All Entries Tagged With: "physicians"
Promoting efficient use of resources and appropriate hospitalization length of stay to physicians, a different approach
Physicians sometimes acquiesce to family wishes and desires and admit a patient for “social” reasons. On the other hand, a physician may keep a patient in the hospital an extra day because the patient expresses a desire to stay just “one more day.” These unnecessary, avoidable hospital days have a material effect on potential revenue loss for the hospital through denied days or denied hospital stays by third party payers.
A major challenge in motivating physicians to move the patient along the continuum is the disconnect between prudent hospital fiscal management and the practice patterns of physicians. The physician generally receives payment for his evaluation and management services regardless of whether the hospital is paid or denied for the patient care.
However, change is on the horizon. Medicare is currently considering provisions that will promote efficiency in the practice of medicine. Medicare and other third party payers are also committed to transitioning from physician payment based strictly on volume to payment based upon the relationship between quality, costs, and outcome. The efficiency and effectiveness of a physician’s practice of medicine will determine the physician’s financial welfare and business success.
Evidence of this impending change in reimbursement can be found in the General Accountability Office’s (GAO) report entitled “Per Capita Method Can Be Used to Profile Physicians and Provide Feedback on Resource Use.” This report is a must read. In essence the report concluded that it is feasible to use Medicare claims data to profile physicians on resource use, taking into account patient acuity through risk adjustment methodologies.
The report examined the following:
- The extent to which physicians in selected specialties show stable practice patterns and how beneficiary utilization of services varies by physician resource use level
- The factors to consider in developing feedback reports on physicians’ performance, including per capita resource use
- The extent to which feedback reports may influence physician behavior
The GAO focused on four medical specialties (cardiology, diagnostic radiology, internal medicine, and orthopedic surgery) and chose four metropolitan areas (Miami, Phoenix, Pittsburgh, and Sacramento).
Take this oppurtunity to educate physicians about the possible changes in the reimbursement model
The message is out!
Now is the time for case managers to become familiar with these eventual changes to the healthcare reimbursement model from a physician and a hospital perspective. This reimbursement model transition will not only drive out waste in the practice of medicine. It will also drive and promote a collaborative approach to healthcare delivery by using financial incentives.
Case managers should educate physicians on the need to collaborate with case management to move the patient along the continuum efficiently because physicians will receive reduced reimbursement for excessive resources.
Let the education begin.
Whiteboards help communicate across departments
Placing whiteboards at the foot of the patient’s bed was innovated by Planetree, a not-for-profit organization that works with hospitals to improve the patient experience and it has spread across the country. Unfortunately, in most hospitals whiteboards stand blank except for some flower doodling. That’s a shame because whiteboards are a fantastic way for departments to talk to one another and the patient about the plan of care in a simple, direct, way.
The intent of whiteboards is much more than simply identifying discharge dates and times. The whiteboard is meant as a means of communicating the plan for the patient’s day—what tests, what new procedures, and medications the patient can expect on a given day. Just think, different caregivers can walk into a patient’s room and in a glance see what the attending physician has prescribed for the day. For the patient’s benefit, information written on the whiteboard should be in layman’s language. Patients don’t know what NPO stands for.
Using the whiteboard as a means to inform everyone of the patient’s targeted discharge is example of making sure everyone is on the same page regarding progression of care plans for the patient. According to nurses and case managers I have spoken with, the feedback from patient families is consistently positive.
However physicians are not always excited about whiteboards. In one client hospital, physicians were annoyed and complained to the CEO when staff members started using whiteboards to write patients’ plan for the day and targeted discharge. He was seriously thinking of putting a stop to their use, but the physicians’ complaints were quickly over-taken by the number of complements he received from patients, families, and hospital caregivers. Even dietary and housekeeping staff members endorsed the practice. So, the CEO told the grumbling physicians to learn to deal with it….they are staying.
Does you facility use whiteboards? If so please share the ways you use them to communicate and how you handle HIPAA concerns.
Documentation requirements for critcal care services
Editor’s Note: This blog was originally posted by Melissa Varnavas, CPC, the associate director of the Association for Clinical Documentation Improvement Specialists, for the ACDIS Blog. Read the original post here.
In the July 23 issue of CDI Strategies, Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, offered a tip to help CDI specialists gain physician support for improved documentation in the medical record regarding critical care. In a subsequent e-mail, Gold added comments from his “guru” on physician professional billing, Paul Dickson, MD.
Here is the amended information:
Critical care does not include ongoing monitoring of a patient who has stabilized, regardless of how many organs have failed in the past, but have now stabilized, how many lines and tubes were inserted, or how many devices were instituted. When the patient is stable, it is not critical care.
Too many physicians, however, do not realize that we can bill:
- Critical care delivery by time increments for the first encounter
- Additional critical care when the patient crashes again
- A level three subsequent visit for noncritical care in addition to the critical care delivery on the same day
Any usual evaluation and management (E/M) service appropriate for services and documentation provided may be billed prior to a critical episode, but not vice versa. Consider the following case study.
A patient presents to the cardiac care unit after a coronary artery bypass graft. The patient is intubated with a left ventricular assist device still in place but is not active and receives low-dose dopamine for renal perfusion. The patient’s vital signs are stable with a little hypotension due to lack of vascular tone due to residual effects of anesthesia, however, it is easily controlled. The external pacer is in place, chest tubes are in place to underwater seal, and diluted urine is flowing through the Foley. A physician accepts the patient onto the intensive care unit (ICU) and performs an evaluation. The patient is not critically ill. However, the patient is on a respirator, and the physician manages that respirator. This may be ventilator management 94002-3 alone, and no E /M service may be billed with these codes.
In this case, the patient does not have acute respiratory failure. Writing the words “acute respiratory failure,” means a condition exists that involves the respiratory tree due to a disease process. If, indeed, the patient does have acute respiratory failure due to a disease process when he underwent the surgery, then it is appropriate to document that, if it still exists. If this is not the case, then the presence of the words “acute respiratory failure” will give the heart surgeon a black mark since the condition would be considered a complication of the surgery. [more]
The physician advisor: An invaluable resource
If your facility does not have a physician advisor, my recommendation is to get one. The physician advisor at our facility is great. Dr. Jim Chambers is very knowledgeable, not only in the field of cardiology, but he is quite knowledgeable in the area of coding. Dr. Chambers has spend countless hours educating and assisting our hospital billing department in establishing correct billing codes.
Documentation is key in obtaining the appropriate billing code. Physicians work hard taking great care of their patients, but what they lack is being able to document everything they have done for the patient and the outcomes. Outcomes are essential in the world of coding. For example, when a patient comes in with an abnormal prealbumin level, the physician treats this, but yet sometimes only documents that the patient has malnutrition. In this case, the hospital is reimbursed at the lowest level for malnutrition.
The stages of malnutrition are based on the prealbumin level, so the physician needs to document what level of malnutrition the patient is experiencing as there is dollar difference in the different levels of malnutrition. Our physician advisor has been working with our physicians to correct this. [more]
Medical necessity beyond screening criteria
An underlying foundation for case management is the practical and consistent use of commercially available screening criteria as guidance for initial admission patient status designation as well as continued stay determinations. I call your attention to the term “guidance” from the perspective of Medicare and the Recovery Audit Contractors (RAC).
In a RAC Special Open Door Forum held by Medicare on April 9th, several comments by Medicare representatives and RAC representatives, including the medical director for Health Data Insights, make it very clear that the screening criteria will not be used in and of itself to determine medical necessity or lack thereof for inpatient hospitalization. Consider the HDI medical director comment regarding his organization’s application of screening criteria in the medical necessity determination process:
“We follow CMS guidelines which are that these different products are guidelines. They’re not conclusive for a decision to or for a finding or not a finding. We have contracts with both Milliman and Interqual and intend to use those along with clinical review judgment and of course, first and foremost the CMS guidelines.”
The implications for the case manager
Unequivocally, screening criteria should be applied and followed as part of the patient status
designation determination process. Just the same, the physician’s clinical judgment, medical-
decision making and clinical impression can and must be incorporated in this decision-making
guidance process.
The real challenge faced by case managers is the physician’s medical record documentation of the same. Commonly, the documentation available to the case manager upon initial and continued stay chart review fails to accurately and completely capture and represent the patient’s true clinical acuity, risk of morbidity and mortality, and other physician clinical concerns that ultimately led the physician decision to admit the patient to the hospital. This lack of focus in clinical documentation further challenges the case manger in providing objective guidance in the complex, arbitrary patient designation status process. [more]
What do hospital case managers do, anyway?
This is a question frequently asked by patients, family members, physicians, and other members of the medical staff.
Many people think that case managers are discharge planners, and that the only time a patient needs a case manager is when he or she has discharge needs. Case management is much more than that. It is important that we make sure that, not only do patients and families know what case management is, but that the nursing staff members know also.
Case managers work in forces behind the scenes, much like the crowd of people in the Verizon commercials. Case management is a hidden resource for patients. Often, the case managers work in the trenches, with their heads in charts, communicating with an interdisciplinary team of healthcare professionals to make sure that the patient is moving smoothly through the continuum of care, and there are no delays or detours in their care. This is usually an unknown aspect of case management.
Hospital personnel and the public need to be aware that case managers are advocates for all patients; they ensure that their healthcare facility and professionals are doing what is truly right for the patient, in the right setting, receiving the most appropriate care, and in the most cost-effective manner. Case management follows the patient’s plan of care to make sure that it is appropriate and timely, that their hospital admission status is appropriate, that their discharge planning is initiated, and that goals are set to meet the discharge plan. It is imperative that the case manager build a relationship with the patient and their families in order to reach a mutual goal of discharge.
It is also important for the bedside nurses to know that case managers are an excellent resource for them in planning the patients’ care and goals. One thing I did at our institution while we were redesigning our case management model was to do a mandatory in-service to nursing staff on how case management affects not only patient outcomes, but the financial outcomes for hospitals.
At our institution this year, we included a station on case management and interdisciplinary rounds at the nursing annual competency testing. Case management had a display booth with information about what case management is and the importance of interdisciplinary rounds. We also had a test for the nurses to complete. The comments we received from staff were very interesting.
Does your institution do anything like this? Are you confident that nursing staff members truly understand what case management is?
And one more important question: Do your physicians really know what case management is?
CMW News: Patients unable to recognize physicians, study finds
A new study conducted by the University of Chicago and published in the Annals of Internal Medicine showed that 75% of hospital patients are unable to name a single physician in charge of their care.
Of the 75% who said they could name a physician, only 40% of them got a name right. Additionally, those who were able to name a physician were more likely to be unsatisfied with their care. [more]
CMW News: California bans “balance billing”
The California Supreme Court recently ruled that physicians can no longer bill patients for emergency room treatments that physicians feel HMOs do not adequately pay.
HMOs and patient advocates celebrate the decision as a way to stop physicians and hospitals from overcharging for emergency services. Physicians say the court has taken away their only leverage against HMOs to receive fair payments, and this ruling may put emergency departments in economic jeopardy.
Regulations require HMOs to pay physicians and hospitals reasonable amounts, but do not specify what constitutes reasonable.
Sources: HealthLeaders Media, Los Angeles Times
CMW Tip of the Week: A second look at observation orders
Last week’s tip on standardizing physician level of care orders inspired some readers to write in about what works for their facilities.
Joby Kolson, DO, the medical director of quality and care management for AtlantiCare Regional Medical Center in Atlantic City, NJ, says:
What we have found works best for us is to make observation orders very specific. We use orders like:
“Place in observation status on
____med/surg
___telemetry”
In this case, the option for floor designation would be checked or circled. This eliminates the confusion around admission and observation since there is no mention of admission, and also specifies in which location in the hospital the patient should be placed.
Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to editor Julie McGinley at jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!
CMW Tip of the Week: Standardize physician level of care orders
This week’s tip is provided by Deborah K. Hale, CCS.
When it comes to discerning level of care orders, free-hand orders are not always consistent from one physician to another, making it difficult to determine the physician’s intention.
An attempt to use standardized order sets to promote clarity of the physician’s order may be problematic if the format is poorly designed or if the level of care description is unique to your hospital. Orders such as “admit to medical short stay” (an internal description representing observation status for medical patients) would not likely be recognized as an appropriate observation order by an outside auditor.
For best results, checkboxes allowing the physician to choose the intended level of care will improve the level of care order accuracy if they are easily visualized and the opportunity to select the level of care is large enough to identify the physician’s selection. Wording should be consistent with Medicare/Medicaid regulatory guidelines and admission screening criteria sets:
- Admit as inpatient
- Admit to observation status
- Outpatient status (outpatient surgery, outpatient blood transfusion, etc.)
Computerized order entry should be designed to require the physician to select the level of care before proceeding with any other orders. To avoid any confusion, the level of care choices should reflect CMS required terminology described above.
Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to editor Julie McGinley at jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!
