As hospital medicine progresses, it is important that our new specialty be seen as a true academic discipline—not just as a service specialty. Starting our own journal, the Journal of Hospital Medicine, in 2006 was an important step. While there are a growing number of hospitalist researchers around the country, it is important that SHM promote and support further development of researchers in hospital medicine.

This year, SHM’s research efforts will include the development of a wide research network, support for individual and organizational research initiatives, and a focus on strengthening the internal research organization. These efforts will necessarily be broad and will cut across and incorporate the efforts that are already underway in the areas of education and quality.

Goals for SHM Research Efforts

1. Increase extramural research funding to SHM and its members;
2. Contribute to the growing number of SHM members choosing the society for the career development and research opportunities it offers; and
3. Improve visibility and credibility for SHM nationally (e.g., hospitalists in prominent academic leadership positions and on national panels).

The development of a wide research network will include the identification of researchers in the SHM membership with common research interests. A preliminary list has been generated from an e-mail sent to all SHM members in November 2006 promoting two NIH opportunities to study venous thromboembolism (VTE) and asking for a response from members interested in receiving similar information. A monthly grant opportunity bulletin is planned for release to this audience. As this Research Forum develops, a type of research dating service could match research interests and experience with those interested in funding such projects.

An important networking activity is finding ways to link academic and community sites. One possible mechanism to enable such collaboration is an Internet-based tool for abstracting information from a medical chart. The resulting data could be shared and used to validate quality measures, tailor therapies, or assess the prevalence of disease. Also, an inter-society Academic Summit is planned to investigate areas in which collaboration with other professional societies would be appropriate. Be sure to voice your opinions during the Special Interest Forum on Research at the 2007 Annual Meeting on May 24, 2007, in Dallas.

Support for individual and organizational research initiatives will take the form of identifying opportunities and showcasing more opportunities for research at national conferences and local meetings. By working closely to identify commonalities with the Hospital Quality and Patient Safety (HQPS) Committee around research, implementation, and education, this support is designed to be seamless and coordinated. Currently under consideration is the development of research pages on the SHM Web site to highlight ongoing research efforts, possibly including a searchable, online catalog or a database of research opportunities. As time allows, assistance with individual grant applications will be offered.

By focusing on strengthening the internal SHM research organization, an increasingly visible research committee will present a consistent message of support for research and will hopefully empower individual hospital researchers to access the resources of SHM in all possible ways, from using the resource rooms on the SHM Web site to reading the Journal of Hospital Medicine to attending chapter meetings. Strengthening the internal research infrastructure will extend the sphere of influence and raise the profile of SHM as hospitalists appear on national panels, co-authoring key papers, and participating in other research communities. Increased visibility will lead to more support for training, fellowships, and pilot grant programs for promising potential projects in high-priority areas such as health services, quality improvement, clinical epidemiologic studies (clinical trial, genomics, biomarkers), and educational and health technology research.

 

In 2007, expect to see a new emphasis on research at SHM. We’ll be busy developing funding streams to increase investment in promising researchers, particularly those whose projects may lead to grants and/or collaboration with other SHM researchers. Look for surveys designed to assess the unique academic and research needs of hospitalists and to find new opportunities to get involved in research at SHM conferences and the annual meeting. These efforts will be successful if they lead to an increase in the quality and the quantity of the dialogue around research in hospital medicine. Please contact Carolyn Brennan, director of Research Program Development, at [email protected] for more information or to get involved.

click for large version

February Leadership Academy

SHM hosted another sold-out Level I Leadership Academy in sunny Orlando at the Gaylord Palms Resort and Convention Center. The meeting attracted more than 130 hospital medicine leaders who gathered to learn—among many things—how to evaluate personal leadership strengths and weaknesses and how to apply this knowledge to everyday leadership and management challenges.

Nationally respected speakers Mike Guthrie, MD; David Javitch, PhD; Jack Silversin, DMD; Tim Keogh, PhD; Eric Howell, MD; Larry Wellikson, MD; and Russell Holman, MD, led the group in discussions on a variety of different leadership topics. Dr. Keogh kept attendees intrigued by tackling the wide range of personality traits in the industry and instructing attendees in how to work effectively with others by using his DiSC survey. As always, the group was enthusiastic and worked collaboratively during Dr. Silversin’s infamous broken squares activity, in which attendees are involved in an eye-opening experience on effective communication.

“This is our fifth time hosting this course and, every time, I’m amazed to see how enthusiastic attendees are about what they have learned and how they plan to go back and improve their organizations,” says Dr. Holman, SHM Leadership Academy Course Director and president-elect of SHM.

Leadership Academy Level I is a great networking opportunity designed to provide leaders in hospital medicine with the tangible skills and resources required to successfully lead and manage hospitalist programs now and in the future. The intimate setting allows for small group sessions in which attendees have a chance to interact with faculty and share real-life situations from their own institutions. In addition to Level I, SHM will host the advanced course, Leadership Academy Level II, in the fall. This course will allow attendees to expand and enhance the skills learned in Level I and features keynote speaker Leonard Marcus, PhD, who defined the term “Meta-Leadership” in hospital medicine.

Don’t miss out on your chance to become a leader in hospital medicine. Mark your calendar for our next Leadership Academy, November 12-15, 2007, in San Antonio.

As hospital medicine progresses, it is important that our new specialty be seen as a true academic discipline—not just as a service specialty. Starting our own journal, the Journal of Hospital Medicine, in 2006 was an important step. While there are a growing number of hospitalist researchers around the country, it is important that SHM promote and support further development of researchers in hospital medicine.

This year, SHM’s research efforts will include the development of a wide research network, support for individual and organizational research initiatives, and a focus on strengthening the internal research organization. These efforts will necessarily be broad and will cut across and incorporate the efforts that are already underway in the areas of education and quality.

Goals for SHM Research Efforts

1. Increase extramural research funding to SHM and its members;
2. Contribute to the growing number of SHM members choosing the society for the career development and research opportunities it offers; and
3. Improve visibility and credibility for SHM nationally (e.g., hospitalists in prominent academic leadership positions and on national panels).

The development of a wide research network will include the identification of researchers in the SHM membership with common research interests. A preliminary list has been generated from an e-mail sent to all SHM members in November 2006 promoting two NIH opportunities to study venous thromboembolism (VTE) and asking for a response from members interested in receiving similar information. A monthly grant opportunity bulletin is planned for release to this audience. As this Research Forum develops, a type of research dating service could match research interests and experience with those interested in funding such projects.

An important networking activity is finding ways to link academic and community sites. One possible mechanism to enable such collaboration is an Internet-based tool for abstracting information from a medical chart. The resulting data could be shared and used to validate quality measures, tailor therapies, or assess the prevalence of disease. Also, an inter-society Academic Summit is planned to investigate areas in which collaboration with other professional societies would be appropriate. Be sure to voice your opinions during the Special Interest Forum on Research at the 2007 Annual Meeting on May 24, 2007, in Dallas.

Support for individual and organizational research initiatives will take the form of identifying opportunities and showcasing more opportunities for research at national conferences and local meetings. By working closely to identify commonalities with the Hospital Quality and Patient Safety (HQPS) Committee around research, implementation, and education, this support is designed to be seamless and coordinated. Currently under consideration is the development of research pages on the SHM Web site to highlight ongoing research efforts, possibly including a searchable, online catalog or a database of research opportunities. As time allows, assistance with individual grant applications will be offered.

By focusing on strengthening the internal SHM research organization, an increasingly visible research committee will present a consistent message of support for research and will hopefully empower individual hospital researchers to access the resources of SHM in all possible ways, from using the resource rooms on the SHM Web site to reading the Journal of Hospital Medicine to attending chapter meetings. Strengthening the internal research infrastructure will extend the sphere of influence and raise the profile of SHM as hospitalists appear on national panels, co-authoring key papers, and participating in other research communities. Increased visibility will lead to more support for training, fellowships, and pilot grant programs for promising potential projects in high-priority areas such as health services, quality improvement, clinical epidemiologic studies (clinical trial, genomics, biomarkers), and educational and health technology research.

 

In 2007, expect to see a new emphasis on research at SHM. We’ll be busy developing funding streams to increase investment in promising researchers, particularly those whose projects may lead to grants and/or collaboration with other SHM researchers. Look for surveys designed to assess the unique academic and research needs of hospitalists and to find new opportunities to get involved in research at SHM conferences and the annual meeting. These efforts will be successful if they lead to an increase in the quality and the quantity of the dialogue around research in hospital medicine. Please contact Carolyn Brennan, director of Research Program Development, at [email protected] for more information or to get involved.

click for large version

February Leadership Academy

SHM hosted another sold-out Level I Leadership Academy in sunny Orlando at the Gaylord Palms Resort and Convention Center. The meeting attracted more than 130 hospital medicine leaders who gathered to learn—among many things—how to evaluate personal leadership strengths and weaknesses and how to apply this knowledge to everyday leadership and management challenges.

Nationally respected speakers Mike Guthrie, MD; David Javitch, PhD; Jack Silversin, DMD; Tim Keogh, PhD; Eric Howell, MD; Larry Wellikson, MD; and Russell Holman, MD, led the group in discussions on a variety of different leadership topics. Dr. Keogh kept attendees intrigued by tackling the wide range of personality traits in the industry and instructing attendees in how to work effectively with others by using his DiSC survey. As always, the group was enthusiastic and worked collaboratively during Dr. Silversin’s infamous broken squares activity, in which attendees are involved in an eye-opening experience on effective communication.

“This is our fifth time hosting this course and, every time, I’m amazed to see how enthusiastic attendees are about what they have learned and how they plan to go back and improve their organizations,” says Dr. Holman, SHM Leadership Academy Course Director and president-elect of SHM.

Leadership Academy Level I is a great networking opportunity designed to provide leaders in hospital medicine with the tangible skills and resources required to successfully lead and manage hospitalist programs now and in the future. The intimate setting allows for small group sessions in which attendees have a chance to interact with faculty and share real-life situations from their own institutions. In addition to Level I, SHM will host the advanced course, Leadership Academy Level II, in the fall. This course will allow attendees to expand and enhance the skills learned in Level I and features keynote speaker Leonard Marcus, PhD, who defined the term “Meta-Leadership” in hospital medicine.

Don’t miss out on your chance to become a leader in hospital medicine. Mark your calendar for our next Leadership Academy, November 12-15, 2007, in San Antonio.

As hospital medicine progresses, it is important that our new specialty be seen as a true academic discipline—not just as a service specialty. Starting our own journal, the Journal of Hospital Medicine, in 2006 was an important step. While there are a growing number of hospitalist researchers around the country, it is important that SHM promote and support further development of researchers in hospital medicine.

This year, SHM’s research efforts will include the development of a wide research network, support for individual and organizational research initiatives, and a focus on strengthening the internal research organization. These efforts will necessarily be broad and will cut across and incorporate the efforts that are already underway in the areas of education and quality.

Goals for SHM Research Efforts

1. Increase extramural research funding to SHM and its members;
2. Contribute to the growing number of SHM members choosing the society for the career development and research opportunities it offers; and
3. Improve visibility and credibility for SHM nationally (e.g., hospitalists in prominent academic leadership positions and on national panels).

The development of a wide research network will include the identification of researchers in the SHM membership with common research interests. A preliminary list has been generated from an e-mail sent to all SHM members in November 2006 promoting two NIH opportunities to study venous thromboembolism (VTE) and asking for a response from members interested in receiving similar information. A monthly grant opportunity bulletin is planned for release to this audience. As this Research Forum develops, a type of research dating service could match research interests and experience with those interested in funding such projects.

An important networking activity is finding ways to link academic and community sites. One possible mechanism to enable such collaboration is an Internet-based tool for abstracting information from a medical chart. The resulting data could be shared and used to validate quality measures, tailor therapies, or assess the prevalence of disease. Also, an inter-society Academic Summit is planned to investigate areas in which collaboration with other professional societies would be appropriate. Be sure to voice your opinions during the Special Interest Forum on Research at the 2007 Annual Meeting on May 24, 2007, in Dallas.

Support for individual and organizational research initiatives will take the form of identifying opportunities and showcasing more opportunities for research at national conferences and local meetings. By working closely to identify commonalities with the Hospital Quality and Patient Safety (HQPS) Committee around research, implementation, and education, this support is designed to be seamless and coordinated. Currently under consideration is the development of research pages on the SHM Web site to highlight ongoing research efforts, possibly including a searchable, online catalog or a database of research opportunities. As time allows, assistance with individual grant applications will be offered.

By focusing on strengthening the internal SHM research organization, an increasingly visible research committee will present a consistent message of support for research and will hopefully empower individual hospital researchers to access the resources of SHM in all possible ways, from using the resource rooms on the SHM Web site to reading the Journal of Hospital Medicine to attending chapter meetings. Strengthening the internal research infrastructure will extend the sphere of influence and raise the profile of SHM as hospitalists appear on national panels, co-authoring key papers, and participating in other research communities. Increased visibility will lead to more support for training, fellowships, and pilot grant programs for promising potential projects in high-priority areas such as health services, quality improvement, clinical epidemiologic studies (clinical trial, genomics, biomarkers), and educational and health technology research.

 

In 2007, expect to see a new emphasis on research at SHM. We’ll be busy developing funding streams to increase investment in promising researchers, particularly those whose projects may lead to grants and/or collaboration with other SHM researchers. Look for surveys designed to assess the unique academic and research needs of hospitalists and to find new opportunities to get involved in research at SHM conferences and the annual meeting. These efforts will be successful if they lead to an increase in the quality and the quantity of the dialogue around research in hospital medicine. Please contact Carolyn Brennan, director of Research Program Development, at [email protected] for more information or to get involved.

click for large version

February Leadership Academy

SHM hosted another sold-out Level I Leadership Academy in sunny Orlando at the Gaylord Palms Resort and Convention Center. The meeting attracted more than 130 hospital medicine leaders who gathered to learn—among many things—how to evaluate personal leadership strengths and weaknesses and how to apply this knowledge to everyday leadership and management challenges.

Nationally respected speakers Mike Guthrie, MD; David Javitch, PhD; Jack Silversin, DMD; Tim Keogh, PhD; Eric Howell, MD; Larry Wellikson, MD; and Russell Holman, MD, led the group in discussions on a variety of different leadership topics. Dr. Keogh kept attendees intrigued by tackling the wide range of personality traits in the industry and instructing attendees in how to work effectively with others by using his DiSC survey. As always, the group was enthusiastic and worked collaboratively during Dr. Silversin’s infamous broken squares activity, in which attendees are involved in an eye-opening experience on effective communication.

“This is our fifth time hosting this course and, every time, I’m amazed to see how enthusiastic attendees are about what they have learned and how they plan to go back and improve their organizations,” says Dr. Holman, SHM Leadership Academy Course Director and president-elect of SHM.

Leadership Academy Level I is a great networking opportunity designed to provide leaders in hospital medicine with the tangible skills and resources required to successfully lead and manage hospitalist programs now and in the future. The intimate setting allows for small group sessions in which attendees have a chance to interact with faculty and share real-life situations from their own institutions. In addition to Level I, SHM will host the advanced course, Leadership Academy Level II, in the fall. This course will allow attendees to expand and enhance the skills learned in Level I and features keynote speaker Leonard Marcus, PhD, who defined the term “Meta-Leadership” in hospital medicine.

Don’t miss out on your chance to become a leader in hospital medicine. Mark your calendar for our next Leadership Academy, November 12-15, 2007, in San Antonio.

Whatever with the past has gone, the best is always yet to come.

—Lucy Larcom, 19th century poet and writer

It is hard to believe, but this is my last column to write as president of SHM. It has been another remarkable year for hospital medicine. The field continues to grow, and that presents our growing organization with many challenges. Once again, we are rising to the challenge, and it has been a big year at SHM. Most of what we have done has had very little to do with me, but is the result of tremendous work by our many members and our staff.

Just a few highlights of the last 12 months:

• The number of hospitalists surpassed 20,000;
• The number of Hospital Medicine Groups (HMGs) grew to more than 2,000;
• Registration for the SHM Annual Meeting exceeded 1,000 for the first time;
• Almost 200 abstracts were submitted to the SHM Poster Competition;
• The Journal of Hospital Medicine (JHM) published its first issue in 2006 and within a year took its place with established journals by being listed by the National Library of Medicine in PubMed; and
• In a landmark decision, the ABIM Board approved Focused Recognition of Hospital Medicine as part of Internal Medicine Maintenance of Certification.

The board spent two days with our key committee chairmen and staff to examine our current projects and direction. This will lay the groundwork for continuing the dialogue about how we can best serve our members and be prepared to meet the needs of the sea change in healthcare.

• Don Berwick invited SHM leadership to represent the only medical professional society on stage at the Institute for Healthcare Improvement (IHI) Annual Convention as IHI announced its latest national quality improvement campaign;
• SHM embarked on a unique effort to use one-on-one hospitalist leader mentoring to push the implementation of quality improvement to the front lines;
• The SHM board approved funds for a study that will examine the feasibility of a foundation to support research and education in hospital medicine;
• SHM became a player in advocacy when almost 100 hospitalists met with their legislators in Washington, D.C.;
• More than 400 SHM members used the Legislative Action Center to write to their legislators as SHM lobbied Congress to improve Medicare reimbursement; and
• SHM grew into a solid organization with more than $5 million in revenues.

We continue to receive grant funding to support our efforts in quality improvement and to export our resources to the front lines of healthcare. A growing number of organizations recognize our expanding role in caring for the country’s patients. We have a reputation for moving relentlessly forward. This makes us different than many other organizations. It is a characteristic that we need to hold onto as the organization grows and ages.

My best wishes to the next slate of officers and to all of our members. Thank you for the opportunity; it’s been a privilege. There are more great things to come! TH

Dr. Gorman is the outgoing president of SHM.

Whatever with the past has gone, the best is always yet to come.

—Lucy Larcom, 19th century poet and writer

It is hard to believe, but this is my last column to write as president of SHM. It has been another remarkable year for hospital medicine. The field continues to grow, and that presents our growing organization with many challenges. Once again, we are rising to the challenge, and it has been a big year at SHM. Most of what we have done has had very little to do with me, but is the result of tremendous work by our many members and our staff.

Just a few highlights of the last 12 months:

• The number of hospitalists surpassed 20,000;
• The number of Hospital Medicine Groups (HMGs) grew to more than 2,000;
• Registration for the SHM Annual Meeting exceeded 1,000 for the first time;
• Almost 200 abstracts were submitted to the SHM Poster Competition;
• The Journal of Hospital Medicine (JHM) published its first issue in 2006 and within a year took its place with established journals by being listed by the National Library of Medicine in PubMed; and
• In a landmark decision, the ABIM Board approved Focused Recognition of Hospital Medicine as part of Internal Medicine Maintenance of Certification.

The board spent two days with our key committee chairmen and staff to examine our current projects and direction. This will lay the groundwork for continuing the dialogue about how we can best serve our members and be prepared to meet the needs of the sea change in healthcare.

• Don Berwick invited SHM leadership to represent the only medical professional society on stage at the Institute for Healthcare Improvement (IHI) Annual Convention as IHI announced its latest national quality improvement campaign;
• SHM embarked on a unique effort to use one-on-one hospitalist leader mentoring to push the implementation of quality improvement to the front lines;
• The SHM board approved funds for a study that will examine the feasibility of a foundation to support research and education in hospital medicine;
• SHM became a player in advocacy when almost 100 hospitalists met with their legislators in Washington, D.C.;
• More than 400 SHM members used the Legislative Action Center to write to their legislators as SHM lobbied Congress to improve Medicare reimbursement; and
• SHM grew into a solid organization with more than $5 million in revenues.

We continue to receive grant funding to support our efforts in quality improvement and to export our resources to the front lines of healthcare. A growing number of organizations recognize our expanding role in caring for the country’s patients. We have a reputation for moving relentlessly forward. This makes us different than many other organizations. It is a characteristic that we need to hold onto as the organization grows and ages.

My best wishes to the next slate of officers and to all of our members. Thank you for the opportunity; it’s been a privilege. There are more great things to come! TH

Dr. Gorman is the outgoing president of SHM.

Whatever with the past has gone, the best is always yet to come.

—Lucy Larcom, 19th century poet and writer

It is hard to believe, but this is my last column to write as president of SHM. It has been another remarkable year for hospital medicine. The field continues to grow, and that presents our growing organization with many challenges. Once again, we are rising to the challenge, and it has been a big year at SHM. Most of what we have done has had very little to do with me, but is the result of tremendous work by our many members and our staff.

Just a few highlights of the last 12 months:

• The number of hospitalists surpassed 20,000;
• The number of Hospital Medicine Groups (HMGs) grew to more than 2,000;
• Registration for the SHM Annual Meeting exceeded 1,000 for the first time;
• Almost 200 abstracts were submitted to the SHM Poster Competition;
• The Journal of Hospital Medicine (JHM) published its first issue in 2006 and within a year took its place with established journals by being listed by the National Library of Medicine in PubMed; and
• In a landmark decision, the ABIM Board approved Focused Recognition of Hospital Medicine as part of Internal Medicine Maintenance of Certification.

The board spent two days with our key committee chairmen and staff to examine our current projects and direction. This will lay the groundwork for continuing the dialogue about how we can best serve our members and be prepared to meet the needs of the sea change in healthcare.

• Don Berwick invited SHM leadership to represent the only medical professional society on stage at the Institute for Healthcare Improvement (IHI) Annual Convention as IHI announced its latest national quality improvement campaign;
• SHM embarked on a unique effort to use one-on-one hospitalist leader mentoring to push the implementation of quality improvement to the front lines;
• The SHM board approved funds for a study that will examine the feasibility of a foundation to support research and education in hospital medicine;
• SHM became a player in advocacy when almost 100 hospitalists met with their legislators in Washington, D.C.;
• More than 400 SHM members used the Legislative Action Center to write to their legislators as SHM lobbied Congress to improve Medicare reimbursement; and
• SHM grew into a solid organization with more than $5 million in revenues.

We continue to receive grant funding to support our efforts in quality improvement and to export our resources to the front lines of healthcare. A growing number of organizations recognize our expanding role in caring for the country’s patients. We have a reputation for moving relentlessly forward. This makes us different than many other organizations. It is a characteristic that we need to hold onto as the organization grows and ages.

My best wishes to the next slate of officers and to all of our members. Thank you for the opportunity; it’s been a privilege. There are more great things to come! TH

Dr. Gorman is the outgoing president of SHM.

Clinical practice guidelines (CPGs) for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adults represent a consensus on the minimal standards and most reasonable, evidence-based practices.^1-3 ADHD is too complex for any set of guidelines to address every situation, but CPGs are an excellent starting point for the conscientious practitioner who wants to make ADHD treatment as effective as possible.

Obtain a copy of the CPG that best fits your patients. Several are available for free at www.pediatrics.org/cgi/content/full/105/5/1158 (children) and www.aacap.org/galleries/PracticeParameters/New_ADHD_Parameter.pdf (children, adolescents, and adults).

Use a validated rating scale to confirm your clinical judgment and monitor treatment progress. Several rating scales for childhood psychiatric conditions are available at www.massgeneral.org/schoolpsychiatry/screeningtools_table.asp.

For adults with suspected ADHD, consider asking those who knew the patient as a child to fill out the Adult ADHD Self-Report Scale—available at www.med.nyu.edu/psych/assets/adhdscreen18.pdf—and corroborate the patient’s memory of childhood symptoms. This step is not always necessary, however, because adults with ADHD have been shown to adequately report childhood impairment.⁴

Start treatment with stimulant medications unless there are clinical reasons to avoid them, such as active substance abuse, glaucoma, or unstablized bipolar disorder. CPGs note that many FDA contraindications for stimulants have little basis in practice or research. These drugs therefore can be used as first-line treatment of ADHD in patients with comorbid tics, anxiety disorders, seizures, stabilized bipolar disorder, carefully monitored substance abuse, and during pregnancy.

Nineteen medications are FDA-approved for ADHD, and 18 are delivery systems of amphetamine or methylphenidate. In large groups, both chemicals have:

• similar effect size (about 0.95)
• the same side effects
• a response rate of 70% to 75%, which increases to 80% to 90% when both are tried.⁵

Although studies do not show either molecule to be more effective, individuals usually have a clear preference based on how well the medication manages their target symptoms.

Adjust medication according to the patient’s target symptoms. This process educates the patient about why he or she should take the medication. Remember that the patient with ADHD rarely seeks treatment; the primary motivation usually comes from parents or significant others.

Asking “What bothers you the most about your ADHD, and what do you want to get fixed today?” speaks to how the patient can benefit from therapy and indicates what symptoms he or she should look for. Remember, these patients always have had ADHD; they do not know what is possible with treatment.

This answer also tells you what the patient—as opposed to the family—defines as success and reveals his or her motivation to adhere to the medication. Particularly when treating adolescents, get a list of target symptoms from them and their parents because the lists may be different. Unless both the parents and adolescent are satisfied, one might sabotage therapy.

Fine-tune the medication for optimal relief of target symptoms. Although this seems obvious, the prevailing practice pattern is to increase the dosage until the first sign of improvement and then stop. This practice forfeits many potential benefits of medication. Instead, increase the dosage by the lowest increment available as long as the patient:

• reports clear improvement of his or her target symptoms with each dosage increase
• experiences no side effects other than a mild loss of appetite.

When the patient no longer sees improvement, the lowest dose that resolved the target symptoms will be that individual’s optimal dose.

Clinical practice guidelines (CPGs) for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adults represent a consensus on the minimal standards and most reasonable, evidence-based practices.^1-3 ADHD is too complex for any set of guidelines to address every situation, but CPGs are an excellent starting point for the conscientious practitioner who wants to make ADHD treatment as effective as possible.

Obtain a copy of the CPG that best fits your patients. Several are available for free at www.pediatrics.org/cgi/content/full/105/5/1158 (children) and www.aacap.org/galleries/PracticeParameters/New_ADHD_Parameter.pdf (children, adolescents, and adults).

Use a validated rating scale to confirm your clinical judgment and monitor treatment progress. Several rating scales for childhood psychiatric conditions are available at www.massgeneral.org/schoolpsychiatry/screeningtools_table.asp.

For adults with suspected ADHD, consider asking those who knew the patient as a child to fill out the Adult ADHD Self-Report Scale—available at www.med.nyu.edu/psych/assets/adhdscreen18.pdf—and corroborate the patient’s memory of childhood symptoms. This step is not always necessary, however, because adults with ADHD have been shown to adequately report childhood impairment.⁴

Start treatment with stimulant medications unless there are clinical reasons to avoid them, such as active substance abuse, glaucoma, or unstablized bipolar disorder. CPGs note that many FDA contraindications for stimulants have little basis in practice or research. These drugs therefore can be used as first-line treatment of ADHD in patients with comorbid tics, anxiety disorders, seizures, stabilized bipolar disorder, carefully monitored substance abuse, and during pregnancy.

Nineteen medications are FDA-approved for ADHD, and 18 are delivery systems of amphetamine or methylphenidate. In large groups, both chemicals have:

• similar effect size (about 0.95)
• the same side effects
• a response rate of 70% to 75%, which increases to 80% to 90% when both are tried.⁵

Although studies do not show either molecule to be more effective, individuals usually have a clear preference based on how well the medication manages their target symptoms.

Adjust medication according to the patient’s target symptoms. This process educates the patient about why he or she should take the medication. Remember that the patient with ADHD rarely seeks treatment; the primary motivation usually comes from parents or significant others.

Asking “What bothers you the most about your ADHD, and what do you want to get fixed today?” speaks to how the patient can benefit from therapy and indicates what symptoms he or she should look for. Remember, these patients always have had ADHD; they do not know what is possible with treatment.

This answer also tells you what the patient—as opposed to the family—defines as success and reveals his or her motivation to adhere to the medication. Particularly when treating adolescents, get a list of target symptoms from them and their parents because the lists may be different. Unless both the parents and adolescent are satisfied, one might sabotage therapy.

Fine-tune the medication for optimal relief of target symptoms. Although this seems obvious, the prevailing practice pattern is to increase the dosage until the first sign of improvement and then stop. This practice forfeits many potential benefits of medication. Instead, increase the dosage by the lowest increment available as long as the patient:

• reports clear improvement of his or her target symptoms with each dosage increase
• experiences no side effects other than a mild loss of appetite.

When the patient no longer sees improvement, the lowest dose that resolved the target symptoms will be that individual’s optimal dose.

Clinical practice guidelines (CPGs) for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adults represent a consensus on the minimal standards and most reasonable, evidence-based practices.^1-3 ADHD is too complex for any set of guidelines to address every situation, but CPGs are an excellent starting point for the conscientious practitioner who wants to make ADHD treatment as effective as possible.

Obtain a copy of the CPG that best fits your patients. Several are available for free at www.pediatrics.org/cgi/content/full/105/5/1158 (children) and www.aacap.org/galleries/PracticeParameters/New_ADHD_Parameter.pdf (children, adolescents, and adults).

Use a validated rating scale to confirm your clinical judgment and monitor treatment progress. Several rating scales for childhood psychiatric conditions are available at www.massgeneral.org/schoolpsychiatry/screeningtools_table.asp.

For adults with suspected ADHD, consider asking those who knew the patient as a child to fill out the Adult ADHD Self-Report Scale—available at www.med.nyu.edu/psych/assets/adhdscreen18.pdf—and corroborate the patient’s memory of childhood symptoms. This step is not always necessary, however, because adults with ADHD have been shown to adequately report childhood impairment.⁴

Start treatment with stimulant medications unless there are clinical reasons to avoid them, such as active substance abuse, glaucoma, or unstablized bipolar disorder. CPGs note that many FDA contraindications for stimulants have little basis in practice or research. These drugs therefore can be used as first-line treatment of ADHD in patients with comorbid tics, anxiety disorders, seizures, stabilized bipolar disorder, carefully monitored substance abuse, and during pregnancy.

Nineteen medications are FDA-approved for ADHD, and 18 are delivery systems of amphetamine or methylphenidate. In large groups, both chemicals have:

• similar effect size (about 0.95)
• the same side effects
• a response rate of 70% to 75%, which increases to 80% to 90% when both are tried.⁵

Although studies do not show either molecule to be more effective, individuals usually have a clear preference based on how well the medication manages their target symptoms.

Adjust medication according to the patient’s target symptoms. This process educates the patient about why he or she should take the medication. Remember that the patient with ADHD rarely seeks treatment; the primary motivation usually comes from parents or significant others.

Asking “What bothers you the most about your ADHD, and what do you want to get fixed today?” speaks to how the patient can benefit from therapy and indicates what symptoms he or she should look for. Remember, these patients always have had ADHD; they do not know what is possible with treatment.

This answer also tells you what the patient—as opposed to the family—defines as success and reveals his or her motivation to adhere to the medication. Particularly when treating adolescents, get a list of target symptoms from them and their parents because the lists may be different. Unless both the parents and adolescent are satisfied, one might sabotage therapy.

Fine-tune the medication for optimal relief of target symptoms. Although this seems obvious, the prevailing practice pattern is to increase the dosage until the first sign of improvement and then stop. This practice forfeits many potential benefits of medication. Instead, increase the dosage by the lowest increment available as long as the patient:

• reports clear improvement of his or her target symptoms with each dosage increase
• experiences no side effects other than a mild loss of appetite.

When the patient no longer sees improvement, the lowest dose that resolved the target symptoms will be that individual’s optimal dose.

Improper treatment of depression,
psychosis blamed for suicide

Kings County (NY) Supreme Court

A 52-year-old patient with a history of mental illness was hospitalized for treatment of major depression with recurrent psychotic features. After release she underwent counseling with a psychiatrist at a mental health center.

One month after discharge the patient was rehospitalized for 2 weeks. After this release she resumed counseling at the mental health center.

Six months later the patient’s husband telephoned the center and reported that the patient needed further treatment. The husband was instructed to bring the patient to a hospital, but he did not do so. The next day the patient committed suicide by jumping from a fourth-floor window.

The case went to trial against the psychiatrist, a social worker, and the mental health center. The patient’s family claimed that she should have been prescribed antidepressant medication, enrolled in family therapy, and received immediate care when her husband telephoned the mental health center with concerns. The psychiatrist, a social worker, and the mental health center argued that the patient was properly treated and medication was prescribed. They counterclaimed that the husband was negligent toward his wife by failing to take her to the hospital as instructed.

A $75,000 settlement was reached with the social worker prior to the verdict. Remaining parties reached a $650,000/$250,000 high/low agreement.

• A defense verdict was returned
  

A woman with prescription drug abuse
commits suicide 19 days after discharge

Floyd County (GA) Superior Court

A patient, in her early 40s, was under a psychiatrist’s care and admitted to an acute care psychiatric facility for prescription drug abuse. The patient was discharged from the psychiatric facility with instructions to continue outpatient therapy with the psychiatrist. The patient committed suicide 19 days later.

The patient’s family alleged that the psychiatrist failed to properly diagnose and treat the patient’s mental condition, arguing that the clinician should not have discharged the patient from the acute care psychiatric facility while she experienced drug withdrawal symptoms and depression. The psychiatrist claimed that the patient was treated properly for substance abuse, and depression was secondary and related to drug abuse. The psychiatrist also said that the patient received a comprehensive discharge plan, which included follow-up treatment with him and counselors.

• A defense verdict was returned
  

Dr. Grant’s observations

Suicide rates are highest immediately after hospital discharge.^1,2 Inadequate follow-up care or discharge planning may increase the risk for suicide.³ A recent study of 121,933 psychiatric patients at VA hospitals found that 481 (0.4%) died of suicide within 1 year of discharge; 46% of those deaths occurred within the first 3 months. Patients who stayed less than 14 days or had poor continuity of care had a higher risk of suicide.⁴

Discharge may form the basis for a negligence claim if the release is not a valid exercise in professional judgment. In Bell vs New York City Health and Hospitals Corporation, a patient attempted suicide after hospital discharge. He was released despite suicidal ideation and psychosis. Citing the lack of a well documented psychiatric examination, the court found the hospital negligent because the psychiatrist failed to investigate the patient’s psychiatric history and delusions or an incident when the patient was restrained the night before.^5,6

The courts have not found psychiatrists negligent when they perform a risk assessment and reasonably conclude that the benefits of release outweigh the risks.⁷

Reasonable protection

When a doctor-patient relationship is established, the psychiatrist has a duty of care to the patient. The psychiatrist must act affirmatively to protect the patient from violent acts against himself. This becomes a duty to reasonably attempt to prevent patient suicide. Negligence occurs when this duty is breached. A negligence claim can be established if the breach was proximately related to a suicide.

Two factors determine liability in suicide cases: forseeability and reasonable care.

Forseeability refers to the reasonable evaluation of suicide potential based on a risk assessment. Failure to perform and document this assessment may be evidence of negligence.

Document in your risk assessment the patient’s:

• short-term suicide risk factors (Box 1)
  
• suicidal thoughts, plans, intents, and actions
  
• feelings of hopelessness
  
• substance abuse
  
• evidence of poor impulse control^8,9
  
• protective factors such as coping and survival skills, family responsibilities, child-related concerns, and moral/ religious beliefs.^10,11
  

Box 1

Reasonable care indicates a systematic approach to treatment within the profession’s standards. Appropriate suicide precautions—which are part of reasonable care—must be performed based on a risk assessment. In the first case, instructing the family to bring the patient to the hospital constituted reasonable care. If the family refused over the phone to bring the patient to the hospital, the psychiatrist would have had to assess the risk of suicide and deliver reasonable care, which might have included summoning emergency services to the patient’s home.

 

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

The discharge records should indicate:

• information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
  
• factors that went into the decision to discharge (such as response to medications)
  
• how these factors were balanced against the option of keeping the patient in the hospital.
  

Consider and record the risks and benefits of discharge versus continued hospitalization. Patient anxiety about leaving the security of the hospital can precipitate a crisis and should be part of the risk-benefit analysis.¹⁴

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Improper treatment of depression,
psychosis blamed for suicide

Kings County (NY) Supreme Court

A 52-year-old patient with a history of mental illness was hospitalized for treatment of major depression with recurrent psychotic features. After release she underwent counseling with a psychiatrist at a mental health center.

One month after discharge the patient was rehospitalized for 2 weeks. After this release she resumed counseling at the mental health center.

Six months later the patient’s husband telephoned the center and reported that the patient needed further treatment. The husband was instructed to bring the patient to a hospital, but he did not do so. The next day the patient committed suicide by jumping from a fourth-floor window.

The case went to trial against the psychiatrist, a social worker, and the mental health center. The patient’s family claimed that she should have been prescribed antidepressant medication, enrolled in family therapy, and received immediate care when her husband telephoned the mental health center with concerns. The psychiatrist, a social worker, and the mental health center argued that the patient was properly treated and medication was prescribed. They counterclaimed that the husband was negligent toward his wife by failing to take her to the hospital as instructed.

A $75,000 settlement was reached with the social worker prior to the verdict. Remaining parties reached a $650,000/$250,000 high/low agreement.

• A defense verdict was returned
  

A woman with prescription drug abuse
commits suicide 19 days after discharge

Floyd County (GA) Superior Court

A patient, in her early 40s, was under a psychiatrist’s care and admitted to an acute care psychiatric facility for prescription drug abuse. The patient was discharged from the psychiatric facility with instructions to continue outpatient therapy with the psychiatrist. The patient committed suicide 19 days later.

The patient’s family alleged that the psychiatrist failed to properly diagnose and treat the patient’s mental condition, arguing that the clinician should not have discharged the patient from the acute care psychiatric facility while she experienced drug withdrawal symptoms and depression. The psychiatrist claimed that the patient was treated properly for substance abuse, and depression was secondary and related to drug abuse. The psychiatrist also said that the patient received a comprehensive discharge plan, which included follow-up treatment with him and counselors.

• A defense verdict was returned
  

Dr. Grant’s observations

Suicide rates are highest immediately after hospital discharge.^1,2 Inadequate follow-up care or discharge planning may increase the risk for suicide.³ A recent study of 121,933 psychiatric patients at VA hospitals found that 481 (0.4%) died of suicide within 1 year of discharge; 46% of those deaths occurred within the first 3 months. Patients who stayed less than 14 days or had poor continuity of care had a higher risk of suicide.⁴

Discharge may form the basis for a negligence claim if the release is not a valid exercise in professional judgment. In Bell vs New York City Health and Hospitals Corporation, a patient attempted suicide after hospital discharge. He was released despite suicidal ideation and psychosis. Citing the lack of a well documented psychiatric examination, the court found the hospital negligent because the psychiatrist failed to investigate the patient’s psychiatric history and delusions or an incident when the patient was restrained the night before.^5,6

The courts have not found psychiatrists negligent when they perform a risk assessment and reasonably conclude that the benefits of release outweigh the risks.⁷

Reasonable protection

When a doctor-patient relationship is established, the psychiatrist has a duty of care to the patient. The psychiatrist must act affirmatively to protect the patient from violent acts against himself. This becomes a duty to reasonably attempt to prevent patient suicide. Negligence occurs when this duty is breached. A negligence claim can be established if the breach was proximately related to a suicide.

Two factors determine liability in suicide cases: forseeability and reasonable care.

Forseeability refers to the reasonable evaluation of suicide potential based on a risk assessment. Failure to perform and document this assessment may be evidence of negligence.

Document in your risk assessment the patient’s:

• short-term suicide risk factors (Box 1)
  
• suicidal thoughts, plans, intents, and actions
  
• feelings of hopelessness
  
• substance abuse
  
• evidence of poor impulse control^8,9
  
• protective factors such as coping and survival skills, family responsibilities, child-related concerns, and moral/ religious beliefs.^10,11
  

Box 1

Reasonable care indicates a systematic approach to treatment within the profession’s standards. Appropriate suicide precautions—which are part of reasonable care—must be performed based on a risk assessment. In the first case, instructing the family to bring the patient to the hospital constituted reasonable care. If the family refused over the phone to bring the patient to the hospital, the psychiatrist would have had to assess the risk of suicide and deliver reasonable care, which might have included summoning emergency services to the patient’s home.

 

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

The discharge records should indicate:

• information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
  
• factors that went into the decision to discharge (such as response to medications)
  
• how these factors were balanced against the option of keeping the patient in the hospital.
  

Consider and record the risks and benefits of discharge versus continued hospitalization. Patient anxiety about leaving the security of the hospital can precipitate a crisis and should be part of the risk-benefit analysis.¹⁴

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Improper treatment of depression,
psychosis blamed for suicide

Kings County (NY) Supreme Court

A 52-year-old patient with a history of mental illness was hospitalized for treatment of major depression with recurrent psychotic features. After release she underwent counseling with a psychiatrist at a mental health center.

One month after discharge the patient was rehospitalized for 2 weeks. After this release she resumed counseling at the mental health center.

Six months later the patient’s husband telephoned the center and reported that the patient needed further treatment. The husband was instructed to bring the patient to a hospital, but he did not do so. The next day the patient committed suicide by jumping from a fourth-floor window.

The case went to trial against the psychiatrist, a social worker, and the mental health center. The patient’s family claimed that she should have been prescribed antidepressant medication, enrolled in family therapy, and received immediate care when her husband telephoned the mental health center with concerns. The psychiatrist, a social worker, and the mental health center argued that the patient was properly treated and medication was prescribed. They counterclaimed that the husband was negligent toward his wife by failing to take her to the hospital as instructed.

A $75,000 settlement was reached with the social worker prior to the verdict. Remaining parties reached a $650,000/$250,000 high/low agreement.

• A defense verdict was returned
  

A woman with prescription drug abuse
commits suicide 19 days after discharge

Floyd County (GA) Superior Court

A patient, in her early 40s, was under a psychiatrist’s care and admitted to an acute care psychiatric facility for prescription drug abuse. The patient was discharged from the psychiatric facility with instructions to continue outpatient therapy with the psychiatrist. The patient committed suicide 19 days later.

The patient’s family alleged that the psychiatrist failed to properly diagnose and treat the patient’s mental condition, arguing that the clinician should not have discharged the patient from the acute care psychiatric facility while she experienced drug withdrawal symptoms and depression. The psychiatrist claimed that the patient was treated properly for substance abuse, and depression was secondary and related to drug abuse. The psychiatrist also said that the patient received a comprehensive discharge plan, which included follow-up treatment with him and counselors.

• A defense verdict was returned
  

Dr. Grant’s observations

Suicide rates are highest immediately after hospital discharge.^1,2 Inadequate follow-up care or discharge planning may increase the risk for suicide.³ A recent study of 121,933 psychiatric patients at VA hospitals found that 481 (0.4%) died of suicide within 1 year of discharge; 46% of those deaths occurred within the first 3 months. Patients who stayed less than 14 days or had poor continuity of care had a higher risk of suicide.⁴

Discharge may form the basis for a negligence claim if the release is not a valid exercise in professional judgment. In Bell vs New York City Health and Hospitals Corporation, a patient attempted suicide after hospital discharge. He was released despite suicidal ideation and psychosis. Citing the lack of a well documented psychiatric examination, the court found the hospital negligent because the psychiatrist failed to investigate the patient’s psychiatric history and delusions or an incident when the patient was restrained the night before.^5,6

The courts have not found psychiatrists negligent when they perform a risk assessment and reasonably conclude that the benefits of release outweigh the risks.⁷

Reasonable protection

When a doctor-patient relationship is established, the psychiatrist has a duty of care to the patient. The psychiatrist must act affirmatively to protect the patient from violent acts against himself. This becomes a duty to reasonably attempt to prevent patient suicide. Negligence occurs when this duty is breached. A negligence claim can be established if the breach was proximately related to a suicide.

Two factors determine liability in suicide cases: forseeability and reasonable care.

Forseeability refers to the reasonable evaluation of suicide potential based on a risk assessment. Failure to perform and document this assessment may be evidence of negligence.

Document in your risk assessment the patient’s:

• short-term suicide risk factors (Box 1)
  
• suicidal thoughts, plans, intents, and actions
  
• feelings of hopelessness
  
• substance abuse
  
• evidence of poor impulse control^8,9
  
• protective factors such as coping and survival skills, family responsibilities, child-related concerns, and moral/ religious beliefs.^10,11
  

Box 1

Reasonable care indicates a systematic approach to treatment within the profession’s standards. Appropriate suicide precautions—which are part of reasonable care—must be performed based on a risk assessment. In the first case, instructing the family to bring the patient to the hospital constituted reasonable care. If the family refused over the phone to bring the patient to the hospital, the psychiatrist would have had to assess the risk of suicide and deliver reasonable care, which might have included summoning emergency services to the patient’s home.

 

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

The discharge records should indicate:

• information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
  
• factors that went into the decision to discharge (such as response to medications)
  
• how these factors were balanced against the option of keeping the patient in the hospital.
  

Consider and record the risks and benefits of discharge versus continued hospitalization. Patient anxiety about leaving the security of the hospital can precipitate a crisis and should be part of the risk-benefit analysis.¹⁴

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Is injectable contraceptive “medical necessity”?

Q. One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

A. Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

Q. I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

A. Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

Q. What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

A. To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

• Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  
• Other specified complications of pregnancy (646.83)
  
• Other specified indications for care or intervention related to labor and delivery (659.8X)
  
• No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).
  

Get reimbursed for counseling absent patient?

Q. What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

A. This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.

Is injectable contraceptive “medical necessity”?

Q. One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

A. Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

Q. I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

A. Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

Q. What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

A. To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

• Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  
• Other specified complications of pregnancy (646.83)
  
• Other specified indications for care or intervention related to labor and delivery (659.8X)
  
• No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).
  

Get reimbursed for counseling absent patient?

Q. What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

A. This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.

Is injectable contraceptive “medical necessity”?

Q. One of our patients receives Depo-Provera (medroxyprogesterone acetate) injection, 150 mg, for contraception (code J1055) solely because oral contraceptives unduly raise her blood pressure. We assign diagnosis code V25.49 (Surveillance of previously prescribed contraceptive methods, other contraceptive method) for this service. The insurance company is denying the injection, claiming that the diagnosis code is routine.

The insurance company told the patient that it would pay the claim if we used a different diagnosis code. What code should we assign to indicate that Depo-Provera is medically indicated?

A. Only routine contraception management codes can be used in this case; it’s the patient’s desire for contraception, not the hypertension, that is the prime motivator for the Depo-Provera. I would have reported V25.8 (Other specified contraceptive management) because the encounter isn’t really for surveillance.

The real problem here, however, may be that the patient’s insurance policy does not cover contraception. If that’s the case, route of administration won’t affect coverage and she is responsible for paying for injections.

Advise the patient to contact the insurer to resolve the matter of coverage. If the company confirms that contraception is covered but insists that you use a different diagnosis code, try V25.8, as I recommended. Or have the patient ask the insurer to state—in writing—what the correct code is so that you can submit the claim according to their rules.

Retained cerclage suture just part of E/M service

Q. I removed a retained fragment of a cerclage suture from a patient as part of her 6-week postpartum visit. I also cauterized some granulation tissue at the episiotomy site with silver nitrate. Can I bill for this?

A. Because granulation tissue was on the perineum and you applied silver nitrate to cauterize it, you can use a code from the integumentary system to report this service. Code 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]) can be billed separately from the postpartum visit. This service, however, is likely to be bundled into the postpartum care for your patient because it is treating a condition related to the episiotomy repair and therefore may fall within the global service.

There is no code for removing the remnant of cerclage suture. In fact, if it was removed without anesthesia by a physician who did not place the cerclage suture, it is just part of an E/M service. If you are providing postpartum care, I assume that you or a member of your group placed the cerclage suture; removal is therefore not billable separately.

Vaginal gush of fluid: How do you select a code?

Q. What diagnosis code can be reported when a patient reports a vaginal gush, or leakage, of fluid?

A. To report this finding, evaluate the patient to determine the likely cause: Leakage or a gush of fluid could signal any of several problems. Options that you can consider, based on your evaluation, include:

• Vaginal discharge: 623.5 (Leukorrhea, not specified as infective), with V22.2 (Pregnant state, incidental). Because the patient is pregnant, this option would require that you have documented that the condition is either incidental to the pregnancy or not affecting management of the mother, the pregnancy, or the fetus.
  
• Other specified complications of pregnancy (646.83)
  
• Other specified indications for care or intervention related to labor and delivery (659.8X)
  
• No leakage or evidence of fluid was found: V65.5 (Feared condition not demonstrated) with V22.2 (Pregnant state, incidental).
  

Get reimbursed for counseling absent patient?

Q. What is the consultation code for a mother who schedules an appointment to discuss her minor daughter’s disabilities and contraception, as well as other concerns about the girl? The daughter is my patient but will not be present at the first visit.

A. This situation does not meet criteria under CPT rules for billing a consultation code; in fact, many payers will not reimburse an E/M service unless the patient is present. The diagnosis code would have to be V65.19 (Other person consulting on behalf of another person, but not the patient’s problems) because you are not evaluating the patient at this visit.

If the patient’s treatment for an illness or condition is being discussed, you can report a problem E/M service. Otherwise, this is a preventive counseling service reported by time using 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]).

Remember to caution the mother that the visit may not be covered, making her responsible for the bill.