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Background Checks
If the hospitalist recruitment process is a puzzle, then the background check is the vacuum cleaner, sweeping the area for any missing puzzle pieces.
“You are trying to get the whole picture,” Tim Lary, vice president of physician staffing at North Hollywood, Calif.-based IPC: The Hospitalist Company, says. “You are trying to see if something doesn’t fit right.”
Any competent healthcare organization will conduct a background check on hospitalist job candidates, first and foremost to ensure patient safety and a safe practice environment for other healthcare providers, Lary says. There also is the issue of liability.
Financial liability for the negative acts of employees, whether accidental or intentional, is an area of exposure for businesses, says Les Rosen, president and CEO of Employment Screening Resources, a consumer reporting agency and human resources consulting firm in Novato, Calif. Businesses can be held liable for injuries resulting from the failure to adequately screen the people it hires. Background checks demonstrate the organization has done its due diligence in assessing the safety and competence of job candidates.
“It enables an organization to hire based upon facts, not just instincts,” Rosen says.
Background Basics
Hospitalists must be prepared to effectively deal with background checks throughout their professional careers. Employment checks often involve three areas: credentials verification, reference checking, and an additional background investigation.
Credentialing includes a review of the hospitalist’s completed education, training, residency, licenses, and any certifications, and often encompasses the candidate’s hospital privileges history, malpractice claims history, and peer reviews.
Reference checking involves verifying dates of employment and title at the hospitalist’s previous jobs, and contacting references to speak with them about the candidate’s qualifications.
Background investigations often are done by a third-party agency. The investigation will vary depending on the policies of the healthcare organization contracting the review, but, generally speaking, it includes a check of the following:
- Criminal and civil court records for criminal convictions, arrests, and lawsuits;
- Motor vehicle records and driver record status;
- The National Practitioner Data Bank for malpractice cases and medical board sanctions;
- Medicare sanction list of the Office of Inspector General in the U.S. Department of Health and Human Services;
- Social Security number; and
- Sex offender and terrorist databases.
Some investigations will include credit checks, which can cover credit payment history, bankruptcies, tax liens, and accounts placed into collections.
It is illegal during a background check to search for information related to a job candidate’s race, age, religion, sexual orientation, or any other protected category under the federal Civil Rights Act, says Cheryl Slack, vice president of human resources at Brentwood, Tenn.-based Cogent Healthcare.
Under the federal Fair Credit Reporting Act (www.ftc.gov/os/statutes/031224fcra.pdf), it also is illegal for a third-party consumer-reporting agency to perform an employment background check in secret, Rosen says. The applicant must authorize the check by signing a standalone disclosure form, he says. For the rare healthcare organizations that do their background checks in-house, most will seek consent.
Disclosure Is Crucial
Hospitalist job candidates should do whatever they can to make sure the people in charge of hiring aren’t surprised by what turns up in a background check, the experts say. “Nothing is more frustrating than finding out there is a problem late in the application process,” Lary says.
Hospitalists should inform the references they list on their resumes that they could be contacted. Such a “heads up” often gives a reference time to organize their thoughts about the job applicant and provide the best possible recommendation.
“You would be shocked at how many references are surprised to learn the hospitalist is looking for a job or how many applicants give as references people who don’t like them personally or professionally,” Lary says. “There are even times when physicians will take a pass on a reference. That speaks volumes.”
The most important thing a candidate should know is if there is something negative in their background that could be professionally damaging if discovered. It is best to make the people hiring aware of the information, Rosen says.
“Disclosure is best 100% of the time,” says Reuben Tovar, MD, chairman of Hospital Internists of Austin, a physician-owned and -managed hospitalist practice in Texas. “To deny or not include something on a resume or in an interview makes it look like you are a liar, or haven’t come to terms with what happened.”
The main impediment to disclosure is embarrassment and shame, says Dr. Tovar, who has encountered a number of physician candidates who have had problems. Those who disclose past issues are in a much better position to explain the situation and show how they have cleaned up a messy situation.
“Physicians are generally willing to at least consider giving their colleagues a second chance in employment and [hospital] credentialing if they are forthright,” Dr. Tovar says. “Not being forthright is an automatic exclusion.” TH
Lisa Ryan is a freelance writer based in New Jersey.
If the hospitalist recruitment process is a puzzle, then the background check is the vacuum cleaner, sweeping the area for any missing puzzle pieces.
“You are trying to get the whole picture,” Tim Lary, vice president of physician staffing at North Hollywood, Calif.-based IPC: The Hospitalist Company, says. “You are trying to see if something doesn’t fit right.”
Any competent healthcare organization will conduct a background check on hospitalist job candidates, first and foremost to ensure patient safety and a safe practice environment for other healthcare providers, Lary says. There also is the issue of liability.
Financial liability for the negative acts of employees, whether accidental or intentional, is an area of exposure for businesses, says Les Rosen, president and CEO of Employment Screening Resources, a consumer reporting agency and human resources consulting firm in Novato, Calif. Businesses can be held liable for injuries resulting from the failure to adequately screen the people it hires. Background checks demonstrate the organization has done its due diligence in assessing the safety and competence of job candidates.
“It enables an organization to hire based upon facts, not just instincts,” Rosen says.
Background Basics
Hospitalists must be prepared to effectively deal with background checks throughout their professional careers. Employment checks often involve three areas: credentials verification, reference checking, and an additional background investigation.
Credentialing includes a review of the hospitalist’s completed education, training, residency, licenses, and any certifications, and often encompasses the candidate’s hospital privileges history, malpractice claims history, and peer reviews.
Reference checking involves verifying dates of employment and title at the hospitalist’s previous jobs, and contacting references to speak with them about the candidate’s qualifications.
Background investigations often are done by a third-party agency. The investigation will vary depending on the policies of the healthcare organization contracting the review, but, generally speaking, it includes a check of the following:
- Criminal and civil court records for criminal convictions, arrests, and lawsuits;
- Motor vehicle records and driver record status;
- The National Practitioner Data Bank for malpractice cases and medical board sanctions;
- Medicare sanction list of the Office of Inspector General in the U.S. Department of Health and Human Services;
- Social Security number; and
- Sex offender and terrorist databases.
Some investigations will include credit checks, which can cover credit payment history, bankruptcies, tax liens, and accounts placed into collections.
It is illegal during a background check to search for information related to a job candidate’s race, age, religion, sexual orientation, or any other protected category under the federal Civil Rights Act, says Cheryl Slack, vice president of human resources at Brentwood, Tenn.-based Cogent Healthcare.
Under the federal Fair Credit Reporting Act (www.ftc.gov/os/statutes/031224fcra.pdf), it also is illegal for a third-party consumer-reporting agency to perform an employment background check in secret, Rosen says. The applicant must authorize the check by signing a standalone disclosure form, he says. For the rare healthcare organizations that do their background checks in-house, most will seek consent.
Disclosure Is Crucial
Hospitalist job candidates should do whatever they can to make sure the people in charge of hiring aren’t surprised by what turns up in a background check, the experts say. “Nothing is more frustrating than finding out there is a problem late in the application process,” Lary says.
Hospitalists should inform the references they list on their resumes that they could be contacted. Such a “heads up” often gives a reference time to organize their thoughts about the job applicant and provide the best possible recommendation.
“You would be shocked at how many references are surprised to learn the hospitalist is looking for a job or how many applicants give as references people who don’t like them personally or professionally,” Lary says. “There are even times when physicians will take a pass on a reference. That speaks volumes.”
The most important thing a candidate should know is if there is something negative in their background that could be professionally damaging if discovered. It is best to make the people hiring aware of the information, Rosen says.
“Disclosure is best 100% of the time,” says Reuben Tovar, MD, chairman of Hospital Internists of Austin, a physician-owned and -managed hospitalist practice in Texas. “To deny or not include something on a resume or in an interview makes it look like you are a liar, or haven’t come to terms with what happened.”
The main impediment to disclosure is embarrassment and shame, says Dr. Tovar, who has encountered a number of physician candidates who have had problems. Those who disclose past issues are in a much better position to explain the situation and show how they have cleaned up a messy situation.
“Physicians are generally willing to at least consider giving their colleagues a second chance in employment and [hospital] credentialing if they are forthright,” Dr. Tovar says. “Not being forthright is an automatic exclusion.” TH
Lisa Ryan is a freelance writer based in New Jersey.
If the hospitalist recruitment process is a puzzle, then the background check is the vacuum cleaner, sweeping the area for any missing puzzle pieces.
“You are trying to get the whole picture,” Tim Lary, vice president of physician staffing at North Hollywood, Calif.-based IPC: The Hospitalist Company, says. “You are trying to see if something doesn’t fit right.”
Any competent healthcare organization will conduct a background check on hospitalist job candidates, first and foremost to ensure patient safety and a safe practice environment for other healthcare providers, Lary says. There also is the issue of liability.
Financial liability for the negative acts of employees, whether accidental or intentional, is an area of exposure for businesses, says Les Rosen, president and CEO of Employment Screening Resources, a consumer reporting agency and human resources consulting firm in Novato, Calif. Businesses can be held liable for injuries resulting from the failure to adequately screen the people it hires. Background checks demonstrate the organization has done its due diligence in assessing the safety and competence of job candidates.
“It enables an organization to hire based upon facts, not just instincts,” Rosen says.
Background Basics
Hospitalists must be prepared to effectively deal with background checks throughout their professional careers. Employment checks often involve three areas: credentials verification, reference checking, and an additional background investigation.
Credentialing includes a review of the hospitalist’s completed education, training, residency, licenses, and any certifications, and often encompasses the candidate’s hospital privileges history, malpractice claims history, and peer reviews.
Reference checking involves verifying dates of employment and title at the hospitalist’s previous jobs, and contacting references to speak with them about the candidate’s qualifications.
Background investigations often are done by a third-party agency. The investigation will vary depending on the policies of the healthcare organization contracting the review, but, generally speaking, it includes a check of the following:
- Criminal and civil court records for criminal convictions, arrests, and lawsuits;
- Motor vehicle records and driver record status;
- The National Practitioner Data Bank for malpractice cases and medical board sanctions;
- Medicare sanction list of the Office of Inspector General in the U.S. Department of Health and Human Services;
- Social Security number; and
- Sex offender and terrorist databases.
Some investigations will include credit checks, which can cover credit payment history, bankruptcies, tax liens, and accounts placed into collections.
It is illegal during a background check to search for information related to a job candidate’s race, age, religion, sexual orientation, or any other protected category under the federal Civil Rights Act, says Cheryl Slack, vice president of human resources at Brentwood, Tenn.-based Cogent Healthcare.
Under the federal Fair Credit Reporting Act (www.ftc.gov/os/statutes/031224fcra.pdf), it also is illegal for a third-party consumer-reporting agency to perform an employment background check in secret, Rosen says. The applicant must authorize the check by signing a standalone disclosure form, he says. For the rare healthcare organizations that do their background checks in-house, most will seek consent.
Disclosure Is Crucial
Hospitalist job candidates should do whatever they can to make sure the people in charge of hiring aren’t surprised by what turns up in a background check, the experts say. “Nothing is more frustrating than finding out there is a problem late in the application process,” Lary says.
Hospitalists should inform the references they list on their resumes that they could be contacted. Such a “heads up” often gives a reference time to organize their thoughts about the job applicant and provide the best possible recommendation.
“You would be shocked at how many references are surprised to learn the hospitalist is looking for a job or how many applicants give as references people who don’t like them personally or professionally,” Lary says. “There are even times when physicians will take a pass on a reference. That speaks volumes.”
The most important thing a candidate should know is if there is something negative in their background that could be professionally damaging if discovered. It is best to make the people hiring aware of the information, Rosen says.
“Disclosure is best 100% of the time,” says Reuben Tovar, MD, chairman of Hospital Internists of Austin, a physician-owned and -managed hospitalist practice in Texas. “To deny or not include something on a resume or in an interview makes it look like you are a liar, or haven’t come to terms with what happened.”
The main impediment to disclosure is embarrassment and shame, says Dr. Tovar, who has encountered a number of physician candidates who have had problems. Those who disclose past issues are in a much better position to explain the situation and show how they have cleaned up a messy situation.
“Physicians are generally willing to at least consider giving their colleagues a second chance in employment and [hospital] credentialing if they are forthright,” Dr. Tovar says. “Not being forthright is an automatic exclusion.” TH
Lisa Ryan is a freelance writer based in New Jersey.
Concurrent Care
Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.
A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:
- Does the patient’s condition warrant more than one physician? and
- Are the services provided by each physician reasonable and necessary?1
When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).
When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.
Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.
Reasons for Denial
Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:
- Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
- Services by one physician duplicate or overlap those of another provider without recognizable distinction.2
For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.
Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.
Group Practice
Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.
The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.
Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.
References
- Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.
Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.
A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:
- Does the patient’s condition warrant more than one physician? and
- Are the services provided by each physician reasonable and necessary?1
When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).
When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.
Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.
Reasons for Denial
Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:
- Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
- Services by one physician duplicate or overlap those of another provider without recognizable distinction.2
For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.
Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.
Group Practice
Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.
The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.
Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.
References
- Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.
Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.
A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:
- Does the patient’s condition warrant more than one physician? and
- Are the services provided by each physician reasonable and necessary?1
When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).
When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.
Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.
Reasons for Denial
Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:
- Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
- Services by one physician duplicate or overlap those of another provider without recognizable distinction.2
For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.
Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.
Group Practice
Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.
The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.
Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.
References
- Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.
Toxic Employees
The providers in every hospitalist practice should be a good fit for the practice’s culture. They should have reasonable relationships with their colleagues in the practice, patients and families, and other staff at the hospital.
I can’t imagine anyone arguing with this point of view. But in my work with hundreds of hospitalist practices over the past 15 years, I’ve found that many practices seem to have a hard time ensuring their providers meet that standard. I can think of lots of reasons for this. The first that comes to mind is the difficult HM recruiting environment. Almost all hospitalist practices needed to grow quickly, and many lowered the bar in the qualifications and the fit of the candidates they hired to make sure they filled all of their positions.
Even if it later becomes clear a provider isn’t a good fit for the group culture, or worse still lacks the knowledge base and judgment to perform well, many practices are reluctant to replace the hospitalist because it might be difficult to find a replacement—and there is no guarantee the new person will perform any better. Because of this, a number of practices have ended up with providers who in many cases have a negative influence on others in the practice, and both the practice and the problem provider would be better off if the provider went elsewhere.
The Problem Physician
To their credit, most practices do act when a provider simply lacks the skill and judgment to perform adequately. This can mean close proctoring/mentoring for an extended period, or requiring specific CME course work to correct a skill that is lacking. But it also means reassigning the person to a different job, or termination.
But in the case of someone with a toxic personality, practices often are more reluctant to act. I’ll often hear the leadership of a practice say something like, “We knew Alice wasn’t a good fit for our practice within a few weeks of her start date.” The start date was several years ago and nothing has been done about this. Not surprisingly, Alice still performs poorly.
I’m not talking about someone who has occasional problems. I’m talking about people who cause problems almost every time they show up to work. Here are some real anecdotes, with fictitious names to ensure anonymity for the person and institution:
- Dr. Lee routinely disappears for several hours, during which he doesn’t answer pages. This even happens when he is the only doctor covering the practice.
- Dr. Lifeson, while generally getting along well with his fellow hospitalists and the nursing staff, can be counted on to complain bitterly about all levels of the hospital administration and leadership. He never misses an opportunity to try to convince other hospitalists that the leadership is not only inept, but also clearly has a malicious intent toward hospitalists.
- Dr. Peart complains incessantly about even tiny inequities in the work schedule or patient load. Others in the group have found that it is easier to ensure he always has the best schedule and lightest patient load, hoping they won’t have to hear his constant complaining. But even that hasn’t stemmed the steady downpour of negativity from him.
In all three of these cases, it seemed clear that the doctor should be terminated. And while the practice leadership agreed with me, they offered several excuses for why they hadn’t taken this step.
- “Who knows if we can find a replacement who will be any better?”
- “But he’s actually a decent doctor and doesn’t get a lot of complaints from patients.”
- “He’s such an angry guy, we worry about litigation if we fire him.”
I can’t offer any clear rule about when a practice should stop trying to improve a provider’s behavior and recognize that it is time to terminate the provider. But it is worth remembering that waiting too long has many costs, including the satisfaction of others in the group. Everyone will think less of the practice they are part of if poor behavior is tolerated.
Assess the Situation, Then Take Action
Most doctors who serve as the lead physician for their group have little or no experience dealing with problem behavior, let alone experience ensuring that necessary steps are followed prior to disciplining or terminating someone. But every hospital has someone who is very knowledgeable about these things; they should be engaged for advice, and, in the case of hospital-employed groups, should participate in the process of counseling and/or termination. It is important to take advantage of the expertise that is available.
Of course, the best approach is to prevent such problems from coming up. The best way to do this is to be very careful when hiring new providers. Checking references carefully is probably the best way to get an idea about whether someone might have behavior or personality problems. There are “job fit” survey instruments that you can use, but I’m not sure how effective they are, or how much value they add for a hospitalist practice beyond other means of assessing the candidate. And in the process of hiring someone, be sure to set behavior expectations very clearly. A new candidate should know that you will not tolerate not living up to behavioral expectations.
When dealing with bad behavior, make sure that you follow a careful and well-documented process. If someone still makes it through the hiring process only to be revealed as a troublemaker soon after their start date, don’t wait to sit that person down for very clear counseling; insist that their behavior change. Take notes of each meeting, and consider having the problem doctor sign and date the notes. While it might be easier to just wait and see if the first instance of bad behavior was an anomaly, that usually is a bad idea.
You should consider bringing the problem provider into the tent. The root of some bad behavior (i.e. criticism of leadership) is a person’s insecurity and lack of a feeling of ownership or control of their role in the practice. In that case, it might be reasonable to invite such a person into a role of greater responsibility in the practice so that they feel more in control. For example, a doctor who constantly complains about the work schedule might be invited to join the group’s executive committee or take on some other formal leadership role in the practice. This could backfire, so it should be tried only in carefully selected cases, and with the problem doctor’s clear understanding that they are being given a chance to have a bigger role in the practice but must improve their behavior or face serious consequences that could include termination.
I have seen this work beautifully in some cases, curing the problem behavior and turning the doctor into a valuable asset. I only wish there were a reliable way to know when to try this strategy. Sadly, it just requires judgment and intuition. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder 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 course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.
The providers in every hospitalist practice should be a good fit for the practice’s culture. They should have reasonable relationships with their colleagues in the practice, patients and families, and other staff at the hospital.
I can’t imagine anyone arguing with this point of view. But in my work with hundreds of hospitalist practices over the past 15 years, I’ve found that many practices seem to have a hard time ensuring their providers meet that standard. I can think of lots of reasons for this. The first that comes to mind is the difficult HM recruiting environment. Almost all hospitalist practices needed to grow quickly, and many lowered the bar in the qualifications and the fit of the candidates they hired to make sure they filled all of their positions.
Even if it later becomes clear a provider isn’t a good fit for the group culture, or worse still lacks the knowledge base and judgment to perform well, many practices are reluctant to replace the hospitalist because it might be difficult to find a replacement—and there is no guarantee the new person will perform any better. Because of this, a number of practices have ended up with providers who in many cases have a negative influence on others in the practice, and both the practice and the problem provider would be better off if the provider went elsewhere.
The Problem Physician
To their credit, most practices do act when a provider simply lacks the skill and judgment to perform adequately. This can mean close proctoring/mentoring for an extended period, or requiring specific CME course work to correct a skill that is lacking. But it also means reassigning the person to a different job, or termination.
But in the case of someone with a toxic personality, practices often are more reluctant to act. I’ll often hear the leadership of a practice say something like, “We knew Alice wasn’t a good fit for our practice within a few weeks of her start date.” The start date was several years ago and nothing has been done about this. Not surprisingly, Alice still performs poorly.
I’m not talking about someone who has occasional problems. I’m talking about people who cause problems almost every time they show up to work. Here are some real anecdotes, with fictitious names to ensure anonymity for the person and institution:
- Dr. Lee routinely disappears for several hours, during which he doesn’t answer pages. This even happens when he is the only doctor covering the practice.
- Dr. Lifeson, while generally getting along well with his fellow hospitalists and the nursing staff, can be counted on to complain bitterly about all levels of the hospital administration and leadership. He never misses an opportunity to try to convince other hospitalists that the leadership is not only inept, but also clearly has a malicious intent toward hospitalists.
- Dr. Peart complains incessantly about even tiny inequities in the work schedule or patient load. Others in the group have found that it is easier to ensure he always has the best schedule and lightest patient load, hoping they won’t have to hear his constant complaining. But even that hasn’t stemmed the steady downpour of negativity from him.
In all three of these cases, it seemed clear that the doctor should be terminated. And while the practice leadership agreed with me, they offered several excuses for why they hadn’t taken this step.
- “Who knows if we can find a replacement who will be any better?”
- “But he’s actually a decent doctor and doesn’t get a lot of complaints from patients.”
- “He’s such an angry guy, we worry about litigation if we fire him.”
I can’t offer any clear rule about when a practice should stop trying to improve a provider’s behavior and recognize that it is time to terminate the provider. But it is worth remembering that waiting too long has many costs, including the satisfaction of others in the group. Everyone will think less of the practice they are part of if poor behavior is tolerated.
Assess the Situation, Then Take Action
Most doctors who serve as the lead physician for their group have little or no experience dealing with problem behavior, let alone experience ensuring that necessary steps are followed prior to disciplining or terminating someone. But every hospital has someone who is very knowledgeable about these things; they should be engaged for advice, and, in the case of hospital-employed groups, should participate in the process of counseling and/or termination. It is important to take advantage of the expertise that is available.
Of course, the best approach is to prevent such problems from coming up. The best way to do this is to be very careful when hiring new providers. Checking references carefully is probably the best way to get an idea about whether someone might have behavior or personality problems. There are “job fit” survey instruments that you can use, but I’m not sure how effective they are, or how much value they add for a hospitalist practice beyond other means of assessing the candidate. And in the process of hiring someone, be sure to set behavior expectations very clearly. A new candidate should know that you will not tolerate not living up to behavioral expectations.
When dealing with bad behavior, make sure that you follow a careful and well-documented process. If someone still makes it through the hiring process only to be revealed as a troublemaker soon after their start date, don’t wait to sit that person down for very clear counseling; insist that their behavior change. Take notes of each meeting, and consider having the problem doctor sign and date the notes. While it might be easier to just wait and see if the first instance of bad behavior was an anomaly, that usually is a bad idea.
You should consider bringing the problem provider into the tent. The root of some bad behavior (i.e. criticism of leadership) is a person’s insecurity and lack of a feeling of ownership or control of their role in the practice. In that case, it might be reasonable to invite such a person into a role of greater responsibility in the practice so that they feel more in control. For example, a doctor who constantly complains about the work schedule might be invited to join the group’s executive committee or take on some other formal leadership role in the practice. This could backfire, so it should be tried only in carefully selected cases, and with the problem doctor’s clear understanding that they are being given a chance to have a bigger role in the practice but must improve their behavior or face serious consequences that could include termination.
I have seen this work beautifully in some cases, curing the problem behavior and turning the doctor into a valuable asset. I only wish there were a reliable way to know when to try this strategy. Sadly, it just requires judgment and intuition. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder 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 course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.
The providers in every hospitalist practice should be a good fit for the practice’s culture. They should have reasonable relationships with their colleagues in the practice, patients and families, and other staff at the hospital.
I can’t imagine anyone arguing with this point of view. But in my work with hundreds of hospitalist practices over the past 15 years, I’ve found that many practices seem to have a hard time ensuring their providers meet that standard. I can think of lots of reasons for this. The first that comes to mind is the difficult HM recruiting environment. Almost all hospitalist practices needed to grow quickly, and many lowered the bar in the qualifications and the fit of the candidates they hired to make sure they filled all of their positions.
Even if it later becomes clear a provider isn’t a good fit for the group culture, or worse still lacks the knowledge base and judgment to perform well, many practices are reluctant to replace the hospitalist because it might be difficult to find a replacement—and there is no guarantee the new person will perform any better. Because of this, a number of practices have ended up with providers who in many cases have a negative influence on others in the practice, and both the practice and the problem provider would be better off if the provider went elsewhere.
The Problem Physician
To their credit, most practices do act when a provider simply lacks the skill and judgment to perform adequately. This can mean close proctoring/mentoring for an extended period, or requiring specific CME course work to correct a skill that is lacking. But it also means reassigning the person to a different job, or termination.
But in the case of someone with a toxic personality, practices often are more reluctant to act. I’ll often hear the leadership of a practice say something like, “We knew Alice wasn’t a good fit for our practice within a few weeks of her start date.” The start date was several years ago and nothing has been done about this. Not surprisingly, Alice still performs poorly.
I’m not talking about someone who has occasional problems. I’m talking about people who cause problems almost every time they show up to work. Here are some real anecdotes, with fictitious names to ensure anonymity for the person and institution:
- Dr. Lee routinely disappears for several hours, during which he doesn’t answer pages. This even happens when he is the only doctor covering the practice.
- Dr. Lifeson, while generally getting along well with his fellow hospitalists and the nursing staff, can be counted on to complain bitterly about all levels of the hospital administration and leadership. He never misses an opportunity to try to convince other hospitalists that the leadership is not only inept, but also clearly has a malicious intent toward hospitalists.
- Dr. Peart complains incessantly about even tiny inequities in the work schedule or patient load. Others in the group have found that it is easier to ensure he always has the best schedule and lightest patient load, hoping they won’t have to hear his constant complaining. But even that hasn’t stemmed the steady downpour of negativity from him.
In all three of these cases, it seemed clear that the doctor should be terminated. And while the practice leadership agreed with me, they offered several excuses for why they hadn’t taken this step.
- “Who knows if we can find a replacement who will be any better?”
- “But he’s actually a decent doctor and doesn’t get a lot of complaints from patients.”
- “He’s such an angry guy, we worry about litigation if we fire him.”
I can’t offer any clear rule about when a practice should stop trying to improve a provider’s behavior and recognize that it is time to terminate the provider. But it is worth remembering that waiting too long has many costs, including the satisfaction of others in the group. Everyone will think less of the practice they are part of if poor behavior is tolerated.
Assess the Situation, Then Take Action
Most doctors who serve as the lead physician for their group have little or no experience dealing with problem behavior, let alone experience ensuring that necessary steps are followed prior to disciplining or terminating someone. But every hospital has someone who is very knowledgeable about these things; they should be engaged for advice, and, in the case of hospital-employed groups, should participate in the process of counseling and/or termination. It is important to take advantage of the expertise that is available.
Of course, the best approach is to prevent such problems from coming up. The best way to do this is to be very careful when hiring new providers. Checking references carefully is probably the best way to get an idea about whether someone might have behavior or personality problems. There are “job fit” survey instruments that you can use, but I’m not sure how effective they are, or how much value they add for a hospitalist practice beyond other means of assessing the candidate. And in the process of hiring someone, be sure to set behavior expectations very clearly. A new candidate should know that you will not tolerate not living up to behavioral expectations.
When dealing with bad behavior, make sure that you follow a careful and well-documented process. If someone still makes it through the hiring process only to be revealed as a troublemaker soon after their start date, don’t wait to sit that person down for very clear counseling; insist that their behavior change. Take notes of each meeting, and consider having the problem doctor sign and date the notes. While it might be easier to just wait and see if the first instance of bad behavior was an anomaly, that usually is a bad idea.
You should consider bringing the problem provider into the tent. The root of some bad behavior (i.e. criticism of leadership) is a person’s insecurity and lack of a feeling of ownership or control of their role in the practice. In that case, it might be reasonable to invite such a person into a role of greater responsibility in the practice so that they feel more in control. For example, a doctor who constantly complains about the work schedule might be invited to join the group’s executive committee or take on some other formal leadership role in the practice. This could backfire, so it should be tried only in carefully selected cases, and with the problem doctor’s clear understanding that they are being given a chance to have a bigger role in the practice but must improve their behavior or face serious consequences that could include termination.
I have seen this work beautifully in some cases, curing the problem behavior and turning the doctor into a valuable asset. I only wish there were a reliable way to know when to try this strategy. Sadly, it just requires judgment and intuition. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder 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 course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.
Chronic pain after vaginal wall repair…and more
What caused chronic pain after repair of the vaginal wall?
A WOMAN IN HER THIRTIES underwent anterior and posterior repair of the vaginal wall, including repair of a cystocele and a rectocystocele. Postoperatively, the patient developed a chronic pain syndrome.
PATIENT’S CLAIM The ObGyn failed to properly perform the surgery, and damaged the pudendal nerve, which causes chronic pain. The ObGyn moved the levator ani muscle; the muscle shifted into the vaginal canal and damaged the pudendal nerve. Informed consent was not obtained.
PHYSICIAN’S DEFENSE The patient was fully informed of all the procedure’s risks. The injury could not have been from displacement of the levator ani muscle because the muscle cannot reach the vaginal canal. Pain is from scar formation that is entrapping a nerve.
VERDICT A New York defense verdict was returned.
DVT + estrogen-based contraception=stroke?
AFTER A DEEP VENOUS THROMBOSIS (DVT) in her leg at age 29, a woman was told by her family physician to avoid birth control that contained estrogen. She claimed she told her ObGyn of the history of DVT and the no-estrogen advice, but he prescribed and inserted a Nuva Ring, which contains ethinyl estradiol. A few months later, the woman was hospitalized with a severe headache, and suffered a stroke that affected her speech and cognitive functions.
PATIENT’S CLAIM The ObGyn was negligent in prescribing a contraceptive that contained estrogen, knowing the patient’s history of blood clot.
PHYSICIAN’S DEFENSE An injury caused the first clot; the Nuva Ring did not cause the second clot or stroke.
VERDICT A $523,000 Georgia verdict was returned.
New mother dies; was preeclampsia treated properly?
AT HER SEVENTH-MONTH VISIT to her ObGyn (Dr. A), a woman began to show signs of preeclampsia. Two weeks later, she went to the emergency department (ED) with chest pain, cough, and shortness of breath; she was found to have hypertension and tachycardia. She was examined by an emergency medicine physician (Dr. B), and discharged with a diagnosis of bronchitis and a finding of dyspnea.
At a scheduled prenatal visit 2 days later, she was hypertensive. Dr. A sent her to the ED, where a physician assistant noted signs of edema in her extremities. Attempts to draw arterial blood were unsuccessful, and crackles were heard in her lungs. She was diagnosed as having worsening preeclampsia with pulmonary edema, and admitted.
Dr. C, another ObGyn, decided to perform a cesarean delivery, but on the way to the OR, the patient became unresponsive. After delivery, she went into cardiopulmonary arrest and sustained anoxic brain injury. She died after life support was removed. An autopsy determined cause of death was anoxic encephalopathy due to respiratory arrest caused by preeclampsia.
ESTATE’S CLAIM Dr. A failed to provide proper prenatal care, and failed to recognize preeclampsia. Dr. B failed to recognize preeclampsia, failed to contact a specialist, and failed to immediately admit the patient for monitoring and treatment. Dr. C negligently administered a bolus of IV fluids when the patient showed signs of preeclampsia. He failed to administer medication to reduce fluid retention, and failed to timely admit the patient to the hospital.
PHYSICIANS’ DEFENSE All three physicians denied negligence.
VERDICT A $1.5 million Michigan settlement was reached.
Did resident use forceful traction with shoulder dystocia?
SHOULDER DYSTOCIA was encountered during vaginal delivery, and managed by a resident. The child suffered a brachial plexus injury.
PATIENT’S CLAIM The attending physician failed to 1) properly supervise the resident who was delivering the infant, and 2) prevent the use of traction after it was determined that shoulder dystocia was present.
PHYSICIANS’ DEFENSE The resident, under full supervision of the attending physician, utilized traction after the baby’s head was delivered and shoulder dystocia became evident—but traction was gentle. The maternal forces of labor caused the injury.
VERDICT A $950,000 Virginia settlement was reached.
Was patient informed that tubal ligation had not been performed?
PREGNANT WITH HER FOURTH CHILD despite birth control, a woman and her husband told the ObGyn that they did not want, nor could they afford, a fifth child. They requested bilateral tubal ligation during cesarean delivery. Two days before the scheduled birth, the mother went into labor. Her prenatal records could not be found, and the ObGyn’s office was closed. The ObGyn delivered the baby, but did not perform tubal ligation. She claimed she was never told that the tubal ligation had not been completed, even at the 6-week postpartum visit. She did not take precautions to prevent pregnancy, and later conceived a fifth child.
PATIENT’S CLAIM The ObGyn was negligent in not performing the tubal ligation and in not telling the patient until after the fifth child’s conception.
PHYSICIAN’S DEFENSE The mother was told that tubal ligation had not been performed at the 6-week visit. She was advised to use birth control until she recovered from the cesarean delivery and could undergo a tubal ligation procedure. The ObGyn acknowledged he had forgotten to perform the tubal ligation at delivery, but insisted there was no negligence under the circumstances.
VERDICT A California defense verdict was returned.
Patient claims stomach injury caused GERD
DUE TO PELVIC PAIN, a woman underwent laparoscopy by her ObGyn. During the procedure, a trocar punctured her stomach. The injury was discovered, the procedure converted to a laparotomy with a vertical incision, and the injury repaired.
PATIENT’S CLAIM She developed gastroesophageal reflux disease (GERD) because of the puncture wound, and anxiety because of the scar.
PHYSICIAN’S DEFENSE Gastric perforation is a rare but recognized complication of abdominal laparoscopy, and can occur without negligence. Her GERD is either due to a hiatal hernia or pychosomatic disorder.
VERDICT A Virginia defense verdict was returned.
Physicians not responsible for stroke
SEVERAL DAYS AFTER GIVING BIRTH, a 33-year-old woman visited the ED with chest pain, headache, and abdominal pain. An emergency medicine physician and an ObGyn ordered a chest CT scan and administered anticoagulants. By the time the CT scan was completed, the woman denied having chest pain. No pulmonary emboli (PE) were detected on chest CT, and she was discharged.
The next day, she went to another hospital’s ED with a headache and right-side weakness. A CT scan revealed a large left parietal-lobe intracerebral hematoma. A ventricular catheter was placed and she underwent a stereotactic craniotomy for evacuation of the hematoma. She was transferred to a rehabilitation facility a month later.
She suffers permanent neurologic damage, including short-term memory loss and an inability to lift or walk for any great distance.
PATIENT’S CLAIM The ED physicians failed to diagnose and treat an acute neurologic event in a timely manner, and did not obtain specialist consults. Administration of anticoagulants was negligent; protamine therapy should have been started to reverse the anticoagulant effects. Laboratory testing of clotting times and a ventilation-perfusion lung scan should have been conducted to confirm the presence of PE.
PHYSICIANS’ DEFENSE The patient’s condition was appropriately diagnosed and treated in the ED. Administration of anticoagulants was necessary because of suspected PE. There is no evidence that the heparin given to the plaintiff the day before her stroke was related to the stroke.
VERDICT A Florida defense verdict was returned.
Did failure to diagnose preeclampsia lead to infant’s death?
AT 38-WEEKS’ GESTATION, a 21-year-old woman was seen at a hospital’s obstetric clinic, and sent to the ED with complaints of leaking fluid and lack of fetal movement. She claimed she showed signs of preeclampsia, pregnancy-induced hypertension, and oligohydramnios, but was not admitted to the hospital. The baby was born 2 days later with persistent pulmonary hypertension (PPH), which led to the child’s death at 33 days of age.
PATIENT’S CLAIM There was negligence in failing to diagnose preeclampsia, pregnancy-induced hypertension, and oligohydramnios, which caused the baby to be born with PPH.
PHYSICIAN’S DEFENSE The cause of the infant’s PPH was unknown, and most likely arose in utero prior to birth. An earlier delivery would not have resulted in a different outcome.
VERDICT A Illinois defense verdict was returned.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
We want to hear from you! Tell us what you think.
What caused chronic pain after repair of the vaginal wall?
A WOMAN IN HER THIRTIES underwent anterior and posterior repair of the vaginal wall, including repair of a cystocele and a rectocystocele. Postoperatively, the patient developed a chronic pain syndrome.
PATIENT’S CLAIM The ObGyn failed to properly perform the surgery, and damaged the pudendal nerve, which causes chronic pain. The ObGyn moved the levator ani muscle; the muscle shifted into the vaginal canal and damaged the pudendal nerve. Informed consent was not obtained.
PHYSICIAN’S DEFENSE The patient was fully informed of all the procedure’s risks. The injury could not have been from displacement of the levator ani muscle because the muscle cannot reach the vaginal canal. Pain is from scar formation that is entrapping a nerve.
VERDICT A New York defense verdict was returned.
DVT + estrogen-based contraception=stroke?
AFTER A DEEP VENOUS THROMBOSIS (DVT) in her leg at age 29, a woman was told by her family physician to avoid birth control that contained estrogen. She claimed she told her ObGyn of the history of DVT and the no-estrogen advice, but he prescribed and inserted a Nuva Ring, which contains ethinyl estradiol. A few months later, the woman was hospitalized with a severe headache, and suffered a stroke that affected her speech and cognitive functions.
PATIENT’S CLAIM The ObGyn was negligent in prescribing a contraceptive that contained estrogen, knowing the patient’s history of blood clot.
PHYSICIAN’S DEFENSE An injury caused the first clot; the Nuva Ring did not cause the second clot or stroke.
VERDICT A $523,000 Georgia verdict was returned.
New mother dies; was preeclampsia treated properly?
AT HER SEVENTH-MONTH VISIT to her ObGyn (Dr. A), a woman began to show signs of preeclampsia. Two weeks later, she went to the emergency department (ED) with chest pain, cough, and shortness of breath; she was found to have hypertension and tachycardia. She was examined by an emergency medicine physician (Dr. B), and discharged with a diagnosis of bronchitis and a finding of dyspnea.
At a scheduled prenatal visit 2 days later, she was hypertensive. Dr. A sent her to the ED, where a physician assistant noted signs of edema in her extremities. Attempts to draw arterial blood were unsuccessful, and crackles were heard in her lungs. She was diagnosed as having worsening preeclampsia with pulmonary edema, and admitted.
Dr. C, another ObGyn, decided to perform a cesarean delivery, but on the way to the OR, the patient became unresponsive. After delivery, she went into cardiopulmonary arrest and sustained anoxic brain injury. She died after life support was removed. An autopsy determined cause of death was anoxic encephalopathy due to respiratory arrest caused by preeclampsia.
ESTATE’S CLAIM Dr. A failed to provide proper prenatal care, and failed to recognize preeclampsia. Dr. B failed to recognize preeclampsia, failed to contact a specialist, and failed to immediately admit the patient for monitoring and treatment. Dr. C negligently administered a bolus of IV fluids when the patient showed signs of preeclampsia. He failed to administer medication to reduce fluid retention, and failed to timely admit the patient to the hospital.
PHYSICIANS’ DEFENSE All three physicians denied negligence.
VERDICT A $1.5 million Michigan settlement was reached.
Did resident use forceful traction with shoulder dystocia?
SHOULDER DYSTOCIA was encountered during vaginal delivery, and managed by a resident. The child suffered a brachial plexus injury.
PATIENT’S CLAIM The attending physician failed to 1) properly supervise the resident who was delivering the infant, and 2) prevent the use of traction after it was determined that shoulder dystocia was present.
PHYSICIANS’ DEFENSE The resident, under full supervision of the attending physician, utilized traction after the baby’s head was delivered and shoulder dystocia became evident—but traction was gentle. The maternal forces of labor caused the injury.
VERDICT A $950,000 Virginia settlement was reached.
Was patient informed that tubal ligation had not been performed?
PREGNANT WITH HER FOURTH CHILD despite birth control, a woman and her husband told the ObGyn that they did not want, nor could they afford, a fifth child. They requested bilateral tubal ligation during cesarean delivery. Two days before the scheduled birth, the mother went into labor. Her prenatal records could not be found, and the ObGyn’s office was closed. The ObGyn delivered the baby, but did not perform tubal ligation. She claimed she was never told that the tubal ligation had not been completed, even at the 6-week postpartum visit. She did not take precautions to prevent pregnancy, and later conceived a fifth child.
PATIENT’S CLAIM The ObGyn was negligent in not performing the tubal ligation and in not telling the patient until after the fifth child’s conception.
PHYSICIAN’S DEFENSE The mother was told that tubal ligation had not been performed at the 6-week visit. She was advised to use birth control until she recovered from the cesarean delivery and could undergo a tubal ligation procedure. The ObGyn acknowledged he had forgotten to perform the tubal ligation at delivery, but insisted there was no negligence under the circumstances.
VERDICT A California defense verdict was returned.
Patient claims stomach injury caused GERD
DUE TO PELVIC PAIN, a woman underwent laparoscopy by her ObGyn. During the procedure, a trocar punctured her stomach. The injury was discovered, the procedure converted to a laparotomy with a vertical incision, and the injury repaired.
PATIENT’S CLAIM She developed gastroesophageal reflux disease (GERD) because of the puncture wound, and anxiety because of the scar.
PHYSICIAN’S DEFENSE Gastric perforation is a rare but recognized complication of abdominal laparoscopy, and can occur without negligence. Her GERD is either due to a hiatal hernia or pychosomatic disorder.
VERDICT A Virginia defense verdict was returned.
Physicians not responsible for stroke
SEVERAL DAYS AFTER GIVING BIRTH, a 33-year-old woman visited the ED with chest pain, headache, and abdominal pain. An emergency medicine physician and an ObGyn ordered a chest CT scan and administered anticoagulants. By the time the CT scan was completed, the woman denied having chest pain. No pulmonary emboli (PE) were detected on chest CT, and she was discharged.
The next day, she went to another hospital’s ED with a headache and right-side weakness. A CT scan revealed a large left parietal-lobe intracerebral hematoma. A ventricular catheter was placed and she underwent a stereotactic craniotomy for evacuation of the hematoma. She was transferred to a rehabilitation facility a month later.
She suffers permanent neurologic damage, including short-term memory loss and an inability to lift or walk for any great distance.
PATIENT’S CLAIM The ED physicians failed to diagnose and treat an acute neurologic event in a timely manner, and did not obtain specialist consults. Administration of anticoagulants was negligent; protamine therapy should have been started to reverse the anticoagulant effects. Laboratory testing of clotting times and a ventilation-perfusion lung scan should have been conducted to confirm the presence of PE.
PHYSICIANS’ DEFENSE The patient’s condition was appropriately diagnosed and treated in the ED. Administration of anticoagulants was necessary because of suspected PE. There is no evidence that the heparin given to the plaintiff the day before her stroke was related to the stroke.
VERDICT A Florida defense verdict was returned.
Did failure to diagnose preeclampsia lead to infant’s death?
AT 38-WEEKS’ GESTATION, a 21-year-old woman was seen at a hospital’s obstetric clinic, and sent to the ED with complaints of leaking fluid and lack of fetal movement. She claimed she showed signs of preeclampsia, pregnancy-induced hypertension, and oligohydramnios, but was not admitted to the hospital. The baby was born 2 days later with persistent pulmonary hypertension (PPH), which led to the child’s death at 33 days of age.
PATIENT’S CLAIM There was negligence in failing to diagnose preeclampsia, pregnancy-induced hypertension, and oligohydramnios, which caused the baby to be born with PPH.
PHYSICIAN’S DEFENSE The cause of the infant’s PPH was unknown, and most likely arose in utero prior to birth. An earlier delivery would not have resulted in a different outcome.
VERDICT A Illinois defense verdict was returned.
What caused chronic pain after repair of the vaginal wall?
A WOMAN IN HER THIRTIES underwent anterior and posterior repair of the vaginal wall, including repair of a cystocele and a rectocystocele. Postoperatively, the patient developed a chronic pain syndrome.
PATIENT’S CLAIM The ObGyn failed to properly perform the surgery, and damaged the pudendal nerve, which causes chronic pain. The ObGyn moved the levator ani muscle; the muscle shifted into the vaginal canal and damaged the pudendal nerve. Informed consent was not obtained.
PHYSICIAN’S DEFENSE The patient was fully informed of all the procedure’s risks. The injury could not have been from displacement of the levator ani muscle because the muscle cannot reach the vaginal canal. Pain is from scar formation that is entrapping a nerve.
VERDICT A New York defense verdict was returned.
DVT + estrogen-based contraception=stroke?
AFTER A DEEP VENOUS THROMBOSIS (DVT) in her leg at age 29, a woman was told by her family physician to avoid birth control that contained estrogen. She claimed she told her ObGyn of the history of DVT and the no-estrogen advice, but he prescribed and inserted a Nuva Ring, which contains ethinyl estradiol. A few months later, the woman was hospitalized with a severe headache, and suffered a stroke that affected her speech and cognitive functions.
PATIENT’S CLAIM The ObGyn was negligent in prescribing a contraceptive that contained estrogen, knowing the patient’s history of blood clot.
PHYSICIAN’S DEFENSE An injury caused the first clot; the Nuva Ring did not cause the second clot or stroke.
VERDICT A $523,000 Georgia verdict was returned.
New mother dies; was preeclampsia treated properly?
AT HER SEVENTH-MONTH VISIT to her ObGyn (Dr. A), a woman began to show signs of preeclampsia. Two weeks later, she went to the emergency department (ED) with chest pain, cough, and shortness of breath; she was found to have hypertension and tachycardia. She was examined by an emergency medicine physician (Dr. B), and discharged with a diagnosis of bronchitis and a finding of dyspnea.
At a scheduled prenatal visit 2 days later, she was hypertensive. Dr. A sent her to the ED, where a physician assistant noted signs of edema in her extremities. Attempts to draw arterial blood were unsuccessful, and crackles were heard in her lungs. She was diagnosed as having worsening preeclampsia with pulmonary edema, and admitted.
Dr. C, another ObGyn, decided to perform a cesarean delivery, but on the way to the OR, the patient became unresponsive. After delivery, she went into cardiopulmonary arrest and sustained anoxic brain injury. She died after life support was removed. An autopsy determined cause of death was anoxic encephalopathy due to respiratory arrest caused by preeclampsia.
ESTATE’S CLAIM Dr. A failed to provide proper prenatal care, and failed to recognize preeclampsia. Dr. B failed to recognize preeclampsia, failed to contact a specialist, and failed to immediately admit the patient for monitoring and treatment. Dr. C negligently administered a bolus of IV fluids when the patient showed signs of preeclampsia. He failed to administer medication to reduce fluid retention, and failed to timely admit the patient to the hospital.
PHYSICIANS’ DEFENSE All three physicians denied negligence.
VERDICT A $1.5 million Michigan settlement was reached.
Did resident use forceful traction with shoulder dystocia?
SHOULDER DYSTOCIA was encountered during vaginal delivery, and managed by a resident. The child suffered a brachial plexus injury.
PATIENT’S CLAIM The attending physician failed to 1) properly supervise the resident who was delivering the infant, and 2) prevent the use of traction after it was determined that shoulder dystocia was present.
PHYSICIANS’ DEFENSE The resident, under full supervision of the attending physician, utilized traction after the baby’s head was delivered and shoulder dystocia became evident—but traction was gentle. The maternal forces of labor caused the injury.
VERDICT A $950,000 Virginia settlement was reached.
Was patient informed that tubal ligation had not been performed?
PREGNANT WITH HER FOURTH CHILD despite birth control, a woman and her husband told the ObGyn that they did not want, nor could they afford, a fifth child. They requested bilateral tubal ligation during cesarean delivery. Two days before the scheduled birth, the mother went into labor. Her prenatal records could not be found, and the ObGyn’s office was closed. The ObGyn delivered the baby, but did not perform tubal ligation. She claimed she was never told that the tubal ligation had not been completed, even at the 6-week postpartum visit. She did not take precautions to prevent pregnancy, and later conceived a fifth child.
PATIENT’S CLAIM The ObGyn was negligent in not performing the tubal ligation and in not telling the patient until after the fifth child’s conception.
PHYSICIAN’S DEFENSE The mother was told that tubal ligation had not been performed at the 6-week visit. She was advised to use birth control until she recovered from the cesarean delivery and could undergo a tubal ligation procedure. The ObGyn acknowledged he had forgotten to perform the tubal ligation at delivery, but insisted there was no negligence under the circumstances.
VERDICT A California defense verdict was returned.
Patient claims stomach injury caused GERD
DUE TO PELVIC PAIN, a woman underwent laparoscopy by her ObGyn. During the procedure, a trocar punctured her stomach. The injury was discovered, the procedure converted to a laparotomy with a vertical incision, and the injury repaired.
PATIENT’S CLAIM She developed gastroesophageal reflux disease (GERD) because of the puncture wound, and anxiety because of the scar.
PHYSICIAN’S DEFENSE Gastric perforation is a rare but recognized complication of abdominal laparoscopy, and can occur without negligence. Her GERD is either due to a hiatal hernia or pychosomatic disorder.
VERDICT A Virginia defense verdict was returned.
Physicians not responsible for stroke
SEVERAL DAYS AFTER GIVING BIRTH, a 33-year-old woman visited the ED with chest pain, headache, and abdominal pain. An emergency medicine physician and an ObGyn ordered a chest CT scan and administered anticoagulants. By the time the CT scan was completed, the woman denied having chest pain. No pulmonary emboli (PE) were detected on chest CT, and she was discharged.
The next day, she went to another hospital’s ED with a headache and right-side weakness. A CT scan revealed a large left parietal-lobe intracerebral hematoma. A ventricular catheter was placed and she underwent a stereotactic craniotomy for evacuation of the hematoma. She was transferred to a rehabilitation facility a month later.
She suffers permanent neurologic damage, including short-term memory loss and an inability to lift or walk for any great distance.
PATIENT’S CLAIM The ED physicians failed to diagnose and treat an acute neurologic event in a timely manner, and did not obtain specialist consults. Administration of anticoagulants was negligent; protamine therapy should have been started to reverse the anticoagulant effects. Laboratory testing of clotting times and a ventilation-perfusion lung scan should have been conducted to confirm the presence of PE.
PHYSICIANS’ DEFENSE The patient’s condition was appropriately diagnosed and treated in the ED. Administration of anticoagulants was necessary because of suspected PE. There is no evidence that the heparin given to the plaintiff the day before her stroke was related to the stroke.
VERDICT A Florida defense verdict was returned.
Did failure to diagnose preeclampsia lead to infant’s death?
AT 38-WEEKS’ GESTATION, a 21-year-old woman was seen at a hospital’s obstetric clinic, and sent to the ED with complaints of leaking fluid and lack of fetal movement. She claimed she showed signs of preeclampsia, pregnancy-induced hypertension, and oligohydramnios, but was not admitted to the hospital. The baby was born 2 days later with persistent pulmonary hypertension (PPH), which led to the child’s death at 33 days of age.
PATIENT’S CLAIM There was negligence in failing to diagnose preeclampsia, pregnancy-induced hypertension, and oligohydramnios, which caused the baby to be born with PPH.
PHYSICIAN’S DEFENSE The cause of the infant’s PPH was unknown, and most likely arose in utero prior to birth. An earlier delivery would not have resulted in a different outcome.
VERDICT A Illinois defense verdict was returned.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
We want to hear from you! Tell us what you think.
These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.
We want to hear from you! Tell us what you think.
Alert! The 2011 ICD-9 code set is already in force
This year, ObGyn-related additions and revisions to the International Classification of Diseases, Clinical Modification (ICD-9-CM), involve tinkering with existing codes and adding some new code categories. The latter development means that more information will be required of you to code to the highest level of specificity.
On the obstetrics side, there are now specific codes for placental status for multiple gestations and some revised terminology.
In gynecology, changes include new codes for congenital anomalies of the cervix, vagina, and uterus; reporting an expanded list of a history of dysplasia; and reporting the insertion and removal of an intrauterine device for contraception.
In addition, new codes have been established for fecal incontinence and for reporting a body mass index >40.
Last, changes to the alphabetical index of codes have been put in place that will help you select the most appropriate code.
The new and revised ICD-9-CM codes were added to the national code set on October 1, 2010. As in previous years, there is no grace period for failing to use the new code set!
Changes to obstetric codes
PLACENTAL/AMNIOTIC SAC SPECIFICATION FOR MULTIPLE-GESTATION PREGNANCY
Multiple-gestation pregnancies are classified as monochorionic/monoamniotic, monochorionic/diamniotic, and dichorionic/diamniotic. Until now, however, you’ve had no way to report this additional information to a payer.
For fiscal year 2011, you are able to be more specific, which can increase your ability to report medical support care for a higher-risk pregnancy or an expanded treatment plan.
Because the current category of multiple-gestation codes (651) did not allow for expansion to include this information, a new code category, V91 (multiple gestation placenta status), was created for that purpose. The V91 category has distinct codes for twin gestation, triplet gestation, quadruplet gestation, and other “unspecified” gestations to denote placental/amniotic sac status.
Be aware that use of the V91 codes is optional, and that they can be reported only as a secondary diagnosis, with a category 651.xx (multiple gestation, etc.) code as primary. As I noted, however, the new codes may provide better information to the payer—and that might result in additional reimbursement for your care of such pregnancies.
The new codes for a twin pregnancy are:
V91.00 Twin gestation, unspecified number of placentae, unspecified number of amniotic sacs
V91.01 Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac)
V91.02 Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs)
V91.03 Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs)
V91.09 Twin gestation, unable to determine number of placentae and number of amniotic sacs
There are similar V codes for triplet gestations (V91.10–V91.19), quadruplet gestations (V91.20–V91.29), and other unspecified multiple gestations (V91.91– V91.99).
RECURRENT PREGNANCY LOSS
The term “habitual aborter” has been replaced for 2011 with the more clinically accurate term “recurrent pregnancy loss.” This change is noted in both the ICD-9 alphabetical index and in the code definitions in the tabular section. The codes affected by this terminology change are:
629.81 Recurrent pregnancy loss without current pregnancy
646.3x Recurrent pregnancy loss (affecting the current pregnancy)
INDEX AND INSTRUCTIONAL CHANGES
These OB changes took effect on October 1, 2010:
- Periurethral trauma should be reported using 664.8x (other specified trauma to perineum and vulva), not 665.5x (other injury to pelvic organs).
- If you report puerperal sepsis (670.2x), you must report an additional code to identify severe sepsis (995.92) and any associated acute organ dysfunction, if applicable.
- If your diagnosis is superficial thrombosis (671.2x), an additional code—either 453.6, 453.71, or 453.81—should be reported to further explain the type of thrombophlebitis.
- If your patient has either asymptomatic, inactive, or a history of genital herpes that is complicating her current pregnancy, report 647.6x (other viral diseases).
- If you report pneumonia as complicating pregnancy, assign code 648.9x (other current conditions classifiable elsewhere).
Changes to gyn codes
CONGENITAL ANOMALIES OF THE UTERUS, CERVIX, AND VAGINA
Before October 1, 2010, of the seven distinct types of uterine anomalies, only a didelphus uterus (752.2, doubling of the uterus) and a diethylstilbestrol-related anomaly (760.76 [noxious influences affecting fetus or newborn via placenta or breast milk; diethylstilbestrol (DES)]) had specific codes. All other uterine anomalies were coded to “other” or “unspecified” codes that could include many different conditions.
Although vaginal and cervical anomalies may be less common, the only codes available before October 1, 2010, were ones that described an unspecified anomaly (753.40), imperforate hymen (752.42), or an embryonic cyst (752.41).
A higher level of specificity in coding, however, can make all the difference in receiving adequate reimbursement and preventing denials. For example, if you perform a Pap smear on a patient who has two cervices, a code that specifies a duplicate cervix can clearly tell the payer that billing for both is not a duplicate service or billing error.
Changes to codes in this area of care take the form of expanding existing codes. Code 752.3 (other anomalies of uterus) has been expanded to seven distinct five-digit codes to capture the seven anomalies of the uterus:
752.31 Agenesis of uterus
752.32 Hypoplasia of uterus
752.33 Unicornuate uterus (This code would be reported if the unicornuate uterus did or did not have a separate uterine horn, or if the uterus had only one functioning horn.)
752.34 Bicornuate uterus
752.35 Septate uterus (This code would be reported whether the septate was complete or partial.)
752.36 Arcuate uterus
752.39 Other anomalies of uterus (This code category includes aplasia or any other Müllerian anomaly of the uterus that is not otherwise or elsewhere classified.)
New codes have been added to the 752.4 code category (anomalies of cervix, vagina, and external female genitalia) to expand the options. Before October 1, 2010, any of these conditions would have been coded as 752.49, an “other” category.
752.43 Cervical agenesis
752.44 Cervical duplication
752.45 Vaginal agenesis (This code can also be reported for vaginal hypoplasia.)
752.46 Transverse vaginal septum
752.47 Longitudinal vaginal septum
For a patient who has a history of one of these anomalies, you would report new code V13.62, (personal history of other [corrected] congenital malformations of genitourinary system) if this history was a factor in her current care.
Inserting and removing an IUD are integral services that most ObGyn practices provide, so it is imperative that your encounter forms reflect two new codes, to avoid denials for an invalid diagnosis code. A reminder: Code V45.51 (intrauterine contraceptive device) is a status code. It indicates that a patient has an IUD in place but you should never use it as a diagnosis code when the purpose of the visit is for you to check on the device and assess how it is working.
Changes in this area are:
Before October 1, 2010:
V25.1 Insertion
V25.42 Checking, reinsertion and/or removal After October 1, 2010:
V25.11 Encounter for insertion of intrauterine contraceptive device
V25.12 Encounter for removal of intrauterine contraceptive device
V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device
V25.42 Encounter for routine checking of intrauterine contraceptive device
Regrettably, the number of patients who have a very high body mass index (BMI) is increasing. When surgery is planned, reporting this information in your coding can help establish 1) the medical need for significant additional work during the procedure or 2) health risks in support of therapy.
Code V85.4 (Body mass index 40 and over, adult) has been expanded to five new codes. They should be reported secondary to the type of obesity (i.e., codes 278.0x [overweight and obesity]).
V85.41 Body Mass Index 40.0–44.9, adult
V85.42 Body Mass Index 45.0–49.9, adult
V85.43 Body Mass Index 50.0–59.9, adult
V85.44 Body Mass Index 60.0–69.9, adult
V85.45 Body Mass Index 70 and over, adult
Fecal incontinence can present as problematic symptoms—fecal smearing, fecal urgency, incomplete defecation—but, until now, you only had one code to report any of these problems.
For that reason, 787.6 (incontinence of feces) has been expanded into four new five-digit codes. In addition, a new code has been added to report fecal impaction, which, in the past, was reported as 560.39, an “other” category code that was not specific to this problem.
New codes are:
560.32 Fecal impaction
787.60 Full incontinence of feces
787.61 Incomplete defecation
787.62 Fecal smearing
787.63 Fecal urgency
PERSONAL HISTORY OF DYSPLASIA
New codes have been added to complete the personal history codes for dysplasia. In addition to the existing code for cervical dysplasia history (V13.22), you can now report:
V13.23 Personal history of vaginal dysplasia
V13.34 Personal history of vulvar dysplasia
INDEX AND INSTRUCTIONAL CHANGES
These changes take effect October 1, 2010:
- Clarification that an abnormal Pap result indicated non-atypical endometrial cells should be reported using 795.09.
- Clearly indicate whether a fistula between the uterus and another organ is congenital (752.39) or noncongenital (619.0-619.9).
- Precocious menstruation should be coded as 259.1, not as a menstrual disorder.
- The terminology in the index and tabular sections has been revised to more clearly differentiate long-term from prophylactic use of medications. This change affects only code category titles and lookup terms, not existing code numbers.
We want to hear from you! Tell us what you think.
This year, ObGyn-related additions and revisions to the International Classification of Diseases, Clinical Modification (ICD-9-CM), involve tinkering with existing codes and adding some new code categories. The latter development means that more information will be required of you to code to the highest level of specificity.
On the obstetrics side, there are now specific codes for placental status for multiple gestations and some revised terminology.
In gynecology, changes include new codes for congenital anomalies of the cervix, vagina, and uterus; reporting an expanded list of a history of dysplasia; and reporting the insertion and removal of an intrauterine device for contraception.
In addition, new codes have been established for fecal incontinence and for reporting a body mass index >40.
Last, changes to the alphabetical index of codes have been put in place that will help you select the most appropriate code.
The new and revised ICD-9-CM codes were added to the national code set on October 1, 2010. As in previous years, there is no grace period for failing to use the new code set!
Changes to obstetric codes
PLACENTAL/AMNIOTIC SAC SPECIFICATION FOR MULTIPLE-GESTATION PREGNANCY
Multiple-gestation pregnancies are classified as monochorionic/monoamniotic, monochorionic/diamniotic, and dichorionic/diamniotic. Until now, however, you’ve had no way to report this additional information to a payer.
For fiscal year 2011, you are able to be more specific, which can increase your ability to report medical support care for a higher-risk pregnancy or an expanded treatment plan.
Because the current category of multiple-gestation codes (651) did not allow for expansion to include this information, a new code category, V91 (multiple gestation placenta status), was created for that purpose. The V91 category has distinct codes for twin gestation, triplet gestation, quadruplet gestation, and other “unspecified” gestations to denote placental/amniotic sac status.
Be aware that use of the V91 codes is optional, and that they can be reported only as a secondary diagnosis, with a category 651.xx (multiple gestation, etc.) code as primary. As I noted, however, the new codes may provide better information to the payer—and that might result in additional reimbursement for your care of such pregnancies.
The new codes for a twin pregnancy are:
V91.00 Twin gestation, unspecified number of placentae, unspecified number of amniotic sacs
V91.01 Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac)
V91.02 Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs)
V91.03 Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs)
V91.09 Twin gestation, unable to determine number of placentae and number of amniotic sacs
There are similar V codes for triplet gestations (V91.10–V91.19), quadruplet gestations (V91.20–V91.29), and other unspecified multiple gestations (V91.91– V91.99).
RECURRENT PREGNANCY LOSS
The term “habitual aborter” has been replaced for 2011 with the more clinically accurate term “recurrent pregnancy loss.” This change is noted in both the ICD-9 alphabetical index and in the code definitions in the tabular section. The codes affected by this terminology change are:
629.81 Recurrent pregnancy loss without current pregnancy
646.3x Recurrent pregnancy loss (affecting the current pregnancy)
INDEX AND INSTRUCTIONAL CHANGES
These OB changes took effect on October 1, 2010:
- Periurethral trauma should be reported using 664.8x (other specified trauma to perineum and vulva), not 665.5x (other injury to pelvic organs).
- If you report puerperal sepsis (670.2x), you must report an additional code to identify severe sepsis (995.92) and any associated acute organ dysfunction, if applicable.
- If your diagnosis is superficial thrombosis (671.2x), an additional code—either 453.6, 453.71, or 453.81—should be reported to further explain the type of thrombophlebitis.
- If your patient has either asymptomatic, inactive, or a history of genital herpes that is complicating her current pregnancy, report 647.6x (other viral diseases).
- If you report pneumonia as complicating pregnancy, assign code 648.9x (other current conditions classifiable elsewhere).
Changes to gyn codes
CONGENITAL ANOMALIES OF THE UTERUS, CERVIX, AND VAGINA
Before October 1, 2010, of the seven distinct types of uterine anomalies, only a didelphus uterus (752.2, doubling of the uterus) and a diethylstilbestrol-related anomaly (760.76 [noxious influences affecting fetus or newborn via placenta or breast milk; diethylstilbestrol (DES)]) had specific codes. All other uterine anomalies were coded to “other” or “unspecified” codes that could include many different conditions.
Although vaginal and cervical anomalies may be less common, the only codes available before October 1, 2010, were ones that described an unspecified anomaly (753.40), imperforate hymen (752.42), or an embryonic cyst (752.41).
A higher level of specificity in coding, however, can make all the difference in receiving adequate reimbursement and preventing denials. For example, if you perform a Pap smear on a patient who has two cervices, a code that specifies a duplicate cervix can clearly tell the payer that billing for both is not a duplicate service or billing error.
Changes to codes in this area of care take the form of expanding existing codes. Code 752.3 (other anomalies of uterus) has been expanded to seven distinct five-digit codes to capture the seven anomalies of the uterus:
752.31 Agenesis of uterus
752.32 Hypoplasia of uterus
752.33 Unicornuate uterus (This code would be reported if the unicornuate uterus did or did not have a separate uterine horn, or if the uterus had only one functioning horn.)
752.34 Bicornuate uterus
752.35 Septate uterus (This code would be reported whether the septate was complete or partial.)
752.36 Arcuate uterus
752.39 Other anomalies of uterus (This code category includes aplasia or any other Müllerian anomaly of the uterus that is not otherwise or elsewhere classified.)
New codes have been added to the 752.4 code category (anomalies of cervix, vagina, and external female genitalia) to expand the options. Before October 1, 2010, any of these conditions would have been coded as 752.49, an “other” category.
752.43 Cervical agenesis
752.44 Cervical duplication
752.45 Vaginal agenesis (This code can also be reported for vaginal hypoplasia.)
752.46 Transverse vaginal septum
752.47 Longitudinal vaginal septum
For a patient who has a history of one of these anomalies, you would report new code V13.62, (personal history of other [corrected] congenital malformations of genitourinary system) if this history was a factor in her current care.
Inserting and removing an IUD are integral services that most ObGyn practices provide, so it is imperative that your encounter forms reflect two new codes, to avoid denials for an invalid diagnosis code. A reminder: Code V45.51 (intrauterine contraceptive device) is a status code. It indicates that a patient has an IUD in place but you should never use it as a diagnosis code when the purpose of the visit is for you to check on the device and assess how it is working.
Changes in this area are:
Before October 1, 2010:
V25.1 Insertion
V25.42 Checking, reinsertion and/or removal After October 1, 2010:
V25.11 Encounter for insertion of intrauterine contraceptive device
V25.12 Encounter for removal of intrauterine contraceptive device
V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device
V25.42 Encounter for routine checking of intrauterine contraceptive device
Regrettably, the number of patients who have a very high body mass index (BMI) is increasing. When surgery is planned, reporting this information in your coding can help establish 1) the medical need for significant additional work during the procedure or 2) health risks in support of therapy.
Code V85.4 (Body mass index 40 and over, adult) has been expanded to five new codes. They should be reported secondary to the type of obesity (i.e., codes 278.0x [overweight and obesity]).
V85.41 Body Mass Index 40.0–44.9, adult
V85.42 Body Mass Index 45.0–49.9, adult
V85.43 Body Mass Index 50.0–59.9, adult
V85.44 Body Mass Index 60.0–69.9, adult
V85.45 Body Mass Index 70 and over, adult
Fecal incontinence can present as problematic symptoms—fecal smearing, fecal urgency, incomplete defecation—but, until now, you only had one code to report any of these problems.
For that reason, 787.6 (incontinence of feces) has been expanded into four new five-digit codes. In addition, a new code has been added to report fecal impaction, which, in the past, was reported as 560.39, an “other” category code that was not specific to this problem.
New codes are:
560.32 Fecal impaction
787.60 Full incontinence of feces
787.61 Incomplete defecation
787.62 Fecal smearing
787.63 Fecal urgency
PERSONAL HISTORY OF DYSPLASIA
New codes have been added to complete the personal history codes for dysplasia. In addition to the existing code for cervical dysplasia history (V13.22), you can now report:
V13.23 Personal history of vaginal dysplasia
V13.34 Personal history of vulvar dysplasia
INDEX AND INSTRUCTIONAL CHANGES
These changes take effect October 1, 2010:
- Clarification that an abnormal Pap result indicated non-atypical endometrial cells should be reported using 795.09.
- Clearly indicate whether a fistula between the uterus and another organ is congenital (752.39) or noncongenital (619.0-619.9).
- Precocious menstruation should be coded as 259.1, not as a menstrual disorder.
- The terminology in the index and tabular sections has been revised to more clearly differentiate long-term from prophylactic use of medications. This change affects only code category titles and lookup terms, not existing code numbers.
We want to hear from you! Tell us what you think.
This year, ObGyn-related additions and revisions to the International Classification of Diseases, Clinical Modification (ICD-9-CM), involve tinkering with existing codes and adding some new code categories. The latter development means that more information will be required of you to code to the highest level of specificity.
On the obstetrics side, there are now specific codes for placental status for multiple gestations and some revised terminology.
In gynecology, changes include new codes for congenital anomalies of the cervix, vagina, and uterus; reporting an expanded list of a history of dysplasia; and reporting the insertion and removal of an intrauterine device for contraception.
In addition, new codes have been established for fecal incontinence and for reporting a body mass index >40.
Last, changes to the alphabetical index of codes have been put in place that will help you select the most appropriate code.
The new and revised ICD-9-CM codes were added to the national code set on October 1, 2010. As in previous years, there is no grace period for failing to use the new code set!
Changes to obstetric codes
PLACENTAL/AMNIOTIC SAC SPECIFICATION FOR MULTIPLE-GESTATION PREGNANCY
Multiple-gestation pregnancies are classified as monochorionic/monoamniotic, monochorionic/diamniotic, and dichorionic/diamniotic. Until now, however, you’ve had no way to report this additional information to a payer.
For fiscal year 2011, you are able to be more specific, which can increase your ability to report medical support care for a higher-risk pregnancy or an expanded treatment plan.
Because the current category of multiple-gestation codes (651) did not allow for expansion to include this information, a new code category, V91 (multiple gestation placenta status), was created for that purpose. The V91 category has distinct codes for twin gestation, triplet gestation, quadruplet gestation, and other “unspecified” gestations to denote placental/amniotic sac status.
Be aware that use of the V91 codes is optional, and that they can be reported only as a secondary diagnosis, with a category 651.xx (multiple gestation, etc.) code as primary. As I noted, however, the new codes may provide better information to the payer—and that might result in additional reimbursement for your care of such pregnancies.
The new codes for a twin pregnancy are:
V91.00 Twin gestation, unspecified number of placentae, unspecified number of amniotic sacs
V91.01 Twin gestation, monochorionic/monoamniotic (one placenta, one amniotic sac)
V91.02 Twin gestation, monochorionic/diamniotic (one placenta, two amniotic sacs)
V91.03 Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs)
V91.09 Twin gestation, unable to determine number of placentae and number of amniotic sacs
There are similar V codes for triplet gestations (V91.10–V91.19), quadruplet gestations (V91.20–V91.29), and other unspecified multiple gestations (V91.91– V91.99).
RECURRENT PREGNANCY LOSS
The term “habitual aborter” has been replaced for 2011 with the more clinically accurate term “recurrent pregnancy loss.” This change is noted in both the ICD-9 alphabetical index and in the code definitions in the tabular section. The codes affected by this terminology change are:
629.81 Recurrent pregnancy loss without current pregnancy
646.3x Recurrent pregnancy loss (affecting the current pregnancy)
INDEX AND INSTRUCTIONAL CHANGES
These OB changes took effect on October 1, 2010:
- Periurethral trauma should be reported using 664.8x (other specified trauma to perineum and vulva), not 665.5x (other injury to pelvic organs).
- If you report puerperal sepsis (670.2x), you must report an additional code to identify severe sepsis (995.92) and any associated acute organ dysfunction, if applicable.
- If your diagnosis is superficial thrombosis (671.2x), an additional code—either 453.6, 453.71, or 453.81—should be reported to further explain the type of thrombophlebitis.
- If your patient has either asymptomatic, inactive, or a history of genital herpes that is complicating her current pregnancy, report 647.6x (other viral diseases).
- If you report pneumonia as complicating pregnancy, assign code 648.9x (other current conditions classifiable elsewhere).
Changes to gyn codes
CONGENITAL ANOMALIES OF THE UTERUS, CERVIX, AND VAGINA
Before October 1, 2010, of the seven distinct types of uterine anomalies, only a didelphus uterus (752.2, doubling of the uterus) and a diethylstilbestrol-related anomaly (760.76 [noxious influences affecting fetus or newborn via placenta or breast milk; diethylstilbestrol (DES)]) had specific codes. All other uterine anomalies were coded to “other” or “unspecified” codes that could include many different conditions.
Although vaginal and cervical anomalies may be less common, the only codes available before October 1, 2010, were ones that described an unspecified anomaly (753.40), imperforate hymen (752.42), or an embryonic cyst (752.41).
A higher level of specificity in coding, however, can make all the difference in receiving adequate reimbursement and preventing denials. For example, if you perform a Pap smear on a patient who has two cervices, a code that specifies a duplicate cervix can clearly tell the payer that billing for both is not a duplicate service or billing error.
Changes to codes in this area of care take the form of expanding existing codes. Code 752.3 (other anomalies of uterus) has been expanded to seven distinct five-digit codes to capture the seven anomalies of the uterus:
752.31 Agenesis of uterus
752.32 Hypoplasia of uterus
752.33 Unicornuate uterus (This code would be reported if the unicornuate uterus did or did not have a separate uterine horn, or if the uterus had only one functioning horn.)
752.34 Bicornuate uterus
752.35 Septate uterus (This code would be reported whether the septate was complete or partial.)
752.36 Arcuate uterus
752.39 Other anomalies of uterus (This code category includes aplasia or any other Müllerian anomaly of the uterus that is not otherwise or elsewhere classified.)
New codes have been added to the 752.4 code category (anomalies of cervix, vagina, and external female genitalia) to expand the options. Before October 1, 2010, any of these conditions would have been coded as 752.49, an “other” category.
752.43 Cervical agenesis
752.44 Cervical duplication
752.45 Vaginal agenesis (This code can also be reported for vaginal hypoplasia.)
752.46 Transverse vaginal septum
752.47 Longitudinal vaginal septum
For a patient who has a history of one of these anomalies, you would report new code V13.62, (personal history of other [corrected] congenital malformations of genitourinary system) if this history was a factor in her current care.
Inserting and removing an IUD are integral services that most ObGyn practices provide, so it is imperative that your encounter forms reflect two new codes, to avoid denials for an invalid diagnosis code. A reminder: Code V45.51 (intrauterine contraceptive device) is a status code. It indicates that a patient has an IUD in place but you should never use it as a diagnosis code when the purpose of the visit is for you to check on the device and assess how it is working.
Changes in this area are:
Before October 1, 2010:
V25.1 Insertion
V25.42 Checking, reinsertion and/or removal After October 1, 2010:
V25.11 Encounter for insertion of intrauterine contraceptive device
V25.12 Encounter for removal of intrauterine contraceptive device
V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device
V25.42 Encounter for routine checking of intrauterine contraceptive device
Regrettably, the number of patients who have a very high body mass index (BMI) is increasing. When surgery is planned, reporting this information in your coding can help establish 1) the medical need for significant additional work during the procedure or 2) health risks in support of therapy.
Code V85.4 (Body mass index 40 and over, adult) has been expanded to five new codes. They should be reported secondary to the type of obesity (i.e., codes 278.0x [overweight and obesity]).
V85.41 Body Mass Index 40.0–44.9, adult
V85.42 Body Mass Index 45.0–49.9, adult
V85.43 Body Mass Index 50.0–59.9, adult
V85.44 Body Mass Index 60.0–69.9, adult
V85.45 Body Mass Index 70 and over, adult
Fecal incontinence can present as problematic symptoms—fecal smearing, fecal urgency, incomplete defecation—but, until now, you only had one code to report any of these problems.
For that reason, 787.6 (incontinence of feces) has been expanded into four new five-digit codes. In addition, a new code has been added to report fecal impaction, which, in the past, was reported as 560.39, an “other” category code that was not specific to this problem.
New codes are:
560.32 Fecal impaction
787.60 Full incontinence of feces
787.61 Incomplete defecation
787.62 Fecal smearing
787.63 Fecal urgency
PERSONAL HISTORY OF DYSPLASIA
New codes have been added to complete the personal history codes for dysplasia. In addition to the existing code for cervical dysplasia history (V13.22), you can now report:
V13.23 Personal history of vaginal dysplasia
V13.34 Personal history of vulvar dysplasia
INDEX AND INSTRUCTIONAL CHANGES
These changes take effect October 1, 2010:
- Clarification that an abnormal Pap result indicated non-atypical endometrial cells should be reported using 795.09.
- Clearly indicate whether a fistula between the uterus and another organ is congenital (752.39) or noncongenital (619.0-619.9).
- Precocious menstruation should be coded as 259.1, not as a menstrual disorder.
- The terminology in the index and tabular sections has been revised to more clearly differentiate long-term from prophylactic use of medications. This change affects only code category titles and lookup terms, not existing code numbers.
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Accounts Receivable: Standardized Strategy
Management of accounts receivable is a significant issue in all private offices, and I've addressed it from multiple angles in previous columns.
In most cases, the patient-owed portion can be kept out of the accounts receivable in the first place. Collect as much as possible at the time of service, even if you have to offer a discount for immediate payment. When immediate payment is impossible, or you must wait for the insurance explanation of benefits, ask for a credit card number that you can keep on file and charge as soon as you know the balance due.
Sending statements should be a last resort, but they should be sent promptly, and no more than three times before you refer the account for collection.
Most difficult or awkward collection problems can be categorized, and you should have a standardized strategy for dealing with each of them. Those strategies should be assembled as a formal written policy and applied consistently each time they arise. Such a policy begins by considering possible scenarios.
Standardize as many situations as possible; for example, make a list of any situation in which you always want the patient balance written off, or always want the balance sent to a collection agency without your direction, or always want to make a case-by-case decision.
Be as specific as possible. What do you want done, for example, when a patient is deceased? Do you want to bill the family or estate, or write off the balance as a bad debt, or some combination of the two? My office has a “sliding scale” based on the size of the balance due, ranging from writing off the smallest balances to deciding the fate of the largest on a case-by-case basis. The occasional very large balance might merit referral to a specialized company for a probate search, or other identification of accessible funds.
What about a patient who claims to have been laid off from work and does not pay a balance or discontinues payments? Options include referring the account to your collection agency, writing off the balance, or negotiating payment of a reduced balance.
If a patient has no insurance and requests a discount at, or prior to, the time of service, decide if you want to give one, and if so, how much and under which circumstances. My basic no-insurance discount is 40% if payment is made at the time of the visit. Those who can't pay immediately are offered 25% off if they pay within 30 days of service, 10% if within 60 days. Cases of particular hardship are worked out on an individual basis. We have a similar policy for patients who have insurance that my office does not accept.
For inpatient services, when the hospital has discounted or written off the patient balance and the patient requests a discount, we match the discount granted by the hospital. For small balances that remain unpaid after reasonable efforts have been made to collect from the patient, we write off balances of less than $25.00 and refer the rest for collection.
Delinquent accounts, after collection efforts have been exhausted without success, are usually unsalvageable; but, occasionally, patients will attempt to negotiate a settlement, once they realize the damage done to their credit rating. I am less generous with discounts under such circumstances, of course, but I usually take 5% off if the balance is paid in full within 10 days, and 10% if paid by credit card immediately, by phone. We require them to complete a standard “hardship form” to apply for a larger discount.
Nobody collects every balance owed. This is the reality in any business, especially a medical one. The main objective is to do everything possible to minimize uncollected accounts. Develop a system that works, and be disciplined about implementing it.
Management of accounts receivable is a significant issue in all private offices, and I've addressed it from multiple angles in previous columns.
In most cases, the patient-owed portion can be kept out of the accounts receivable in the first place. Collect as much as possible at the time of service, even if you have to offer a discount for immediate payment. When immediate payment is impossible, or you must wait for the insurance explanation of benefits, ask for a credit card number that you can keep on file and charge as soon as you know the balance due.
Sending statements should be a last resort, but they should be sent promptly, and no more than three times before you refer the account for collection.
Most difficult or awkward collection problems can be categorized, and you should have a standardized strategy for dealing with each of them. Those strategies should be assembled as a formal written policy and applied consistently each time they arise. Such a policy begins by considering possible scenarios.
Standardize as many situations as possible; for example, make a list of any situation in which you always want the patient balance written off, or always want the balance sent to a collection agency without your direction, or always want to make a case-by-case decision.
Be as specific as possible. What do you want done, for example, when a patient is deceased? Do you want to bill the family or estate, or write off the balance as a bad debt, or some combination of the two? My office has a “sliding scale” based on the size of the balance due, ranging from writing off the smallest balances to deciding the fate of the largest on a case-by-case basis. The occasional very large balance might merit referral to a specialized company for a probate search, or other identification of accessible funds.
What about a patient who claims to have been laid off from work and does not pay a balance or discontinues payments? Options include referring the account to your collection agency, writing off the balance, or negotiating payment of a reduced balance.
If a patient has no insurance and requests a discount at, or prior to, the time of service, decide if you want to give one, and if so, how much and under which circumstances. My basic no-insurance discount is 40% if payment is made at the time of the visit. Those who can't pay immediately are offered 25% off if they pay within 30 days of service, 10% if within 60 days. Cases of particular hardship are worked out on an individual basis. We have a similar policy for patients who have insurance that my office does not accept.
For inpatient services, when the hospital has discounted or written off the patient balance and the patient requests a discount, we match the discount granted by the hospital. For small balances that remain unpaid after reasonable efforts have been made to collect from the patient, we write off balances of less than $25.00 and refer the rest for collection.
Delinquent accounts, after collection efforts have been exhausted without success, are usually unsalvageable; but, occasionally, patients will attempt to negotiate a settlement, once they realize the damage done to their credit rating. I am less generous with discounts under such circumstances, of course, but I usually take 5% off if the balance is paid in full within 10 days, and 10% if paid by credit card immediately, by phone. We require them to complete a standard “hardship form” to apply for a larger discount.
Nobody collects every balance owed. This is the reality in any business, especially a medical one. The main objective is to do everything possible to minimize uncollected accounts. Develop a system that works, and be disciplined about implementing it.
Management of accounts receivable is a significant issue in all private offices, and I've addressed it from multiple angles in previous columns.
In most cases, the patient-owed portion can be kept out of the accounts receivable in the first place. Collect as much as possible at the time of service, even if you have to offer a discount for immediate payment. When immediate payment is impossible, or you must wait for the insurance explanation of benefits, ask for a credit card number that you can keep on file and charge as soon as you know the balance due.
Sending statements should be a last resort, but they should be sent promptly, and no more than three times before you refer the account for collection.
Most difficult or awkward collection problems can be categorized, and you should have a standardized strategy for dealing with each of them. Those strategies should be assembled as a formal written policy and applied consistently each time they arise. Such a policy begins by considering possible scenarios.
Standardize as many situations as possible; for example, make a list of any situation in which you always want the patient balance written off, or always want the balance sent to a collection agency without your direction, or always want to make a case-by-case decision.
Be as specific as possible. What do you want done, for example, when a patient is deceased? Do you want to bill the family or estate, or write off the balance as a bad debt, or some combination of the two? My office has a “sliding scale” based on the size of the balance due, ranging from writing off the smallest balances to deciding the fate of the largest on a case-by-case basis. The occasional very large balance might merit referral to a specialized company for a probate search, or other identification of accessible funds.
What about a patient who claims to have been laid off from work and does not pay a balance or discontinues payments? Options include referring the account to your collection agency, writing off the balance, or negotiating payment of a reduced balance.
If a patient has no insurance and requests a discount at, or prior to, the time of service, decide if you want to give one, and if so, how much and under which circumstances. My basic no-insurance discount is 40% if payment is made at the time of the visit. Those who can't pay immediately are offered 25% off if they pay within 30 days of service, 10% if within 60 days. Cases of particular hardship are worked out on an individual basis. We have a similar policy for patients who have insurance that my office does not accept.
For inpatient services, when the hospital has discounted or written off the patient balance and the patient requests a discount, we match the discount granted by the hospital. For small balances that remain unpaid after reasonable efforts have been made to collect from the patient, we write off balances of less than $25.00 and refer the rest for collection.
Delinquent accounts, after collection efforts have been exhausted without success, are usually unsalvageable; but, occasionally, patients will attempt to negotiate a settlement, once they realize the damage done to their credit rating. I am less generous with discounts under such circumstances, of course, but I usually take 5% off if the balance is paid in full within 10 days, and 10% if paid by credit card immediately, by phone. We require them to complete a standard “hardship form” to apply for a larger discount.
Nobody collects every balance owed. This is the reality in any business, especially a medical one. The main objective is to do everything possible to minimize uncollected accounts. Develop a system that works, and be disciplined about implementing it.
Accounts Receivable
Management of accounts receivable is a significant issue in all private offices, and I’ve addressed it from multiple angles in previous columns.
In most cases, the patient-owed portion can be kept out of the accounts receivable in the first place. Collect as much as possible at the time of service, even if you have to offer a discount for immediate payment. When immediate payment is impossible, or you must wait for the insurance explanation of benefits, ask for a credit card number that you can keep on file and charge as soon as you know the balance due.
Sending statements should be a last resort, but they should be sent promptly, and no more than three times before you refer the account for collection.
All of these points, and others, were covered in detail in several previous columns, which you can find by clicking on Managing Your Dermatology Practice at the Skin & Allergy News Web site.
Most difficult or awkward collection problems can be categorized, and you should have a standardized strategy or process for dealing with each of them. Those strategies should be assembled as a formal written policy and applied consistently each time they arise. Such a policy begins by considering possible scenarios.
Try to standardize as many situations as possible; for example, make a list of any situation in which you always want the patient balance written off, or always want the balance sent to a collection agency without your direction, or always want to make a case-by-case decision.
Be as specific as possible. What do you want done, for example, when a patient is deceased? Do you want to bill the family or estate, or write off the balance as a bad debt, or some combination of the two? My office has a “sliding scale” based on the size of the balance due, ranging from writing off the smallest balances to deciding the fate of the largest on a case-by-case basis. The occasional very large balance might merit referral to a specialized company for a probate search, or other identification of accessible funds.
What about a patient who claims to have been laid off from his or her job and does not pay a balance or discontinues payments? Options include referring the account to your collection agency, writing off the balance, or negotiating payment of a reduced balance.
If a patient has no insurance and requests a discount at, or prior to, the time of service, you will need to decide if you want to give one, and if so, how much and under which circumstances. As an example, my basic no-insurance discount is 40% if payment is made at the time of the visit. Those who can’t pay immediately are offered 25% off if they pay within 30 days of service, 10% if within 60 days. Cases of particular hardship are worked out on an individual basis.
We have a similar policy for patients who have insurance that my office does not accept. In many states, such discounts must be indiscriminant, as I discussed in a previous column, although most statutes permit exceptions in situations of financial hardship.
For inpatient services, when the hospital has discounted or written off the patient balance and the patient requests a discount, our standard policy is to match the discount granted by the hospital.
For small balances that remain unpaid after reasonable efforts have been made to collect from the patient, my standard policy is to write off balances of less than $25.00 and refer the rest for collection.
Delinquent accounts, after collection efforts have been exhausted without success, are usually unsalvageable; but, occasionally, patients will attempt to negotiate a settlement, once they realize the damage done to their credit rating by a delinquency. I am less generous with discounts under such circumstances, of course, but I usually take 5% off if the balance is paid in full within 10 days, and 10% if paid by credit card immediately, over the phone. We require them to complete a standard “hardship form” in order to apply for a larger discount.
Keep in mind that nobody collects every balance owed. This is the reality in any business, especially a medical one. The main objective here is to do everything possible to minimize uncollected accounts. The keys are to develop a system that works, and to be disciplined about implementing it.
Management of accounts receivable is a significant issue in all private offices, and I’ve addressed it from multiple angles in previous columns.
In most cases, the patient-owed portion can be kept out of the accounts receivable in the first place. Collect as much as possible at the time of service, even if you have to offer a discount for immediate payment. When immediate payment is impossible, or you must wait for the insurance explanation of benefits, ask for a credit card number that you can keep on file and charge as soon as you know the balance due.
Sending statements should be a last resort, but they should be sent promptly, and no more than three times before you refer the account for collection.
All of these points, and others, were covered in detail in several previous columns, which you can find by clicking on Managing Your Dermatology Practice at the Skin & Allergy News Web site.
Most difficult or awkward collection problems can be categorized, and you should have a standardized strategy or process for dealing with each of them. Those strategies should be assembled as a formal written policy and applied consistently each time they arise. Such a policy begins by considering possible scenarios.
Try to standardize as many situations as possible; for example, make a list of any situation in which you always want the patient balance written off, or always want the balance sent to a collection agency without your direction, or always want to make a case-by-case decision.
Be as specific as possible. What do you want done, for example, when a patient is deceased? Do you want to bill the family or estate, or write off the balance as a bad debt, or some combination of the two? My office has a “sliding scale” based on the size of the balance due, ranging from writing off the smallest balances to deciding the fate of the largest on a case-by-case basis. The occasional very large balance might merit referral to a specialized company for a probate search, or other identification of accessible funds.
What about a patient who claims to have been laid off from his or her job and does not pay a balance or discontinues payments? Options include referring the account to your collection agency, writing off the balance, or negotiating payment of a reduced balance.
If a patient has no insurance and requests a discount at, or prior to, the time of service, you will need to decide if you want to give one, and if so, how much and under which circumstances. As an example, my basic no-insurance discount is 40% if payment is made at the time of the visit. Those who can’t pay immediately are offered 25% off if they pay within 30 days of service, 10% if within 60 days. Cases of particular hardship are worked out on an individual basis.
We have a similar policy for patients who have insurance that my office does not accept. In many states, such discounts must be indiscriminant, as I discussed in a previous column, although most statutes permit exceptions in situations of financial hardship.
For inpatient services, when the hospital has discounted or written off the patient balance and the patient requests a discount, our standard policy is to match the discount granted by the hospital.
For small balances that remain unpaid after reasonable efforts have been made to collect from the patient, my standard policy is to write off balances of less than $25.00 and refer the rest for collection.
Delinquent accounts, after collection efforts have been exhausted without success, are usually unsalvageable; but, occasionally, patients will attempt to negotiate a settlement, once they realize the damage done to their credit rating by a delinquency. I am less generous with discounts under such circumstances, of course, but I usually take 5% off if the balance is paid in full within 10 days, and 10% if paid by credit card immediately, over the phone. We require them to complete a standard “hardship form” in order to apply for a larger discount.
Keep in mind that nobody collects every balance owed. This is the reality in any business, especially a medical one. The main objective here is to do everything possible to minimize uncollected accounts. The keys are to develop a system that works, and to be disciplined about implementing it.
Management of accounts receivable is a significant issue in all private offices, and I’ve addressed it from multiple angles in previous columns.
In most cases, the patient-owed portion can be kept out of the accounts receivable in the first place. Collect as much as possible at the time of service, even if you have to offer a discount for immediate payment. When immediate payment is impossible, or you must wait for the insurance explanation of benefits, ask for a credit card number that you can keep on file and charge as soon as you know the balance due.
Sending statements should be a last resort, but they should be sent promptly, and no more than three times before you refer the account for collection.
All of these points, and others, were covered in detail in several previous columns, which you can find by clicking on Managing Your Dermatology Practice at the Skin & Allergy News Web site.
Most difficult or awkward collection problems can be categorized, and you should have a standardized strategy or process for dealing with each of them. Those strategies should be assembled as a formal written policy and applied consistently each time they arise. Such a policy begins by considering possible scenarios.
Try to standardize as many situations as possible; for example, make a list of any situation in which you always want the patient balance written off, or always want the balance sent to a collection agency without your direction, or always want to make a case-by-case decision.
Be as specific as possible. What do you want done, for example, when a patient is deceased? Do you want to bill the family or estate, or write off the balance as a bad debt, or some combination of the two? My office has a “sliding scale” based on the size of the balance due, ranging from writing off the smallest balances to deciding the fate of the largest on a case-by-case basis. The occasional very large balance might merit referral to a specialized company for a probate search, or other identification of accessible funds.
What about a patient who claims to have been laid off from his or her job and does not pay a balance or discontinues payments? Options include referring the account to your collection agency, writing off the balance, or negotiating payment of a reduced balance.
If a patient has no insurance and requests a discount at, or prior to, the time of service, you will need to decide if you want to give one, and if so, how much and under which circumstances. As an example, my basic no-insurance discount is 40% if payment is made at the time of the visit. Those who can’t pay immediately are offered 25% off if they pay within 30 days of service, 10% if within 60 days. Cases of particular hardship are worked out on an individual basis.
We have a similar policy for patients who have insurance that my office does not accept. In many states, such discounts must be indiscriminant, as I discussed in a previous column, although most statutes permit exceptions in situations of financial hardship.
For inpatient services, when the hospital has discounted or written off the patient balance and the patient requests a discount, our standard policy is to match the discount granted by the hospital.
For small balances that remain unpaid after reasonable efforts have been made to collect from the patient, my standard policy is to write off balances of less than $25.00 and refer the rest for collection.
Delinquent accounts, after collection efforts have been exhausted without success, are usually unsalvageable; but, occasionally, patients will attempt to negotiate a settlement, once they realize the damage done to their credit rating by a delinquency. I am less generous with discounts under such circumstances, of course, but I usually take 5% off if the balance is paid in full within 10 days, and 10% if paid by credit card immediately, over the phone. We require them to complete a standard “hardship form” in order to apply for a larger discount.
Keep in mind that nobody collects every balance owed. This is the reality in any business, especially a medical one. The main objective here is to do everything possible to minimize uncollected accounts. The keys are to develop a system that works, and to be disciplined about implementing it.
ONLINE EXCLUSIVE: Early-Career Hospitalists Spark Growth in On-Site Night Coverage
They have grown up in an era of reality television and hyperbolic politics. They prefer news alerts and fantasy football on their handhelds to daily newspapers and leather-bound novels. They text, they text, they text.
The generation known as millennials—those who were born in the years 1982 to 1995—is a breed unto itself. Millennials have grown up in the information age, are adept with new technologies, and have been trained under the umbrella of duty-hour guidelines that protect both the patient and the physician.
So when you hire a millennial for your hospitalist group, you’d better be clear about your expectations. “Millennials are looking for jobs that provide flexibility—time with family, time with friends, time to do other things,” says Troy Ahlstrom, MD, FHM, CFO of Traverse City-based Hospitalists of Northern Michigan and a member of SHM’s Practice Analysis committee. “There is nothing wrong with that, except that the baby boomers look at millennials and say, ‘Gosh, you slugs don’t want to work.’ ”
Dr. Ahlstrom says the influx of millennials into HM in recent years has had a significant impact on group administration—namely, an increase in use of 24/7 on-site coverage. The State of Hospital Medicine: 2010 Report Based on 2009 Data shows 68% of hospitalist groups provide on-site coverage at night. SHM’s 2007-2008 survey data showed only 53% of HM groups provided on-site coverage at night; the 2005-2006 figure was 51%. (Although the 2010 report includes a small percentage of truly academic hospitalist groups and, therefore, probably pushes the on-site coverage a little higher than in past years, Dr. Ahlstrom says he expects the trend toward on-site coverage at night to continue in the near future.)
“Baby boomers are perfectly fine with the idea of working more. They grew up working those horrifically long shifts, 36 hours straight,” Dr. Ahlstrom says. “The millennials would rather have clearly defined shifts, with nocturnists around to work the nights. Or maybe they get to be the nocturnist and work the nights. That’s the trend with younger physicians: They are more interested in seeing that split, where the days and nights are clearly set off.”
Then again, not all physicians, young or old, are against the idea of working long hours. And plenty of well-seasoned physicians are more than happy to have a nocturnist around, “but not if it’s going to cost them a lot of money or productivity,” Dr. Ahlstrom says.
They have grown up in an era of reality television and hyperbolic politics. They prefer news alerts and fantasy football on their handhelds to daily newspapers and leather-bound novels. They text, they text, they text.
The generation known as millennials—those who were born in the years 1982 to 1995—is a breed unto itself. Millennials have grown up in the information age, are adept with new technologies, and have been trained under the umbrella of duty-hour guidelines that protect both the patient and the physician.
So when you hire a millennial for your hospitalist group, you’d better be clear about your expectations. “Millennials are looking for jobs that provide flexibility—time with family, time with friends, time to do other things,” says Troy Ahlstrom, MD, FHM, CFO of Traverse City-based Hospitalists of Northern Michigan and a member of SHM’s Practice Analysis committee. “There is nothing wrong with that, except that the baby boomers look at millennials and say, ‘Gosh, you slugs don’t want to work.’ ”
Dr. Ahlstrom says the influx of millennials into HM in recent years has had a significant impact on group administration—namely, an increase in use of 24/7 on-site coverage. The State of Hospital Medicine: 2010 Report Based on 2009 Data shows 68% of hospitalist groups provide on-site coverage at night. SHM’s 2007-2008 survey data showed only 53% of HM groups provided on-site coverage at night; the 2005-2006 figure was 51%. (Although the 2010 report includes a small percentage of truly academic hospitalist groups and, therefore, probably pushes the on-site coverage a little higher than in past years, Dr. Ahlstrom says he expects the trend toward on-site coverage at night to continue in the near future.)
“Baby boomers are perfectly fine with the idea of working more. They grew up working those horrifically long shifts, 36 hours straight,” Dr. Ahlstrom says. “The millennials would rather have clearly defined shifts, with nocturnists around to work the nights. Or maybe they get to be the nocturnist and work the nights. That’s the trend with younger physicians: They are more interested in seeing that split, where the days and nights are clearly set off.”
Then again, not all physicians, young or old, are against the idea of working long hours. And plenty of well-seasoned physicians are more than happy to have a nocturnist around, “but not if it’s going to cost them a lot of money or productivity,” Dr. Ahlstrom says.
They have grown up in an era of reality television and hyperbolic politics. They prefer news alerts and fantasy football on their handhelds to daily newspapers and leather-bound novels. They text, they text, they text.
The generation known as millennials—those who were born in the years 1982 to 1995—is a breed unto itself. Millennials have grown up in the information age, are adept with new technologies, and have been trained under the umbrella of duty-hour guidelines that protect both the patient and the physician.
So when you hire a millennial for your hospitalist group, you’d better be clear about your expectations. “Millennials are looking for jobs that provide flexibility—time with family, time with friends, time to do other things,” says Troy Ahlstrom, MD, FHM, CFO of Traverse City-based Hospitalists of Northern Michigan and a member of SHM’s Practice Analysis committee. “There is nothing wrong with that, except that the baby boomers look at millennials and say, ‘Gosh, you slugs don’t want to work.’ ”
Dr. Ahlstrom says the influx of millennials into HM in recent years has had a significant impact on group administration—namely, an increase in use of 24/7 on-site coverage. The State of Hospital Medicine: 2010 Report Based on 2009 Data shows 68% of hospitalist groups provide on-site coverage at night. SHM’s 2007-2008 survey data showed only 53% of HM groups provided on-site coverage at night; the 2005-2006 figure was 51%. (Although the 2010 report includes a small percentage of truly academic hospitalist groups and, therefore, probably pushes the on-site coverage a little higher than in past years, Dr. Ahlstrom says he expects the trend toward on-site coverage at night to continue in the near future.)
“Baby boomers are perfectly fine with the idea of working more. They grew up working those horrifically long shifts, 36 hours straight,” Dr. Ahlstrom says. “The millennials would rather have clearly defined shifts, with nocturnists around to work the nights. Or maybe they get to be the nocturnist and work the nights. That’s the trend with younger physicians: They are more interested in seeing that split, where the days and nights are clearly set off.”
Then again, not all physicians, young or old, are against the idea of working long hours. And plenty of well-seasoned physicians are more than happy to have a nocturnist around, “but not if it’s going to cost them a lot of money or productivity,” Dr. Ahlstrom says.
ONLINE EXCLUSIVE: Audio interview with MGMA systems analyst David Litzau
MGMA analyst David Litzau discusses the new compensation and productivity report, and gives advice on how best to use benchmarking data in your practice
MGMA analyst David Litzau discusses the new compensation and productivity report, and gives advice on how best to use benchmarking data in your practice
MGMA analyst David Litzau discusses the new compensation and productivity report, and gives advice on how best to use benchmarking data in your practice
Back to Basics
Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.
A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:
- Does the patient’s condition warrant more than one physician? and
- Are the services provided by each physician reasonable and necessary?1
When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).
When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.
Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.
Reasons for Denial
Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:
- Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
- Services by one physician duplicate or overlap those of another provider without recognizable distinction.2
For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.
Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.
Group Practice
Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.
The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.
Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.
References
- Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.
Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.
A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:
- Does the patient’s condition warrant more than one physician? and
- Are the services provided by each physician reasonable and necessary?1
When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).
When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.
Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.
Reasons for Denial
Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:
- Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
- Services by one physician duplicate or overlap those of another provider without recognizable distinction.2
For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.
Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.
Group Practice
Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.
The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.
Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.
References
- Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.
Let’s examine a documentation case for hospitalists providing daily care: A 65-year-old male patient is admitted with a left hip fracture. The patient also has hypertension and Type 2 diabetes, which might complicate his care. The orthopedic surgeon manages the patient’s perioperative course for the fracture while the hospitalist provides daily post-op care for hypertension and diabetes.
A common scenario is the hospitalist will provide concurrent care, along with a varying number of specialists, depending on the complexity of the patient’s presenting problems and existing comorbidities. Payors define concurrent care as more than one physician providing care to the same patient on the same date, or during the same hospitalization. Payors often consider two key principles before reimbursing concurrent care:
- Does the patient’s condition warrant more than one physician? and
- Are the services provided by each physician reasonable and necessary?1
When more than one medical condition exists and each physician actively treats the condition related to their expertise, each physician can demonstrate medical necessity. As in the above example, the orthopedic surgeon cares for the patient’s fracture while the hospitalist oversees diabetes and hypertension management. Claim submission follows the same logic. Report each subsequent hospital care code (99231-99233) with the corresponding diagnosis each physician primarily manages (i.e., orthopedic surgeon: 9923x with 820.8; hospitalist: 9923x with 250.00, 401.1).
When each physician assigns a different primary diagnosis code to the visit code, each is more likely to receive payment. Because each of these physicians are in different specialties and different provider groups, most payors do not require modifier 25 (separately identifiable E/M service on the same day as a procedure or other service) appended to the visit code. However, some managed-care payors require each physician to append modifier 25 to the concurrent E/M visit code (i.e., 99232-25) despite claim submission under different tax identification numbers.
Unfortunately, the physicians might not realize this until a claim rejection has been issued. Furthermore, payors might want to see the proof before rendering payment. In other words, they pay the first claim received and deny any subsequent claim in order to confirm medical necessity of the concurrent visit. Appeal denied such claims rejections with supporting documentation that distinguishes each physician visit, if possible. This assists the payors in understanding each physician’s contribution to care.
Reasons for Denial
Concurrent care services are more easily distinguished when separate diagnoses are reported with each service. Conversely, payors are likely to deny services that are hard to differentiate. Furthermore, payors frequently deny concurrent care services for the following reasons:
- Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
- Services by one physician duplicate or overlap those of another provider without recognizable distinction.2
For example, a hospitalist might be involved in the post-op care of patients with fractures and no other identifiable chronic or acute conditions or complications. In these cases, the hospitalist’s continued involvement might constitute a facility policy (e.g., quality of care, risk reduction, etc.) rather than active clinical management. Claim submission could erroneously occur with each physician reporting 9923x for 820.8. Payors deny medically unnecessary services, or request refunds for inappropriate payments.
Hospitalists might attempt to negotiate other terms with the facility to account for the unpaid time and effort directed toward these types of cases.
Group Practice
Physicians in the same group practice with the same specialty designation must report, and are paid, as a single physician. Multiple visits to the same patient can occur on the same day by members of the same group (e.g., hospitalist A evaluates the patient in the morning, and hospitalist B reviews test results and the resulting course of treatment in the afternoon). However, only one subsequent hospital care service can be reported for the day.
The hospitalists should select the visit level representative of the combined services and submit one appropriately determined code (e.g., 99233), thereby capturing the medically necessary efforts of each physician. To complicate matters, the hospitalists must determine which name to report on the claim: the physician who provided the first encounter, or the physician who provided the most extensive or best-documented encounter.
Tracking productivity for these cases proves challenging. Some practices develop an internal accounting system and credit each physician for their medically necessary efforts (a labor-intensive task for administrators and physicians). TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.
References
- Medicare Benefit Policy Manual: Concurrent Care. Chapter 15, Section 30.E. CMS website. Available at: www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Physicians in Group Practice. Chapter 12, Section 30.6.5. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Pohlig, C. Daily care conundrums. The Hospitalist website. Available at: www.the-hospitalist.org/details/article/188735/Daily_Care_Conundrums_.html. Accessed July 9, 2010.
- Medicare Claims Processing Manual: Hospital Visits Same Day But by Different Physicians. Chapter 12, Section 30.6.9.C. CMS website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed July 9, 2010.
- Abraham M, Beebe M, Dalton J, Evans D, Glenn R. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2010:15.