors may or may not prescribe a continuous infusion dose (basal rate) in addition to an as needed (prn) dose for patient comfort. Patients are given a button to push for on demand delivery of medication for management of their severe pain. This button tells the pain pump to deliver intravenous morphine at a dose determined by the doctor's orders.

On the PCA morphine protocol orders, the doctor will write for a prn bolus dose with a lockout period. In other words, if the doctor only allows 1 mg of morphine every 8 minutes, then the patient will receive a maximum of 1 mg every eight minutes, if they push their pain button at least once every 8 minutes. If the patient pushed their button 100 times in that eight minutes the pain pump settings will only allow one 1 mg bolus dose to be delivered every eight minutes. This is the lockout period.

The customary lockout period for most of the IV opiates is to allow one dose of pain medication every 5-15 minutes, the exact time period of which is determined by the physician's order. This is a built in safety method to prevent a patient from overdosing on the medication. If patients become too sleepy to push the pain button, they will stop pushing it. This is also why families need to understand when it is safe to push the patient's PCA button and when it is not. Please consult with your nurse before you push your loved one's pain button. You may be killing them by doing so.

Hospitals are invested in optimizing severe pain control management because patient satisfaction scores depend on it. If patients believe their pain is not being adequately addressed, hospitals will get dinged on their HCAHPS surveys and they risk losing millions of Medicare dollars. PCA morphine is one way to give patients control of their severe pain management in the hospital and to ensure great survey scores on the back end.

How does the doctor determine the correct dosage of the basal and as needed bolus morphine? That's the wild, wild west of PCA management. Some hospitals have simplified the process, as this medical someecard explains. You can't get any more satisfied than less than one call light per shift, and by satisfied I mean nurses AND patients. Consider implementing this dose protocol for your PCA morphine orders in your hospital today and experience great patient and nursing satisfaction scores in an instant!

Do Not Incubate The Patient, Please.

2013-03-15T23:15:00.000-05:00

Every patient that gets admitted to a hospital is, by default, a full code. That means if their heart stops beating or their lungs stop breathing, emergency resuscitation teams will rush in to save 98 year old grandma who wants every thing done. "Of course, why wouldn't she?" Grandma hasn't been in the upright position for 3 years, but somehow, doing CPR and cracking all her ribs in a horrifying assault is considered standard of care to be demanded by families who need grandma's social security check to make their boat payment every month.

On the other hand, some patients and families understand the limitations and fragile nature of human life and rightfully demand doctors and nurses to not take out their daily aggressions on grandma's decomposing body by allowing a natural death when that day comes. They ask that an order be placed in the chart to allow a natural death (often written as do not resuscitate (DNR) and or do not intubate (DNI)) when that day comes. These patients and families understand the reality of the human body.

And then there are the patients who know what they want, but have a hard time articulating their needs, as this medical someecard helps to explain. I once took care of a crazy chick who didn't want to be incubated. I don't blame her. She wanted me to write an order for Do Not Incubate, but I was too chicken to do it. I didn't want some nurse crying fowl on me. I told her I would not allow a Do Not Incubate order on my watch and that if she needed incubating I was going to personally order a rapid sequence incubation on her and consult the poulmunologist to assist with her cares.

Daily Weight Fluctuations In the Hospital Explained Away As Magical.

2013-03-14T18:11:00.000-05:00

After ten years as a practicing clinical hospitalist, I have settled on the only rational conclusion I can think of regarding unexplainable daily weight fluctuations in the hospital: Many nurses and nurses' aides are part-time magicians. That's right folks. After seeing hundreds of patients over the years experience radical increases or decreases in their daily weight measurement despite negative ins-and-outs, I have no other rational conclusion but to assume many nurses and aides are incredible magicians just waiting to get their big break in the up-and-coming genre of hospital magic.

Got congestive heart failure and the need for accurate I/Os and daily weights? Got severe sepsis requiring liters upon liters of fluid? Got a hospitalist who orders daily I/Os for no good reason at all? Then accurate weights are necessary to make quality medical decisions. While obtaining daily weights may seem simple to the untrained eye, the process actually requires hours of additional training to be certified as an expert weight taker. Some hospitals even have bulletin reminders for their staff on how to obtain accurate daily weights. Here is one example below of a hospital's daily weight protocol sent to me by a reader.

Weighing patients is easy. I know for a fact that many patients enter the hospital with magical expectations. When I tell them we have a magic force field that surrounds our hospital walls, they are in ah of our power. When it comes to erratic daily weight measurements that makes no clinical sense, nursing magic is the only plausible explanation I have, as this nursing someecard below describes.

iPotty For Kids Inspires iCommode For Adults. Get iPoop Out In iStyle.

2013-03-14T08:43:00.000-05:00

We definitely live in interesting times. Only in America, and on Amazon, can you buy an iPotty chair for your potty training baby. Yes folks, you heard that right. It's an iPotty and it's for real! Is your child already addicted to your hundreds of free baby apps you loaded up just for them (and you)? Do they cry every time you turn off Micky Mouse Club House for some digital free entertainment with your Sam's Club grocery box? Do they scream and shout at the thought of going to sleep without the soothing sounds of Daniel Tiger's Neighborhood echoing throughout your home? Then ask yourself if the iPotty is for you. For only $39.99, you too can have the CTA Digital 2:1 iPotty, a fully functional potty chair made specifically for around the clock iPad entertainment. Never let your kid leave the comforts of their iPad ever again.

This baby iPotty got me thinking. Why not an iCommode for all of our hospitalized patients? Hospital care is more about image than it is reality. Anyone in health care knows that to be an absolute truth. Make the patient feel good about their care, no matter how rotten it is, and hospitals will not get penalized for bad surveys. Hospitals must provide amenities and luxuries that patients understand or they aren't going to get paid. Nothing would make me happier than to walk into a patient room and see my patient pooping on their iCommode while Skyping with their grandson on thier iPotty. Talk about an iParty.

Want great satisfaction scores? Don't deny your hospitalized elderly the right to poop in the luxury of their own iCommode. Since I can't find an adult version of the iPotty, it's going to be up to your hospital maintenance crew to custom build these for you. And for your extra large patients, consider equipping their iCommode with large 32 inch monitors for optimal satisfaction. Your patients will thank you from the bottom of their poop. iPromise.

Billing Two E/M Codes Same Day, Same Specialty and Group Explained.

2013-03-02T16:57:00.004-06:00

Is it possible to get paid for providing two separate and identifiable face-to-face evaluation and management (E/M) charges on the same calendar date that are provided by the same physician or physicians in the same speciality from the same group practice? The answer is yes, under certain circumstances. Just make sure the documentation meets certain criteria.

The Centers for Medicare and Medicaid Services reviewed a specific situation in an August 26th, 2011 claims processing transmittal titled Clarification of Evaluation and Management Payment Policy (change request 7405) that mandates Medicare carriers to approve payment for two E/M charges in the same day by the same physician or physicians in the same specialty and group practice, under certain circumstances.

What are the circumstances for which two E/M charges will get paid in the same day? You can find the exact text and associated explanation in the above linked pdf file under section 30.6.9 A (11 pages into the document) which describes a hospital visit and critical care on the same day. The key to billing two E/M charges is to provide critical care CPT® 99291 for your second face-to-face encounter.

For many hospitalist groups, signing out to cross covering physicians is part of the job. For years I have been paged to the bedside to provide a face-to-face evaluation on patients who have already been seen and billed for their Initial Hospital Care (CPT® 99221-99223) or Subsequent Hospital Care (CPT® 99231-99233) by the physician who provided a face-to-face encounter earlier in the day. I recommend obtaining your own AMA ®CPT manual as the definitive resource for CPT® coding.

In this transmittal linked above, CMS confirms these two sets of codes (initial and subsequent care) are "per diem" services and can only be billed once per day by the same physician or physicians in the same specialty from the same group practice. The key to getting paid for two E/M charges in the same day is to provide documentation in your second face-to-face encounter to show that critical care service was provided.

A lot of what I do in cross coverage for patient care is non-billable work. If I provide 15 minutes of face-to-face evaluation, I can't bill for that service if my partner has already seen the patient earlier in the day, unless they have documented their time in their note and I meet the criteria for an add on prolonged service codes CPT® code 99356 or 99357. I could bill for critical care if my documentation supports use of the critical care codes. In addition, the first face-to-face initial or subsequent E/M charge could get up coded if the documentation in both encounters supports a higher level of care. Again, 99221-99223 and 99231-99233 are per diem codes and only one physician in the same specialty and group should submit a CPT® code in a calendar date, regardless of whether the issues addressed by different physicians were unrelated. Which physician you choose in your group is up to you. Customarily, the first face-to-face encounter gets credit for the encounter.

How many times a month do I get called to the bedside for an acute change in mental status? Rapid atrial fibrillation? Hypotension? Tachycardia? Seizure? Unstable vital signs? I have never billed for these cross cover encounters or reevaluations on my own patients if the encounter lasted less than 30 minutes because nobody I work with is in the habit of documenting total time in their notes, including me. The per diem rule applies. Only if the visit meets criteria for critical care and it is 30 minutes or more can a second E/M charge be billed on the second face-to-face encounter. Here is the important part of the CMS documentation.

When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes 99291 and 99292) and the previous E/M service may be paid on the same date of service. Hospital emergency department services are not paid for the same date as critical care services when provided by the same physician to the same patient.

During critical care management of a patient those services that do not meet the level of critical care shall be reported using an inpatient hospital care service with CPT Subsequent Hospital Care using a code from CPT code range 99231 – 99233.

Both Initial Hospital Care (CPT codes 99221 – 99223) and Subsequent Hospital Care codes are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice.

Physicians and qualified nonphysician practitioners (NPPs) are advised to retain documentation for discretionary contractor review should claims be questioned for both hospital care and critical care claims. The retained documentation shall support claims for critical care when the same physician or physicians of the same specialty in a group practice report critical care services for the same patient on the same calendar date as other E/M services.

Make sure to review all my free lectures on hospitalist E/M coding and my collection of resources for hospitalists.

LINK TO HOSPITALIST POCKET CODING CARD POST

Click image for high definition view

What Does Sequestration Mean To Physicians and Hospitals?

2013-03-01T23:10:00.000-06:00

What does sequestration meant to physicians and hospitals? It means starting April 1st, 2013, The Centers For Medicare and Medicaid Services (CMS) will pay 2% less for Medicare services than they did on February 28th, 2013. Sequestration cuts are the result of a badly played political poker hand at the dysfunctional casino. On April 1st, 2013, will my post-sequestration medical opinion be worth 2% less than it was a month previously? Yes, it will.

For physicians and hospitals, the shot across the bow has been fired. What this cut says today is that no matter how perfect the game is played, politics will prevail. I've been a hospitalist now for ten years. In that decade of experience, I have seen many sticks and carrots implemented in various attempts to control healthcare costs and define quality. As I've said for the last five years on The Happy Hospitalist, the only way to control costs is to stop paying for it. It appears the sequestration has proved me right. If we simply stop paying for care, costs will decline.

Over my decade of experience, I have seen implementation of ORYX measures and SCIP requirements and never events that are, well, never mind. There are the MCCs and CCs and MS-DRG. There are the RAC audits and 30 day readmission penalties. There are the bundled care and accountable care programs. Plus, don't forget about the patient satisfaction penalties and a soon to be mortality penalty too. We've also got PQRS and E/M rules that turn honest physicians into criminals by default and despite all this noise, we still take care of patients.

But, no matter how well the rules are learned and how well the game is played, the house always wins. They control the money. If hospitals and doctors want to continue getting paid by the Medicare National Bank, they have to accept the consequences of their decision to play by the house's rules. It means 74 minutes of critical care and a total knee arthorplasty and a heart catheterization will all be worth 2% less on April 1st than they were on February 28th, 2013.

How private practices plan to absorb that cost is something only they can determine. Will they reduce their own costs? Will they delay capital expenditures? Will they reduce labor expenses by freezing wages or reducing benefits? Will they fire staff and place a greater burden of work on remaining employees? Will they increase health care deductibles or reduce 401K contributions for their employees? Will the doctors eat the costs and take home less pay?

Will practices attempt to increase revenue? Will they start charging patients for phone calls? Will they collect handicap parking application fees and charge for FMLA paperwork? Will they start collecting a 2% sequestration penalty fee? Will they charge for parking? Will they start selling vitamins and supplements in their office? Will they order unnecessary lab to boost ancillary services? Will they recommend unnecessary surgery to save their bottom line? Will they implement a concierge option and slowly but surely squeeze the Medicare patient out of their practice?

How will hospitals survive? Hospital profit margins have been negative for the better part of a decade. Billions of dollars have disappeared in an instant from operating budgets. How about all those hospital owned physician practices and all those teaching hospitals who need money to pay their residents? Who's going to eat that cost? The sequestration cuts are certain to wreak havoc on hospitals that can least afford the cut. Inner city systems will struggle and many hospitals may close.

What effect will sequestration have on hospitalists? That's hard to say. Much of our value comes from our ability to learn the system of sticks and carrots. We create efficiencies, reduce length of stay and play the revenue optimization games. Will compensation for hospitalists suffer under sequestration? That's hard to say. My gut instinct says no. We are still a growing field who's services are high in demand. The market is speaking loudly of the value we provide. If anything, I think sequestration places a continued demand and a rising premium for our service as a means of maintaining margins in this declining revenue scenario. In other words, our cost is the lesser of two evils.

The sequestration cuts should be a wake up call to all hospitals and physicians. Medicare and Medicaid are sinking ships without a captain. They are lost in a sea of debt with no dock to anchor at and the tough decisions that must be made are being ignored. Who's going to survive the Medicare axe? Those who are well prepared for life without their government cheese. If Washington can do it once, I guarantee they will do it again. Another day. Another poker hand. Another sequestration.

How To Dispose of Medical Waste? Take It Home and Frame It! (Picture)

2013-02-20T14:48:00.000-06:00

I'm not sure what to think of this. A reader sent me a picture of their professionally framed gallbladder they saved after having it surgically removed for cholelithiasis. As far as I'm concerned, it's medical waste. Heck, it's wrapped in plastic and even has a biohazard danger sticker attached to it! We can't eat or drink at the nurses station, but patients can take their formaldehyde infested cancer causing medical waste home with their discharge papers? It says, "CAUTION, CONTAINS FORMALDEHYDE". That looks like a warning to me! I'm just waiting for the day a hospital gets sued for giving a patient cancer in the name of patient satisfaction. Oh, wait, we do that everyday with our patient satisfaction scans.

If you ask me, this guy must have been stoned when he did this. Or maybe he just bagged his common sense when he decided to hang toxic medical waste as a show piece in his living room. Why not just let the hospital dispose of it like everyone else? Let's think about the possibilities, shall we? Perhaps he's part of a growing movement of environmentalists trying to reduce their carbon foot print by keeping their medical waste from ending up in the local landfill. I don't know how common it is for people to request their own body parts or other waste after surgery. For some folks, saving their surgical waste might be a fetish. Remember, there are folks who like to cut off their balls. Heck, this might even be a reality TV series some day. For others, it might be the cool factor. And for others yet, they may want to keep their body parts for religious reasons.

I heard a story once about an elderly woman who had to have both of her legs amputated after a freak car accident. She requested both her legs be given back to her after surgery so they could be placed in the coffin with her body upon her death. Where do you store human legs while waiting to die? Why, with the leg-of-lamb, of course. What was the reason for wanting to keep the legs? She wanted to make sure she had a leg up on everyone once she got into Heaven. Personally, I suspect she wanted to make one of those leg lamps from the movie A Christmas Story.

As for our guy with the gallbladder, whatever his motivation for saving his toxic organic waste, you have to admire him for being bold. How many of you would frame your sack for all your friends and family to see?

Baby Lion Cubs Playing at Omaha Henry Doorly Zoo (Picture/Video)

2013-02-14T14:11:00.000-06:00

Mrs Happy and I took a stroll through the Omaha Henry Doorly Zoo yesterday and had an opportunity to check out the five new baby lion cubs on exhibit in the Cat Complex. These newborn kitties were born December 29th, 2012. These six week old cubs were so fun to watch with their playful innocence. It's hard to imagine how ferocious they may be become when they're all grown up. We stood there with a bunch of moms and dads and kids watching them roll around and claw at each other.

The adult lions were off in the corner doing their own thing. One female lion would occasional peak over and check on things. It was pretty cute to watch. Here's a YouTube video below I took of the five baby cubs running around and playing while two female adult lions look on. I'm not sure which is the mother or if these cubs will have a two mommy family.

I wonder what it would be like to be the lions behind the glass staring back at all the humans gawcking at you. Do you ever wonder what they're thinking? Perhaps, "Leave me alone"? Or, "There's nothing going on here. Feel free to go checkout the monkeys". We'll have to make a special trip back to the Omaha Zoo to check up on these little guys.

On a more serious note, I am concerned one of the adult males ate a zookeeper . I was able to snap an incredibly close up picture of the male lion with its big mane when it came right up to the glass. I've never had such an amazing close encounter with a lion. I was surprised at how content it was.

Until it turned around and I realized there was a hand sticking out of its bottom end. We were all petrified to see such a horrible thing. I'm shocked none of this has made the national news. I don't know who it was. I just wish I could have lend him a hand. But it was too late.

Sterile Water Irrigation Denied By Insurance. Patient Not Sterile Enough.

2013-02-08T11:54:00.001-06:00

I feel bad for our patients.   Insurance economic algorithms are defining the patient and doctor experience regardless of situations unique to the patient experience. If our recommendations as physicians or your needs as a patient do not comply with your insurance company's economic algorithms, you and your physician will likely get denial of care letters. That means hours of headaches and delayed therapy for you and hours of headaches and uncompensated expenses for your physician's office in communication with your insurance company. It is no wonder many offices have started charging patients for their busy work.

That denial of care can come in the way of preauthorization headaches. I experienced that tragedy while trying to authorize a lidoderm patch for a patient of mine that was getting great pain relief in the hospital. That patient was denied coverage for the patch as an outpatient. We too have experienced the frustration. Mrs Happy was recently at Walmart. She learned our Blue Cross Blue Shield insurance would not authorize coverage on her medication refill required for our 9 week baby pregnancy related care last week because she was two days early to pick up the prescription..   That's right folks. BCBS algorithms are denying care to our unborn baby because Mrs Happy is too compliant with her therapy.

CMS would be thrilled at Mrs Happy's actions!    They actually have a program in place to track how compliant you are with your medication adherence. You think big brother isn't watching? Think again. This information will be used against you when the time is right. Follow this link for the crazy details.

If you need outpatient radiology imaging such as MRI or CT or ultrasound, more than likely your insurance company will require your physician's office to obtain preauthorization. Every insurance company is different. One algorithm may allow the scan while another may deny it. That formula will change from year to year and from company to company.    Some medications will be covered, some will not. It changes from year to year and from company to company.

Medicare wants hospitals to make our patients happy. They care so much about our patient's hospital experience that they are withholding money from hospitals that don't win the patient satisfaction game. We could spend hundreds of thousands of dollars a year training staff to be nice, but if a physician writes an order for that Lidoderm patch and the patient can't fill it, they aren't going to care about being AIDETized.

Then there's this patient below. They most certainly aren't going to give my hospital glowing patient satisfaction scores after experiencing a devastating denial of payment on their sterile water irrigation solution script. The insurance company said it wasn't on their formulary. More likely, I suspect the algorithm denied payment because the patient wasn't sterile enough to benefit from sterile irrigation.

The same insurance company that will pay $100,000 for seven smoking related COPD readmissions has decided to deny their patient insurance benefits to sterile water. In fact, I guarantee if this patient came to the ER saying they needed to be admitted because they couldn't get access to sterile water, I would bring them in under observation care just for spite. At least then they could get their sterile water irrigation flushes with a diagnosis of rule out lack of access to sterile water irrigation flushes and they will pay $3000 a day for the right to do so and I will get paid form my highly complex level 3 observation history and physical.

Denying sterile water irrigation flushes. This is what our life as doctors and patients have become. And it's only going to get worse from here. America has spoken. They are getting what they asked for. Algorithms rule our health care decisions. More and more decisions are going to be made based on computer models and actuaries. ObamaCare says we can't deny care based on preexisting conditions. From where I'm sitting, there's plenty of denying going on.   One solution is to stay healthy, exercise, don't smoke and hopefully you can live a long and happy life away from this madness. For the rest of you, you had better plan on saving lots of money to pay your physicians extra.   It's only a matter of time before patients who can afford to pay extra do and those that can't will be denied.

External Condom Catheters For Men Reviewed: Girth and Length Analysis!

2013-02-03T14:36:00.000-06:00

Placement of a urinary bladder catheter comes with the territory for many hospitalized patients. Indwelling Foley catheters are often inserted through the urethra and into the bladder of men and women. An internal ballon is then expanded to prevent the catheter from falling out. These catheters have an appropriate role in the management of some hospitalized patients. Bladder outlet obstruction and urinary retention require internal bladder catheters to manage the problem. Sometimes the catheter is the cause of the problem. Here is an example of bilateral hydronephrosis from a Foley catheter.

Too often, hospitalized patients get indwelling urinary catheters ordered out of convenience, ignorance or because that's the way the doctor has always practiced. Patients or nurses may request them and doctors may order them for any number of reasons, some appropriate, some not. Far too often, these catheters get placed and forgotten. Many hospitals have implemented policies and procedures to reduce the incidence of prolonged catheter placement and the complications that are sure to follow. The best way to prevent a complication of an indwelling catheter is not to place one. Catheter related infections and hematuria due to catheter trauma are just two of the many bad outcomes.

What can hospitals do to limit complications from internal bladder catheters? Some hospitals think outside the box and use external catheters instead. For men, these external catheters are called condom catheters. Don't worry, I have verified these condom catheters are Catholic compliant. They are placed just like a condom. No more concerns about bladder infections. No more concerns about traumatic clots inside the bladder. No more concerns about dirty old men having unprotected sex in the hospital. Just place a condom catheter on them and be done with it. Or at least until they pull it off 32 times a day and ask the nurse for help putting it back on. I guess Uncle Eddie isn't so demented after all.

How do these condom catheters work? What about their length? What about their girth? Surely, one size does not fit all. So many questions, yet so few answers. I did what any hospitalist would do when they have free time on their hands. I commandeered the condom catheter directions for my review. Boy, was that a shocker. These things are definitely not one size fits all. Below are a couple of pictures from the folding insert, complete with directions, a 20 cm ruler (8 inches) and a girth sizing guide for the Coloplast Conveen® Optima external condom catheter. For best results, I suggest you follow their advice. I have provided a summary of their recommendations here as a public service announcement. If you ever find yourself hospitalized and need a urine capturing device, and a nurse calls you sport, I recommend you give them all zeros on your patient satisfaction scores.

Step 1 Prepare Skin: Make sure the skin is clean and dry, free from oils and moisturizers. A protectant wipe may be used. If necessary, trim pubic hair.

WOW! I don't know how many nurses or men can ever get past step one. A clean and dry penis in a 90 year old nursing home patient? Oils and moisturizers? What kind of nursing how is THAT guy staying in. And trimming the pubic hair? I'm sure nurses didn't graduate from nursing school with pubic hair trimmer expert in their job description. Certainly, hospitals MUST be considering a pubic hair trim as an add on amenity worthy of extra revenue.

Step 2 Size: Use sizing guide to measure circumference and length to determine correct catheter. Four circumference sizes are available in STANDARD length and four circumferences sizes in SPORT length for short/retracted shafts.

WOW! Call me crazy, but I'm certain becoming an expert in measuring penis girth was not an elective in nursing school. It's great that Coloplast has the girth and length measuring device available, but I think their good intentions may have unintended consequences. I can see it now, patient and nurse arguing over which girth size to pick. Don't even think about telling him he's a sport. You'll crush his manhood and force me to consult a psychiatrist for suicidal thoughts. Way to go Coloplast. Maybe these condom catheters aren't such a great idea. "Oh, to be 20 again..."

Step 3 Open it. Ok, easy enough.

Step 4 Apply the Catheter: Place the catheter on the head of the penis, keeping a 1/4 to 3/4 inch gap between the penis and the outlet tube. Hold the catheter in place with one hand, while gripping the double strip pull tab with the other. Then pull the double strip pull-tab, slowly un-rolling the catheter towards the base of the penis. Gently squeeze the catheter around the shaft of the penis for a few seconds to ensure adhesion.

OH MY! There goes my length of stay and 30 day readmission rate. With service like this, my patients will never want to leave the hospital.

Step 5 Leg Bag: Connect the catheter to the urine bag.

Step 6 Removal: Catheter should be exchanged daily.

Perform steps 1-5 daily to ensure great patient satisfaction scores! Expect longer lengths of stays and higher 30 day readmission rates as we trade excellence in one measured outcome for another.

I do have one suggestion for the folks over at Coloplast. I recommend you offer these condom catheters in an assortment of colors and designs. Think about it. How many crazy old men love their hunting. Camouflage condom catheters to the rescue. Since they haven't felt anything in the last 20 years, you might as well help them make it disappear. Favorite football team? The Chargers? The Jets? The Giants? The Packers? Come on. Offering an upgraded football catheter is a gold mine for you and your client hospital's amenity of services. Keep your marketing team active and we'll all get to WIN-WIN.

Gram Positive Cockeye vs Cocci Explained.

2013-02-01T08:27:00.002-06:00

Here's a letter I wrote to the National Academy of Nursing Vocabulary last week regarding my concerns about an epidemic of gram positive cockeye sweeping our hospitals. You think the flu was bad this year? You think C diff is bad. You have no idea how aggressive the cockeye has been.

Dear Academy,
I have been a practicing hospitalist now for ten years. I want to commend your organization's mission to improve nursing vocabulary. Helping nurses achieve proficiency in medical terminology is important for doctor-nurse and nurse-nurse communication of critical patient information. Quite obviously, some nursing schools do not make this a top priority. Your contributions to the field of nursing are important in many regards. I rarely hear mispronunciation of meto-pro-lol or at-in-ol any more. I understand your nursing organization has made an aggressive push into the field of cardiac pronunciation. Your efforts do not go unnoticed. You have nipped these mispronunciations in the bud.

However, I feel you have failed miserably in the field of infectious disease. I continue to experience grave concerns regarding correct pronunciation in the transfer of critical blood culture notification results from nursing staff to physician staff. I have specific concerns about gram positive cocci (pronounced kok-sahy). There should be no debate about pronouncing gram positive cocci. Unfortunately, patients and doctors have experienced grave harm when nurses inform doctors their patients have the cockeye instead.

When I tell my patients they have cockeye they look at me with shock and horror. I've had a few patients slap me silly. I apologize and tell them they must have caught cockeye from their nurse. In my decade of hospitalist medicine, I have been assaulted numerous times and faced dozens of lawsuits from patients claiming they got hospital acquired cockeye. Families are angry. Patients are scared. They want answers. Unfortunately, I have to tell them the only treatment for their gram positive cockeye is more aggressive intervention by national organizations like yourself. Unfortunately, that process takes years and they don't have years. Telling patieints they have gram positive cockeye in their blood is a drag on patient satisfaction and disrupts the trust patients have in medical staff. I believe your organization should make correct pronunciation of gram positive cocci a top priority for 2013.

Respectfully,

Happy

With that said, I once had an unexpected response from a 95 year old lady. When I told her she had cockeye, she thanked me for the opportunity to experience cockeye one last time before she died of unnatural causes at the hands of her cocci infested doctors.I think this medical someecard summarizes this epidemic of hospital acquired tragedy.

Hospitalist Wingman Response: GOMERology as a New Subspecialty.

2013-01-24T12:49:00.000-06:00

I have been a practicing hospitalist now since 2003. In that ten years, hospitalist medicine has been the fasting growing medical specialty in America. Our tentacles run deep and they run far. We offer incredible value, directly and indirectly, in the delivery of hospital based medicine. We are maturing as a field and we shall continue to define our role in the constantly changing Medicare landscape.

Hospitalist medicine even has its own focused maintenance of certification board exam. I believe this vindicates the field as a stand alone specialty. However, just as it took a decade to divide internal medicine into an inpatient vs outpatient experience, a great divide is occurring within the field of hospitalist medicine that is spilling over into the field of emergency medicine too.

I present to you the fastest growing subspecialist in hospitalist and emergency medicine: The GOMERologist. That's right folks. You heard it here first on The Happy Hospitalist. Mark your calendars. In ten years, the fields of hospitalist medicine and emergency medicine are going to offer a combined subspecialty board in GOMERology. I sat for my internal medicine boards late last year and rocked them solidly. Ten years from now I am going kill my GOMERology boards without even lifting a finger.

Emergency Medicine News recently published an article by Dr Edwin Leap titled Second Opinion: The Hospitalist's Wingman. Dr Leap eloquently described the fraternal relationship hospitalists have with emergency medicine physicians. We are the last men and women standing in a rapidly collapsing health care financial tsunami coming our way. He feels our pain. We feel his pain. We are the poster children for it hurts all over.

The Baby Boomers are here and they aren't going away. They're getting older. They're getting weaker. They're getting too old to go home from the ER. As Dr Leap astutely points out, they see the GOMERs first. We are their wingman to get them out of the emergency room. Us hospitalists are not alone in our on the job training to become experts in managing suboptimal wound care orders and strange tube feed regimens that pepper the nursing home landscapes of America. Excuse me, I meant skilled nursing facilities (SNF).

We are in this together. The old are getting older and the younger generation is too busy sharing the latest cat picture on Facebook to jimmy rig their basement bathroom with handicap toilet bars for grandma and grandpa to live out their final decade of life with family. Nope, they have Medicare and the three midnight rule, which if played correctly, will provide decades of fraudulent nursing home care on the backs of half the tax paying American public who are stricken with such difficult life decisions about whether to pay the cable bill or the data plan on their smart phone that is 2 months overdue.

Every year that passes in my tenure as a hospitalist, I admit more and more GOMERs to the hospital. I work feverishly to maximize their intensity of service and create complexity where none exists, all in an effort to qualify this Medicare beneficiary for their three midnight stay and a 100 day ride on the Medicare National Banks' merry-go-round of life. You see, it's not good enough anymore to be a great doctor providing great care. What hospitals really need these days are experts in optimizing the game of Medicare 2.0.

What better way to process old people in the ER than to combine emergency medicine's expertise in initial point of care contact with the GOMExpertise of hospitalists who excel in this madness consuming inpatient medicine. In a few short years emergency medicine physicians and hospitalists will have the opportunity to combine forces as expert GOMERologists to provide care for Medicare patients that are too wrinkled to see or too crooked to stand. GOMER patrols promise to revolutionize the delivery of hospital based nursing home care forever.

Ten years from now I can see myself working full time from home as a GOMERologist, using our MARTI translation system to personally speak GOMER with my patients to complete my 10 point review of systems and physical exam. I'll even get to fill out my prepopulated level three hospital followup electronic progress note template while drinking a pot of coffee and watching cartoons with my kids.

Subjective: ROS and HPI unable. Patient is a GOMER
Objective: VSS--see EMR
Head: Looks normal
Eyes: closed: Exam unable
Mouth: Q-sign present
Neck: No JVD
CV: Chest wall motion means blood is flowing.
Lungs: Normal chest wall movement.
Abdomen: Constipated
MS and skin: Both are present
Neuro: Arms flailing
Psychiatric: Crazy
Assessment: GOMER: Too weak to go home with major complicating condition of too old to order telemetry.
Plan: Q 4 hour neurochecks, IVFs at 125 cc/hour. IV vancomycin in case there is infection. Blood cultures to verify presence of blood flow. Qualify for 3 midnight SNF stay and discharge when nursing home has a bed next month. Reviewed case details with RN.

Hey docs. Yeah you, the ones that mock hospitalists and ER physicians as beneath your skill set . Our day has arrived. Who's laughing now. If only you knew just how great a life you could have as a GOMERologist, submitting 100 E/M charges a day from the comforts of your own home. We're livin' the American dream! Someday you're going to be a GOMER too. When that day comes, you're going to thank us for our skills. This hospitalist someecard helps explain.

Incidentalomas Explained With Case History and someecard Humor.

2013-01-21T08:22:00.000-06:00

Turn on the television these days and it's impossible to escape news stories describing breakthroughs in cancer diagnosis and treatment. Excluding squamous cell and basal cell cancers of the skin, over 1.6 million Americans were diagnosed with cancer last year. This cancer.org file has some great graphics and up-to-date data on America's cancer statistics from 2012. Unfortunately, I believe our cancer societies have failed to properly recognize the biggest threat to public safety since the invention of the doctor. What might that be, you ask? Incidentalomas. I searched the entire pdf file linked above and I couldn't find a single reference to this kind of tumor. What is an incidentaloma? Wikipedia has a nice review on the rapid rise in prevalence of this tumor. Here is their definition:

In medicine, an incidentaloma is a tumor (-oma) found by coincidence (incidental) without clinical symptoms or suspicion.

What does that mean Wikipedia? No clinical symptoms? No suspicion? Suspicion of what? This sounds like a conspiracy theory to me. Not to mention, what is the patient supposed to think about all this?

ER: Hi ma'am. Remember that CT scan you demanded we get? It shows you have an incidentaloma.
Ma'am: An incidental what?
ER: An incidentaloma.
Ma'am. Did my boyfriend do this to me? I'm going to kill him!
ER: No ma'am. It's not his fault.
Ma'am: Who's fault is it?
ER: It's a tumor, ma'am. Nobody gave you this tumor.
Ma'am. Are you saying I have cancer?
ER: No. It's not cancer. It's benign. At least I think it is.
Ma'am: You think it is?
ER: You know, in medicine, nothing is 100% certain. Would you like us to stick a needle in it just to be sure it's not cancer?
Ma'am: I came in here by ambulance saying I had chest pain so I could get through triage and get my free pregnancy test with my Medicaid card and now you want to stick a needle in my lung? What's wrong with you?
ER: I take that as a no.
Ma'am: I'm taking my tumor outa here and going to MickyDs.
ER: If there's anything I can do to make you happy before you leave let me know. My job is to make sure I get great satisfaction scores for me and my hospital before you leave. Would you like a free coupon to the Golden Corral?

I am ashamed at our cancer societies for not recognizing the incredible physical and mental burden incidentalomas are causing Americans. It's time to include these tumors on all their fancy charts and graphs. These tumors are a cancer of our soul. In fact, I recently read a discharge summary on a patient of mine who visited the Mayo Clinic. That's right. The Mayo clinic. There it was. Discharge diagnosis #5: Left adrenal mass incidentaloma: No further work up necessary. I suppose if the resident at the Mayo clinic isn't worried about incidentalomas, I shouldn't be either. But, try being the patient with the tumor. All they hear is, "I have a tumor". Try going through your life with that nagging feeling that maybe the doctor isn't right. Maybe it is cancer. Maybe I should get a biopsy.

Many doctors reserve use the term incidentaloma to describe tumors that are benign non-issues. Why? If your doctor found a tumor incidentally and it looked malignant and they recommended further workup, they want to take credit for finding it. There is no coincidence in these cases. These tumors were not found incidentally. Your doctor is the best doctor in the world for finding your cancer when nobody else could.

Why are incidentalomas being diagnosed with such frequency? The rapid rise in advanced radiology imaging has lead to their discovery. Every CT scan patients demand or physicians order to rule out a diagnosis, however unlikely, risks finding an incidentaloma. Once this diagnosis is made, physicians and patients must go through painful decisions and wishy-washy informed consent to decide what to do next.

Should that spot on the lung be biopsied? Should that tumor in the adrenal gland be ignored because it's just an adrenal incidentaloma? Should that asymptomatic pituitary tumor undergo a transsphenoidal biopsy (sticking a needle through the nose into the brain) just to be sure it's not cancer?

The more scans we order, the more incidentalomas we are going to find. Should these tumors be ignored? Should they be followed through time with highly radiating CT scans that will surely cause cancer that makes the charts and graphs in the future? It's times like this I'm glad I'm a hospitalist who can write an order to:

Follow up with PCP regarding incidentaloma. No inpatient workup indicated.

Wong-Baker Faces Vs Pain In My Ass Rating Scale Reviewed.

2013-01-15T10:56:00.000-06:00

Neither medicine nor nursing is practiced at the bedside anymore. Charting has consumed our professions. Charting is the act of writing and documenting patient care details. Do you want to know where your doctor or nurse is? More than likely, they have their heads buried in a computer somewhere far away from your every need.

You're having pain, you say? Your call light is going unaswered, you say? Don't worry, your nurse is probably at the computer down the hall charting your Wong-Baker Faces Pain Rating Scale. If you've ever been admitted to a hospital, I'm sure you've seen these cartoon-like facial images depicting pain and a number associated with that level of pain. The scale offers a number from 0-10 with zero indicating no pain and ten meaning "hurts worst". For the general public, please note the scale ends at ten. If you say you have 12/10 pain, your electronic charting will spit out a value of not acceptable (N/A). Nurses have been instructed to treat N/A as 0/10 pain.

I'm sorry Mrs Wong and or whomever you are. Your pain scale is irrelevant into today's excessive charting environment. Nurses just don't have time to care about answering their patient's call light in a reasonable amount of time. They don't have time to provide bedside pain scale evaluations that your organization is so proud of. They are too busy trying to figure out the newest change of the week in their EHR.

So, what's important for nurses to know and to document these days? I present to you Happy's Pain In My Ass Scale. Nurses don't care if their patients are having pain. During nursing checkout, they want to know from their colleagues if their patient is going to be a pain in the ass today. So I've created a proprietary new pain scale for use by nurses, for nurses to help them summarize how their day is going to be.

How does the Pain In My Ass Scale work? In the interest of robotic Joint Commission standards, I offer only two possible scenarios. Nurses should chart a 0 if the patient is not a pain in the ass. Nurses should chart a 10 if the patient is a pain in the ass. By charting this vitally important 5th vital sign, nurses can emotionally prepare for their tough day in the trenches. Go forth great nurses. Help your fellow nurses prepare for their day by always charting your Pain In My Ass Scale, as this original Happy someecard helps explain.

Hospitalist Charge Capture Daily Rounding Cards (With PQRS).

2013-01-15T08:13:00.001-06:00

I've been a hospitalist now for ten years. In those ten years I have continued to use a manual process for capturing patient billing information during daily rounds. These cards contain all the information necessary to generate payment claims from Medicare and other third party insurance companies. Over the years the cards have changed to add or remove elements required to receive payments and stay in compliance with third party payers. These cards fit nicely into our scrubs or white coat pockets.

I know many organizations have moved to real time submission of daily rounding charges to their billing company. I have seen a few smart phone applications out there that allow physicians to provide bedside charge capture with immediate transmission to their billing company or staff. In addition, some EHR products provide algorithms that provide physicians with the correct CPT code and electronic transmission of the charges in real time. This software and the fees that come with them can be quite expensive. As a group, we have continued to use our billing and coding cards as a manual physician data entry process that is scanned to the billing company for claims processing.

In my five years at The Happy Hospitalist, realized I have never given the general public a sense of how complex every single patient encounter is from the insurance side of daily hospitalist rounds. I'm not talking about how to choose the correct CPT® code to submit for each and every patient encounter. That's an entirely different topic for discussion. For that I created a bedside E/M reference card to help me stay in compliance with complex CMS billing rules.

I wrote this article to show the public how complex the business side of medicine is for every single encounter we generate and how we have chosen to organize all the necessary elements of a daily encounter, including CPT® codes, ICD codes and the PQRS elements. We created these cards in house. Through trial and error, we have found a layout for our daily charge capture card that works with great efficiency and accuracy.

Many physicians who don't do their own charge capturing do not appreciate how complex this process is. I have provided below our most updated daily rounding charge capture cards currently in use for 2013. Each component is described below. This is the present state of American medicine. Physicians must comply with this process thousands of times a year with every patient encounter to get paid for the work they have provided. The first card is the side scanned to our billing company on every patient. The second picture is the backside of the card used only as a reference for physicians to determine the correct information to submit. See, you didn't just get a $90 out-of-pocket high deductible copay from doctor to tell you there is no treatment for you cold. You got a $10 opinion and an $80 bill to pay for all this madness.

Room number. Where is the patient at? This information is not necessary for getting paid, but can be helpful for our colleagues at times. Most of the time though, we'll use our hospital generated patient census to find you.
Code status. Do you want to be resuscitated in case your heart stops? Again, this information is not mandatory but is helpful to know if all heck breaks loose. Many hospitals have no hospital wide standard for capturing accurate information for the patient record.
Patient information. This is were we place our patient sticker with that contains the patient's name, hospital ID numbers and date of birth necessary to submit payment to third parties.
Site of service. I work at two hospitals. This information lets us and the billing company know which hospital this service was provided at.
Attending or consultant. This information is helpful to know whether we are required to provide the discharge summary. The discharge summary is provided by the attending physician or their representative. I don't know what effect this has on getting paid.
PCP and referring physicians. We use this information to internally track who our referring physicians. This information is also helpful to know who to contact on discharge when patients leave the hospital and whom we should send our discharge summary.
Diagnosis. We have 13 lines to provide our diagnoses. These are the ICD codes. It's a free-for-all here. Most physicians have never been trained in ICD coding, including me. I'm sure 90% of my codes make no sense, forcing some coding person is trying to decipher what I write to the nearest applicable ICD code. I can't wait for ICD-10.
More lines for diagnosis. Yes, sometimes we fill all the lines, and more.
PQRS ICD codes. These are the ICD codes we have chosen for our PQRS program. There aren't a lot of PQRS measures applicable to hospitalist medicine, but we have found these ICD codes capture the intent of our PQRS process. In 2015, if physicians have chosen not to participate in PQRS, they will be penalized 1.5% of all Medicare charges. This penalty will be based on 2013 PQRS data. These ICD codes are linked to the CPT codes in line 13, when applicable, to remain in compliance with PQRS requirements.
Time of referral. We use this information to understand the busiest times of day for new encounters. Medicare does not pay more for a 2 am admission, but your plumber will. This is helpful for creating staffing solutions for our hospitalist program.
Date of service. This information is mandatory for generating claims.
Doctor providing service. This information is mandatory for generating claims. We use a number system to define the doctor. It's much shorter than writing out all the names. We hand over our cards to other doctors when we go off service so there may be more than one doctor with billing information on one card. We trust each other not to lose the cards or change our billing information.
Diagnosis for that visit. This is where we write the number of the diagnosis (#7,8) to link the ICD code to our CPT code (#14). These are mandatory for claims submission. I usually pick the four most important ICD codes for my visit and write them here, even though I may manage 18 different issues during an encounter. We don't get paid based on how many ICD codes we write and I believe Medicare carriers only allow up to four ICD codes to be submitted during the claims process.
CPT code number. All these numbers here are the CPT codes us doctors choose that we believe accurately reflects the level of service we have provided and that our documentation supports. The CPT code determines how much the doctor gets paid for that day's visit. It is the most important part of the whole card. Physicians should learn how to choose the correct code every time. This code is mandatory for claims submission.
CPT code description. These are the general descriptive categories of our CPT codes.
PQRS explanation. Here, we are attempting to help the physician define which ICD code to use with which PQRS G code. PQRS codes only apply to certain ICD codes. Certain PQRS codes only apply to certain CPT codes. Got it? Yeah, us too.
PQRS G codes. This is the actual code we need to choose for our visit. Just pick one for each PQRS measure. Got it? Make sure you pick the right one!
CPT options. Here we attempt to describe what the options are for our CPT codes (#14). Please pick the correct code doctor. We don't want you being accused of fraud.
Admit/Consult/Discharge codes. We have elected to pull out these CPT codes from the above madness to allow more clarity for us and our billing company. As you can see, these codes require all the same elements of our daily rounding. But remember, Medicare does not recognize consult codes anymore. I know, it's too complicated.
PQRS for admit/consult/discharge codes. This is self explanatory.
CPT codes for additional procedures. We use this as reference for the CPT codes of additional procedures we may provide that aren't listed on the front of our cards. There just isn't room for everything!
In depth PQRS descriptions. For our reference to decide which correct PQRS code is required.
I have no idea what this is.

Any questions?

Hospital Pet Policy? Yes, You Can Bring Your Dog To The Hospital.

2013-01-09T13:33:00.001-06:00

Over the last few years as a hospitalist I have had the honor of meeting some mighty fine service dogs in the hospital. These amazing animals bring an incredible sense of happiness and independence to their chronically debilitated masters. It's not only trained service dogs that bring such joy. I've seen some amazing family pets, mostly dogs, brought to the bedside of the healing patient as well.

I'm a dog lover. We call our Italian greyhounds, Marty and Cooper, our little angels! If I ever found myself sick enough to be in the hospital, I would hope my little pups would be allowed to visit me during my stressful times. That begs the question to be asked? What does your hospital pet policy say? Can patients bring service dogs or other family pets to the bedside for some comforting animal assisted therapy?

That was a question I found myself asking the other day. I know I'd seen pets in the hospital during the course of my normal work, but I'd never taken the time to understand what my hospital policy was. What if a patient asked me about our policy for allowing pets in the hospital? I found myself searching for answers.

Some facilities may balk at the thought of allowing entry of pets into the hospital. These folks don't understand the comforting power of pet therapy. In fact, many hospitals offer animal therapy with designated dogs and their trained volunteers. Should all pets be allowed into a patient's room? Should only pets with proven immunization records by allowed entry? Should size be a factor? How about potty training status. These are all reasonable questions to ask when introducing a family pet into a patient's period of recovery.

I took this time to review the pet policy at my own institution. The first introductory paragraph detailed all the added benefits of allowing animals into the patient's healing process, noting that studies have shown improvement in patient cardiovascular parameters, muscle rigidity, social interaction and psychological well being. My hospital went on to define three specific scenarios of having animals in the hospital. These were:

Animal Assisted Therapy (ATT), defined as a goal directed intervention involving a skilled handler and a trained animal to provide a therapy used to help the patient heal.
Personal pet visitation, which I think is self explanatory.
Service dogs, which are animals trained to provide assistance to disabled patients.

I presume animal assisted therapy involves organized pet therapy interventions. These are the animals I have seen over the years. As for the service dogs, some students have sued their University, and won, when their school refused to allow them to have their family pet in their dorm room. These students filed a lawsuit under the Americans with Disabilities Act (ADA) by claiming their dog was necessary for their emotional well being. The court agreed and provided students an opportunity to bring their family pet with them if they had physician documentation supporting this mental health need.

What about pets? Should hospitals allow visitation rights to any family pet? What are the restrictions or requirements? It's an important topic to review. Many patients may find allowing their pets at the bedside to be a great patient satisfaction issue. With Medicare reducing payments to hospitals that fail to keep their patients happy, I suspect most hospitals will allow families to bring pets to the bedside.

Unfortunately, many doctors may not be happy having pets around their post operative site. The way I see it, many patients go home and physicians have no control over what their pets do. Many patients have been around their pets for years and are not at risk of contracting a communicable disease. In fact, I suspect, patients are more likely to get a surgical site infection from doctors and nurses who don't wash their hands than they are from a family pet. Many nurses may not want a pet in the room disrupting their work flow.

As a pet lover and believer in the value of pet therapy, I was happy to see my hospital allows pets at the bedside, with some reasonable restrictions, including:

The pet must be accompanied an adult who will take responsibility for the pet. I said responsible adult. Remember that.
Pets will be limited to dogs, cats and rabbits, to the exclusion of amphibians, birds and non-human primates due to the increased risk of disease transmission. That means you have to leave your pet monkey at home.
Pets should not be near the beside of neutropenic patients, undergoing solid organ transplant or bone marrow transplant, burn patients or critically ill patients. In my opinion, I think some family should not be allowed near them either.
Pet's must be housebroken. This rule does not apply to family, only the pets.
Vaccination records should be current. If you are an antivaxxer, please keep fido away from our hospital.
Animals must be well groomed and free of skin leasons, ticks and fleas. Again, I don't believe this rule applies to family members, but I might be wrong.
Disruptive and aggressive pets will be asked to leave. Disruptive patients and their families, on the other hand will be offered free meal tickets and a carton of cigarettes as arbitration. You know, to keep them happy.

In addition, I learned no physician order is required by me for my patients to be allowed visitation by their pet dogs, cats or rabbits. I think that's appropriate. I don't need to give the OK when rude, smelly, incontinent alcoholic Uncle Joe visits grandma in the hospital after her cholecystectomy.

I don't think my patients' dogs or cats are any more likely to make my patients sick in the hospital than they are at home. I have no control over their actions once they leave the hospital. Perhaps ObamaCare has given us a right to remove pets from the homes of our patients as a readmission prevention measure. I'll have to look into that. I think our failures in hand washing as doctors and nurses are more dangerous than any cute little puppy or kitty Mrs Smith can bring to the bedside. In fact, the next phase of ObamaCare mandates that all visiting pets achieve greater than 90% on their satisfaction scores as well. Welcome to the hospital Fido, can I get you a warm towel and some biscuits?

Got Sick From Flu Shot? No You Didn't.

2013-01-08T12:32:00.001-06:00

The 2012-2013 flu season is turning out to be one of the worst seasons I've seen in the last ten years. I started my professional hospitalist career in 2003. I remember the West Nile outbreak shortly after that. Everyone with a headache was getting a spinal tap to evaluate for viral meningitis. And then there was the 2009 H1N1 scare a few years ago that turned out to be a bunch of nothing in my neck of the woods.

I've seen a few cases of the flu during the winter flu season in years past, but nothing compared to what I'm seeing the last few weeks. Hospitals have been aggressively asking or forcing their employees and medical professionals to get their flu vaccine as a way of protecting the patients, a population especially at risk for complications from a hospital wide flu outbreak.

My hospital has achieved over 97% compliance this year with flu vaccination. The other 3% are being shamed into compliance as I write this. Being a doctor or a nurse at a hospital is great. We get our flu vaccines for free from highly professional nurses. Almost everyone who is a candidate for the flu shot and who hasn't decided to get one yet should strongly consider getting to their doctor or local pharmacy to get immunized quickly. In a couple of weeks your body will have a major advantage to protect you against all the crazy antivaxxers out there who are convinced vaccines will make them or their children sick.

Don't be stupid. If you get a reaction after getting the flu shot, it's highly unlikely the flu virus did it and more likely a preservative in the vaccine. Get a preservative free vaccine if you have to. I can understand your concern. A few years ago I thought I was having a major reaction to the H1N1 vaccine. I was wrong. Do whatever you have to do to get vaccinated this year and protect you and your family from the incredible burden of disease I am seeing in the hospital this year. Don't become my next patient. Don't watch your children die helplessly because of your warped sense of reality.

If you decide you don't want to protect yourself or your family from the flu because you are worried you read on the internet that people were getting sick from the flu shot, I am here to set you straight. Those people who say they got sick from flu shot vaccine effects actually had a raging case of that's the stupidest think I've ever heard, as this e-card helps explain. You can see all my original and not so original someecards on my Pinterest site. This is serious people.