Managing Your Practice

Necessity, as they say, is the mother of invention, and the growing focus on the need for high-quality and cost-effective care is bringing a host of new innovations to light. One that hospitalists are likely to hear about far more about is the evolving role of an “extensivist,” an inpatient provider who ventures to outpatient settings to assist with care transitions.

In many ways, the expanding discussion of what extensivists are and do reflects the success of hospitalists in coordinating inpatient care and improving such metrics as length of stay (LOS). Why should that coordination end upon discharge? healthcare experts have wondered. Instead of a pure hospitalist system, could the experience and training of hospitalists be extended to include transitional or interim settings that provide a safety net between the hospital and a primary-care physician (PCP)? Might that improved inpatient-outpatient coordination help with other metrics, such as reduced rehospitalizations (see “All Aboard,” p. 1)?

We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care.—Adam Singer, MD, CEO, IPC: The Hospitalist Co., North Hollywood, Calif.

One tangible result of those questions has been the growth of high-risk clinics. Hospitalist programs can provide clinic referrals for discharged patients who still require hands-on care, while PCPs can likewise refer some of their more complex patients. The clinic, then, becomes an alternative to hospitalization, or a preventive measure to avoid rehospitalization.

Philip Sanger, MD, founder and former CEO of Houston-based Inpatient Medical Services (now Intercede Health), is credited with one of the first uses of the term “extensivist.” Initially, it only described a hospitalist or other care provider who sees high-risk patients in an outpatient clinic.

Writing in Managed Healthcare Executive in 2002, Dr. Sanger explained: “To move from generally sick to generally well, high-risk patients need something extra—more attention than a busy PCP can offer [and] more individualized care than most protocol-driven disease management programs can provide. A high-risk clinic system is one way to fill this care gap. Also referred to as transitional-care clinics, these outpatient clinics focus on preventing hospital admissions and stabilizing high-risk patients.”¹

Measured Improvements

Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Co., says this extensivist model provides a respite for hospitalists, who typically spend a month at a time in these transitional clinics before heading back into the fray of the hospital. As hospitals, independent physician associations, and managed-care organizations try out new models of care, though, the definition of an extensivist has broadened to include providers in a range of outpatient settings, such as skilled nursing facilities, assistant living communities, and even home health services. California’s CareMore Medicare Advantage plan, in particular, has been cited by the Agency for Healthcare Research and Quality (AHRQ) for using hospitalists as extensivists in both outpatient clinics and skilled nursing facilities to reduce hospital readmission rates, LOS, and inpatient resource use.

The CareMore model reduces the caseload of its hospitalists to about six or eight patients per half-day, giving doctors more time to talk to patients and their family members. Based on those conversations, the extensivist works with a case manager to provide needed resources to each patient after discharge. The doctors also spend roughly half of each day in clinics seeing their own recently discharged patients, and one or two days each week in a skilled nursing facility to visit patients transferred from the hospital (for more details, visit www.innovations.ahrq.gov/content.aspx?id=2903).

Average inpatient LOS among the plan’s 44,000 members dipped to 3.2 days, compared with 5.8 days for Medicare fee-for-service providers and 4.5 days for traditional HM programs in the state. Last April, CareMore’s 30-day readmission rate averaged 13.4%, compared with a 19.6% rate for Medicare.

Baltimore-based Bravo Health has begun opening its own transitional advanced-care centers for members of its Medicare Advantage program, offering case management for complex conditions and immediate care when a PCP is unavailable. Another model has been advanced through team approaches practiced by the likes of Kaiser Permanente, though hospitalists aren’t necessarily the ones providing outpatient follow-up care. No matter what the model is called, Dr. Singer says, the main point is the same: “trying to connect the dots so that we get patients continuing to get better along the continuum without having to be readmitted.”

In December, IPC did some more dot-connecting of its own with its announced acquisition of Senior Care of Colorado, which operates more than 200 geriatric-care facilities in the Denver area. Don Murphy, MD, IPC’s practice group leader for Senior Care of Colorado, says the model emphasizes a continuum of care and information flow from hospitalists in the hospital to affiliated providers in skilled nursing facilities and other outpatient settings. “We think that model, where we tie everything together, will be one of the best that we can do,” Dr. Murphy says.

From Dr. Singer’s perspective, the growing opportunities have sprung from efforts to address a persistent challenge. “We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care,” he says. One of the central ideas of healthcare reform—creating true accountability around an episode of care—will require doctors to be linked “not just during what used to be the episode of care in the hospital,” he adds, “but throughout the continuum until that patient is really returned healthy back to wherever they’re going to be living.”

With a new emphasis on avoidable hospitalizations, hospitals will increasingly need to team up with other providers to avoid fragmentation of care. Using extensivists to help avoid gaps might be a good fit for accountable-care organizations, and Dr. Murphy says the process may be easier for big systems, such as Ochsner in New Orleans or the Cleveland Clinic, which are working in a confined geographic area with a defined patient population.

“The real challenge will be those of us out there in larger metropolitan areas where we’re not under the roof of one big conglomerate but still having to work together creatively and effectively to smooth the continuum,” Dr. Singer says.

Emerging Trends

Other trends are making inpatient-outpatient partnerships, whether formal or informal, an increasingly necessary part of providing high-quality healthcare. “We are seeing folks come out of the hospitals who 30 years ago clearly would have been in the hospital for a prolonged stay,” Dr. Murphy says. “A lot of these [patients], instead of going to SNFs, are going back to their homes and to assisted living with additional services; they require a lot of follow-up.”

Dr. Singer says he’s seeing another trend in which PCPs are likewise transitioning to newly created extensivist roles in sub-acute settings such as nursing homes. The position, he says, offers the attraction of a high-impact, longer-term relationship with patients without the high overhead of standalone clinics. The blurring of lines between outpatient and inpatient providers has created questions for hospitalists, too. For example, at what point does a hospitalist working much of the time in an outpatient clinic or skilled nursing facility no longer fit the traditional definition of a hospitalist? Does that detract from the doctor’s hospital duties? TH

Bryn Nelson is a freelance medical writer based in Seattle.

Reference

1. Sanger, P. Health plans juggle precarious patients. Managed Healthcare Executive. 2002:40-41.

Necessity, as they say, is the mother of invention, and the growing focus on the need for high-quality and cost-effective care is bringing a host of new innovations to light. One that hospitalists are likely to hear about far more about is the evolving role of an “extensivist,” an inpatient provider who ventures to outpatient settings to assist with care transitions.

In many ways, the expanding discussion of what extensivists are and do reflects the success of hospitalists in coordinating inpatient care and improving such metrics as length of stay (LOS). Why should that coordination end upon discharge? healthcare experts have wondered. Instead of a pure hospitalist system, could the experience and training of hospitalists be extended to include transitional or interim settings that provide a safety net between the hospital and a primary-care physician (PCP)? Might that improved inpatient-outpatient coordination help with other metrics, such as reduced rehospitalizations (see “All Aboard,” p. 1)?

We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care.—Adam Singer, MD, CEO, IPC: The Hospitalist Co., North Hollywood, Calif.

One tangible result of those questions has been the growth of high-risk clinics. Hospitalist programs can provide clinic referrals for discharged patients who still require hands-on care, while PCPs can likewise refer some of their more complex patients. The clinic, then, becomes an alternative to hospitalization, or a preventive measure to avoid rehospitalization.

Philip Sanger, MD, founder and former CEO of Houston-based Inpatient Medical Services (now Intercede Health), is credited with one of the first uses of the term “extensivist.” Initially, it only described a hospitalist or other care provider who sees high-risk patients in an outpatient clinic.

Writing in Managed Healthcare Executive in 2002, Dr. Sanger explained: “To move from generally sick to generally well, high-risk patients need something extra—more attention than a busy PCP can offer [and] more individualized care than most protocol-driven disease management programs can provide. A high-risk clinic system is one way to fill this care gap. Also referred to as transitional-care clinics, these outpatient clinics focus on preventing hospital admissions and stabilizing high-risk patients.”¹

Measured Improvements

Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Co., says this extensivist model provides a respite for hospitalists, who typically spend a month at a time in these transitional clinics before heading back into the fray of the hospital. As hospitals, independent physician associations, and managed-care organizations try out new models of care, though, the definition of an extensivist has broadened to include providers in a range of outpatient settings, such as skilled nursing facilities, assistant living communities, and even home health services. California’s CareMore Medicare Advantage plan, in particular, has been cited by the Agency for Healthcare Research and Quality (AHRQ) for using hospitalists as extensivists in both outpatient clinics and skilled nursing facilities to reduce hospital readmission rates, LOS, and inpatient resource use.

The CareMore model reduces the caseload of its hospitalists to about six or eight patients per half-day, giving doctors more time to talk to patients and their family members. Based on those conversations, the extensivist works with a case manager to provide needed resources to each patient after discharge. The doctors also spend roughly half of each day in clinics seeing their own recently discharged patients, and one or two days each week in a skilled nursing facility to visit patients transferred from the hospital (for more details, visit www.innovations.ahrq.gov/content.aspx?id=2903).

Average inpatient LOS among the plan’s 44,000 members dipped to 3.2 days, compared with 5.8 days for Medicare fee-for-service providers and 4.5 days for traditional HM programs in the state. Last April, CareMore’s 30-day readmission rate averaged 13.4%, compared with a 19.6% rate for Medicare.

Baltimore-based Bravo Health has begun opening its own transitional advanced-care centers for members of its Medicare Advantage program, offering case management for complex conditions and immediate care when a PCP is unavailable. Another model has been advanced through team approaches practiced by the likes of Kaiser Permanente, though hospitalists aren’t necessarily the ones providing outpatient follow-up care. No matter what the model is called, Dr. Singer says, the main point is the same: “trying to connect the dots so that we get patients continuing to get better along the continuum without having to be readmitted.”

In December, IPC did some more dot-connecting of its own with its announced acquisition of Senior Care of Colorado, which operates more than 200 geriatric-care facilities in the Denver area. Don Murphy, MD, IPC’s practice group leader for Senior Care of Colorado, says the model emphasizes a continuum of care and information flow from hospitalists in the hospital to affiliated providers in skilled nursing facilities and other outpatient settings. “We think that model, where we tie everything together, will be one of the best that we can do,” Dr. Murphy says.

From Dr. Singer’s perspective, the growing opportunities have sprung from efforts to address a persistent challenge. “We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care,” he says. One of the central ideas of healthcare reform—creating true accountability around an episode of care—will require doctors to be linked “not just during what used to be the episode of care in the hospital,” he adds, “but throughout the continuum until that patient is really returned healthy back to wherever they’re going to be living.”

With a new emphasis on avoidable hospitalizations, hospitals will increasingly need to team up with other providers to avoid fragmentation of care. Using extensivists to help avoid gaps might be a good fit for accountable-care organizations, and Dr. Murphy says the process may be easier for big systems, such as Ochsner in New Orleans or the Cleveland Clinic, which are working in a confined geographic area with a defined patient population.

“The real challenge will be those of us out there in larger metropolitan areas where we’re not under the roof of one big conglomerate but still having to work together creatively and effectively to smooth the continuum,” Dr. Singer says.

Emerging Trends

Other trends are making inpatient-outpatient partnerships, whether formal or informal, an increasingly necessary part of providing high-quality healthcare. “We are seeing folks come out of the hospitals who 30 years ago clearly would have been in the hospital for a prolonged stay,” Dr. Murphy says. “A lot of these [patients], instead of going to SNFs, are going back to their homes and to assisted living with additional services; they require a lot of follow-up.”

Dr. Singer says he’s seeing another trend in which PCPs are likewise transitioning to newly created extensivist roles in sub-acute settings such as nursing homes. The position, he says, offers the attraction of a high-impact, longer-term relationship with patients without the high overhead of standalone clinics. The blurring of lines between outpatient and inpatient providers has created questions for hospitalists, too. For example, at what point does a hospitalist working much of the time in an outpatient clinic or skilled nursing facility no longer fit the traditional definition of a hospitalist? Does that detract from the doctor’s hospital duties? TH

Bryn Nelson is a freelance medical writer based in Seattle.

Reference

1. Sanger, P. Health plans juggle precarious patients. Managed Healthcare Executive. 2002:40-41.

Necessity, as they say, is the mother of invention, and the growing focus on the need for high-quality and cost-effective care is bringing a host of new innovations to light. One that hospitalists are likely to hear about far more about is the evolving role of an “extensivist,” an inpatient provider who ventures to outpatient settings to assist with care transitions.

In many ways, the expanding discussion of what extensivists are and do reflects the success of hospitalists in coordinating inpatient care and improving such metrics as length of stay (LOS). Why should that coordination end upon discharge? healthcare experts have wondered. Instead of a pure hospitalist system, could the experience and training of hospitalists be extended to include transitional or interim settings that provide a safety net between the hospital and a primary-care physician (PCP)? Might that improved inpatient-outpatient coordination help with other metrics, such as reduced rehospitalizations (see “All Aboard,” p. 1)?

We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care.—Adam Singer, MD, CEO, IPC: The Hospitalist Co., North Hollywood, Calif.

One tangible result of those questions has been the growth of high-risk clinics. Hospitalist programs can provide clinic referrals for discharged patients who still require hands-on care, while PCPs can likewise refer some of their more complex patients. The clinic, then, becomes an alternative to hospitalization, or a preventive measure to avoid rehospitalization.

Philip Sanger, MD, founder and former CEO of Houston-based Inpatient Medical Services (now Intercede Health), is credited with one of the first uses of the term “extensivist.” Initially, it only described a hospitalist or other care provider who sees high-risk patients in an outpatient clinic.

Writing in Managed Healthcare Executive in 2002, Dr. Sanger explained: “To move from generally sick to generally well, high-risk patients need something extra—more attention than a busy PCP can offer [and] more individualized care than most protocol-driven disease management programs can provide. A high-risk clinic system is one way to fill this care gap. Also referred to as transitional-care clinics, these outpatient clinics focus on preventing hospital admissions and stabilizing high-risk patients.”¹

Measured Improvements

Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Co., says this extensivist model provides a respite for hospitalists, who typically spend a month at a time in these transitional clinics before heading back into the fray of the hospital. As hospitals, independent physician associations, and managed-care organizations try out new models of care, though, the definition of an extensivist has broadened to include providers in a range of outpatient settings, such as skilled nursing facilities, assistant living communities, and even home health services. California’s CareMore Medicare Advantage plan, in particular, has been cited by the Agency for Healthcare Research and Quality (AHRQ) for using hospitalists as extensivists in both outpatient clinics and skilled nursing facilities to reduce hospital readmission rates, LOS, and inpatient resource use.

The CareMore model reduces the caseload of its hospitalists to about six or eight patients per half-day, giving doctors more time to talk to patients and their family members. Based on those conversations, the extensivist works with a case manager to provide needed resources to each patient after discharge. The doctors also spend roughly half of each day in clinics seeing their own recently discharged patients, and one or two days each week in a skilled nursing facility to visit patients transferred from the hospital (for more details, visit www.innovations.ahrq.gov/content.aspx?id=2903).

Average inpatient LOS among the plan’s 44,000 members dipped to 3.2 days, compared with 5.8 days for Medicare fee-for-service providers and 4.5 days for traditional HM programs in the state. Last April, CareMore’s 30-day readmission rate averaged 13.4%, compared with a 19.6% rate for Medicare.

Baltimore-based Bravo Health has begun opening its own transitional advanced-care centers for members of its Medicare Advantage program, offering case management for complex conditions and immediate care when a PCP is unavailable. Another model has been advanced through team approaches practiced by the likes of Kaiser Permanente, though hospitalists aren’t necessarily the ones providing outpatient follow-up care. No matter what the model is called, Dr. Singer says, the main point is the same: “trying to connect the dots so that we get patients continuing to get better along the continuum without having to be readmitted.”

In December, IPC did some more dot-connecting of its own with its announced acquisition of Senior Care of Colorado, which operates more than 200 geriatric-care facilities in the Denver area. Don Murphy, MD, IPC’s practice group leader for Senior Care of Colorado, says the model emphasizes a continuum of care and information flow from hospitalists in the hospital to affiliated providers in skilled nursing facilities and other outpatient settings. “We think that model, where we tie everything together, will be one of the best that we can do,” Dr. Murphy says.

From Dr. Singer’s perspective, the growing opportunities have sprung from efforts to address a persistent challenge. “We write an order of discharge to a skilled nursing facility, and patients go off into the community and we have no idea where they’re going, who they’re going to, what’s the quality of care out there, what’s the capacity of care,” he says. One of the central ideas of healthcare reform—creating true accountability around an episode of care—will require doctors to be linked “not just during what used to be the episode of care in the hospital,” he adds, “but throughout the continuum until that patient is really returned healthy back to wherever they’re going to be living.”

With a new emphasis on avoidable hospitalizations, hospitals will increasingly need to team up with other providers to avoid fragmentation of care. Using extensivists to help avoid gaps might be a good fit for accountable-care organizations, and Dr. Murphy says the process may be easier for big systems, such as Ochsner in New Orleans or the Cleveland Clinic, which are working in a confined geographic area with a defined patient population.

“The real challenge will be those of us out there in larger metropolitan areas where we’re not under the roof of one big conglomerate but still having to work together creatively and effectively to smooth the continuum,” Dr. Singer says.

Emerging Trends

Other trends are making inpatient-outpatient partnerships, whether formal or informal, an increasingly necessary part of providing high-quality healthcare. “We are seeing folks come out of the hospitals who 30 years ago clearly would have been in the hospital for a prolonged stay,” Dr. Murphy says. “A lot of these [patients], instead of going to SNFs, are going back to their homes and to assisted living with additional services; they require a lot of follow-up.”

Dr. Singer says he’s seeing another trend in which PCPs are likewise transitioning to newly created extensivist roles in sub-acute settings such as nursing homes. The position, he says, offers the attraction of a high-impact, longer-term relationship with patients without the high overhead of standalone clinics. The blurring of lines between outpatient and inpatient providers has created questions for hospitalists, too. For example, at what point does a hospitalist working much of the time in an outpatient clinic or skilled nursing facility no longer fit the traditional definition of a hospitalist? Does that detract from the doctor’s hospital duties? TH

Bryn Nelson is a freelance medical writer based in Seattle.

Reference

1. Sanger, P. Health plans juggle precarious patients. Managed Healthcare Executive. 2002:40-41.

I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.

Thad Horton, MD

St. Louis

Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.

Basically, the highlights of the new rules are:

• Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
• Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
• PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
• Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
• Residents cannot work more than six consecutive nights as night float; and
• Residents cannot be scheduled for in-house call more frequently than every third night.

I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.

The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.

Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.

If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.

Communication, Comfort Zone Key to Managing Hypertensive Emergencies

I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?

Dennis Swanson, MD

Grand Rapids, Mich.

Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.

Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.

It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH

I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.

Thad Horton, MD

St. Louis

Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.

Basically, the highlights of the new rules are:

• Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
• Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
• PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
• Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
• Residents cannot work more than six consecutive nights as night float; and
• Residents cannot be scheduled for in-house call more frequently than every third night.

I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.

The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.

Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.

If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.

Communication, Comfort Zone Key to Managing Hypertensive Emergencies

I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?

Dennis Swanson, MD

Grand Rapids, Mich.

Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.

Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.

It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH

I heard that there are new resident work-hour rules that preclude interns from spending the night in the hospital. Tell me this isn’t true! I am an old-timer.

Thad Horton, MD

St. Louis

Dr. Hospitalist responds: On Sept. 26, 2010, the Accreditation Council for Graduate Medical Education (ACGME) approved new resident duty-hours and supervision standards; the new rules go into effect July 1. ACGME accredits more than 8,800 medical residency programs in the U.S. in more than 130 specialties and subspecialties. More than 111,000 residents and fellows train in these programs annually. ACGME first instituted duty-hour regulations in 2003; those led to a dramatic decrease in resident work-hours.

Basically, the highlights of the new rules are:

• Residents are limited to 80 hours weekly, averaged over a four-week period, and inclusive of all in-house call activities and moonlighting;
• Residents must be allowed one day free of duty every week (at-home call cannot be assigned on these free days);
• PGY-1 residents cannot work more than 16 hours daily, and residents beyond their PGY-1 year cannot work more than 24 hours daily;
• Residents must have at least eight hours off between shifts, and residents who work a 24-hour shift must have a minimum of 14 hours off before starting another shift;
• Residents cannot work more than six consecutive nights as night float; and
• Residents cannot be scheduled for in-house call more frequently than every third night.

I have not seen any specific prohibition on interns working overnight in the hospital. However, the new rules restrict interns to working no more than 16 hours daily, so that will mean interns who stay overnight in the hospital, until 7 or 8 a.m., cannot begin that overnight shift until 3 or 4 p.m. the day before. That means programs planning to keep their interns in-house overnight will have to be creative in their scheduling.

The demand for innovative scheduling won’t be the only implication of these new regulations. A number of forces have driven the rapid expansion of HM over the past decade. We have seen the development of sizable hospitalist programs at a number of teaching hospitals across the country. Hospitalists at teaching hospitals are not only supervising the care provided by residents, but they are also caring for patients without resident involvement. Since the original ACGME duty-hours cutback in 2002, we have seen the development and expansion of hospitalist-staffed, non-resident-covered medical services at most teaching hospitals across the country. Any further restriction in resident work-hours likely will result in the need to hire additional hospitalists to care for patients.

Virtually all HM programs require financial support to make ends meet. The most recent SHM/MGMA compensation and productivity survey found that the average hospitalist full-time equivalent (FTE) requires a little more than $100,000 of support annually. Regardless of the employer, much of that support comes from the hospital. So it appears that hospitals with teaching programs will end up footing the bill for the new resident regulations. I expect HM programs at teaching hospitals will face pushback from hospital administrators, but hiring additional hospitalists is a cost-effective proposition—and not complying with the ACGME rules is not an option, unless your program wants to risk losing its accreditation.

If you are a hospitalist program leader at a teaching hospital, I encourage you to plan accordingly and discuss the impact of these revisions in duty-hours with your teaching program director and your hospital administration.

Communication, Comfort Zone Key to Managing Hypertensive Emergencies

I just saw a patient in our urgent-care clinic sent from an ophthalmologist’s office with newly diagnosed retinal hemorrhages in both eyes and repeated BPs of 170/115. She had no history of hypertension (HTN) and no other symptoms. Does this qualify as an emergency? I couldn’t find any literature in this regard. My sense was it was an emergency, as her vision seemed to be at risk, so I sent her to the ED for IV meds in a controlled environment. Did I overreact?

Dennis Swanson, MD

Grand Rapids, Mich.

Dr. Hospitalist responds: Thank you for your question. There are numerous potential causes of retinal hemorrhages. Aside from trauma, we most commonly see retinal hemorrhages in patients with diabetic retinopathy and/or HTN. As you know, the retina is the only part of the vasculature that we can visualize noninvasively. This is a good example of why it is always important for providers to perform a fundoscopy on every patient with newly discovered HTN.

Retinal hemorrhage is one of several ocular diseases directly related to HTN. Based on your description, it sounds as if the ophthalmologist discovered the retinal hemorrhages and sent the patient to you, given the concern that uncontrolled HTN was the cause of the hemorrhages. You stated that you sent the patient to the ED because you were concerned the patient’s vision “seemed to be at risk.” Most retinal hemorrhages are asymptomatic unless the macular is affected, in which case the patient experiences a change in their visual acuity. Progressive microvascular changes in the retina can cause a loss of visual acuity. Aside from addressing the underlying problem causing the hemorrhages, laser surgery is the typical treatment of retinal hemorrhages. The laser seals off the abnormally bleeding vessels in the retina.

It would be useful to know about any communication that occurred between you and the ophthalmologist. I imagine the ophthalmologist was going to perform laser surgery but sent the patient to the hospital to address the HTN. If you did not feel comfortable managing the patient’s HTN in the urgent-care clinic, you did the right thing by sending the patient to the ED. It also is important to note that patients with hypertensive retinopathy often have other microvascular diseases, including in the kidneys. This patient should be evaluated for any evidence of proteinuria, which can suggest progressive microvascular renal disease, also as a result of uncontrolled HTN. TH

The Current Procedural Terminology (CPT) code set for 2011 includes several changes of interest to ObGyns. These include 1) guideline clarifications regarding wound debridement and obstetric care codes; 2) new codes for subsequent observation care; micro-remodeling of the bladder neck; insertion of a vaginal after-loading device; and 3) a lab code for detecting amniotic fluid in cervicovaginal secretions (using the AmniSure kit).

There is also a new code for vaccine counseling that will have an impact on you if your practice offers the human papillomavirus (HPV) vaccine to patients younger than 19 years.

There are changes to Medicare this year that you should take note of if you care for these patients, particularly in the area of preventive visit billing.

CPT and Medicare changes both took effect on January 1. The Health Insurance Portability and Accountability Act (HIPAA) requires that insurers accepted the new codes on that date.

Changes to the CPT code set

OBSERVATION CARE

One of the biggest headaches for medical practices has been standardized coding and billing for observation care that lasts more than 1 day. In the past, payers accepted a problem E/M for Day 2 of observation care, or instructed practices to code an unlisted E/M service. Now, you may report all care rendered in the observation setting with the addition of three new codes for subsequent care:

99244 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: problem focused interval history, problem focused examination; medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.

99225 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.

99226 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.

Note that each of these codes 1) “suggests” the status of the patient for each level of billing, and 2) includes a typical time. This means that, unlike the observation care admission codes or the observation admission/same-day discharge codes, time that is spent with the patient, or on the unit, may be used to select the code—if you document 1) the requirement that more than 50% of the typical time was spent on counseling or coordination of care, or both, and 2) a detailed description of this activity.

WOUND MANAGEMENT

Codes for wound debridement were given a facelift with the addition of a new guideline that addresses both surgical and medical debridement. The surgical debridement codes, (11042–11047) are now reported on the basis of the depth of tissue removed and the surface area of the wound. This means that codes 11040 and 11041 were deleted to make room for new and revised codes.

This change will mean that, when you report these codes, you will need to document more information to bill. It’s also understood that coding separately for debridement of dermis or epidermis at the same time you code for debriding underlying structures would be inappropriate.

CPT has also indicated that active wound management codes 97597 and 97598 can now be reported by physicians or nonphysician providers as long as the provider has direct (one-on-one) contact. These codes should be reported for skin-surface debridement only.

The new and revised codes (some of which have been published in CPT in nonsequential order) are:

11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

+11045 (new add-on code reported with 11042 only) each additional 20 sq cm or part thereof

11043 Debridement, muscle and/or facia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less

+11046 (new add-on code reported with 11043 only) each additional 20 sq cm or part thereof

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

+11047 (new add-on code reported with 11044 only) each additional 20 sq cm or part thereof

97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

+95798 (add-on code reported with 97597 only) Each additional 20 sq cm, or part thereof.

TRANSURETHRAL RADIOFREQUENCY

Category III code 0193T, which described transurethral radiofrequency micro-remodeling for stress urinary incontinence, has been deleted and converted to a Category I CPT code, 53860 (Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence). The procedure includes a periurethral block and flushing the bladder with a lidocaine slurry, and can be performed in the office.

In all, the procedure requires nine treatment cycles during the session, but the code is billed only once. Catheterization and measurement of a voiding sample after the procedure are included in the code.

AFTERLOADING DEVICES FOR CLINICAL BRACHYTHERAPY

CPT revised—slightly—existing code 57155, and added code 57156 (Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy).

• Code 57155 was revised to clarify that only a single tandem is inserted into the uterus. There had been confusion earlier in this regard.
• The new code describes a procedure that may also include dilation of the vaginal canal to remove postradiation adhesions. That procedure also involves 1) placement of bladder and rectal catheters and 2) radiographic imaging to confirm placement, which are not coded separately.

CLARIFICATION OF OBSTETRIC GUIDELINES

Been having problems with payers and their interpretation of the delivery only, postpartum only, and delivery with postpartum care codes? CPT has, at last, clarified what you can, and cannot, bill in those circumstances. (Keep in mind, however, that you may not unbundle these procedures if more extensive care is provided: Most payers want you to bill the global OB care code that includes antepartum, intrapartum, and postpartum care.)

In some cases (such as Medicaid), the payer stipulates that only the physician who actually performed the delivery may bill for it, even if the delivering physician is covering for, or is a member of, the same group practice as the primary attending of record. The “delivery-only” codes should be reported when 1) an unaffiliated physician has delivered the baby but will not be providing any outpatient postpartum care or 2) the payer has specified this method of billing for the covering or affiliated provider.

CPT has clarified that delivery-only codes (59409, 59514, or 59612, 59620) include admission to the hospital, the admission history and physical exam, uncomplicated labor and delivery (including delivery of the placenta, or use of forceps or vacuum extraction). These codes do not include inpatient rounding or discharge day care after delivery (and, of course, include no outpatient postpartum care). When, as the delivering physician, you also provide inpatient postdelivery care, therefore, you may additionally bill subsequent hospital care codes and discharge day management codes (99231-99233, 99238-99239).

If the unaffiliated physician performs the delivery and also intends on providing outpatient postpartum care, the CPT codes for delivery with postpartum are to be reported (59410, 59515, 59614, 59622). In addition to the delivery, these codes include all inpatient and outpatient postpartum care. And finally, for those physicians who are only providing outpatient postpartum care, the code 59430, Postpartum care only, should be reported.

PLACENTAL ALPHA MICROGLOBULIN-1

A new code, 84112 (Placental alpha microglobulin-1 [PAMG-11], cervicovaginal secretion, qualitative), has been added to allow the clinical laboratory to bill for this immunoassay that detects amniotic fluid in the secretions. Physician work involves collection of the specimen but, under CPT rules, collection is included as part of any E/M service.

Note: An existing code for this test that is used by Blue Cross/Blue Shield payers (S3628) remains valid in 2011.

HPV VACCINE COUNSELING

Before January 1, 2011, if you counseled a patient about the HPV vaccine, you could report preventive counseling codes, such as 99401–99404, in addition to the vaccine administration code, 90471 (Immunization administration, 1 vaccine). Now, however, you have a new code for counseling and vaccine administration for a patient who is younger than 19 years—the age group most likely to be counseled about this vaccine. When you see, and counsel, such a patient before administering the vaccine, on the same date of service, code 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care profession; first vaccine/toxoid component), and 90649 for the quadrivalent or 90650 for the bivalent HPV vaccine.

If your patient is 19 years or older and requires counseling, continue to bill 99401– 99404 for counseling, with 90471 for immunization and 90649 or 90650 for the vaccine. Keep in mind: Whether you report 90460 or the 9940X codes, you are required to document the content of the counseling. Codes 9940X also require documentation of the duration of counseling.

INFLUENZA VACCINE

New codes have been established for the flu vaccine, but you won’t be using them: They are intended to address future pandemic strains of influenza. This year’s vaccine contains the H1N1 strain, but is coded as the normal seasonal flu vaccine, based on the type given:

90656 (preservative-free)

90658 (split virus)

90660 (intranasal)

90662 (enhanced vaccine for patients older than 65 years).

Changes to Medicare billing

Some of the coding and billing changes this year that have an impact on ObGyn practice come from the Centers of Medicare and Medicaid Services (CMS) and the Affordable Care Act.

TIMELY FILING

The Affordable Care Act calls for a reduction in the maximum time period for submission of Medicare fee-for-service claims. Before January 1, a provider had 15 to 27 months to submit first-time claims to Medicare. Now, these claims must be filed within a calendar year of the date of service. Exceptions can be made for retroactive entitlement or in situations in which there is a secondary payer.

PAYMENTS TO CERTIFIED NURSE MIDWIVES

Next, more good news—if you employ a certified nurse midwife (CNM) in your practice. Before January 1, Medicare reimbursed direct billing from a CNM at only 65% of the Medicare Physician Fee Schedule. Now, a CNM is paid the same as a physician when she (he) bills under her own number.

In the past, some practices billed for the services of a CNM under “incident to” rules, to capture the physician payment—but this also meant that the CNM could not see a new patient. Under the change I’m describing, all CNMs can bill Medicare directly; see new patients; and be paid the same as the physician is paid. In addition, CNMs are no longer required to be supervised by a physician when they perform diagnostic tests that fall under the scope of their practice.

ANNUAL WELLNESS VISIT

The Affordable Care Act extended preventive coverage to Medicare beneficiaries in the form of an annual wellness visit. The two new codes here have been valued based on a level 4-problem new and established E/M service:

G0438 Annual wellness visit, including personalized prevention plan services, first visit

G0439 Annual wellness visit, including personalized prevention plan services, subsequent visit

Payment for the initial visit is made only beginning the second year the patient is eligible for Medicare Part B—during the first year of coverage, only the Initial Preventive Physical Examination (IPPE) (the “Welcome to Medicare”) exam will be covered.

CMS has stated that only one physician will be paid for the initial visit; when the patient returns to the same or a new physician in the third year, only a subsequent visit will be paid. It is, therefore, important that this information be conveyed to any new physician who sees the patient.

The annual codes can be billed in addition to any other preventive service, such as G0101 or Q0091; no modifier is needed for this combination. Medicare has waived both the copayment and the deductible for the annual wellness visit, as well as all Medicare-covered preventive services that have been recommended with a grade of “A” (“strongly recommends”) or “B” (“recommends”) by the US Preventive Services Task Force.

The annual wellness visit requires seven elements at a minimum (i.e., you may document and perform more elements than this, but not fewer):

• Establish or update the patient’s medical and family history
• List her current medical providers and suppliers and all prescribed medications
• Record measurements of height, weight, body mass index (initial visit only), blood pressure, and other routine measurements
• Detect any cognitive impairment
• Establish or update a screening schedule for the next 5 to 10 years, including screenings appropriate for the general population, and any additional screenings that may be appropriate because of her particular risk factors
• Review the patient’s 1) potential (i.e., risk factors) for depression, based on use of an appropriate screening instrument, and 2) functional ability and level of safety based on direct observation or screening questions
• Furnish 1) personalized health advice and 2) refer her appropriately to health education or preventive services.

CMS has also indicated that, although they will pay for a problem E/M service and the annual wellness visit on the same date of service with a modifier -25 added to the E/M service, they expect this type of billing to be rare—because of the nature of the wellness visit, which is time-intensive. They also expect that, given these requirements, the patient will not be billed additionally for a noncovered preventive service.

We want to hear from you! Tell us what you think.

The Current Procedural Terminology (CPT) code set for 2011 includes several changes of interest to ObGyns. These include 1) guideline clarifications regarding wound debridement and obstetric care codes; 2) new codes for subsequent observation care; micro-remodeling of the bladder neck; insertion of a vaginal after-loading device; and 3) a lab code for detecting amniotic fluid in cervicovaginal secretions (using the AmniSure kit).

There is also a new code for vaccine counseling that will have an impact on you if your practice offers the human papillomavirus (HPV) vaccine to patients younger than 19 years.

There are changes to Medicare this year that you should take note of if you care for these patients, particularly in the area of preventive visit billing.

CPT and Medicare changes both took effect on January 1. The Health Insurance Portability and Accountability Act (HIPAA) requires that insurers accepted the new codes on that date.

Changes to the CPT code set

OBSERVATION CARE

One of the biggest headaches for medical practices has been standardized coding and billing for observation care that lasts more than 1 day. In the past, payers accepted a problem E/M for Day 2 of observation care, or instructed practices to code an unlisted E/M service. Now, you may report all care rendered in the observation setting with the addition of three new codes for subsequent care:

99244 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: problem focused interval history, problem focused examination; medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.

99225 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.

99226 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.

Note that each of these codes 1) “suggests” the status of the patient for each level of billing, and 2) includes a typical time. This means that, unlike the observation care admission codes or the observation admission/same-day discharge codes, time that is spent with the patient, or on the unit, may be used to select the code—if you document 1) the requirement that more than 50% of the typical time was spent on counseling or coordination of care, or both, and 2) a detailed description of this activity.

WOUND MANAGEMENT

Codes for wound debridement were given a facelift with the addition of a new guideline that addresses both surgical and medical debridement. The surgical debridement codes, (11042–11047) are now reported on the basis of the depth of tissue removed and the surface area of the wound. This means that codes 11040 and 11041 were deleted to make room for new and revised codes.

This change will mean that, when you report these codes, you will need to document more information to bill. It’s also understood that coding separately for debridement of dermis or epidermis at the same time you code for debriding underlying structures would be inappropriate.

CPT has also indicated that active wound management codes 97597 and 97598 can now be reported by physicians or nonphysician providers as long as the provider has direct (one-on-one) contact. These codes should be reported for skin-surface debridement only.

The new and revised codes (some of which have been published in CPT in nonsequential order) are:

11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

+11045 (new add-on code reported with 11042 only) each additional 20 sq cm or part thereof

11043 Debridement, muscle and/or facia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less

+11046 (new add-on code reported with 11043 only) each additional 20 sq cm or part thereof

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

+11047 (new add-on code reported with 11044 only) each additional 20 sq cm or part thereof

97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

+95798 (add-on code reported with 97597 only) Each additional 20 sq cm, or part thereof.

TRANSURETHRAL RADIOFREQUENCY

Category III code 0193T, which described transurethral radiofrequency micro-remodeling for stress urinary incontinence, has been deleted and converted to a Category I CPT code, 53860 (Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence). The procedure includes a periurethral block and flushing the bladder with a lidocaine slurry, and can be performed in the office.

In all, the procedure requires nine treatment cycles during the session, but the code is billed only once. Catheterization and measurement of a voiding sample after the procedure are included in the code.

AFTERLOADING DEVICES FOR CLINICAL BRACHYTHERAPY

CPT revised—slightly—existing code 57155, and added code 57156 (Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy).

• Code 57155 was revised to clarify that only a single tandem is inserted into the uterus. There had been confusion earlier in this regard.
• The new code describes a procedure that may also include dilation of the vaginal canal to remove postradiation adhesions. That procedure also involves 1) placement of bladder and rectal catheters and 2) radiographic imaging to confirm placement, which are not coded separately.

CLARIFICATION OF OBSTETRIC GUIDELINES

Been having problems with payers and their interpretation of the delivery only, postpartum only, and delivery with postpartum care codes? CPT has, at last, clarified what you can, and cannot, bill in those circumstances. (Keep in mind, however, that you may not unbundle these procedures if more extensive care is provided: Most payers want you to bill the global OB care code that includes antepartum, intrapartum, and postpartum care.)

In some cases (such as Medicaid), the payer stipulates that only the physician who actually performed the delivery may bill for it, even if the delivering physician is covering for, or is a member of, the same group practice as the primary attending of record. The “delivery-only” codes should be reported when 1) an unaffiliated physician has delivered the baby but will not be providing any outpatient postpartum care or 2) the payer has specified this method of billing for the covering or affiliated provider.

CPT has clarified that delivery-only codes (59409, 59514, or 59612, 59620) include admission to the hospital, the admission history and physical exam, uncomplicated labor and delivery (including delivery of the placenta, or use of forceps or vacuum extraction). These codes do not include inpatient rounding or discharge day care after delivery (and, of course, include no outpatient postpartum care). When, as the delivering physician, you also provide inpatient postdelivery care, therefore, you may additionally bill subsequent hospital care codes and discharge day management codes (99231-99233, 99238-99239).

If the unaffiliated physician performs the delivery and also intends on providing outpatient postpartum care, the CPT codes for delivery with postpartum are to be reported (59410, 59515, 59614, 59622). In addition to the delivery, these codes include all inpatient and outpatient postpartum care. And finally, for those physicians who are only providing outpatient postpartum care, the code 59430, Postpartum care only, should be reported.

PLACENTAL ALPHA MICROGLOBULIN-1

A new code, 84112 (Placental alpha microglobulin-1 [PAMG-11], cervicovaginal secretion, qualitative), has been added to allow the clinical laboratory to bill for this immunoassay that detects amniotic fluid in the secretions. Physician work involves collection of the specimen but, under CPT rules, collection is included as part of any E/M service.

Note: An existing code for this test that is used by Blue Cross/Blue Shield payers (S3628) remains valid in 2011.

HPV VACCINE COUNSELING

Before January 1, 2011, if you counseled a patient about the HPV vaccine, you could report preventive counseling codes, such as 99401–99404, in addition to the vaccine administration code, 90471 (Immunization administration, 1 vaccine). Now, however, you have a new code for counseling and vaccine administration for a patient who is younger than 19 years—the age group most likely to be counseled about this vaccine. When you see, and counsel, such a patient before administering the vaccine, on the same date of service, code 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care profession; first vaccine/toxoid component), and 90649 for the quadrivalent or 90650 for the bivalent HPV vaccine.

If your patient is 19 years or older and requires counseling, continue to bill 99401– 99404 for counseling, with 90471 for immunization and 90649 or 90650 for the vaccine. Keep in mind: Whether you report 90460 or the 9940X codes, you are required to document the content of the counseling. Codes 9940X also require documentation of the duration of counseling.

INFLUENZA VACCINE

New codes have been established for the flu vaccine, but you won’t be using them: They are intended to address future pandemic strains of influenza. This year’s vaccine contains the H1N1 strain, but is coded as the normal seasonal flu vaccine, based on the type given:

90656 (preservative-free)

90658 (split virus)

90660 (intranasal)

90662 (enhanced vaccine for patients older than 65 years).

Changes to Medicare billing

Some of the coding and billing changes this year that have an impact on ObGyn practice come from the Centers of Medicare and Medicaid Services (CMS) and the Affordable Care Act.

TIMELY FILING

The Affordable Care Act calls for a reduction in the maximum time period for submission of Medicare fee-for-service claims. Before January 1, a provider had 15 to 27 months to submit first-time claims to Medicare. Now, these claims must be filed within a calendar year of the date of service. Exceptions can be made for retroactive entitlement or in situations in which there is a secondary payer.

PAYMENTS TO CERTIFIED NURSE MIDWIVES

Next, more good news—if you employ a certified nurse midwife (CNM) in your practice. Before January 1, Medicare reimbursed direct billing from a CNM at only 65% of the Medicare Physician Fee Schedule. Now, a CNM is paid the same as a physician when she (he) bills under her own number.

In the past, some practices billed for the services of a CNM under “incident to” rules, to capture the physician payment—but this also meant that the CNM could not see a new patient. Under the change I’m describing, all CNMs can bill Medicare directly; see new patients; and be paid the same as the physician is paid. In addition, CNMs are no longer required to be supervised by a physician when they perform diagnostic tests that fall under the scope of their practice.

ANNUAL WELLNESS VISIT

The Affordable Care Act extended preventive coverage to Medicare beneficiaries in the form of an annual wellness visit. The two new codes here have been valued based on a level 4-problem new and established E/M service:

G0438 Annual wellness visit, including personalized prevention plan services, first visit

G0439 Annual wellness visit, including personalized prevention plan services, subsequent visit

Payment for the initial visit is made only beginning the second year the patient is eligible for Medicare Part B—during the first year of coverage, only the Initial Preventive Physical Examination (IPPE) (the “Welcome to Medicare”) exam will be covered.

CMS has stated that only one physician will be paid for the initial visit; when the patient returns to the same or a new physician in the third year, only a subsequent visit will be paid. It is, therefore, important that this information be conveyed to any new physician who sees the patient.

The annual codes can be billed in addition to any other preventive service, such as G0101 or Q0091; no modifier is needed for this combination. Medicare has waived both the copayment and the deductible for the annual wellness visit, as well as all Medicare-covered preventive services that have been recommended with a grade of “A” (“strongly recommends”) or “B” (“recommends”) by the US Preventive Services Task Force.

The annual wellness visit requires seven elements at a minimum (i.e., you may document and perform more elements than this, but not fewer):

• Establish or update the patient’s medical and family history
• List her current medical providers and suppliers and all prescribed medications
• Record measurements of height, weight, body mass index (initial visit only), blood pressure, and other routine measurements
• Detect any cognitive impairment
• Establish or update a screening schedule for the next 5 to 10 years, including screenings appropriate for the general population, and any additional screenings that may be appropriate because of her particular risk factors
• Review the patient’s 1) potential (i.e., risk factors) for depression, based on use of an appropriate screening instrument, and 2) functional ability and level of safety based on direct observation or screening questions
• Furnish 1) personalized health advice and 2) refer her appropriately to health education or preventive services.

CMS has also indicated that, although they will pay for a problem E/M service and the annual wellness visit on the same date of service with a modifier -25 added to the E/M service, they expect this type of billing to be rare—because of the nature of the wellness visit, which is time-intensive. They also expect that, given these requirements, the patient will not be billed additionally for a noncovered preventive service.

We want to hear from you! Tell us what you think.

The Current Procedural Terminology (CPT) code set for 2011 includes several changes of interest to ObGyns. These include 1) guideline clarifications regarding wound debridement and obstetric care codes; 2) new codes for subsequent observation care; micro-remodeling of the bladder neck; insertion of a vaginal after-loading device; and 3) a lab code for detecting amniotic fluid in cervicovaginal secretions (using the AmniSure kit).

There is also a new code for vaccine counseling that will have an impact on you if your practice offers the human papillomavirus (HPV) vaccine to patients younger than 19 years.

There are changes to Medicare this year that you should take note of if you care for these patients, particularly in the area of preventive visit billing.

CPT and Medicare changes both took effect on January 1. The Health Insurance Portability and Accountability Act (HIPAA) requires that insurers accepted the new codes on that date.

Changes to the CPT code set

OBSERVATION CARE

One of the biggest headaches for medical practices has been standardized coding and billing for observation care that lasts more than 1 day. In the past, payers accepted a problem E/M for Day 2 of observation care, or instructed practices to code an unlisted E/M service. Now, you may report all care rendered in the observation setting with the addition of three new codes for subsequent care:

99244 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: problem focused interval history, problem focused examination; medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.

99225 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.

99226 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.

Note that each of these codes 1) “suggests” the status of the patient for each level of billing, and 2) includes a typical time. This means that, unlike the observation care admission codes or the observation admission/same-day discharge codes, time that is spent with the patient, or on the unit, may be used to select the code—if you document 1) the requirement that more than 50% of the typical time was spent on counseling or coordination of care, or both, and 2) a detailed description of this activity.

WOUND MANAGEMENT

Codes for wound debridement were given a facelift with the addition of a new guideline that addresses both surgical and medical debridement. The surgical debridement codes, (11042–11047) are now reported on the basis of the depth of tissue removed and the surface area of the wound. This means that codes 11040 and 11041 were deleted to make room for new and revised codes.

This change will mean that, when you report these codes, you will need to document more information to bill. It’s also understood that coding separately for debridement of dermis or epidermis at the same time you code for debriding underlying structures would be inappropriate.

CPT has also indicated that active wound management codes 97597 and 97598 can now be reported by physicians or nonphysician providers as long as the provider has direct (one-on-one) contact. These codes should be reported for skin-surface debridement only.

The new and revised codes (some of which have been published in CPT in nonsequential order) are:

11042 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less

+11045 (new add-on code reported with 11042 only) each additional 20 sq cm or part thereof

11043 Debridement, muscle and/or facia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less

+11046 (new add-on code reported with 11043 only) each additional 20 sq cm or part thereof

11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less

+11047 (new add-on code reported with 11044 only) each additional 20 sq cm or part thereof

97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

+95798 (add-on code reported with 97597 only) Each additional 20 sq cm, or part thereof.

TRANSURETHRAL RADIOFREQUENCY

Category III code 0193T, which described transurethral radiofrequency micro-remodeling for stress urinary incontinence, has been deleted and converted to a Category I CPT code, 53860 (Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence). The procedure includes a periurethral block and flushing the bladder with a lidocaine slurry, and can be performed in the office.

In all, the procedure requires nine treatment cycles during the session, but the code is billed only once. Catheterization and measurement of a voiding sample after the procedure are included in the code.

AFTERLOADING DEVICES FOR CLINICAL BRACHYTHERAPY

CPT revised—slightly—existing code 57155, and added code 57156 (Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy).

• Code 57155 was revised to clarify that only a single tandem is inserted into the uterus. There had been confusion earlier in this regard.
• The new code describes a procedure that may also include dilation of the vaginal canal to remove postradiation adhesions. That procedure also involves 1) placement of bladder and rectal catheters and 2) radiographic imaging to confirm placement, which are not coded separately.

CLARIFICATION OF OBSTETRIC GUIDELINES

Been having problems with payers and their interpretation of the delivery only, postpartum only, and delivery with postpartum care codes? CPT has, at last, clarified what you can, and cannot, bill in those circumstances. (Keep in mind, however, that you may not unbundle these procedures if more extensive care is provided: Most payers want you to bill the global OB care code that includes antepartum, intrapartum, and postpartum care.)

In some cases (such as Medicaid), the payer stipulates that only the physician who actually performed the delivery may bill for it, even if the delivering physician is covering for, or is a member of, the same group practice as the primary attending of record. The “delivery-only” codes should be reported when 1) an unaffiliated physician has delivered the baby but will not be providing any outpatient postpartum care or 2) the payer has specified this method of billing for the covering or affiliated provider.

CPT has clarified that delivery-only codes (59409, 59514, or 59612, 59620) include admission to the hospital, the admission history and physical exam, uncomplicated labor and delivery (including delivery of the placenta, or use of forceps or vacuum extraction). These codes do not include inpatient rounding or discharge day care after delivery (and, of course, include no outpatient postpartum care). When, as the delivering physician, you also provide inpatient postdelivery care, therefore, you may additionally bill subsequent hospital care codes and discharge day management codes (99231-99233, 99238-99239).

If the unaffiliated physician performs the delivery and also intends on providing outpatient postpartum care, the CPT codes for delivery with postpartum are to be reported (59410, 59515, 59614, 59622). In addition to the delivery, these codes include all inpatient and outpatient postpartum care. And finally, for those physicians who are only providing outpatient postpartum care, the code 59430, Postpartum care only, should be reported.

PLACENTAL ALPHA MICROGLOBULIN-1

A new code, 84112 (Placental alpha microglobulin-1 [PAMG-11], cervicovaginal secretion, qualitative), has been added to allow the clinical laboratory to bill for this immunoassay that detects amniotic fluid in the secretions. Physician work involves collection of the specimen but, under CPT rules, collection is included as part of any E/M service.

Note: An existing code for this test that is used by Blue Cross/Blue Shield payers (S3628) remains valid in 2011.

HPV VACCINE COUNSELING

Before January 1, 2011, if you counseled a patient about the HPV vaccine, you could report preventive counseling codes, such as 99401–99404, in addition to the vaccine administration code, 90471 (Immunization administration, 1 vaccine). Now, however, you have a new code for counseling and vaccine administration for a patient who is younger than 19 years—the age group most likely to be counseled about this vaccine. When you see, and counsel, such a patient before administering the vaccine, on the same date of service, code 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care profession; first vaccine/toxoid component), and 90649 for the quadrivalent or 90650 for the bivalent HPV vaccine.

If your patient is 19 years or older and requires counseling, continue to bill 99401– 99404 for counseling, with 90471 for immunization and 90649 or 90650 for the vaccine. Keep in mind: Whether you report 90460 or the 9940X codes, you are required to document the content of the counseling. Codes 9940X also require documentation of the duration of counseling.

INFLUENZA VACCINE

New codes have been established for the flu vaccine, but you won’t be using them: They are intended to address future pandemic strains of influenza. This year’s vaccine contains the H1N1 strain, but is coded as the normal seasonal flu vaccine, based on the type given:

90656 (preservative-free)

90658 (split virus)

90660 (intranasal)

90662 (enhanced vaccine for patients older than 65 years).

Changes to Medicare billing

Some of the coding and billing changes this year that have an impact on ObGyn practice come from the Centers of Medicare and Medicaid Services (CMS) and the Affordable Care Act.

TIMELY FILING

The Affordable Care Act calls for a reduction in the maximum time period for submission of Medicare fee-for-service claims. Before January 1, a provider had 15 to 27 months to submit first-time claims to Medicare. Now, these claims must be filed within a calendar year of the date of service. Exceptions can be made for retroactive entitlement or in situations in which there is a secondary payer.

PAYMENTS TO CERTIFIED NURSE MIDWIVES

Next, more good news—if you employ a certified nurse midwife (CNM) in your practice. Before January 1, Medicare reimbursed direct billing from a CNM at only 65% of the Medicare Physician Fee Schedule. Now, a CNM is paid the same as a physician when she (he) bills under her own number.

In the past, some practices billed for the services of a CNM under “incident to” rules, to capture the physician payment—but this also meant that the CNM could not see a new patient. Under the change I’m describing, all CNMs can bill Medicare directly; see new patients; and be paid the same as the physician is paid. In addition, CNMs are no longer required to be supervised by a physician when they perform diagnostic tests that fall under the scope of their practice.

ANNUAL WELLNESS VISIT

The Affordable Care Act extended preventive coverage to Medicare beneficiaries in the form of an annual wellness visit. The two new codes here have been valued based on a level 4-problem new and established E/M service:

G0438 Annual wellness visit, including personalized prevention plan services, first visit

G0439 Annual wellness visit, including personalized prevention plan services, subsequent visit

Payment for the initial visit is made only beginning the second year the patient is eligible for Medicare Part B—during the first year of coverage, only the Initial Preventive Physical Examination (IPPE) (the “Welcome to Medicare”) exam will be covered.

CMS has stated that only one physician will be paid for the initial visit; when the patient returns to the same or a new physician in the third year, only a subsequent visit will be paid. It is, therefore, important that this information be conveyed to any new physician who sees the patient.

The annual codes can be billed in addition to any other preventive service, such as G0101 or Q0091; no modifier is needed for this combination. Medicare has waived both the copayment and the deductible for the annual wellness visit, as well as all Medicare-covered preventive services that have been recommended with a grade of “A” (“strongly recommends”) or “B” (“recommends”) by the US Preventive Services Task Force.

The annual wellness visit requires seven elements at a minimum (i.e., you may document and perform more elements than this, but not fewer):

• Establish or update the patient’s medical and family history
• List her current medical providers and suppliers and all prescribed medications
• Record measurements of height, weight, body mass index (initial visit only), blood pressure, and other routine measurements
• Detect any cognitive impairment
• Establish or update a screening schedule for the next 5 to 10 years, including screenings appropriate for the general population, and any additional screenings that may be appropriate because of her particular risk factors
• Review the patient’s 1) potential (i.e., risk factors) for depression, based on use of an appropriate screening instrument, and 2) functional ability and level of safety based on direct observation or screening questions
• Furnish 1) personalized health advice and 2) refer her appropriately to health education or preventive services.

CMS has also indicated that, although they will pay for a problem E/M service and the annual wellness visit on the same date of service with a modifier -25 added to the E/M service, they expect this type of billing to be rare—because of the nature of the wellness visit, which is time-intensive. They also expect that, given these requirements, the patient will not be billed additionally for a noncovered preventive service.

We want to hear from you! Tell us what you think.

In response to internal and external pressures to minimize length of stay, adhere to limitations on the maximum number of admitted patients, focus on evidence-based care, and improve outcomes of care, hospitalists have incorporated nonphysician providers (NPPs), such as acute-care nurse practitioners (ACNPs), into their group practices.¹ HM groups employing these practitioners must be aware of state and federal regulations, as well as billing and documentation standards surrounding NPP services.

Consider the following common hospitalist scenario: A nurse practitioner evaluates a 67-year-old patient admitted for chronic obstructive bronchitis and progressing shortness of breath. The nurse practitioner documents the service and provides the attending physician with an update on the patient’s status. Later in the day, the physician makes rounds and concurs with the patient’s current plan of care.

The above scenario represents a shared/split service in which two providers from the same group perform a service for the same patient on the same calendar day. The Centers for Medicare & Medicaid Services (CMS) allows these visits to be combined and reported under a single provider’s name if the shared/split billing criteria are met and appropriately documented.

Eligible Providers

The shared/split billing option only applies to services rendered by the attending physician and specified NPPs: nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives. Both the attending physician and the NPP must be part of the same group practice, either through direct employment or a leased arrangement that contractually links the two individuals. The “leased” relationship often occurs when the facility directly employs the NPP but arranges for the NPP to provide services exclusively for the physician group. It is imperative that the bills for the NPP services are captured and reported by one entity—the hospitalist group.

Several other NPPs (e.g. clinical psychologists or certified registered nurse anesthetists) are recognized by CMS but are ineligible for shared/split billing and must report their services under a different Medicare billing option. Additionally, shared/split services do not apply to physicians in training (interns, residents, fellows) or students.

Qualifying Services

Medicare reimburses services that are considered reasonable and necessary and not otherwise excluded from coverage. From a clinical perspective, NPPs might provide any service permitted by the state scope of practice and performed under the appropriate level of supervision or collaboration as depicted in licensure requirements. These typically comprise visits or procedures rendered by ancillary staff or considered a “physician” service.

Alternatively, shared/split billing regulations limit the types of services that can be reported under this methodology, recognizing only evaluation and management (E/M) services provided in explicit facility-based settings: EDs, outpatient hospital clinics, or inpatient hospitals. Critical-care services and procedures are excluded.

Physician Involvement

The NPP and the physician must have a face-to-face encounter with the same patient on the same calendar day, and there are no constraints on which provider should perform the initial encounter of the day.²

The extent of each provider’s involvement is left to provider discretion and/or local Medicare contractor requirements. Some contractors refer to the physician performing a “substantive” service but do not elaborate with specific service parameters, leaving the physician to determine the critical or key portion of his/her service. A corresponding, detailed notation alleviates any misconceptions of physician involvement.

Documentation by the attending physician should include an attestation that unequivocally demonstrates their personal encounter with the patient—for example, “Patient seen and examined by me.” Additionally, both the NPP and the physician should document the name of the individual with whom the service is shared/split—for example, “Agree with note by ____.” This allows for better charge capture; alerts coders, auditors, and payor representatives to consider both notes in support of the billed service; and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.

Each provider must document their portion of the rendered service, date and legibly sign their corresponding note, and select the visit level supported by the cumulative encounter—for example, “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR.”

Only one claim can be submitted for a shared/split service. The services might either be reported with the physician’s NPI or the NPP’s NPI. Reimbursement is dependent upon this designation. The physician NPI generates 100% of the Medicare allowable rate; the NPP NPI limits reimbursement to 85% of the allowable physician rate.

Non-Medicare Claims

The shared/split billing policy only applies to Medicare beneficiaries. Due to excessive costs of NPP credentialing and enrollment, most non-Medicare insurers do not issue NPP provider numbers.

Effective June 1, 2010, Aetna began to enroll and reimburse NPP services, but it has not yet outlined a policy that parallels Medicare’s shared/split billing policy. However, lack of payor policy does not preclude payment for shared NPP services; it necessitates additional—and initial—efforts to obtain recognition and corresponding reimbursement.

After determining which insurers have applicable shared/split billing policies, develop a reasonable guideline to offer those payors who do not recognize the billing option. Alert the payor, in writing, that policy implementation will take place in a predetermined timeframe unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option:

• Types of NPP involved in patient care;
• Category of services provided (e.g. E/M, procedures);
• Service location(s) (ED, inpatient, or outpatient hospital);
• Physician involvement;
• Mechanism for reporting services; and
• Documentation requirements.

This can be performed for any of the NPP billing options and is not limited to shared/split billing. Be sure to obtain payor response before initiating the shared/split billing process.

Summary

NPPs are involved in numerous services within the hospital, and often share/split services with hospitalists. Successful reporting requires understanding of and adherence to federal, state, and billing guidelines.

It is important to identify NPP employment relationships, the NPP’s role in the provision of services, the state supervisory or collaborative rules, and local payor interpretations to prevent misrepresentations, misunderstandings, or erroneous reporting. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Howie JN, Erickson M. Acute care nurse practitioners: creating and implementing a model of care for an inpatient general medical service. Am J Crit Care. 2002; 11(5):448-458.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare and Medicaid Services website. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Nov. 14, 2010.
3. Pohlig, C. Nonphysician providers in your practice. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians; 2010.
4. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. CMS website. Available at: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Nov. 14, 2010.

In response to internal and external pressures to minimize length of stay, adhere to limitations on the maximum number of admitted patients, focus on evidence-based care, and improve outcomes of care, hospitalists have incorporated nonphysician providers (NPPs), such as acute-care nurse practitioners (ACNPs), into their group practices.¹ HM groups employing these practitioners must be aware of state and federal regulations, as well as billing and documentation standards surrounding NPP services.

Consider the following common hospitalist scenario: A nurse practitioner evaluates a 67-year-old patient admitted for chronic obstructive bronchitis and progressing shortness of breath. The nurse practitioner documents the service and provides the attending physician with an update on the patient’s status. Later in the day, the physician makes rounds and concurs with the patient’s current plan of care.

The above scenario represents a shared/split service in which two providers from the same group perform a service for the same patient on the same calendar day. The Centers for Medicare & Medicaid Services (CMS) allows these visits to be combined and reported under a single provider’s name if the shared/split billing criteria are met and appropriately documented.

Eligible Providers

The shared/split billing option only applies to services rendered by the attending physician and specified NPPs: nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives. Both the attending physician and the NPP must be part of the same group practice, either through direct employment or a leased arrangement that contractually links the two individuals. The “leased” relationship often occurs when the facility directly employs the NPP but arranges for the NPP to provide services exclusively for the physician group. It is imperative that the bills for the NPP services are captured and reported by one entity—the hospitalist group.

Several other NPPs (e.g. clinical psychologists or certified registered nurse anesthetists) are recognized by CMS but are ineligible for shared/split billing and must report their services under a different Medicare billing option. Additionally, shared/split services do not apply to physicians in training (interns, residents, fellows) or students.

Qualifying Services

Medicare reimburses services that are considered reasonable and necessary and not otherwise excluded from coverage. From a clinical perspective, NPPs might provide any service permitted by the state scope of practice and performed under the appropriate level of supervision or collaboration as depicted in licensure requirements. These typically comprise visits or procedures rendered by ancillary staff or considered a “physician” service.

Alternatively, shared/split billing regulations limit the types of services that can be reported under this methodology, recognizing only evaluation and management (E/M) services provided in explicit facility-based settings: EDs, outpatient hospital clinics, or inpatient hospitals. Critical-care services and procedures are excluded.

Physician Involvement

The NPP and the physician must have a face-to-face encounter with the same patient on the same calendar day, and there are no constraints on which provider should perform the initial encounter of the day.²

The extent of each provider’s involvement is left to provider discretion and/or local Medicare contractor requirements. Some contractors refer to the physician performing a “substantive” service but do not elaborate with specific service parameters, leaving the physician to determine the critical or key portion of his/her service. A corresponding, detailed notation alleviates any misconceptions of physician involvement.

Documentation by the attending physician should include an attestation that unequivocally demonstrates their personal encounter with the patient—for example, “Patient seen and examined by me.” Additionally, both the NPP and the physician should document the name of the individual with whom the service is shared/split—for example, “Agree with note by ____.” This allows for better charge capture; alerts coders, auditors, and payor representatives to consider both notes in support of the billed service; and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.

Each provider must document their portion of the rendered service, date and legibly sign their corresponding note, and select the visit level supported by the cumulative encounter—for example, “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR.”

Only one claim can be submitted for a shared/split service. The services might either be reported with the physician’s NPI or the NPP’s NPI. Reimbursement is dependent upon this designation. The physician NPI generates 100% of the Medicare allowable rate; the NPP NPI limits reimbursement to 85% of the allowable physician rate.

Non-Medicare Claims

The shared/split billing policy only applies to Medicare beneficiaries. Due to excessive costs of NPP credentialing and enrollment, most non-Medicare insurers do not issue NPP provider numbers.

Effective June 1, 2010, Aetna began to enroll and reimburse NPP services, but it has not yet outlined a policy that parallels Medicare’s shared/split billing policy. However, lack of payor policy does not preclude payment for shared NPP services; it necessitates additional—and initial—efforts to obtain recognition and corresponding reimbursement.

After determining which insurers have applicable shared/split billing policies, develop a reasonable guideline to offer those payors who do not recognize the billing option. Alert the payor, in writing, that policy implementation will take place in a predetermined timeframe unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option:

• Types of NPP involved in patient care;
• Category of services provided (e.g. E/M, procedures);
• Service location(s) (ED, inpatient, or outpatient hospital);
• Physician involvement;
• Mechanism for reporting services; and
• Documentation requirements.

This can be performed for any of the NPP billing options and is not limited to shared/split billing. Be sure to obtain payor response before initiating the shared/split billing process.

Summary

NPPs are involved in numerous services within the hospital, and often share/split services with hospitalists. Successful reporting requires understanding of and adherence to federal, state, and billing guidelines.

It is important to identify NPP employment relationships, the NPP’s role in the provision of services, the state supervisory or collaborative rules, and local payor interpretations to prevent misrepresentations, misunderstandings, or erroneous reporting. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Howie JN, Erickson M. Acute care nurse practitioners: creating and implementing a model of care for an inpatient general medical service. Am J Crit Care. 2002; 11(5):448-458.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare and Medicaid Services website. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Nov. 14, 2010.
3. Pohlig, C. Nonphysician providers in your practice. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians; 2010.
4. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. CMS website. Available at: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Nov. 14, 2010.

In response to internal and external pressures to minimize length of stay, adhere to limitations on the maximum number of admitted patients, focus on evidence-based care, and improve outcomes of care, hospitalists have incorporated nonphysician providers (NPPs), such as acute-care nurse practitioners (ACNPs), into their group practices.¹ HM groups employing these practitioners must be aware of state and federal regulations, as well as billing and documentation standards surrounding NPP services.

Consider the following common hospitalist scenario: A nurse practitioner evaluates a 67-year-old patient admitted for chronic obstructive bronchitis and progressing shortness of breath. The nurse practitioner documents the service and provides the attending physician with an update on the patient’s status. Later in the day, the physician makes rounds and concurs with the patient’s current plan of care.

The above scenario represents a shared/split service in which two providers from the same group perform a service for the same patient on the same calendar day. The Centers for Medicare & Medicaid Services (CMS) allows these visits to be combined and reported under a single provider’s name if the shared/split billing criteria are met and appropriately documented.

Eligible Providers

The shared/split billing option only applies to services rendered by the attending physician and specified NPPs: nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives. Both the attending physician and the NPP must be part of the same group practice, either through direct employment or a leased arrangement that contractually links the two individuals. The “leased” relationship often occurs when the facility directly employs the NPP but arranges for the NPP to provide services exclusively for the physician group. It is imperative that the bills for the NPP services are captured and reported by one entity—the hospitalist group.

Several other NPPs (e.g. clinical psychologists or certified registered nurse anesthetists) are recognized by CMS but are ineligible for shared/split billing and must report their services under a different Medicare billing option. Additionally, shared/split services do not apply to physicians in training (interns, residents, fellows) or students.

Qualifying Services

Medicare reimburses services that are considered reasonable and necessary and not otherwise excluded from coverage. From a clinical perspective, NPPs might provide any service permitted by the state scope of practice and performed under the appropriate level of supervision or collaboration as depicted in licensure requirements. These typically comprise visits or procedures rendered by ancillary staff or considered a “physician” service.

Alternatively, shared/split billing regulations limit the types of services that can be reported under this methodology, recognizing only evaluation and management (E/M) services provided in explicit facility-based settings: EDs, outpatient hospital clinics, or inpatient hospitals. Critical-care services and procedures are excluded.

Physician Involvement

The NPP and the physician must have a face-to-face encounter with the same patient on the same calendar day, and there are no constraints on which provider should perform the initial encounter of the day.²

The extent of each provider’s involvement is left to provider discretion and/or local Medicare contractor requirements. Some contractors refer to the physician performing a “substantive” service but do not elaborate with specific service parameters, leaving the physician to determine the critical or key portion of his/her service. A corresponding, detailed notation alleviates any misconceptions of physician involvement.

Documentation by the attending physician should include an attestation that unequivocally demonstrates their personal encounter with the patient—for example, “Patient seen and examined by me.” Additionally, both the NPP and the physician should document the name of the individual with whom the service is shared/split—for example, “Agree with note by ____.” This allows for better charge capture; alerts coders, auditors, and payor representatives to consider both notes in support of the billed service; and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.

Each provider must document their portion of the rendered service, date and legibly sign their corresponding note, and select the visit level supported by the cumulative encounter—for example, “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR.”

Only one claim can be submitted for a shared/split service. The services might either be reported with the physician’s NPI or the NPP’s NPI. Reimbursement is dependent upon this designation. The physician NPI generates 100% of the Medicare allowable rate; the NPP NPI limits reimbursement to 85% of the allowable physician rate.

Non-Medicare Claims

The shared/split billing policy only applies to Medicare beneficiaries. Due to excessive costs of NPP credentialing and enrollment, most non-Medicare insurers do not issue NPP provider numbers.

Effective June 1, 2010, Aetna began to enroll and reimburse NPP services, but it has not yet outlined a policy that parallels Medicare’s shared/split billing policy. However, lack of payor policy does not preclude payment for shared NPP services; it necessitates additional—and initial—efforts to obtain recognition and corresponding reimbursement.

After determining which insurers have applicable shared/split billing policies, develop a reasonable guideline to offer those payors who do not recognize the billing option. Alert the payor, in writing, that policy implementation will take place in a predetermined timeframe unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option:

• Types of NPP involved in patient care;
• Category of services provided (e.g. E/M, procedures);
• Service location(s) (ED, inpatient, or outpatient hospital);
• Physician involvement;
• Mechanism for reporting services; and
• Documentation requirements.

This can be performed for any of the NPP billing options and is not limited to shared/split billing. Be sure to obtain payor response before initiating the shared/split billing process.

Summary

NPPs are involved in numerous services within the hospital, and often share/split services with hospitalists. Successful reporting requires understanding of and adherence to federal, state, and billing guidelines.

It is important to identify NPP employment relationships, the NPP’s role in the provision of services, the state supervisory or collaborative rules, and local payor interpretations to prevent misrepresentations, misunderstandings, or erroneous reporting. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Howie JN, Erickson M. Acute care nurse practitioners: creating and implementing a model of care for an inpatient general medical service. Am J Crit Care. 2002; 11(5):448-458.
2. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare and Medicaid Services website. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Nov. 14, 2010.
3. Pohlig, C. Nonphysician providers in your practice. In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians; 2010.
4. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. CMS website. Available at: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed Nov. 14, 2010.

Every clinician in HM depends on a smooth-running hospitalist program to ensure the best possible patient care and efficiency. Even though they might not be visible to hospitalized patients, practice administration issues (e.g. compensation and incentives, reporting return on investment, or the Physician’s Quality Reporting System) are vital components to effectively running an HM group. And that’s what explains the growing popularity of SHM’s new resources for administrators.

In 2010, SHM presented five free online discussions for hospitalist practice leaders. Each session in the Practice Administrators’ Roundtable Series began with a formal presentation and was followed with open discussion from administrators and leaders from around the country.

SHM will continue the program in 2011 with such topics as Hospitalist Recruitment, Retention, & Orientation (Feb. 24) and Patient Satisfaction (May 26).

“The response to new programs for hospitalist administrators has been very positive,” says Kim Dickinson, MA, regional COO for Cogent Healthcare and a member of SHM’s Administrators’ Task Force, which has taken the lead on planning the roundtables. “As hospital medicine programs continue to evolve, there will be a growing need to address their administrative issues, too.”

The program will break new ground in 2011 with the first SHM Award for Excellence in Hospital Medicine. The new award, to be presented at HM11, will recognize a physician assistant, nurse practitioner, RN, pharmacist, administrator, case manager, or a nonphysician member of SHM.

“Hospital medicine groups depend on effective leadership, communication and administration,” says SHM president Jeff Wiese, MD, SFHM. “That’s why these new programs are so critical to improving quality, safety, and efficiency in hospital care. It is appropriate then that the best of the best should be recognized in this regard. I am personally excited to present the first SHM Award for Excellence in Hospital Medicine at the SHM annual meeting in Dallas.”

All of the roundtable discussions are archived in SHM’s Practice Management Institute (www.hospitalmedicine.org/practiceresources).

Every clinician in HM depends on a smooth-running hospitalist program to ensure the best possible patient care and efficiency. Even though they might not be visible to hospitalized patients, practice administration issues (e.g. compensation and incentives, reporting return on investment, or the Physician’s Quality Reporting System) are vital components to effectively running an HM group. And that’s what explains the growing popularity of SHM’s new resources for administrators.

In 2010, SHM presented five free online discussions for hospitalist practice leaders. Each session in the Practice Administrators’ Roundtable Series began with a formal presentation and was followed with open discussion from administrators and leaders from around the country.

SHM will continue the program in 2011 with such topics as Hospitalist Recruitment, Retention, & Orientation (Feb. 24) and Patient Satisfaction (May 26).

“The response to new programs for hospitalist administrators has been very positive,” says Kim Dickinson, MA, regional COO for Cogent Healthcare and a member of SHM’s Administrators’ Task Force, which has taken the lead on planning the roundtables. “As hospital medicine programs continue to evolve, there will be a growing need to address their administrative issues, too.”

The program will break new ground in 2011 with the first SHM Award for Excellence in Hospital Medicine. The new award, to be presented at HM11, will recognize a physician assistant, nurse practitioner, RN, pharmacist, administrator, case manager, or a nonphysician member of SHM.

“Hospital medicine groups depend on effective leadership, communication and administration,” says SHM president Jeff Wiese, MD, SFHM. “That’s why these new programs are so critical to improving quality, safety, and efficiency in hospital care. It is appropriate then that the best of the best should be recognized in this regard. I am personally excited to present the first SHM Award for Excellence in Hospital Medicine at the SHM annual meeting in Dallas.”

All of the roundtable discussions are archived in SHM’s Practice Management Institute (www.hospitalmedicine.org/practiceresources).

Every clinician in HM depends on a smooth-running hospitalist program to ensure the best possible patient care and efficiency. Even though they might not be visible to hospitalized patients, practice administration issues (e.g. compensation and incentives, reporting return on investment, or the Physician’s Quality Reporting System) are vital components to effectively running an HM group. And that’s what explains the growing popularity of SHM’s new resources for administrators.

In 2010, SHM presented five free online discussions for hospitalist practice leaders. Each session in the Practice Administrators’ Roundtable Series began with a formal presentation and was followed with open discussion from administrators and leaders from around the country.

SHM will continue the program in 2011 with such topics as Hospitalist Recruitment, Retention, & Orientation (Feb. 24) and Patient Satisfaction (May 26).

“The response to new programs for hospitalist administrators has been very positive,” says Kim Dickinson, MA, regional COO for Cogent Healthcare and a member of SHM’s Administrators’ Task Force, which has taken the lead on planning the roundtables. “As hospital medicine programs continue to evolve, there will be a growing need to address their administrative issues, too.”

The program will break new ground in 2011 with the first SHM Award for Excellence in Hospital Medicine. The new award, to be presented at HM11, will recognize a physician assistant, nurse practitioner, RN, pharmacist, administrator, case manager, or a nonphysician member of SHM.

“Hospital medicine groups depend on effective leadership, communication and administration,” says SHM president Jeff Wiese, MD, SFHM. “That’s why these new programs are so critical to improving quality, safety, and efficiency in hospital care. It is appropriate then that the best of the best should be recognized in this regard. I am personally excited to present the first SHM Award for Excellence in Hospital Medicine at the SHM annual meeting in Dallas.”

All of the roundtable discussions are archived in SHM’s Practice Management Institute (www.hospitalmedicine.org/practiceresources).

I rent cars regularly, and only occasionally do I get the same model twice. I’m ready to roll after spending a couple of minutes becoming familiar with a car that is new to me. I adjust the seat and climate control, etc. I resist fiddling with the radio until later. This seems OK to me.

The last time I started clinical practice in a new hospital, I did almost the same thing: I jumped right in and started seeing patients. Other than being provided with my password to the computer system and a dictation code, I had no orientation at all, not even to the hospital floor plan. This, too, seemed reasonable to me at the time. Now I see it differently.

Levels of Complexity

Years ago, learning a new hospital might not have been a lot more difficult than familiarizing yourself with a new rental car, so there didn’t seem to be much need for a detailed orientation. I’m generalizing here, but if you go back far enough in time, the general idea was that it was almost entirely up to the hospital and its staff to get to know the new doctor and how he or she practiced, rather than the doctor adapting to the hospital’s way of doing things.

While at one time hospitals and their systems might have been as similar to one another as a four-door Chevy is to a four-door Ford, today’s hospitals are far more complex. The appropriate transportation analogy might be one type of airplane to another.

The basics of what keeps a two-seat Cessna and a huge 747 flying are the same, but there are so many critical differences that specific training and certification are required for each. Even an accomplished professional pilot who is an ace in a 747 isn’t automatically certified to pilot a smaller 737. In fact, few professional pilots are certified to fly more than one type of commercial airplane at a time. One way to look at this is that the orientation to the plane is so complex that one person can’t be expected to maintain a high level of familiarity with the systems and operation of more than one at a time.

EHR: A Tipping Point

The complexity and unique attributes of hospitals have been increasing steadily for decades, but it seems to me that electronic health records (EHR) represent a huge increase in complexity. No longer can a doctor simply arrive at the hospital confident in her ability to fly this new plane. She will require a reasonably detailed introduction to the hospital’s EHR as part of an orientation that should ideally take place prior to seeing patients.

I worry that it will be increasingly difficult, and potentially unwise, for a doctor in any specialty to practice at more than one or two hospitals that don’t share the same EHR. If a doctor is not proficient in the use of the EHR at a particular site, two things are likely to happen: First, and most alarmingly, the new doctor would probably unintentionally miss important information in the EHR, or might not have time to contemplate the series of buttons to click to check all potentially relevant information. For example, he might not realize the patient already had a series of blood tests, because accessing them requires some unfamiliar clicks of the mouse.

The other thing that might happen if a doctor is not proficient in the use of the hospital’s EHR is that he might be inclined to consult the hospitalist “just to cover all the bases.” In this case, that might be the same as asking the hospitalist to be involved as an EHR expert, rather than for medical expertise that the patient needs.

I practice at a hospital that recently installed a new information system, and some doctors have joked that if they can’t figure out how to use it, they will just consult a hospitalist to look up historical data, etc. I’m not aware of any study looking at this issue, but I suspect “soft” hospitalist consults increase when a hospital installs a new information system.

Rethink New Employee Orientation

I’m convinced that new doctors in all specialties that anticipate having a hospital patient volume above a predetermined threshold should be required to have a formal orientation to the hospital, especially for its information system. This is really important for hospitalists. Every practice should think carefully about a meaningful process of orientation to the hospital and the hospitalist practice itself. The latter would include things like scheduling issues, training in CPT coding, group governance and culture, etc.

My experience is that multistate hospitalist companies have pretty detailed orientation programs; for one thing, they can use this as a differentiator when marketing their services. But private hospitalist practices and groups employed by a single hospital usually have a pretty loose orientation process. It is tricky to find the sweet spot between valuable orientation activities and so much detail that the new doctor is overwhelmed or bored, and unlikely to remember much of what is presented.

And there certainly is a role for waiting to learn some things as the new doctor begins seeing patients. For example, my feeling is that a general orientation to the floor plan is sufficient and the new hire can best learn the details independently during the course of patient care. However, all hospitalists should have some reasonable level of proficiency in the EHR before seeing their first patients.

Hospital-Certified?

If you accept my premise that hospitals were once reasonably similar, like one rental car to another, but have now become as complex and different as jumbo jets, then we’re led to another question: Will we one day decide that a doctor must be certified to practice in a particular hospital by demonstrating knowledge and competence in that particular hospital’s systems and procedures?

Nearly all present-day credentialing and privileging related to a doctor’s work in a hospital focus on that doctor’s prior training and experience. In the case of pilots, there is a requirement to demonstrate proficiency when making a transition to a new airplane.

Maybe an analogous system of certification for a doctor to “fly” each hospital would be valuable for our patients. If training might not make sense for all doctors, then perhaps limit it to those, such as hospitalists, who will have a really high patient volume at the facility.

It would be dizzyingly complex to create and referee such a certification system, so I’m not sure anything like this will happen in my career. And the last thing I want is another set of bureaucratic hurdles.

But it might be worth thinking about how to ensure doctors at a particular hospital are expert enough in that hospital’s unique systems and operations. Start with your group’s orientation process. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

I rent cars regularly, and only occasionally do I get the same model twice. I’m ready to roll after spending a couple of minutes becoming familiar with a car that is new to me. I adjust the seat and climate control, etc. I resist fiddling with the radio until later. This seems OK to me.

The last time I started clinical practice in a new hospital, I did almost the same thing: I jumped right in and started seeing patients. Other than being provided with my password to the computer system and a dictation code, I had no orientation at all, not even to the hospital floor plan. This, too, seemed reasonable to me at the time. Now I see it differently.

Levels of Complexity

Years ago, learning a new hospital might not have been a lot more difficult than familiarizing yourself with a new rental car, so there didn’t seem to be much need for a detailed orientation. I’m generalizing here, but if you go back far enough in time, the general idea was that it was almost entirely up to the hospital and its staff to get to know the new doctor and how he or she practiced, rather than the doctor adapting to the hospital’s way of doing things.

While at one time hospitals and their systems might have been as similar to one another as a four-door Chevy is to a four-door Ford, today’s hospitals are far more complex. The appropriate transportation analogy might be one type of airplane to another.

The basics of what keeps a two-seat Cessna and a huge 747 flying are the same, but there are so many critical differences that specific training and certification are required for each. Even an accomplished professional pilot who is an ace in a 747 isn’t automatically certified to pilot a smaller 737. In fact, few professional pilots are certified to fly more than one type of commercial airplane at a time. One way to look at this is that the orientation to the plane is so complex that one person can’t be expected to maintain a high level of familiarity with the systems and operation of more than one at a time.

EHR: A Tipping Point

The complexity and unique attributes of hospitals have been increasing steadily for decades, but it seems to me that electronic health records (EHR) represent a huge increase in complexity. No longer can a doctor simply arrive at the hospital confident in her ability to fly this new plane. She will require a reasonably detailed introduction to the hospital’s EHR as part of an orientation that should ideally take place prior to seeing patients.

I worry that it will be increasingly difficult, and potentially unwise, for a doctor in any specialty to practice at more than one or two hospitals that don’t share the same EHR. If a doctor is not proficient in the use of the EHR at a particular site, two things are likely to happen: First, and most alarmingly, the new doctor would probably unintentionally miss important information in the EHR, or might not have time to contemplate the series of buttons to click to check all potentially relevant information. For example, he might not realize the patient already had a series of blood tests, because accessing them requires some unfamiliar clicks of the mouse.

The other thing that might happen if a doctor is not proficient in the use of the hospital’s EHR is that he might be inclined to consult the hospitalist “just to cover all the bases.” In this case, that might be the same as asking the hospitalist to be involved as an EHR expert, rather than for medical expertise that the patient needs.

I practice at a hospital that recently installed a new information system, and some doctors have joked that if they can’t figure out how to use it, they will just consult a hospitalist to look up historical data, etc. I’m not aware of any study looking at this issue, but I suspect “soft” hospitalist consults increase when a hospital installs a new information system.

Rethink New Employee Orientation

I’m convinced that new doctors in all specialties that anticipate having a hospital patient volume above a predetermined threshold should be required to have a formal orientation to the hospital, especially for its information system. This is really important for hospitalists. Every practice should think carefully about a meaningful process of orientation to the hospital and the hospitalist practice itself. The latter would include things like scheduling issues, training in CPT coding, group governance and culture, etc.

My experience is that multistate hospitalist companies have pretty detailed orientation programs; for one thing, they can use this as a differentiator when marketing their services. But private hospitalist practices and groups employed by a single hospital usually have a pretty loose orientation process. It is tricky to find the sweet spot between valuable orientation activities and so much detail that the new doctor is overwhelmed or bored, and unlikely to remember much of what is presented.

And there certainly is a role for waiting to learn some things as the new doctor begins seeing patients. For example, my feeling is that a general orientation to the floor plan is sufficient and the new hire can best learn the details independently during the course of patient care. However, all hospitalists should have some reasonable level of proficiency in the EHR before seeing their first patients.

Hospital-Certified?

If you accept my premise that hospitals were once reasonably similar, like one rental car to another, but have now become as complex and different as jumbo jets, then we’re led to another question: Will we one day decide that a doctor must be certified to practice in a particular hospital by demonstrating knowledge and competence in that particular hospital’s systems and procedures?

Nearly all present-day credentialing and privileging related to a doctor’s work in a hospital focus on that doctor’s prior training and experience. In the case of pilots, there is a requirement to demonstrate proficiency when making a transition to a new airplane.

Maybe an analogous system of certification for a doctor to “fly” each hospital would be valuable for our patients. If training might not make sense for all doctors, then perhaps limit it to those, such as hospitalists, who will have a really high patient volume at the facility.

It would be dizzyingly complex to create and referee such a certification system, so I’m not sure anything like this will happen in my career. And the last thing I want is another set of bureaucratic hurdles.

But it might be worth thinking about how to ensure doctors at a particular hospital are expert enough in that hospital’s unique systems and operations. Start with your group’s orientation process. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

I rent cars regularly, and only occasionally do I get the same model twice. I’m ready to roll after spending a couple of minutes becoming familiar with a car that is new to me. I adjust the seat and climate control, etc. I resist fiddling with the radio until later. This seems OK to me.

The last time I started clinical practice in a new hospital, I did almost the same thing: I jumped right in and started seeing patients. Other than being provided with my password to the computer system and a dictation code, I had no orientation at all, not even to the hospital floor plan. This, too, seemed reasonable to me at the time. Now I see it differently.

Levels of Complexity

Years ago, learning a new hospital might not have been a lot more difficult than familiarizing yourself with a new rental car, so there didn’t seem to be much need for a detailed orientation. I’m generalizing here, but if you go back far enough in time, the general idea was that it was almost entirely up to the hospital and its staff to get to know the new doctor and how he or she practiced, rather than the doctor adapting to the hospital’s way of doing things.

While at one time hospitals and their systems might have been as similar to one another as a four-door Chevy is to a four-door Ford, today’s hospitals are far more complex. The appropriate transportation analogy might be one type of airplane to another.

The basics of what keeps a two-seat Cessna and a huge 747 flying are the same, but there are so many critical differences that specific training and certification are required for each. Even an accomplished professional pilot who is an ace in a 747 isn’t automatically certified to pilot a smaller 737. In fact, few professional pilots are certified to fly more than one type of commercial airplane at a time. One way to look at this is that the orientation to the plane is so complex that one person can’t be expected to maintain a high level of familiarity with the systems and operation of more than one at a time.

EHR: A Tipping Point

The complexity and unique attributes of hospitals have been increasing steadily for decades, but it seems to me that electronic health records (EHR) represent a huge increase in complexity. No longer can a doctor simply arrive at the hospital confident in her ability to fly this new plane. She will require a reasonably detailed introduction to the hospital’s EHR as part of an orientation that should ideally take place prior to seeing patients.

I worry that it will be increasingly difficult, and potentially unwise, for a doctor in any specialty to practice at more than one or two hospitals that don’t share the same EHR. If a doctor is not proficient in the use of the EHR at a particular site, two things are likely to happen: First, and most alarmingly, the new doctor would probably unintentionally miss important information in the EHR, or might not have time to contemplate the series of buttons to click to check all potentially relevant information. For example, he might not realize the patient already had a series of blood tests, because accessing them requires some unfamiliar clicks of the mouse.

The other thing that might happen if a doctor is not proficient in the use of the hospital’s EHR is that he might be inclined to consult the hospitalist “just to cover all the bases.” In this case, that might be the same as asking the hospitalist to be involved as an EHR expert, rather than for medical expertise that the patient needs.

I practice at a hospital that recently installed a new information system, and some doctors have joked that if they can’t figure out how to use it, they will just consult a hospitalist to look up historical data, etc. I’m not aware of any study looking at this issue, but I suspect “soft” hospitalist consults increase when a hospital installs a new information system.

Rethink New Employee Orientation

I’m convinced that new doctors in all specialties that anticipate having a hospital patient volume above a predetermined threshold should be required to have a formal orientation to the hospital, especially for its information system. This is really important for hospitalists. Every practice should think carefully about a meaningful process of orientation to the hospital and the hospitalist practice itself. The latter would include things like scheduling issues, training in CPT coding, group governance and culture, etc.

My experience is that multistate hospitalist companies have pretty detailed orientation programs; for one thing, they can use this as a differentiator when marketing their services. But private hospitalist practices and groups employed by a single hospital usually have a pretty loose orientation process. It is tricky to find the sweet spot between valuable orientation activities and so much detail that the new doctor is overwhelmed or bored, and unlikely to remember much of what is presented.

And there certainly is a role for waiting to learn some things as the new doctor begins seeing patients. For example, my feeling is that a general orientation to the floor plan is sufficient and the new hire can best learn the details independently during the course of patient care. However, all hospitalists should have some reasonable level of proficiency in the EHR before seeing their first patients.

Hospital-Certified?

If you accept my premise that hospitals were once reasonably similar, like one rental car to another, but have now become as complex and different as jumbo jets, then we’re led to another question: Will we one day decide that a doctor must be certified to practice in a particular hospital by demonstrating knowledge and competence in that particular hospital’s systems and procedures?

Nearly all present-day credentialing and privileging related to a doctor’s work in a hospital focus on that doctor’s prior training and experience. In the case of pilots, there is a requirement to demonstrate proficiency when making a transition to a new airplane.

Maybe an analogous system of certification for a doctor to “fly” each hospital would be valuable for our patients. If training might not make sense for all doctors, then perhaps limit it to those, such as hospitalists, who will have a really high patient volume at the facility.

It would be dizzyingly complex to create and referee such a certification system, so I’m not sure anything like this will happen in my career. And the last thing I want is another set of bureaucratic hurdles.

But it might be worth thinking about how to ensure doctors at a particular hospital are expert enough in that hospital’s unique systems and operations. Start with your group’s orientation process. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

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