Practice Management

The 2014 State of Hospital Medicine report (SOHM), published by SHM in the fall of even years, is unquestionably the most robust and informative data available to understand the hospitalist workforce marketplace. And if you are the person who returned a completed survey for your practice, you get a free copy of the report mailed to you.

Keep in mind that the Medical Group Management Association (MGMA) surveys and reports data on hospitalist productivity and compensation every year. And the data acquired by MGMA in even years is simply folded into the SOHM, along with a ton of additional information added by a separate SHM survey, including things like the amount of financial support provided to hospitalist groups by hospitals (now up to a median of $156, 063 per full-time equivalent, or FTE).

I’ve written previously about some of the ways that the data reported in both of these surveys can be tricky to interpret (September 2013 and October 2013), and in this column I’ll go a little deeper into how to use the data reported on number of shifts worked and productivity.

A Common Question

Assume that, to address a staffing shortage or simply as a way to boost their income, some of the doctors in your group are willing to work more shifts than required for full-time status. And, in your group, some portion of a doctor’s compensation is a function of their individual work relevant value unit (wRVU) productivity—for example, a bonus for wRVUs above a certain threshold. You want to know whether the wRVU productivity generated by a doctor on their extra shifts should factor into compensation the same way it does for “regular” shifts.

You might turn to the MGMA and SOHM surveys to see how other groups handle this issue. But here is where it gets tricky.

First, you need to realize that the MGMA surveys, and similar ones from the American Medical Group Association and others, report wRVUs and compensation per physician, not per FTE. So wRVUs generated by these doctors on extra shifts are included, and you can’t tell from the aggregate data what portion of wRVUs came from regular shifts and what portion came from extra shifts.

And it is critical to keep in mind that any doctor who works at least 0.8 FTE as defined by that particular practice is reported as full time. Those working 79% or less of full time are counted by MGMA as part time.

To summarize: The MGMA and similar surveys don’t provide data on wRVU productivity per FTE, even though in most cases that is how everyone describes the data. Instead, the surveys provide data per individual doctor, many of whom work more or less than 1.0 FTE. So, despite the fact that most people, including me, tend to quote data from the surveys as though it is per FTE, as in “The 2014 MGMA data shows median hospitalist compensation is $253,977 per FTE,” we should say “per doctor” instead.

Theoretically, doctors working slightly less than 1.0 FTE should offset the doctors working slightly more than 1.0 FTE. But, while I think that’s a reasonable assumption for most specialties, such a significant portion of hospitalist groups have had chronic staffing shortages that a lot of hospitalists across the country are working extra shifts, probably more than are working between 0.8 and 1.0 FTE. So the hospitalist survey wRVU data is probably at least a little higher than it would be if it were reported per FTE.

Unfortunately, there is no way to confirm my suspicion, because MGMA doesn’t allow any individual doctor to be reported as more than 1.0 FTE, even if he works far more shifts than the number that defines full time for that practice. In other words, extra shifts just aren’t accounted for in the MGMA survey.

Implications of Individual vs. FTE

For most purposes, it probably doesn’t make any difference if you are erroneously thinking about the compensation and productivity survey numbers on a per FTE basis. But, for some purposes, and for those who work significantly more shifts than most hospitalists, it can start to matter.

Now back to the original question. You’re thinking about whether wRVUs generated by the doctors in your group on extra shifts should count toward the wRVU bonus just like those generated on regular shifts. You’d like to handle this the same way as other groups, but, unfortunately, survey data just isn’t helpful here. You’ll have to decide this for yourself.

I think some, but probably not all, extra shift productivity should count toward your wRVU bonus. You might, for example, say that productivity for somewhere between three or five extra shifts per quarter—that’s totally arbitrary, and of course this would be a negotiation between you and hospital leadership—should count toward the productivity target, and the rest wouldn’t, or that those extra shifts above an agreed-upon number would result in an increase in the wRVU target. The biggest problem with this is that it would be a nightmare to administer—essentially impossible for many practices. But you could accomplish the same thing by including the first few shifts per quarter in the “base” FTE calculation and then, after that, adjusting each person’s FTE value up as they work more shifts.

One more thing about productivity targets…

It’s also important to remember that productivity targets make the most sense at the group—not the individual—level. The MGMA data includes hospitalists who work night shifts (including nocturnists) and doctors who work low-production shifts (i.e., pager or ED triage shifts), as well as daytime rounding doctors. So, if you have a doctor who only works days, you would expect him to generate wRVUs in excess of the global target of wRVUs per FTE to make up for the low-productivity shifts that other doctors have to work.

For example, your practice might decide the group as a whole is expected to generate the MGMA yearly median 4,298 wRVUs per doctor, multiplied by the number of FTEs in the group. But the nocturnists would be expected to generate fewer, while those who work most or all of their shifts in a daytime rounder would be expected to generate more. So the threshold to begin paying the wRVU bonus for daytime rounding doctors might be adjusted up to something like 4,500 wRVUs.

The above example is just as an illustration, of course, and there are all kinds of reasons it might be more appropriate to choose different thresholds for your practice. But it’s a good place to start the thinking.

The 2014 State of Hospital Medicine report (SOHM), published by SHM in the fall of even years, is unquestionably the most robust and informative data available to understand the hospitalist workforce marketplace. And if you are the person who returned a completed survey for your practice, you get a free copy of the report mailed to you.

Keep in mind that the Medical Group Management Association (MGMA) surveys and reports data on hospitalist productivity and compensation every year. And the data acquired by MGMA in even years is simply folded into the SOHM, along with a ton of additional information added by a separate SHM survey, including things like the amount of financial support provided to hospitalist groups by hospitals (now up to a median of $156, 063 per full-time equivalent, or FTE).

I’ve written previously about some of the ways that the data reported in both of these surveys can be tricky to interpret (September 2013 and October 2013), and in this column I’ll go a little deeper into how to use the data reported on number of shifts worked and productivity.

A Common Question

Assume that, to address a staffing shortage or simply as a way to boost their income, some of the doctors in your group are willing to work more shifts than required for full-time status. And, in your group, some portion of a doctor’s compensation is a function of their individual work relevant value unit (wRVU) productivity—for example, a bonus for wRVUs above a certain threshold. You want to know whether the wRVU productivity generated by a doctor on their extra shifts should factor into compensation the same way it does for “regular” shifts.

You might turn to the MGMA and SOHM surveys to see how other groups handle this issue. But here is where it gets tricky.

First, you need to realize that the MGMA surveys, and similar ones from the American Medical Group Association and others, report wRVUs and compensation per physician, not per FTE. So wRVUs generated by these doctors on extra shifts are included, and you can’t tell from the aggregate data what portion of wRVUs came from regular shifts and what portion came from extra shifts.

And it is critical to keep in mind that any doctor who works at least 0.8 FTE as defined by that particular practice is reported as full time. Those working 79% or less of full time are counted by MGMA as part time.

To summarize: The MGMA and similar surveys don’t provide data on wRVU productivity per FTE, even though in most cases that is how everyone describes the data. Instead, the surveys provide data per individual doctor, many of whom work more or less than 1.0 FTE. So, despite the fact that most people, including me, tend to quote data from the surveys as though it is per FTE, as in “The 2014 MGMA data shows median hospitalist compensation is $253,977 per FTE,” we should say “per doctor” instead.

Theoretically, doctors working slightly less than 1.0 FTE should offset the doctors working slightly more than 1.0 FTE. But, while I think that’s a reasonable assumption for most specialties, such a significant portion of hospitalist groups have had chronic staffing shortages that a lot of hospitalists across the country are working extra shifts, probably more than are working between 0.8 and 1.0 FTE. So the hospitalist survey wRVU data is probably at least a little higher than it would be if it were reported per FTE.

Unfortunately, there is no way to confirm my suspicion, because MGMA doesn’t allow any individual doctor to be reported as more than 1.0 FTE, even if he works far more shifts than the number that defines full time for that practice. In other words, extra shifts just aren’t accounted for in the MGMA survey.

Implications of Individual vs. FTE

For most purposes, it probably doesn’t make any difference if you are erroneously thinking about the compensation and productivity survey numbers on a per FTE basis. But, for some purposes, and for those who work significantly more shifts than most hospitalists, it can start to matter.

Now back to the original question. You’re thinking about whether wRVUs generated by the doctors in your group on extra shifts should count toward the wRVU bonus just like those generated on regular shifts. You’d like to handle this the same way as other groups, but, unfortunately, survey data just isn’t helpful here. You’ll have to decide this for yourself.

I think some, but probably not all, extra shift productivity should count toward your wRVU bonus. You might, for example, say that productivity for somewhere between three or five extra shifts per quarter—that’s totally arbitrary, and of course this would be a negotiation between you and hospital leadership—should count toward the productivity target, and the rest wouldn’t, or that those extra shifts above an agreed-upon number would result in an increase in the wRVU target. The biggest problem with this is that it would be a nightmare to administer—essentially impossible for many practices. But you could accomplish the same thing by including the first few shifts per quarter in the “base” FTE calculation and then, after that, adjusting each person’s FTE value up as they work more shifts.

One more thing about productivity targets…

It’s also important to remember that productivity targets make the most sense at the group—not the individual—level. The MGMA data includes hospitalists who work night shifts (including nocturnists) and doctors who work low-production shifts (i.e., pager or ED triage shifts), as well as daytime rounding doctors. So, if you have a doctor who only works days, you would expect him to generate wRVUs in excess of the global target of wRVUs per FTE to make up for the low-productivity shifts that other doctors have to work.

For example, your practice might decide the group as a whole is expected to generate the MGMA yearly median 4,298 wRVUs per doctor, multiplied by the number of FTEs in the group. But the nocturnists would be expected to generate fewer, while those who work most or all of their shifts in a daytime rounder would be expected to generate more. So the threshold to begin paying the wRVU bonus for daytime rounding doctors might be adjusted up to something like 4,500 wRVUs.

The above example is just as an illustration, of course, and there are all kinds of reasons it might be more appropriate to choose different thresholds for your practice. But it’s a good place to start the thinking.

The 2014 State of Hospital Medicine report (SOHM), published by SHM in the fall of even years, is unquestionably the most robust and informative data available to understand the hospitalist workforce marketplace. And if you are the person who returned a completed survey for your practice, you get a free copy of the report mailed to you.

Keep in mind that the Medical Group Management Association (MGMA) surveys and reports data on hospitalist productivity and compensation every year. And the data acquired by MGMA in even years is simply folded into the SOHM, along with a ton of additional information added by a separate SHM survey, including things like the amount of financial support provided to hospitalist groups by hospitals (now up to a median of $156, 063 per full-time equivalent, or FTE).

I’ve written previously about some of the ways that the data reported in both of these surveys can be tricky to interpret (September 2013 and October 2013), and in this column I’ll go a little deeper into how to use the data reported on number of shifts worked and productivity.

A Common Question

Assume that, to address a staffing shortage or simply as a way to boost their income, some of the doctors in your group are willing to work more shifts than required for full-time status. And, in your group, some portion of a doctor’s compensation is a function of their individual work relevant value unit (wRVU) productivity—for example, a bonus for wRVUs above a certain threshold. You want to know whether the wRVU productivity generated by a doctor on their extra shifts should factor into compensation the same way it does for “regular” shifts.

You might turn to the MGMA and SOHM surveys to see how other groups handle this issue. But here is where it gets tricky.

First, you need to realize that the MGMA surveys, and similar ones from the American Medical Group Association and others, report wRVUs and compensation per physician, not per FTE. So wRVUs generated by these doctors on extra shifts are included, and you can’t tell from the aggregate data what portion of wRVUs came from regular shifts and what portion came from extra shifts.

And it is critical to keep in mind that any doctor who works at least 0.8 FTE as defined by that particular practice is reported as full time. Those working 79% or less of full time are counted by MGMA as part time.

To summarize: The MGMA and similar surveys don’t provide data on wRVU productivity per FTE, even though in most cases that is how everyone describes the data. Instead, the surveys provide data per individual doctor, many of whom work more or less than 1.0 FTE. So, despite the fact that most people, including me, tend to quote data from the surveys as though it is per FTE, as in “The 2014 MGMA data shows median hospitalist compensation is $253,977 per FTE,” we should say “per doctor” instead.

Theoretically, doctors working slightly less than 1.0 FTE should offset the doctors working slightly more than 1.0 FTE. But, while I think that’s a reasonable assumption for most specialties, such a significant portion of hospitalist groups have had chronic staffing shortages that a lot of hospitalists across the country are working extra shifts, probably more than are working between 0.8 and 1.0 FTE. So the hospitalist survey wRVU data is probably at least a little higher than it would be if it were reported per FTE.

Unfortunately, there is no way to confirm my suspicion, because MGMA doesn’t allow any individual doctor to be reported as more than 1.0 FTE, even if he works far more shifts than the number that defines full time for that practice. In other words, extra shifts just aren’t accounted for in the MGMA survey.

Implications of Individual vs. FTE

For most purposes, it probably doesn’t make any difference if you are erroneously thinking about the compensation and productivity survey numbers on a per FTE basis. But, for some purposes, and for those who work significantly more shifts than most hospitalists, it can start to matter.

Now back to the original question. You’re thinking about whether wRVUs generated by the doctors in your group on extra shifts should count toward the wRVU bonus just like those generated on regular shifts. You’d like to handle this the same way as other groups, but, unfortunately, survey data just isn’t helpful here. You’ll have to decide this for yourself.

I think some, but probably not all, extra shift productivity should count toward your wRVU bonus. You might, for example, say that productivity for somewhere between three or five extra shifts per quarter—that’s totally arbitrary, and of course this would be a negotiation between you and hospital leadership—should count toward the productivity target, and the rest wouldn’t, or that those extra shifts above an agreed-upon number would result in an increase in the wRVU target. The biggest problem with this is that it would be a nightmare to administer—essentially impossible for many practices. But you could accomplish the same thing by including the first few shifts per quarter in the “base” FTE calculation and then, after that, adjusting each person’s FTE value up as they work more shifts.

One more thing about productivity targets…

It’s also important to remember that productivity targets make the most sense at the group—not the individual—level. The MGMA data includes hospitalists who work night shifts (including nocturnists) and doctors who work low-production shifts (i.e., pager or ED triage shifts), as well as daytime rounding doctors. So, if you have a doctor who only works days, you would expect him to generate wRVUs in excess of the global target of wRVUs per FTE to make up for the low-productivity shifts that other doctors have to work.

For example, your practice might decide the group as a whole is expected to generate the MGMA yearly median 4,298 wRVUs per doctor, multiplied by the number of FTEs in the group. But the nocturnists would be expected to generate fewer, while those who work most or all of their shifts in a daytime rounder would be expected to generate more. So the threshold to begin paying the wRVU bonus for daytime rounding doctors might be adjusted up to something like 4,500 wRVUs.

The above example is just as an illustration, of course, and there are all kinds of reasons it might be more appropriate to choose different thresholds for your practice. But it’s a good place to start the thinking.

“Now that’s a fire!”

—Eddie Murphy

This is the final column in my five-part series tracing the history of the hospitalist movement and the factors that propelled it into becoming the fastest growing medical specialty in history and the mainstay of American medicine that it has become.

In the first column, “Tinder & Spark,” economic forces of the early 1990s pushed Baby Boomer physicians into creative ways of working in the hospital; a seminal article in the most famous journal in the world then sparked a revolution. In part two, “Fuel,” Generation X physicians aligned with the values of the HM movement and joined the field in record numbers. In part three, “Oxygen,” I explained how the patient safety and quality movement propelled hospitalist growth, through both inspiration and funding, to new heights throughout the late 90s and early 2000s. And in the October 2014 issue, I continued my journey through the first 20 years of hospital medicine as a field with the fourth installment, “Heat,” a focus on the rise in importance of patient experience and the Millennial generation’s arrival in our hospitalist workforce.

That brings us to the present and back to a factor that started our rise and is becoming more important than ever, both for us as a specialty and for our success as a country.

The Affordability Crisis

We have known for a long time how expensive healthcare is. If it wasn’t for managed care trying to control costs in the 80s and 90s, hospitalists might very well not even exist. But now, it isn’t just costly. It is unaffordable for the average family.

Table 1 shows projected healthcare costs and growth curves through 2021, with a median four-person household income overlaid.

In most scenarios, the two lines, income and healthcare costs, continue to get closer and closer—with healthcare costs almost $42,000 per family by 2021 in the most aggressive projection (8% growth). I am sure many of you have heard the phrase “bending the curve.” That simply means to try and bend that red line down to something approximating the blue line. It is slowing the growth, not actually decreasing the cost.

But it’s a step.

Only at that slowest healthcare growth rate projection (3%) does household income maintain pace. At the highest projection, two-thirds of family income will go toward healthcare. It simply won’t work. Affordability must be addressed.

Hospitalists are at the center of this storm. If you look at the various factors contributing to costs, we (and our keyboards) have great control and influence over inpatient, professional services, and pharmacy costs. To our credit, and to the credit of our teammates in the hospital, we actually seem to be bending the curve down toward the 5% range in inpatient care and professional services. Nevertheless, even at that level it is outpacing income growth.

In 2013, total healthcare costs for a family of four finally caught up with college costs. It is now just north of $22,000 per year for both healthcare costs and the annual cost of attending an in-state public college. Let’s not catch the private colleges as the biggest family budget buster.

The Triple Aim

So, over the course of five articles, I have talked about how we as hospitalists have faced and learned about key aspects of delivering care in a modern healthcare system. First, it was economics, then patient safety and quality, then patient experience, and now we’re back to economics as we consider patient affordability.

Wouldn’t it be great just to focus on one thing at a time? Unfortunately, life doesn’t work that way. In today’s world, hospitalists must give the best quality care while giving a great experience to their patients, all at an affordable cost. This concept of triple focus has given rise to a new term, “Triple Aim.”

The Institute for Healthcare Improvement (IHI) developed the phrase—and the idea—in 2006. It symbolizes an understanding that all three areas of quality MUST be joined together to achieve true success for our patients. As physicians and hospitalists, we have been taught to focus on health as the cornerstone of our profession. We know about cost pressures, and we now appreciate how important patient experience is. The problem has been that we tend to bounce back and forth in addressing these, silo to silo, depending on the circumstance—JCAHO [Joint Council on Accreditation of Healthcare Organizations] visit, publication of CMS core measures, Press-Ganey scores.

Payers and public data sites already have moved away from just reporting health measures. Experience is nearly as prominent in the discussion now. Affordability measures and transparent pricing are on the verge, especially as we arrive in a world with value-based purchasing and cost bundling.

It is easy to focus on just the crisis of the moment. Today, that might very well be the affordability crisis, but it’s important to understand that when delivering healthcare to real live human beings, with all their complexities and vulnerabilities, we have to tune in to our most creative selves to come up with solutions that don’t just address individual areas of care but that also integrate and synergize.

Into the Future

So why this long, five-column preamble into our history, our grand social movement? Because our society and specialty, even with almost 20 years under our belts, are still in the early days. Our members know this and stay connected and coordinated, either in person, at our annual meeting, or virtually using HMX, to better face the many challenges today and those coming down the road. When SHM surveyed its members last year about why they had attended the annual meeting, the overwhelming response was to “be part of the hospital medicine movement.”

Our specialty started out as a group of one-offs and experiments and then coalesced into a social movement, and although it has changed directions and gathered new areas of focus, we are charging ahead. Much social, cultural, and medical change is to come. It’s why our members have told us they keep coming back—to share in this great and glorious social movement called hospital medicine.

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

“Now that’s a fire!”

—Eddie Murphy

This is the final column in my five-part series tracing the history of the hospitalist movement and the factors that propelled it into becoming the fastest growing medical specialty in history and the mainstay of American medicine that it has become.

In the first column, “Tinder & Spark,” economic forces of the early 1990s pushed Baby Boomer physicians into creative ways of working in the hospital; a seminal article in the most famous journal in the world then sparked a revolution. In part two, “Fuel,” Generation X physicians aligned with the values of the HM movement and joined the field in record numbers. In part three, “Oxygen,” I explained how the patient safety and quality movement propelled hospitalist growth, through both inspiration and funding, to new heights throughout the late 90s and early 2000s. And in the October 2014 issue, I continued my journey through the first 20 years of hospital medicine as a field with the fourth installment, “Heat,” a focus on the rise in importance of patient experience and the Millennial generation’s arrival in our hospitalist workforce.

That brings us to the present and back to a factor that started our rise and is becoming more important than ever, both for us as a specialty and for our success as a country.

The Affordability Crisis

We have known for a long time how expensive healthcare is. If it wasn’t for managed care trying to control costs in the 80s and 90s, hospitalists might very well not even exist. But now, it isn’t just costly. It is unaffordable for the average family.

Table 1 shows projected healthcare costs and growth curves through 2021, with a median four-person household income overlaid.

In most scenarios, the two lines, income and healthcare costs, continue to get closer and closer—with healthcare costs almost $42,000 per family by 2021 in the most aggressive projection (8% growth). I am sure many of you have heard the phrase “bending the curve.” That simply means to try and bend that red line down to something approximating the blue line. It is slowing the growth, not actually decreasing the cost.

But it’s a step.

Only at that slowest healthcare growth rate projection (3%) does household income maintain pace. At the highest projection, two-thirds of family income will go toward healthcare. It simply won’t work. Affordability must be addressed.

Hospitalists are at the center of this storm. If you look at the various factors contributing to costs, we (and our keyboards) have great control and influence over inpatient, professional services, and pharmacy costs. To our credit, and to the credit of our teammates in the hospital, we actually seem to be bending the curve down toward the 5% range in inpatient care and professional services. Nevertheless, even at that level it is outpacing income growth.

In 2013, total healthcare costs for a family of four finally caught up with college costs. It is now just north of $22,000 per year for both healthcare costs and the annual cost of attending an in-state public college. Let’s not catch the private colleges as the biggest family budget buster.

The Triple Aim

So, over the course of five articles, I have talked about how we as hospitalists have faced and learned about key aspects of delivering care in a modern healthcare system. First, it was economics, then patient safety and quality, then patient experience, and now we’re back to economics as we consider patient affordability.

Wouldn’t it be great just to focus on one thing at a time? Unfortunately, life doesn’t work that way. In today’s world, hospitalists must give the best quality care while giving a great experience to their patients, all at an affordable cost. This concept of triple focus has given rise to a new term, “Triple Aim.”

The Institute for Healthcare Improvement (IHI) developed the phrase—and the idea—in 2006. It symbolizes an understanding that all three areas of quality MUST be joined together to achieve true success for our patients. As physicians and hospitalists, we have been taught to focus on health as the cornerstone of our profession. We know about cost pressures, and we now appreciate how important patient experience is. The problem has been that we tend to bounce back and forth in addressing these, silo to silo, depending on the circumstance—JCAHO [Joint Council on Accreditation of Healthcare Organizations] visit, publication of CMS core measures, Press-Ganey scores.

Payers and public data sites already have moved away from just reporting health measures. Experience is nearly as prominent in the discussion now. Affordability measures and transparent pricing are on the verge, especially as we arrive in a world with value-based purchasing and cost bundling.

It is easy to focus on just the crisis of the moment. Today, that might very well be the affordability crisis, but it’s important to understand that when delivering healthcare to real live human beings, with all their complexities and vulnerabilities, we have to tune in to our most creative selves to come up with solutions that don’t just address individual areas of care but that also integrate and synergize.

Into the Future

So why this long, five-column preamble into our history, our grand social movement? Because our society and specialty, even with almost 20 years under our belts, are still in the early days. Our members know this and stay connected and coordinated, either in person, at our annual meeting, or virtually using HMX, to better face the many challenges today and those coming down the road. When SHM surveyed its members last year about why they had attended the annual meeting, the overwhelming response was to “be part of the hospital medicine movement.”

Our specialty started out as a group of one-offs and experiments and then coalesced into a social movement, and although it has changed directions and gathered new areas of focus, we are charging ahead. Much social, cultural, and medical change is to come. It’s why our members have told us they keep coming back—to share in this great and glorious social movement called hospital medicine.

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

“Now that’s a fire!”

—Eddie Murphy

This is the final column in my five-part series tracing the history of the hospitalist movement and the factors that propelled it into becoming the fastest growing medical specialty in history and the mainstay of American medicine that it has become.

In the first column, “Tinder & Spark,” economic forces of the early 1990s pushed Baby Boomer physicians into creative ways of working in the hospital; a seminal article in the most famous journal in the world then sparked a revolution. In part two, “Fuel,” Generation X physicians aligned with the values of the HM movement and joined the field in record numbers. In part three, “Oxygen,” I explained how the patient safety and quality movement propelled hospitalist growth, through both inspiration and funding, to new heights throughout the late 90s and early 2000s. And in the October 2014 issue, I continued my journey through the first 20 years of hospital medicine as a field with the fourth installment, “Heat,” a focus on the rise in importance of patient experience and the Millennial generation’s arrival in our hospitalist workforce.

That brings us to the present and back to a factor that started our rise and is becoming more important than ever, both for us as a specialty and for our success as a country.

The Affordability Crisis

We have known for a long time how expensive healthcare is. If it wasn’t for managed care trying to control costs in the 80s and 90s, hospitalists might very well not even exist. But now, it isn’t just costly. It is unaffordable for the average family.

Table 1 shows projected healthcare costs and growth curves through 2021, with a median four-person household income overlaid.

In most scenarios, the two lines, income and healthcare costs, continue to get closer and closer—with healthcare costs almost $42,000 per family by 2021 in the most aggressive projection (8% growth). I am sure many of you have heard the phrase “bending the curve.” That simply means to try and bend that red line down to something approximating the blue line. It is slowing the growth, not actually decreasing the cost.

But it’s a step.

Only at that slowest healthcare growth rate projection (3%) does household income maintain pace. At the highest projection, two-thirds of family income will go toward healthcare. It simply won’t work. Affordability must be addressed.

Hospitalists are at the center of this storm. If you look at the various factors contributing to costs, we (and our keyboards) have great control and influence over inpatient, professional services, and pharmacy costs. To our credit, and to the credit of our teammates in the hospital, we actually seem to be bending the curve down toward the 5% range in inpatient care and professional services. Nevertheless, even at that level it is outpacing income growth.

In 2013, total healthcare costs for a family of four finally caught up with college costs. It is now just north of $22,000 per year for both healthcare costs and the annual cost of attending an in-state public college. Let’s not catch the private colleges as the biggest family budget buster.

The Triple Aim

So, over the course of five articles, I have talked about how we as hospitalists have faced and learned about key aspects of delivering care in a modern healthcare system. First, it was economics, then patient safety and quality, then patient experience, and now we’re back to economics as we consider patient affordability.

Wouldn’t it be great just to focus on one thing at a time? Unfortunately, life doesn’t work that way. In today’s world, hospitalists must give the best quality care while giving a great experience to their patients, all at an affordable cost. This concept of triple focus has given rise to a new term, “Triple Aim.”

The Institute for Healthcare Improvement (IHI) developed the phrase—and the idea—in 2006. It symbolizes an understanding that all three areas of quality MUST be joined together to achieve true success for our patients. As physicians and hospitalists, we have been taught to focus on health as the cornerstone of our profession. We know about cost pressures, and we now appreciate how important patient experience is. The problem has been that we tend to bounce back and forth in addressing these, silo to silo, depending on the circumstance—JCAHO [Joint Council on Accreditation of Healthcare Organizations] visit, publication of CMS core measures, Press-Ganey scores.

Payers and public data sites already have moved away from just reporting health measures. Experience is nearly as prominent in the discussion now. Affordability measures and transparent pricing are on the verge, especially as we arrive in a world with value-based purchasing and cost bundling.

It is easy to focus on just the crisis of the moment. Today, that might very well be the affordability crisis, but it’s important to understand that when delivering healthcare to real live human beings, with all their complexities and vulnerabilities, we have to tune in to our most creative selves to come up with solutions that don’t just address individual areas of care but that also integrate and synergize.

Into the Future

So why this long, five-column preamble into our history, our grand social movement? Because our society and specialty, even with almost 20 years under our belts, are still in the early days. Our members know this and stay connected and coordinated, either in person, at our annual meeting, or virtually using HMX, to better face the many challenges today and those coming down the road. When SHM surveyed its members last year about why they had attended the annual meeting, the overwhelming response was to “be part of the hospital medicine movement.”

Our specialty started out as a group of one-offs and experiments and then coalesced into a social movement, and although it has changed directions and gathered new areas of focus, we are charging ahead. Much social, cultural, and medical change is to come. It’s why our members have told us they keep coming back—to share in this great and glorious social movement called hospital medicine.

Dr. Kealey is SHM president and medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn.

This

The focus for emergency physicians, says Dr. Heinrich,  is triage and disposition. Differing incentives for hospitalists and emergency physicians can cause stress between the groups, and dialogue is needed to defray the tension, he notes. Dr. Epstein says he thinks that collaboration can be an effective tactic against becoming a “30 day readmission rule” statistic. Shared metrics, developed in partnership, can also improve patient care, he adds.

For more features, visit The Hospitalist's podcast archive.

This

The focus for emergency physicians, says Dr. Heinrich,  is triage and disposition. Differing incentives for hospitalists and emergency physicians can cause stress between the groups, and dialogue is needed to defray the tension, he notes. Dr. Epstein says he thinks that collaboration can be an effective tactic against becoming a “30 day readmission rule” statistic. Shared metrics, developed in partnership, can also improve patient care, he adds.

For more features, visit The Hospitalist's podcast archive.

This

The focus for emergency physicians, says Dr. Heinrich,  is triage and disposition. Differing incentives for hospitalists and emergency physicians can cause stress between the groups, and dialogue is needed to defray the tension, he notes. Dr. Epstein says he thinks that collaboration can be an effective tactic against becoming a “30 day readmission rule” statistic. Shared metrics, developed in partnership, can also improve patient care, he adds.

For more features, visit The Hospitalist's podcast archive.

Dr. Wachter closed SHM's 2013 annual meeting in National Harbor, MD, with a keynote address that identified cost and waste reduction as new planks of hospitalist's value proposition.

Dr. Wachter closed SHM's 2013 annual meeting in National Harbor, MD, with a keynote address that identified cost and waste reduction as new planks of hospitalist's value proposition.

Dr. Wachter closed SHM's 2013 annual meeting in National Harbor, MD, with a keynote address that identified cost and waste reduction as new planks of hospitalist's value proposition.

Why is it that there are no focused looks into the ED? We all know, as hospitalists, that the ED locks us into many admissions. Yet I see no initiatives through the Centers for Medicare and Medicaid Services (CMS) going after the ED for wanting patients admitted rather than trying to get these patients sent home for outpatient therapy.

–Ray Nowaczyk, DO

Dr. Hospitalist responds:

Au contraire, my fellow hospitalist! The ED is monitored and investigated by many hospital committees and governmental agencies. Although we physicians, and I’m sure most hospitals, have always acknowledged our responsibilities to take care of patients during an emergency, this responsibility was enshrined in legalese in 1986 with the passage of the Emergency Medical Treatment and Active Labor Act (EMTALA), also known as the “antidumping law.” Since its passage, any hospital that receives Medicare or Medicaid funding, which includes almost all of them, is at risk of being fined or losing this vital source of funding if this law is violated.

EMTALA essentially states that any patient who presents to the ED must be provided a screening exam and treatment for any “emergent medical condition” (including labor), regardless of the individual’s ability to pay. The hospital is then required to provide “stabilizing” treatment for these patients or transfer them to another facility where this treatment can be provided. Furthermore, hospitals that refuse to accept these patients in transfer without valid reasons (e.g. no open beds) can be charged with an EMTALA violation.

As you well know, what is considered stabilized or at baseline by one clinician can be seen as unstable or requiring urgent care by another. The real day-to-day practice of medicine often defies evidence-based logic and forces us to make decisions based on many clinical and nonclinical variables.

These situations are further compounded by recent CMS attempts to hold hospitals publicly accountable for ED throughput by posting these measures on its website. Along with other metrics, the citizenry can now see how long it takes an ED patient to be seen by a health professional, receive pain medication if they have a broken bone, receive appropriate treatment and be sent home, or, if admitted, how long it takes to get into a bed.

This information makes it clearer that in situations of clinical uncertainty, it may be easier for many ED physicians to admit than to discharge. The “treat-‘em or street-‘em” mentality of triaging patients, of course, varies from doc to doc and can definitely create antipathy towards physicians in the ED. As much as I may disagree with some of our ED doc’s admissions, I always—OK, maybe not always—try to assume they have the patient’s best interest at heart.

Once admitted, the onus is placed on us, as hospitalists, to determine whether the patient requires ongoing inpatient care, can be cared for in an “observation” capacity, or should be discharged. We all have received calls from a nurse informing us that the patient “does not meet inpatient criteria”—even if the patient is hypotensive with systemic inflammatory response syndrome and lactic acidosis. Oh, if we could only send them back to the ED!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Why is it that there are no focused looks into the ED? We all know, as hospitalists, that the ED locks us into many admissions. Yet I see no initiatives through the Centers for Medicare and Medicaid Services (CMS) going after the ED for wanting patients admitted rather than trying to get these patients sent home for outpatient therapy.

–Ray Nowaczyk, DO

Dr. Hospitalist responds:

Au contraire, my fellow hospitalist! The ED is monitored and investigated by many hospital committees and governmental agencies. Although we physicians, and I’m sure most hospitals, have always acknowledged our responsibilities to take care of patients during an emergency, this responsibility was enshrined in legalese in 1986 with the passage of the Emergency Medical Treatment and Active Labor Act (EMTALA), also known as the “antidumping law.” Since its passage, any hospital that receives Medicare or Medicaid funding, which includes almost all of them, is at risk of being fined or losing this vital source of funding if this law is violated.

EMTALA essentially states that any patient who presents to the ED must be provided a screening exam and treatment for any “emergent medical condition” (including labor), regardless of the individual’s ability to pay. The hospital is then required to provide “stabilizing” treatment for these patients or transfer them to another facility where this treatment can be provided. Furthermore, hospitals that refuse to accept these patients in transfer without valid reasons (e.g. no open beds) can be charged with an EMTALA violation.

As you well know, what is considered stabilized or at baseline by one clinician can be seen as unstable or requiring urgent care by another. The real day-to-day practice of medicine often defies evidence-based logic and forces us to make decisions based on many clinical and nonclinical variables.

These situations are further compounded by recent CMS attempts to hold hospitals publicly accountable for ED throughput by posting these measures on its website. Along with other metrics, the citizenry can now see how long it takes an ED patient to be seen by a health professional, receive pain medication if they have a broken bone, receive appropriate treatment and be sent home, or, if admitted, how long it takes to get into a bed.

This information makes it clearer that in situations of clinical uncertainty, it may be easier for many ED physicians to admit than to discharge. The “treat-‘em or street-‘em” mentality of triaging patients, of course, varies from doc to doc and can definitely create antipathy towards physicians in the ED. As much as I may disagree with some of our ED doc’s admissions, I always—OK, maybe not always—try to assume they have the patient’s best interest at heart.

Once admitted, the onus is placed on us, as hospitalists, to determine whether the patient requires ongoing inpatient care, can be cared for in an “observation” capacity, or should be discharged. We all have received calls from a nurse informing us that the patient “does not meet inpatient criteria”—even if the patient is hypotensive with systemic inflammatory response syndrome and lactic acidosis. Oh, if we could only send them back to the ED!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Why is it that there are no focused looks into the ED? We all know, as hospitalists, that the ED locks us into many admissions. Yet I see no initiatives through the Centers for Medicare and Medicaid Services (CMS) going after the ED for wanting patients admitted rather than trying to get these patients sent home for outpatient therapy.

–Ray Nowaczyk, DO

Dr. Hospitalist responds:

Au contraire, my fellow hospitalist! The ED is monitored and investigated by many hospital committees and governmental agencies. Although we physicians, and I’m sure most hospitals, have always acknowledged our responsibilities to take care of patients during an emergency, this responsibility was enshrined in legalese in 1986 with the passage of the Emergency Medical Treatment and Active Labor Act (EMTALA), also known as the “antidumping law.” Since its passage, any hospital that receives Medicare or Medicaid funding, which includes almost all of them, is at risk of being fined or losing this vital source of funding if this law is violated.

EMTALA essentially states that any patient who presents to the ED must be provided a screening exam and treatment for any “emergent medical condition” (including labor), regardless of the individual’s ability to pay. The hospital is then required to provide “stabilizing” treatment for these patients or transfer them to another facility where this treatment can be provided. Furthermore, hospitals that refuse to accept these patients in transfer without valid reasons (e.g. no open beds) can be charged with an EMTALA violation.

As you well know, what is considered stabilized or at baseline by one clinician can be seen as unstable or requiring urgent care by another. The real day-to-day practice of medicine often defies evidence-based logic and forces us to make decisions based on many clinical and nonclinical variables.

These situations are further compounded by recent CMS attempts to hold hospitals publicly accountable for ED throughput by posting these measures on its website. Along with other metrics, the citizenry can now see how long it takes an ED patient to be seen by a health professional, receive pain medication if they have a broken bone, receive appropriate treatment and be sent home, or, if admitted, how long it takes to get into a bed.

This information makes it clearer that in situations of clinical uncertainty, it may be easier for many ED physicians to admit than to discharge. The “treat-‘em or street-‘em” mentality of triaging patients, of course, varies from doc to doc and can definitely create antipathy towards physicians in the ED. As much as I may disagree with some of our ED doc’s admissions, I always—OK, maybe not always—try to assume they have the patient’s best interest at heart.

Once admitted, the onus is placed on us, as hospitalists, to determine whether the patient requires ongoing inpatient care, can be cared for in an “observation” capacity, or should be discharged. We all have received calls from a nurse informing us that the patient “does not meet inpatient criteria”—even if the patient is hypotensive with systemic inflammatory response syndrome and lactic acidosis. Oh, if we could only send them back to the ED!

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

I’m convinced that observation status is rapidly becoming a meaningful factor in patients’ decision to file a malpractice lawsuit.

First, let me concede that I don’t know of any hard data to support my claim. I even asked the nation’s largest malpractice insurer about this, and they didn’t have any data on it. I think that is because observation status has only become a really big issue in the last couple of years, and since it typically takes several years for a malpractice suit to conclude, it just hasn’t found its way onto their radar yet.

But I’m pretty sure that will change within the next few years.

Implications

As any seasoned practitioner in our field knows, all outpatient and inpatient physician charges for Medicare patients, along with those of other licensed practitioners, are billed through Medicare Part B. After meeting a deductible, patients with traditional fee-for-service Medicare are generally responsible for 20% of all approved Part B charges, with no upper limit. For patients seen by a large number of providers while hospitalized, this 20% can really add up. Some patients have a secondary insurance that pays for this.

Hospital charges for patients on inpatient status are billed through Medicare Part A. Patients have an annual Part A deductible, and only in the case of very long inpatient stays will they have to pay more than that for inpatient care each year.

But hospital charges for patients on observation status are billed through Part B. And because hospital charges add up so quickly, the 20% of this that the patient is responsible for can be a lot of money—thousands of dollars, even for stays of less than 24 hours. Understandably, patients are not at all happy about this.

Let’s say you’re admitted overnight on observation status and your doctor orders your usual Advair inhaler. You use it once. Most hospitals aren’t able to ensure compliance with regulations around dispensing medications for home use like a pharmacy, so they won’t let you take the inhaler home. A few weeks later you’re stunned to learn that the hospital charged $10,000 for all services provided, and you’re responsible for 20% of the allowable amount PLUS the cost of all “self administered” drugs, like inhalers, eye drops, and calcitonin nasal spray. You look over your bill to see that you’re asked to pay $350 for the inhaler you used once and couldn’t even take home with you! Many self-administered medications, including eye drops and calcitonin nasal spray, result in similarly alarming charges to patients.

On top of the unpleasant surprise of a large hospital bill, Medicare won’t pay for skilled nursing facility (SNF) care for patients who are on observation status. That is, observation is not a “qualifying” stay for beneficiaries to access their SNF benefit.

It is easy to see why patients are unhappy about observation status.

The Media Message

News media are making the public aware of the potentially high financial costs they face if placed on observation status. But, too often, they oversimplify the issue, making it seem as though the choice of observation vs. inpatient status is entirely up to the treating doctor.

Saying that this decision is entirely up to the doctor is a lot like saying it is entirely up to you to determine how fast you drive on a freeway. In a sense that is correct, because no one else is in your car to control how fast you go and, in theory, you could choose to go 100 mph or 30 mph. The only problem is that it wouldn’t be long before you’d be in trouble with the law. So you don’t have complete autonomy to choose your speed; you have to comply with the laws. The same is true for doctors choosing observation status. We must comply with regulations in choosing the status or face legal consequences like fines or accusations of fraud.

Most news stories, like this one from NBC news (www.nbcnews.com/video/nightly-news/54511352#54511352) in February, are generally accurate but leave out the important fact that hospitals and doctors have little autonomy to choose the status the patient prefers. Instead, media often simply encourage patients on observation status to argue for a change to inpatient status and “be persistent.” More and more often, patients and families are arguing with the treating doctor; in many cases, that is a hospitalist.

Complaints Surge

At the 2014 SHM annual meeting last spring in Las Vegas, I spoke with many hospitalists who said that, increasingly, they are targets of observation-status complaints. One hospitalist group recently had each doctor list his or her top three frustrations with work; difficult and stressful conversations about observation status topped the list.

Patient anger regarding observation status can turn a satisfied patient into an angry one. We all know that unhappy patients are the ones most likely to pursue malpractice lawsuits. While anger over observation status doesn’t equal medical malpractice, it can change a patient’s opinion of our care, which may in some cases result in a malpractice claim.

Solutions

Medicare is unlikely to do away with observation status, so the best way to prevent complaints is to ensure that all its implications are explained to patients and families, ideally before they’re put into the hospital (e.g., while still in the ED). I think it is best if this message is delivered by someone other than the treating doctor(s): For example, a case manager might handle the discussion. Of course, patients and families are often too overwhelmed in the ED to absorb this information, so the message may need to be repeated later.

Maybe everyone should tell observation patients, “We’re going to observe you” without using any form of the word “admission.” And having these patients stay in distinct observation units probably reduces misunderstandings and complaints compared to the common practice of mixing these patients in “regular” hospital floors housing those on inpatient status.

Unfortunately, I couldn’t find research data to support this idea.

I bet some hospitals have even more elegant and effective ways to reduce misunderstandings and complaints around observation status. I’d love to hear from you if you know of any. E-mail me at [email protected].

I’m convinced that observation status is rapidly becoming a meaningful factor in patients’ decision to file a malpractice lawsuit.

First, let me concede that I don’t know of any hard data to support my claim. I even asked the nation’s largest malpractice insurer about this, and they didn’t have any data on it. I think that is because observation status has only become a really big issue in the last couple of years, and since it typically takes several years for a malpractice suit to conclude, it just hasn’t found its way onto their radar yet.

But I’m pretty sure that will change within the next few years.

Implications

As any seasoned practitioner in our field knows, all outpatient and inpatient physician charges for Medicare patients, along with those of other licensed practitioners, are billed through Medicare Part B. After meeting a deductible, patients with traditional fee-for-service Medicare are generally responsible for 20% of all approved Part B charges, with no upper limit. For patients seen by a large number of providers while hospitalized, this 20% can really add up. Some patients have a secondary insurance that pays for this.

Hospital charges for patients on inpatient status are billed through Medicare Part A. Patients have an annual Part A deductible, and only in the case of very long inpatient stays will they have to pay more than that for inpatient care each year.

But hospital charges for patients on observation status are billed through Part B. And because hospital charges add up so quickly, the 20% of this that the patient is responsible for can be a lot of money—thousands of dollars, even for stays of less than 24 hours. Understandably, patients are not at all happy about this.

Let’s say you’re admitted overnight on observation status and your doctor orders your usual Advair inhaler. You use it once. Most hospitals aren’t able to ensure compliance with regulations around dispensing medications for home use like a pharmacy, so they won’t let you take the inhaler home. A few weeks later you’re stunned to learn that the hospital charged $10,000 for all services provided, and you’re responsible for 20% of the allowable amount PLUS the cost of all “self administered” drugs, like inhalers, eye drops, and calcitonin nasal spray. You look over your bill to see that you’re asked to pay $350 for the inhaler you used once and couldn’t even take home with you! Many self-administered medications, including eye drops and calcitonin nasal spray, result in similarly alarming charges to patients.

On top of the unpleasant surprise of a large hospital bill, Medicare won’t pay for skilled nursing facility (SNF) care for patients who are on observation status. That is, observation is not a “qualifying” stay for beneficiaries to access their SNF benefit.

It is easy to see why patients are unhappy about observation status.

The Media Message

News media are making the public aware of the potentially high financial costs they face if placed on observation status. But, too often, they oversimplify the issue, making it seem as though the choice of observation vs. inpatient status is entirely up to the treating doctor.

Saying that this decision is entirely up to the doctor is a lot like saying it is entirely up to you to determine how fast you drive on a freeway. In a sense that is correct, because no one else is in your car to control how fast you go and, in theory, you could choose to go 100 mph or 30 mph. The only problem is that it wouldn’t be long before you’d be in trouble with the law. So you don’t have complete autonomy to choose your speed; you have to comply with the laws. The same is true for doctors choosing observation status. We must comply with regulations in choosing the status or face legal consequences like fines or accusations of fraud.

Most news stories, like this one from NBC news (www.nbcnews.com/video/nightly-news/54511352#54511352) in February, are generally accurate but leave out the important fact that hospitals and doctors have little autonomy to choose the status the patient prefers. Instead, media often simply encourage patients on observation status to argue for a change to inpatient status and “be persistent.” More and more often, patients and families are arguing with the treating doctor; in many cases, that is a hospitalist.

Complaints Surge

At the 2014 SHM annual meeting last spring in Las Vegas, I spoke with many hospitalists who said that, increasingly, they are targets of observation-status complaints. One hospitalist group recently had each doctor list his or her top three frustrations with work; difficult and stressful conversations about observation status topped the list.

Patient anger regarding observation status can turn a satisfied patient into an angry one. We all know that unhappy patients are the ones most likely to pursue malpractice lawsuits. While anger over observation status doesn’t equal medical malpractice, it can change a patient’s opinion of our care, which may in some cases result in a malpractice claim.

Solutions

Medicare is unlikely to do away with observation status, so the best way to prevent complaints is to ensure that all its implications are explained to patients and families, ideally before they’re put into the hospital (e.g., while still in the ED). I think it is best if this message is delivered by someone other than the treating doctor(s): For example, a case manager might handle the discussion. Of course, patients and families are often too overwhelmed in the ED to absorb this information, so the message may need to be repeated later.

Maybe everyone should tell observation patients, “We’re going to observe you” without using any form of the word “admission.” And having these patients stay in distinct observation units probably reduces misunderstandings and complaints compared to the common practice of mixing these patients in “regular” hospital floors housing those on inpatient status.

Unfortunately, I couldn’t find research data to support this idea.

I bet some hospitals have even more elegant and effective ways to reduce misunderstandings and complaints around observation status. I’d love to hear from you if you know of any. E-mail me at [email protected].

I’m convinced that observation status is rapidly becoming a meaningful factor in patients’ decision to file a malpractice lawsuit.

First, let me concede that I don’t know of any hard data to support my claim. I even asked the nation’s largest malpractice insurer about this, and they didn’t have any data on it. I think that is because observation status has only become a really big issue in the last couple of years, and since it typically takes several years for a malpractice suit to conclude, it just hasn’t found its way onto their radar yet.

But I’m pretty sure that will change within the next few years.

Implications

As any seasoned practitioner in our field knows, all outpatient and inpatient physician charges for Medicare patients, along with those of other licensed practitioners, are billed through Medicare Part B. After meeting a deductible, patients with traditional fee-for-service Medicare are generally responsible for 20% of all approved Part B charges, with no upper limit. For patients seen by a large number of providers while hospitalized, this 20% can really add up. Some patients have a secondary insurance that pays for this.

Hospital charges for patients on inpatient status are billed through Medicare Part A. Patients have an annual Part A deductible, and only in the case of very long inpatient stays will they have to pay more than that for inpatient care each year.

But hospital charges for patients on observation status are billed through Part B. And because hospital charges add up so quickly, the 20% of this that the patient is responsible for can be a lot of money—thousands of dollars, even for stays of less than 24 hours. Understandably, patients are not at all happy about this.

Let’s say you’re admitted overnight on observation status and your doctor orders your usual Advair inhaler. You use it once. Most hospitals aren’t able to ensure compliance with regulations around dispensing medications for home use like a pharmacy, so they won’t let you take the inhaler home. A few weeks later you’re stunned to learn that the hospital charged $10,000 for all services provided, and you’re responsible for 20% of the allowable amount PLUS the cost of all “self administered” drugs, like inhalers, eye drops, and calcitonin nasal spray. You look over your bill to see that you’re asked to pay $350 for the inhaler you used once and couldn’t even take home with you! Many self-administered medications, including eye drops and calcitonin nasal spray, result in similarly alarming charges to patients.

On top of the unpleasant surprise of a large hospital bill, Medicare won’t pay for skilled nursing facility (SNF) care for patients who are on observation status. That is, observation is not a “qualifying” stay for beneficiaries to access their SNF benefit.

It is easy to see why patients are unhappy about observation status.

The Media Message

News media are making the public aware of the potentially high financial costs they face if placed on observation status. But, too often, they oversimplify the issue, making it seem as though the choice of observation vs. inpatient status is entirely up to the treating doctor.

Saying that this decision is entirely up to the doctor is a lot like saying it is entirely up to you to determine how fast you drive on a freeway. In a sense that is correct, because no one else is in your car to control how fast you go and, in theory, you could choose to go 100 mph or 30 mph. The only problem is that it wouldn’t be long before you’d be in trouble with the law. So you don’t have complete autonomy to choose your speed; you have to comply with the laws. The same is true for doctors choosing observation status. We must comply with regulations in choosing the status or face legal consequences like fines or accusations of fraud.

Most news stories, like this one from NBC news (www.nbcnews.com/video/nightly-news/54511352#54511352) in February, are generally accurate but leave out the important fact that hospitals and doctors have little autonomy to choose the status the patient prefers. Instead, media often simply encourage patients on observation status to argue for a change to inpatient status and “be persistent.” More and more often, patients and families are arguing with the treating doctor; in many cases, that is a hospitalist.

Complaints Surge

At the 2014 SHM annual meeting last spring in Las Vegas, I spoke with many hospitalists who said that, increasingly, they are targets of observation-status complaints. One hospitalist group recently had each doctor list his or her top three frustrations with work; difficult and stressful conversations about observation status topped the list.

Patient anger regarding observation status can turn a satisfied patient into an angry one. We all know that unhappy patients are the ones most likely to pursue malpractice lawsuits. While anger over observation status doesn’t equal medical malpractice, it can change a patient’s opinion of our care, which may in some cases result in a malpractice claim.

Solutions

Medicare is unlikely to do away with observation status, so the best way to prevent complaints is to ensure that all its implications are explained to patients and families, ideally before they’re put into the hospital (e.g., while still in the ED). I think it is best if this message is delivered by someone other than the treating doctor(s): For example, a case manager might handle the discussion. Of course, patients and families are often too overwhelmed in the ED to absorb this information, so the message may need to be repeated later.

Maybe everyone should tell observation patients, “We’re going to observe you” without using any form of the word “admission.” And having these patients stay in distinct observation units probably reduces misunderstandings and complaints compared to the common practice of mixing these patients in “regular” hospital floors housing those on inpatient status.

Unfortunately, I couldn’t find research data to support this idea.

I bet some hospitals have even more elegant and effective ways to reduce misunderstandings and complaints around observation status. I’d love to hear from you if you know of any. E-mail me at [email protected].

At A Glance

Series: Hospital Medicine: Current Concepts

Title: Becoming a Consummate Clinician: What Every Student, House Officer and Hospital Practitioner Needs to Know.

Authors: Ary L. Goldberger, MD, and Zachary D. Goldberger, MD, MS, eds.

Published: 2012

Pages: 224

EDITOR’S NOTE: Second in an occasional series of reviews of the Hospital Medicine: Current Concepts series by members of Team Hospitalist.

Summary

The third installment in the Hospital Medicine: Current Concepts series, Becoming a Consummate Clinician is written in two parts. Part 1, “Medical Musts and Must-Nots,” is focused on the basics of being a clinician: gathering an appropriate history, performing an effective physical examination, and formulating differential diagnoses. This section in particular is geared toward house officers and attending physicians on teaching teams. While the audience here is primarily clinicians on a teaching service, there is good advice for those in any practice setting about avoiding common mistakes and developing clinical sagacity.

In this first section, we are given advisement on treatment of and with medications. Regardless of a clinician’s level of experience, it is worth reading this text to review and internalize these authors’ advice regarding medication pitfalls. Simply putting this advice into one’s daily practice of medicine will take any practitioner a long way toward becoming a “consummate clinician.”

Part 2, “Medical Masteries,” logically builds upon material presented in Part 1. The final section of the book addresses aspects of critical analysis of medical data and encourages engagement of critical thinking skills in all aspects of clinical decision-making. Specific topics addressed include reducing medical errors, reevaluating evidence-based medicine, deconstructing several widely cited medical aphorisms, identifying sources of cognitive errors, and transforming information into understanding.

The authors devoted the final chapter to the discussion of “What is disease?” and “What is health?” which, quite frankly, adds little value to the book.

Drs. Goldberger and Goldberger discuss what they term the “interstitial curriculum”—what is not explicitly taught but should be. Included in the “interstitial curriculum” is examination of cognitive errors and how we are more apt to make these in the era of “high-throughput” patient care. Another topic included in their “interstitial curriculum” is the paucity of attention paid to addressing uncertainty in all aspects of medicine. These topics are worth the cost of this book, even if it only helps promote awareness of these important ideas and bring the discussion to a larger audience.

Analysis

There are times in this book, particularly in the beginning, when the reader feels this text was written for the benefit of the house officer and those practitioners serving on inpatient teaching services. Continued reading, however, finds brilliant advice for clinicians in all practice settings and in all stages of their careers.

The encouragement of all readers to rethink everything we assume to be true and to seek a deeper understanding of what we “know” is priceless.

The quotes included throughout the book were both valuable and enjoyable. The authors included quotes from Plutarch to Hector Barbosa from Pirates of the Caribbean. One quote that is particularly germane to the practice of hospital medicine in this age of the Hospital Consumer Assessment of Healthcare Providers and Systems comes from Sir William Osler:

“Remember…that every patient upon whom you wait will examine you critically and form an estimate of you by the way in which you conduct yourself at the bedside. Skill and nicety in manipulation, in the simple act of feeling the pulse or in the performance of any minor operation, will do more towards establishing confidence in you than a string of diplomas, or the reputation of extensive hospital experience.”

Conversely, the computer-generated graphics added no value and were, in fact, a detractor. Hopefully, the next edition will not feature the sophomorically rendered bridge advising us to “bridge the classroom-to-clinic gap,” the flamingo, or the zigzagging line, among others.

Dr. Lindsey is chief operations officer and strategist of Synergy Surgicalists, and a member of Team Hospitalist.

At A Glance

Series: Hospital Medicine: Current Concepts

Title: Becoming a Consummate Clinician: What Every Student, House Officer and Hospital Practitioner Needs to Know.

Authors: Ary L. Goldberger, MD, and Zachary D. Goldberger, MD, MS, eds.

Published: 2012

Pages: 224

EDITOR’S NOTE: Second in an occasional series of reviews of the Hospital Medicine: Current Concepts series by members of Team Hospitalist.

Summary

The third installment in the Hospital Medicine: Current Concepts series, Becoming a Consummate Clinician is written in two parts. Part 1, “Medical Musts and Must-Nots,” is focused on the basics of being a clinician: gathering an appropriate history, performing an effective physical examination, and formulating differential diagnoses. This section in particular is geared toward house officers and attending physicians on teaching teams. While the audience here is primarily clinicians on a teaching service, there is good advice for those in any practice setting about avoiding common mistakes and developing clinical sagacity.

In this first section, we are given advisement on treatment of and with medications. Regardless of a clinician’s level of experience, it is worth reading this text to review and internalize these authors’ advice regarding medication pitfalls. Simply putting this advice into one’s daily practice of medicine will take any practitioner a long way toward becoming a “consummate clinician.”

Part 2, “Medical Masteries,” logically builds upon material presented in Part 1. The final section of the book addresses aspects of critical analysis of medical data and encourages engagement of critical thinking skills in all aspects of clinical decision-making. Specific topics addressed include reducing medical errors, reevaluating evidence-based medicine, deconstructing several widely cited medical aphorisms, identifying sources of cognitive errors, and transforming information into understanding.

The authors devoted the final chapter to the discussion of “What is disease?” and “What is health?” which, quite frankly, adds little value to the book.

Drs. Goldberger and Goldberger discuss what they term the “interstitial curriculum”—what is not explicitly taught but should be. Included in the “interstitial curriculum” is examination of cognitive errors and how we are more apt to make these in the era of “high-throughput” patient care. Another topic included in their “interstitial curriculum” is the paucity of attention paid to addressing uncertainty in all aspects of medicine. These topics are worth the cost of this book, even if it only helps promote awareness of these important ideas and bring the discussion to a larger audience.

Analysis

There are times in this book, particularly in the beginning, when the reader feels this text was written for the benefit of the house officer and those practitioners serving on inpatient teaching services. Continued reading, however, finds brilliant advice for clinicians in all practice settings and in all stages of their careers.

The encouragement of all readers to rethink everything we assume to be true and to seek a deeper understanding of what we “know” is priceless.

The quotes included throughout the book were both valuable and enjoyable. The authors included quotes from Plutarch to Hector Barbosa from Pirates of the Caribbean. One quote that is particularly germane to the practice of hospital medicine in this age of the Hospital Consumer Assessment of Healthcare Providers and Systems comes from Sir William Osler:

“Remember…that every patient upon whom you wait will examine you critically and form an estimate of you by the way in which you conduct yourself at the bedside. Skill and nicety in manipulation, in the simple act of feeling the pulse or in the performance of any minor operation, will do more towards establishing confidence in you than a string of diplomas, or the reputation of extensive hospital experience.”

Conversely, the computer-generated graphics added no value and were, in fact, a detractor. Hopefully, the next edition will not feature the sophomorically rendered bridge advising us to “bridge the classroom-to-clinic gap,” the flamingo, or the zigzagging line, among others.

Dr. Lindsey is chief operations officer and strategist of Synergy Surgicalists, and a member of Team Hospitalist.

At A Glance

Series: Hospital Medicine: Current Concepts

Title: Becoming a Consummate Clinician: What Every Student, House Officer and Hospital Practitioner Needs to Know.

Authors: Ary L. Goldberger, MD, and Zachary D. Goldberger, MD, MS, eds.

Published: 2012

Pages: 224

EDITOR’S NOTE: Second in an occasional series of reviews of the Hospital Medicine: Current Concepts series by members of Team Hospitalist.

Summary

The third installment in the Hospital Medicine: Current Concepts series, Becoming a Consummate Clinician is written in two parts. Part 1, “Medical Musts and Must-Nots,” is focused on the basics of being a clinician: gathering an appropriate history, performing an effective physical examination, and formulating differential diagnoses. This section in particular is geared toward house officers and attending physicians on teaching teams. While the audience here is primarily clinicians on a teaching service, there is good advice for those in any practice setting about avoiding common mistakes and developing clinical sagacity.

In this first section, we are given advisement on treatment of and with medications. Regardless of a clinician’s level of experience, it is worth reading this text to review and internalize these authors’ advice regarding medication pitfalls. Simply putting this advice into one’s daily practice of medicine will take any practitioner a long way toward becoming a “consummate clinician.”

Part 2, “Medical Masteries,” logically builds upon material presented in Part 1. The final section of the book addresses aspects of critical analysis of medical data and encourages engagement of critical thinking skills in all aspects of clinical decision-making. Specific topics addressed include reducing medical errors, reevaluating evidence-based medicine, deconstructing several widely cited medical aphorisms, identifying sources of cognitive errors, and transforming information into understanding.

The authors devoted the final chapter to the discussion of “What is disease?” and “What is health?” which, quite frankly, adds little value to the book.

Drs. Goldberger and Goldberger discuss what they term the “interstitial curriculum”—what is not explicitly taught but should be. Included in the “interstitial curriculum” is examination of cognitive errors and how we are more apt to make these in the era of “high-throughput” patient care. Another topic included in their “interstitial curriculum” is the paucity of attention paid to addressing uncertainty in all aspects of medicine. These topics are worth the cost of this book, even if it only helps promote awareness of these important ideas and bring the discussion to a larger audience.

Analysis

There are times in this book, particularly in the beginning, when the reader feels this text was written for the benefit of the house officer and those practitioners serving on inpatient teaching services. Continued reading, however, finds brilliant advice for clinicians in all practice settings and in all stages of their careers.

The encouragement of all readers to rethink everything we assume to be true and to seek a deeper understanding of what we “know” is priceless.

The quotes included throughout the book were both valuable and enjoyable. The authors included quotes from Plutarch to Hector Barbosa from Pirates of the Caribbean. One quote that is particularly germane to the practice of hospital medicine in this age of the Hospital Consumer Assessment of Healthcare Providers and Systems comes from Sir William Osler:

“Remember…that every patient upon whom you wait will examine you critically and form an estimate of you by the way in which you conduct yourself at the bedside. Skill and nicety in manipulation, in the simple act of feeling the pulse or in the performance of any minor operation, will do more towards establishing confidence in you than a string of diplomas, or the reputation of extensive hospital experience.”

Conversely, the computer-generated graphics added no value and were, in fact, a detractor. Hopefully, the next edition will not feature the sophomorically rendered bridge advising us to “bridge the classroom-to-clinic gap,” the flamingo, or the zigzagging line, among others.

Dr. Lindsey is chief operations officer and strategist of Synergy Surgicalists, and a member of Team Hospitalist.

If you are a physician considering employment with a hospital or private practice in which hospital medical staff privileges will be needed or you are currently employed by a hospital or private practice and have medical staff privileges, it is imperative that you understand your rights as an employee and as a member of the hospital’s medical staff, along with the interplay between those two roles.

Employment Agreement and Hospital Medical Staff Bylaws

As an employee of a hospital or private practice, you will have an employment agreement that governs the terms of your employment. In addition, if you are on the hospital’s medical staff, you will also be subject to the hospital’s medical staff bylaws, which govern the terms of your staff membership and clinical privileges.

At the onset of an employment relationship, many physicians focus on the terms of their employment agreements, often ignoring the terms of the medical staff bylaws. This could lead to unexpected surprises, usually toward the end of the employment relationship, because both documents need to be read in conjunction with each other.

Beware of conflicting terms in your employment agreement on the one hand and the medical staff bylaws on the other. Although an employment agreement may include seemingly beneficial terms, hidden language often has the effect of negating its terms by qualifying the employment agreement with language contained in the bylaws. Examples include:

—“In the event of a conflict between the terms of the Physician’s Employment Agreement and the Medical Staff Bylaws, the Medical Staff Bylaws shall control.”

—“Subject to the Medical Staff Bylaws, Physician may …”

—“Except as otherwise stated in the Medical Staff Bylaws, Physician may …”

—“Except as permitted by the Medical Staff Bylaws, Physician may not …”

Termination of Medical Staff Privileges: Impact on Employment Agreement

Whether you are employed by a hospital or a private practice, your employment is likely at risk if your hospital medical staff privileges are suspended, revoked, or restricted. Even if your medical staff privileges are later reinstated, the initial suspension may trigger termination of your employment agreement.

Therefore, it is important to understand your due process rights, outlined in the hospital’s medical staff bylaws, as to how your privileges can be suspended, revoked, or restricted, as well as the procedure the hospital must undergo to make such a decision.

Medical staff bylaws also include a procedure for due process, including fair hearings and appeal mechanisms for medical staff decisions, such as privilege suspension, revocation, and restrictions.

Termination of Employment: Impact on Medical Staff Privileges

For hospital employees and most hospital-based physicians, termination of your employment agreement, whether for cause or without cause, may be automatic grounds for termination of your staff privileges. In such a case, your due process rights under the medical staff bylaws as they relate to your staff privileges are waived, and you will not be afforded the fair hearing and appeal procedure typically available to office-based physicians on the hospital’s medical staff.

Also, your employment agreement may contractually require you to resign from the hospital’s medical staff upon termination of the employment relationship. For example:

“Physician covenants and agrees that upon termination of Physician’s employment with Employer (whether for cause or without cause), Physician will resign from the medical staff of Hospital X, thereby relinquishing any right to due process pursuant to the medical staff bylaws.”

Some employment agreements may go even further and prohibit you from re-applying for medical staff privileges at that hospital for a stated period of time. For example:

“Physician further agrees that Physician shall not re-apply for medical staff privileges at Hospital X within two (2) years following the later of the termination of Physician’s employment or the effective date of termination of such medical staff privileges at Hospital X.”

Don’t forget about the hospital’s medical staff bylaws when entertaining an employment relationship with a hospital or private practice. The hospital’s medical staff bylaws should be reviewed in conjunction with the employment agreement.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

If you are a physician considering employment with a hospital or private practice in which hospital medical staff privileges will be needed or you are currently employed by a hospital or private practice and have medical staff privileges, it is imperative that you understand your rights as an employee and as a member of the hospital’s medical staff, along with the interplay between those two roles.

Employment Agreement and Hospital Medical Staff Bylaws

As an employee of a hospital or private practice, you will have an employment agreement that governs the terms of your employment. In addition, if you are on the hospital’s medical staff, you will also be subject to the hospital’s medical staff bylaws, which govern the terms of your staff membership and clinical privileges.

At the onset of an employment relationship, many physicians focus on the terms of their employment agreements, often ignoring the terms of the medical staff bylaws. This could lead to unexpected surprises, usually toward the end of the employment relationship, because both documents need to be read in conjunction with each other.

Beware of conflicting terms in your employment agreement on the one hand and the medical staff bylaws on the other. Although an employment agreement may include seemingly beneficial terms, hidden language often has the effect of negating its terms by qualifying the employment agreement with language contained in the bylaws. Examples include:

—“In the event of a conflict between the terms of the Physician’s Employment Agreement and the Medical Staff Bylaws, the Medical Staff Bylaws shall control.”

—“Subject to the Medical Staff Bylaws, Physician may …”

—“Except as otherwise stated in the Medical Staff Bylaws, Physician may …”

—“Except as permitted by the Medical Staff Bylaws, Physician may not …”

Termination of Medical Staff Privileges: Impact on Employment Agreement

Whether you are employed by a hospital or a private practice, your employment is likely at risk if your hospital medical staff privileges are suspended, revoked, or restricted. Even if your medical staff privileges are later reinstated, the initial suspension may trigger termination of your employment agreement.

Therefore, it is important to understand your due process rights, outlined in the hospital’s medical staff bylaws, as to how your privileges can be suspended, revoked, or restricted, as well as the procedure the hospital must undergo to make such a decision.

Medical staff bylaws also include a procedure for due process, including fair hearings and appeal mechanisms for medical staff decisions, such as privilege suspension, revocation, and restrictions.

Termination of Employment: Impact on Medical Staff Privileges

For hospital employees and most hospital-based physicians, termination of your employment agreement, whether for cause or without cause, may be automatic grounds for termination of your staff privileges. In such a case, your due process rights under the medical staff bylaws as they relate to your staff privileges are waived, and you will not be afforded the fair hearing and appeal procedure typically available to office-based physicians on the hospital’s medical staff.

Also, your employment agreement may contractually require you to resign from the hospital’s medical staff upon termination of the employment relationship. For example:

“Physician covenants and agrees that upon termination of Physician’s employment with Employer (whether for cause or without cause), Physician will resign from the medical staff of Hospital X, thereby relinquishing any right to due process pursuant to the medical staff bylaws.”

Some employment agreements may go even further and prohibit you from re-applying for medical staff privileges at that hospital for a stated period of time. For example:

“Physician further agrees that Physician shall not re-apply for medical staff privileges at Hospital X within two (2) years following the later of the termination of Physician’s employment or the effective date of termination of such medical staff privileges at Hospital X.”

Don’t forget about the hospital’s medical staff bylaws when entertaining an employment relationship with a hospital or private practice. The hospital’s medical staff bylaws should be reviewed in conjunction with the employment agreement.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

If you are a physician considering employment with a hospital or private practice in which hospital medical staff privileges will be needed or you are currently employed by a hospital or private practice and have medical staff privileges, it is imperative that you understand your rights as an employee and as a member of the hospital’s medical staff, along with the interplay between those two roles.

Employment Agreement and Hospital Medical Staff Bylaws

As an employee of a hospital or private practice, you will have an employment agreement that governs the terms of your employment. In addition, if you are on the hospital’s medical staff, you will also be subject to the hospital’s medical staff bylaws, which govern the terms of your staff membership and clinical privileges.

At the onset of an employment relationship, many physicians focus on the terms of their employment agreements, often ignoring the terms of the medical staff bylaws. This could lead to unexpected surprises, usually toward the end of the employment relationship, because both documents need to be read in conjunction with each other.

Beware of conflicting terms in your employment agreement on the one hand and the medical staff bylaws on the other. Although an employment agreement may include seemingly beneficial terms, hidden language often has the effect of negating its terms by qualifying the employment agreement with language contained in the bylaws. Examples include:

—“In the event of a conflict between the terms of the Physician’s Employment Agreement and the Medical Staff Bylaws, the Medical Staff Bylaws shall control.”

—“Subject to the Medical Staff Bylaws, Physician may …”

—“Except as otherwise stated in the Medical Staff Bylaws, Physician may …”

—“Except as permitted by the Medical Staff Bylaws, Physician may not …”

Termination of Medical Staff Privileges: Impact on Employment Agreement

Whether you are employed by a hospital or a private practice, your employment is likely at risk if your hospital medical staff privileges are suspended, revoked, or restricted. Even if your medical staff privileges are later reinstated, the initial suspension may trigger termination of your employment agreement.

Therefore, it is important to understand your due process rights, outlined in the hospital’s medical staff bylaws, as to how your privileges can be suspended, revoked, or restricted, as well as the procedure the hospital must undergo to make such a decision.

Medical staff bylaws also include a procedure for due process, including fair hearings and appeal mechanisms for medical staff decisions, such as privilege suspension, revocation, and restrictions.

Termination of Employment: Impact on Medical Staff Privileges

For hospital employees and most hospital-based physicians, termination of your employment agreement, whether for cause or without cause, may be automatic grounds for termination of your staff privileges. In such a case, your due process rights under the medical staff bylaws as they relate to your staff privileges are waived, and you will not be afforded the fair hearing and appeal procedure typically available to office-based physicians on the hospital’s medical staff.

Also, your employment agreement may contractually require you to resign from the hospital’s medical staff upon termination of the employment relationship. For example:

“Physician covenants and agrees that upon termination of Physician’s employment with Employer (whether for cause or without cause), Physician will resign from the medical staff of Hospital X, thereby relinquishing any right to due process pursuant to the medical staff bylaws.”

Some employment agreements may go even further and prohibit you from re-applying for medical staff privileges at that hospital for a stated period of time. For example:

“Physician further agrees that Physician shall not re-apply for medical staff privileges at Hospital X within two (2) years following the later of the termination of Physician’s employment or the effective date of termination of such medical staff privileges at Hospital X.”

Don’t forget about the hospital’s medical staff bylaws when entertaining an employment relationship with a hospital or private practice. The hospital’s medical staff bylaws should be reviewed in conjunction with the employment agreement.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

• Continue to educate physicians on proper billing for E/M services;
• Encourage its contractors to review physicians’ billing for E/M services; and
• Review physicians who bill higher level E/M codes for appropriate action.¹

When documenting patient history, physicians must be aware of the common discrepancies that occur. Although the physician becomes familiar with the patient as he/she provides care throughout the hospitalization, the auditor must acquaint himself or herself with the patient using only the limited information provided in the progress note.

When documentation is requested by the payer for a specific service date, only the documentation from that service date is considered. Be sure that the information is adequate to support both clinical care and the reported service level.

Patient History Requirements

Chief complaint. The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).

• Incomplete CC example: “Follow-up”;
• Better CC example: “Follow-up for severe abdominal cramping.”

History of present illness. The history of present illness (HPI) describes the development or progression of the patient’s current problem(s). The traditional HPI elements recognized in the 1995 documentation guidelines are location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.^2,3

The physician must obtain and personally document the HPI. He/she also has the option to link to the HPI documented by residents (i.e., residents, fellows, interns) in compliance with the teaching physician rules or nonphysician practitioners (i.e., nurse practitioners and physician assistants) as defined by the split-shared billing rules. An auditor will not accept HPI information if the physician attempts to link to any other individual, even if that person may be qualified to obtain this (e.g. registered nurse, medical assistant) or is a student (e.g. medical students, nurse practitioner students).

Because auditors recognize both 1995 and 1997 documentation guidelines, they must also recognize the HPI differences. The 1997 HPI format promotes the status of the patient’s chronic or inactive conditions.⁴ The physician receives one credit for each chronic condition that is noted, along with documentation of what has occurred since the last physician encounter as it relates to the chronic condition (e.g. “patient has a history of chronic obstructive bronchitis without acute exacerbation in past six months”).

Physicians may utilize either style of HPI documentation, and auditors must review provider records against each set of guidelines. The final audited result reflects the highest visit level supported by either set of guidelines. For example, if physician documentation yields an “extended” HPI when 1995 guidelines are used but only a “brief” HPI (see Table 2) when 1997 guidelines are reviewed, the auditor awards the physician credit for the “extended” HPI.

• 1995 example: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
• 1997 example: “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90 overnight” (status of three chronic conditions).

Review of systems. A review of systems (ROS) is a series of questions inquiring about additional signs, symptoms, or problems currently or previously experienced by the patient as related to the CC or presenting problem. The recognized systems are constitutional; eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.^2,3

The physician may choose to document the ROS by making a notation for individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal) and occasional runny nose (ears, nose, mouth, throat).” Alternatively, the physician may inquire about all of the systems but only document the positive and pertinent negative findings related to the CC, along with an additional comment that “all other systems are negative.” Most Medicare audit contractors currently accept this method as long as all systems were reviewed.^5,6,7,8,9

Be advised that ROS information can be documented by anyone, including the patient. The physician must remember to reference ROS information that is completed by individuals other than residents or nonphysician practitioners (the physician is already required to reference the documentation of the latter individuals under the Teaching Physician Rules or Split-Shared Billing Rules).

Past, family, and social histories. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. An auditor credits the physician for a single comment correlated to each history for the PFSH. Using the term “noncontributory” (N/C) with any of the histories can result in downcoding. Many contractors do not allow this statement due to previous misunderstandings over its use.

• Incomplete PFSH example: “Patient is status-post cholecystectomy in August 2013; family history N/C; patient is former smoker” (Note: “family history N/C” is not accepted by most contractors).
• Better PFSH example: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s Esophagus; no tobacco or alcohol use.”

PFSH data can also be documented by anyone, including the patient, and the physician must reference the PFSH information in his own progress note. Re-documenting the PFSH is not necessary unless a revision is required. PFSH documentation is only required for initial care services (i.e., initial hospital care, initial observation care, consultations). It is not required for subsequent care services, unless additional pertinent information that impacts care is obtained during the hospital stay.

Common Problems to Avoid

Information cannot be obtained. Some contractors will not penalize the physician for the inability to ascertain complete historical information as long as there is evidenced documentation of an attempt to obtain the information. When the physician cannot extract historical information from the patient directly and no other source is available, the physician documents that he is “unable to obtain” the history. Additionally, the physician must provide a comment to explain why the information is unobtainable (e.g. patient confused, no caregiver present) along with the available information from the limited resources (e.g. emergency medical technicians, records from previous hospitalizations at the same facility).

Previous information referenced. When referencing items from a previous encounter, be sure to include the referenced information when documentation is requested by the payer. Per CMS guidelines, the ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by either describing any new ROS and/or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.²

Pre-op clearance and HPI deficiencies. HPI is typically not as deficient as the ROS or family history elements; however, HPI underdocumentation is mostly associated with encounters for pre-op clearance. The physician may state that “patient requires pre-op clearance for left knee repair.” In the absence of any comorbidities or acute illness, HPI documentation may be missing. The physician should remember to identify the details of the presenting problem: “Patient runs five miles daily. Knee felt unstable after running two weeks ago. Swelling and intermittent sharp pain 7/10. Patient has been taking ibuprofen daily without relief.”

Not medically necessary. Remember not to document any elements for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

Varying levels of history. E/M services are selected based on the content of the three “key” components: history, exam, and decision-making (or visit time). If counseling and/or coordination of care does not encompass >50% of the physician’s total visit time or the service is not exclusively designated as a time-based service (e.g. critical care and discharge day management), the physician’s service time is not considered.

Documentation for each of the three key components must support the reported visit level when reporting initial hospital care and consultations (for those payers who still recognize consultation codes). Subsequent hospital care (e.g. 99233) only requires supportive documentation from two key components. Medical decision-making should be one of the two supporting components in order to demonstrate the medical necessity and nature of the presenting problem; the other supporting component can be history or exam.

Each visit category (e.g. initial hospital care or subsequent hospital care) and service level (e.g. 99221-99233) identifies corresponding documentation requirements. Failure to document any essential element in a given visit level (e.g. family history required for a comprehensive history when billing for 99222 and 99223) may result in service denial or downcoding (e.g. 99221). Be aware of what an auditor expects when reviewing patient history (see Table 1).

There are four levels of history: problem-focused, expanded problem-focused, detailed, and comprehensive. An auditor determines the number of history elements documented in the progress note (see Table 2). The history level corresponds to the lowest documented element. For example, if physician documentation includes four HPI elements, eight ROS, and a comment in each of the PFSHs, the history level is equivalent to “detailed.” The history would support initial hospital care 99221 or subsequent hospital care 99233.

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

References

1. Levinson DR. Department of Health and Human Services, Office of Inspector General: Coding Trends of Medicare Evaluation and Management Services. May 2012. Available at: oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Accessed October 4, 2014.
2. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed October 4, 2014.
3. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. CPT 2013 Professional Edition (Current Procedural Terminology). Chicago: American Medical Association Press; 2012:4-10.
4. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed October 4, 2014.
5. Noridian Healthcare Solutions. Medicare Part B: Evaluation and Management Workshop Questions and Answers. Available at: www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style=part_ab_viewnews Accessed on October 4, 2014.
6. WPS Medicare Health Insurance. J5 MAC Part B: Documentation (Q&As). Available at: www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml. Accessed October 4, 2014.
7. NHIC, Corp. Building Your Medicare Knowledge: Advanced Building Blocks. Available at: www.medicarenhic.com/providers/pubs/AdvdBuildBlocks061212.pdf.
8. Palmetto GBA. Jurisdiction 11 Part B: History Component. Available at: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20B~EM%20Help%20Center~General%20Articles~History%20Component?open&Expand=1. Accessed October 4, 2014.
9. Novitas Solutions. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed October 4, 2014.

• Continue to educate physicians on proper billing for E/M services;
• Encourage its contractors to review physicians’ billing for E/M services; and
• Review physicians who bill higher level E/M codes for appropriate action.¹

When documenting patient history, physicians must be aware of the common discrepancies that occur. Although the physician becomes familiar with the patient as he/she provides care throughout the hospitalization, the auditor must acquaint himself or herself with the patient using only the limited information provided in the progress note.

When documentation is requested by the payer for a specific service date, only the documentation from that service date is considered. Be sure that the information is adequate to support both clinical care and the reported service level.

Patient History Requirements

Chief complaint. The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).

• Incomplete CC example: “Follow-up”;
• Better CC example: “Follow-up for severe abdominal cramping.”

History of present illness. The history of present illness (HPI) describes the development or progression of the patient’s current problem(s). The traditional HPI elements recognized in the 1995 documentation guidelines are location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.^2,3

The physician must obtain and personally document the HPI. He/she also has the option to link to the HPI documented by residents (i.e., residents, fellows, interns) in compliance with the teaching physician rules or nonphysician practitioners (i.e., nurse practitioners and physician assistants) as defined by the split-shared billing rules. An auditor will not accept HPI information if the physician attempts to link to any other individual, even if that person may be qualified to obtain this (e.g. registered nurse, medical assistant) or is a student (e.g. medical students, nurse practitioner students).

Because auditors recognize both 1995 and 1997 documentation guidelines, they must also recognize the HPI differences. The 1997 HPI format promotes the status of the patient’s chronic or inactive conditions.⁴ The physician receives one credit for each chronic condition that is noted, along with documentation of what has occurred since the last physician encounter as it relates to the chronic condition (e.g. “patient has a history of chronic obstructive bronchitis without acute exacerbation in past six months”).

Physicians may utilize either style of HPI documentation, and auditors must review provider records against each set of guidelines. The final audited result reflects the highest visit level supported by either set of guidelines. For example, if physician documentation yields an “extended” HPI when 1995 guidelines are used but only a “brief” HPI (see Table 2) when 1997 guidelines are reviewed, the auditor awards the physician credit for the “extended” HPI.

• 1995 example: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
• 1997 example: “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90 overnight” (status of three chronic conditions).

Review of systems. A review of systems (ROS) is a series of questions inquiring about additional signs, symptoms, or problems currently or previously experienced by the patient as related to the CC or presenting problem. The recognized systems are constitutional; eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.^2,3

The physician may choose to document the ROS by making a notation for individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal) and occasional runny nose (ears, nose, mouth, throat).” Alternatively, the physician may inquire about all of the systems but only document the positive and pertinent negative findings related to the CC, along with an additional comment that “all other systems are negative.” Most Medicare audit contractors currently accept this method as long as all systems were reviewed.^5,6,7,8,9

Be advised that ROS information can be documented by anyone, including the patient. The physician must remember to reference ROS information that is completed by individuals other than residents or nonphysician practitioners (the physician is already required to reference the documentation of the latter individuals under the Teaching Physician Rules or Split-Shared Billing Rules).

Past, family, and social histories. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. An auditor credits the physician for a single comment correlated to each history for the PFSH. Using the term “noncontributory” (N/C) with any of the histories can result in downcoding. Many contractors do not allow this statement due to previous misunderstandings over its use.

• Incomplete PFSH example: “Patient is status-post cholecystectomy in August 2013; family history N/C; patient is former smoker” (Note: “family history N/C” is not accepted by most contractors).
• Better PFSH example: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s Esophagus; no tobacco or alcohol use.”

PFSH data can also be documented by anyone, including the patient, and the physician must reference the PFSH information in his own progress note. Re-documenting the PFSH is not necessary unless a revision is required. PFSH documentation is only required for initial care services (i.e., initial hospital care, initial observation care, consultations). It is not required for subsequent care services, unless additional pertinent information that impacts care is obtained during the hospital stay.

Common Problems to Avoid

Information cannot be obtained. Some contractors will not penalize the physician for the inability to ascertain complete historical information as long as there is evidenced documentation of an attempt to obtain the information. When the physician cannot extract historical information from the patient directly and no other source is available, the physician documents that he is “unable to obtain” the history. Additionally, the physician must provide a comment to explain why the information is unobtainable (e.g. patient confused, no caregiver present) along with the available information from the limited resources (e.g. emergency medical technicians, records from previous hospitalizations at the same facility).

Previous information referenced. When referencing items from a previous encounter, be sure to include the referenced information when documentation is requested by the payer. Per CMS guidelines, the ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by either describing any new ROS and/or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.²

Pre-op clearance and HPI deficiencies. HPI is typically not as deficient as the ROS or family history elements; however, HPI underdocumentation is mostly associated with encounters for pre-op clearance. The physician may state that “patient requires pre-op clearance for left knee repair.” In the absence of any comorbidities or acute illness, HPI documentation may be missing. The physician should remember to identify the details of the presenting problem: “Patient runs five miles daily. Knee felt unstable after running two weeks ago. Swelling and intermittent sharp pain 7/10. Patient has been taking ibuprofen daily without relief.”

Not medically necessary. Remember not to document any elements for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

Varying levels of history. E/M services are selected based on the content of the three “key” components: history, exam, and decision-making (or visit time). If counseling and/or coordination of care does not encompass >50% of the physician’s total visit time or the service is not exclusively designated as a time-based service (e.g. critical care and discharge day management), the physician’s service time is not considered.

Documentation for each of the three key components must support the reported visit level when reporting initial hospital care and consultations (for those payers who still recognize consultation codes). Subsequent hospital care (e.g. 99233) only requires supportive documentation from two key components. Medical decision-making should be one of the two supporting components in order to demonstrate the medical necessity and nature of the presenting problem; the other supporting component can be history or exam.

Each visit category (e.g. initial hospital care or subsequent hospital care) and service level (e.g. 99221-99233) identifies corresponding documentation requirements. Failure to document any essential element in a given visit level (e.g. family history required for a comprehensive history when billing for 99222 and 99223) may result in service denial or downcoding (e.g. 99221). Be aware of what an auditor expects when reviewing patient history (see Table 1).

There are four levels of history: problem-focused, expanded problem-focused, detailed, and comprehensive. An auditor determines the number of history elements documented in the progress note (see Table 2). The history level corresponds to the lowest documented element. For example, if physician documentation includes four HPI elements, eight ROS, and a comment in each of the PFSHs, the history level is equivalent to “detailed.” The history would support initial hospital care 99221 or subsequent hospital care 99233.

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

References

1. Levinson DR. Department of Health and Human Services, Office of Inspector General: Coding Trends of Medicare Evaluation and Management Services. May 2012. Available at: oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Accessed October 4, 2014.
2. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed October 4, 2014.
3. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. CPT 2013 Professional Edition (Current Procedural Terminology). Chicago: American Medical Association Press; 2012:4-10.
4. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed October 4, 2014.
5. Noridian Healthcare Solutions. Medicare Part B: Evaluation and Management Workshop Questions and Answers. Available at: www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style=part_ab_viewnews Accessed on October 4, 2014.
6. WPS Medicare Health Insurance. J5 MAC Part B: Documentation (Q&As). Available at: www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml. Accessed October 4, 2014.
7. NHIC, Corp. Building Your Medicare Knowledge: Advanced Building Blocks. Available at: www.medicarenhic.com/providers/pubs/AdvdBuildBlocks061212.pdf.
8. Palmetto GBA. Jurisdiction 11 Part B: History Component. Available at: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20B~EM%20Help%20Center~General%20Articles~History%20Component?open&Expand=1. Accessed October 4, 2014.
9. Novitas Solutions. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed October 4, 2014.

• Continue to educate physicians on proper billing for E/M services;
• Encourage its contractors to review physicians’ billing for E/M services; and
• Review physicians who bill higher level E/M codes for appropriate action.¹

When documenting patient history, physicians must be aware of the common discrepancies that occur. Although the physician becomes familiar with the patient as he/she provides care throughout the hospitalization, the auditor must acquaint himself or herself with the patient using only the limited information provided in the progress note.

When documentation is requested by the payer for a specific service date, only the documentation from that service date is considered. Be sure that the information is adequate to support both clinical care and the reported service level.

Patient History Requirements

Chief complaint. The chief complaint (CC) is the reason for the visit as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).

• Incomplete CC example: “Follow-up”;
• Better CC example: “Follow-up for severe abdominal cramping.”

History of present illness. The history of present illness (HPI) describes the development or progression of the patient’s current problem(s). The traditional HPI elements recognized in the 1995 documentation guidelines are location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.^2,3

The physician must obtain and personally document the HPI. He/she also has the option to link to the HPI documented by residents (i.e., residents, fellows, interns) in compliance with the teaching physician rules or nonphysician practitioners (i.e., nurse practitioners and physician assistants) as defined by the split-shared billing rules. An auditor will not accept HPI information if the physician attempts to link to any other individual, even if that person may be qualified to obtain this (e.g. registered nurse, medical assistant) or is a student (e.g. medical students, nurse practitioner students).

Because auditors recognize both 1995 and 1997 documentation guidelines, they must also recognize the HPI differences. The 1997 HPI format promotes the status of the patient’s chronic or inactive conditions.⁴ The physician receives one credit for each chronic condition that is noted, along with documentation of what has occurred since the last physician encounter as it relates to the chronic condition (e.g. “patient has a history of chronic obstructive bronchitis without acute exacerbation in past six months”).

Physicians may utilize either style of HPI documentation, and auditors must review provider records against each set of guidelines. The final audited result reflects the highest visit level supported by either set of guidelines. For example, if physician documentation yields an “extended” HPI when 1995 guidelines are used but only a “brief” HPI (see Table 2) when 1997 guidelines are reviewed, the auditor awards the physician credit for the “extended” HPI.

• 1995 example: “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
• 1997 example: “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90 overnight” (status of three chronic conditions).

Review of systems. A review of systems (ROS) is a series of questions inquiring about additional signs, symptoms, or problems currently or previously experienced by the patient as related to the CC or presenting problem. The recognized systems are constitutional; eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.^2,3

The physician may choose to document the ROS by making a notation for individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal) and occasional runny nose (ears, nose, mouth, throat).” Alternatively, the physician may inquire about all of the systems but only document the positive and pertinent negative findings related to the CC, along with an additional comment that “all other systems are negative.” Most Medicare audit contractors currently accept this method as long as all systems were reviewed.^5,6,7,8,9

Be advised that ROS information can be documented by anyone, including the patient. The physician must remember to reference ROS information that is completed by individuals other than residents or nonphysician practitioners (the physician is already required to reference the documentation of the latter individuals under the Teaching Physician Rules or Split-Shared Billing Rules).

Past, family, and social histories. Documentation of past, family, and social histories (PFSH) involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. An auditor credits the physician for a single comment correlated to each history for the PFSH. Using the term “noncontributory” (N/C) with any of the histories can result in downcoding. Many contractors do not allow this statement due to previous misunderstandings over its use.

• Incomplete PFSH example: “Patient is status-post cholecystectomy in August 2013; family history N/C; patient is former smoker” (Note: “family history N/C” is not accepted by most contractors).
• Better PFSH example: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s Esophagus; no tobacco or alcohol use.”

PFSH data can also be documented by anyone, including the patient, and the physician must reference the PFSH information in his own progress note. Re-documenting the PFSH is not necessary unless a revision is required. PFSH documentation is only required for initial care services (i.e., initial hospital care, initial observation care, consultations). It is not required for subsequent care services, unless additional pertinent information that impacts care is obtained during the hospital stay.

Common Problems to Avoid

Information cannot be obtained. Some contractors will not penalize the physician for the inability to ascertain complete historical information as long as there is evidenced documentation of an attempt to obtain the information. When the physician cannot extract historical information from the patient directly and no other source is available, the physician documents that he is “unable to obtain” the history. Additionally, the physician must provide a comment to explain why the information is unobtainable (e.g. patient confused, no caregiver present) along with the available information from the limited resources (e.g. emergency medical technicians, records from previous hospitalizations at the same facility).

Previous information referenced. When referencing items from a previous encounter, be sure to include the referenced information when documentation is requested by the payer. Per CMS guidelines, the ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by either describing any new ROS and/or PFSH information or noting that there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.²

Pre-op clearance and HPI deficiencies. HPI is typically not as deficient as the ROS or family history elements; however, HPI underdocumentation is mostly associated with encounters for pre-op clearance. The physician may state that “patient requires pre-op clearance for left knee repair.” In the absence of any comorbidities or acute illness, HPI documentation may be missing. The physician should remember to identify the details of the presenting problem: “Patient runs five miles daily. Knee felt unstable after running two weeks ago. Swelling and intermittent sharp pain 7/10. Patient has been taking ibuprofen daily without relief.”

Not medically necessary. Remember not to document any elements for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.

Varying levels of history. E/M services are selected based on the content of the three “key” components: history, exam, and decision-making (or visit time). If counseling and/or coordination of care does not encompass >50% of the physician’s total visit time or the service is not exclusively designated as a time-based service (e.g. critical care and discharge day management), the physician’s service time is not considered.

Documentation for each of the three key components must support the reported visit level when reporting initial hospital care and consultations (for those payers who still recognize consultation codes). Subsequent hospital care (e.g. 99233) only requires supportive documentation from two key components. Medical decision-making should be one of the two supporting components in order to demonstrate the medical necessity and nature of the presenting problem; the other supporting component can be history or exam.

Each visit category (e.g. initial hospital care or subsequent hospital care) and service level (e.g. 99221-99233) identifies corresponding documentation requirements. Failure to document any essential element in a given visit level (e.g. family history required for a comprehensive history when billing for 99222 and 99223) may result in service denial or downcoding (e.g. 99221). Be aware of what an auditor expects when reviewing patient history (see Table 1).

There are four levels of history: problem-focused, expanded problem-focused, detailed, and comprehensive. An auditor determines the number of history elements documented in the progress note (see Table 2). The history level corresponds to the lowest documented element. For example, if physician documentation includes four HPI elements, eight ROS, and a comment in each of the PFSHs, the history level is equivalent to “detailed.” The history would support initial hospital care 99221 or subsequent hospital care 99233.

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

References

1. Levinson DR. Department of Health and Human Services, Office of Inspector General: Coding Trends of Medicare Evaluation and Management Services. May 2012. Available at: oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Accessed October 4, 2014.
2. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. Accessed October 4, 2014.
3. Abraham M, Ahlman J, Boudreau A, Connelly J, Levreau-Davis L. CPT 2013 Professional Edition (Current Procedural Terminology). Chicago: American Medical Association Press; 2012:4-10.
4. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation and Management Services. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf. Accessed October 4, 2014.
5. Noridian Healthcare Solutions. Medicare Part B: Evaluation and Management Workshop Questions and Answers. Available at: www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style=part_ab_viewnews Accessed on October 4, 2014.
6. WPS Medicare Health Insurance. J5 MAC Part B: Documentation (Q&As). Available at: www.wpsmedicare.com/j5macpartb/resources/provider_types/evalmngmntqa.shtml. Accessed October 4, 2014.
7. NHIC, Corp. Building Your Medicare Knowledge: Advanced Building Blocks. Available at: www.medicarenhic.com/providers/pubs/AdvdBuildBlocks061212.pdf.
8. Palmetto GBA. Jurisdiction 11 Part B: History Component. Available at: www.palmettogba.com/Palmetto/Providers.nsf/docsCat/Jurisdiction%2011%20Part%20B~EM%20Help%20Center~General%20Articles~History%20Component?open&Expand=1. Accessed October 4, 2014.
9. Novitas Solutions. Frequently Asked Questions: Evaluation and Management Services (Part B). Available at: https://www.novitas-solutions.com/faq/partb/pet/lpet-evaluation_management_services.html. Accessed October 4, 2014.

I think my team of hospitalists is probably tired of hearing my sports analogies. But as I look at the State of Hospital Medicine 2014 report (SOHM), I cannot help but see relationships to athletics.

When you think about football, you automatically contemplate the scope of a particular team and the context of the upcoming season. What are the strengths of the team—do we emphasize offense or defense or special teams? How about the variety of formations or the scheduling and strength of opponents? How about the depth of our roster—what is the talent level available? How do we compare to other teams?

How in the world does this relate to the SOHM? It gives us a chance to evaluate our own hospital medicine groups (HMGs) in the context of the other HMGs across the country. When I look at scope of services and, particularly, the data from Figure 3.1, I am struck with the breadth of the range of services in which HMGs engage. Certainly, our core identity as hospitalists includes admitting referral patients and unassigned patients, but, as of 2014, nearly 90% of hospitalist groups are also managing and co-managing surgical and medical subspecialty patients. To my eyes, the big change since 2012 is the 20% increase in the number of HMGs medically co-managing medical subspecialty patients.

There are some newcomers to our roster, as well—the palliative care and post-acute care work being done by 15% and 25% of our groups, respectively. Particularly striking is the fact that one quarter of HMGs are involved in post-acute care, follow-up clinics, nursing homes, and the like.

My take on this is that factors such as increased complexity of hospitalized patients with lean length of stay and higher acuity needs at discharge transition are driving the need for a measure of continuity and expertise post discharge that may best be provided by HMGs. The trending of the post-acute care challenges/opportunities will certainly be worth watching—sort of like a rookie player who is having a big impact.

As hospitalists may become focused on throughput (admissions discharges and transfers), the interruption to perform procedures may decrease the net value of the hospitalist to the institution.

 

—William A. Landis, MD, FHM

Not surprisingly, nighttime admissions work continues to gain traction. Nearly 60% of HMGs are performing nighttime admissions.

In my regional chapter, we recently heard a presentation on “nocturnists.” An interesting contention that caught my attention was that the nocturnist viewed herself as providing expert clinical care during off-hours—particularly at night—and that she was looking to increase the value and not just “put her finger in the dike,” so to speak, until the cavalry arrived at daybreak. As HMG responsibilities increase during the off-hours, I am thinking that my colleague is right: We are going to have to increase our depth and strength at this particular position so that we might actually become known as the “nighttime experts.” I look for this trend to continue.

Finally, I am drawn to the data on care of patients in the ICU, a number that continues to rise—almost 70% of HMGs now. Meanwhile, procedures have dipped to 33% from 53% in the last report. At first, it seemed a little bit puzzling to me that as involvement in the ICUs seemed to increase, procedures diminished. My anecdotal experience is that most of my procedures occurred on patients who had intensive care requirements. Nonetheless, many hospitalists I have talked to seem to believe that the requirement/expectation of imaging in the performance of more and more invasive procedures—now a standard of care— has increasingly driven procedures to specialized areas of the hospital such as imaging/radiology departments. There may also be a net decrease in the number of procedures performed as more noninvasive diagnostic modalities provide satisfactory information.

As hospitalists may become focused on throughput (admissions discharges and transfers), the interruption to perform procedures may decrease the net value of the hospitalist to the institution. It may make sense for others to be doing procedures. Whatever the cause, my guess is these two trends may continue.

Diving deeper into the granularity of the report will lead the reader to discover subtle differences and trends. Academics, pediatric hospitalists, and independent HMGs all have some nuances, not to mention regional variation. You will have to dig into the report yourself to explore.

Just as there is a freshness to every new sports season, there is a freshness to reviewing the information from the SOHM reports, and evaluating the scope of service is always an exciting moment.

Dr. Landis is medical director of Wellspan Hospitalists in York, Pa., and a member of SHM’s Practice Analysis Committee.

I think my team of hospitalists is probably tired of hearing my sports analogies. But as I look at the State of Hospital Medicine 2014 report (SOHM), I cannot help but see relationships to athletics.

When you think about football, you automatically contemplate the scope of a particular team and the context of the upcoming season. What are the strengths of the team—do we emphasize offense or defense or special teams? How about the variety of formations or the scheduling and strength of opponents? How about the depth of our roster—what is the talent level available? How do we compare to other teams?

How in the world does this relate to the SOHM? It gives us a chance to evaluate our own hospital medicine groups (HMGs) in the context of the other HMGs across the country. When I look at scope of services and, particularly, the data from Figure 3.1, I am struck with the breadth of the range of services in which HMGs engage. Certainly, our core identity as hospitalists includes admitting referral patients and unassigned patients, but, as of 2014, nearly 90% of hospitalist groups are also managing and co-managing surgical and medical subspecialty patients. To my eyes, the big change since 2012 is the 20% increase in the number of HMGs medically co-managing medical subspecialty patients.

There are some newcomers to our roster, as well—the palliative care and post-acute care work being done by 15% and 25% of our groups, respectively. Particularly striking is the fact that one quarter of HMGs are involved in post-acute care, follow-up clinics, nursing homes, and the like.

My take on this is that factors such as increased complexity of hospitalized patients with lean length of stay and higher acuity needs at discharge transition are driving the need for a measure of continuity and expertise post discharge that may best be provided by HMGs. The trending of the post-acute care challenges/opportunities will certainly be worth watching—sort of like a rookie player who is having a big impact.

As hospitalists may become focused on throughput (admissions discharges and transfers), the interruption to perform procedures may decrease the net value of the hospitalist to the institution.

 

—William A. Landis, MD, FHM

Not surprisingly, nighttime admissions work continues to gain traction. Nearly 60% of HMGs are performing nighttime admissions.

In my regional chapter, we recently heard a presentation on “nocturnists.” An interesting contention that caught my attention was that the nocturnist viewed herself as providing expert clinical care during off-hours—particularly at night—and that she was looking to increase the value and not just “put her finger in the dike,” so to speak, until the cavalry arrived at daybreak. As HMG responsibilities increase during the off-hours, I am thinking that my colleague is right: We are going to have to increase our depth and strength at this particular position so that we might actually become known as the “nighttime experts.” I look for this trend to continue.

Finally, I am drawn to the data on care of patients in the ICU, a number that continues to rise—almost 70% of HMGs now. Meanwhile, procedures have dipped to 33% from 53% in the last report. At first, it seemed a little bit puzzling to me that as involvement in the ICUs seemed to increase, procedures diminished. My anecdotal experience is that most of my procedures occurred on patients who had intensive care requirements. Nonetheless, many hospitalists I have talked to seem to believe that the requirement/expectation of imaging in the performance of more and more invasive procedures—now a standard of care— has increasingly driven procedures to specialized areas of the hospital such as imaging/radiology departments. There may also be a net decrease in the number of procedures performed as more noninvasive diagnostic modalities provide satisfactory information.

As hospitalists may become focused on throughput (admissions discharges and transfers), the interruption to perform procedures may decrease the net value of the hospitalist to the institution. It may make sense for others to be doing procedures. Whatever the cause, my guess is these two trends may continue.

Diving deeper into the granularity of the report will lead the reader to discover subtle differences and trends. Academics, pediatric hospitalists, and independent HMGs all have some nuances, not to mention regional variation. You will have to dig into the report yourself to explore.

Just as there is a freshness to every new sports season, there is a freshness to reviewing the information from the SOHM reports, and evaluating the scope of service is always an exciting moment.

Dr. Landis is medical director of Wellspan Hospitalists in York, Pa., and a member of SHM’s Practice Analysis Committee.

I think my team of hospitalists is probably tired of hearing my sports analogies. But as I look at the State of Hospital Medicine 2014 report (SOHM), I cannot help but see relationships to athletics.

When you think about football, you automatically contemplate the scope of a particular team and the context of the upcoming season. What are the strengths of the team—do we emphasize offense or defense or special teams? How about the variety of formations or the scheduling and strength of opponents? How about the depth of our roster—what is the talent level available? How do we compare to other teams?

How in the world does this relate to the SOHM? It gives us a chance to evaluate our own hospital medicine groups (HMGs) in the context of the other HMGs across the country. When I look at scope of services and, particularly, the data from Figure 3.1, I am struck with the breadth of the range of services in which HMGs engage. Certainly, our core identity as hospitalists includes admitting referral patients and unassigned patients, but, as of 2014, nearly 90% of hospitalist groups are also managing and co-managing surgical and medical subspecialty patients. To my eyes, the big change since 2012 is the 20% increase in the number of HMGs medically co-managing medical subspecialty patients.

There are some newcomers to our roster, as well—the palliative care and post-acute care work being done by 15% and 25% of our groups, respectively. Particularly striking is the fact that one quarter of HMGs are involved in post-acute care, follow-up clinics, nursing homes, and the like.

My take on this is that factors such as increased complexity of hospitalized patients with lean length of stay and higher acuity needs at discharge transition are driving the need for a measure of continuity and expertise post discharge that may best be provided by HMGs. The trending of the post-acute care challenges/opportunities will certainly be worth watching—sort of like a rookie player who is having a big impact.

As hospitalists may become focused on throughput (admissions discharges and transfers), the interruption to perform procedures may decrease the net value of the hospitalist to the institution.

 

—William A. Landis, MD, FHM

Not surprisingly, nighttime admissions work continues to gain traction. Nearly 60% of HMGs are performing nighttime admissions.

In my regional chapter, we recently heard a presentation on “nocturnists.” An interesting contention that caught my attention was that the nocturnist viewed herself as providing expert clinical care during off-hours—particularly at night—and that she was looking to increase the value and not just “put her finger in the dike,” so to speak, until the cavalry arrived at daybreak. As HMG responsibilities increase during the off-hours, I am thinking that my colleague is right: We are going to have to increase our depth and strength at this particular position so that we might actually become known as the “nighttime experts.” I look for this trend to continue.

Finally, I am drawn to the data on care of patients in the ICU, a number that continues to rise—almost 70% of HMGs now. Meanwhile, procedures have dipped to 33% from 53% in the last report. At first, it seemed a little bit puzzling to me that as involvement in the ICUs seemed to increase, procedures diminished. My anecdotal experience is that most of my procedures occurred on patients who had intensive care requirements. Nonetheless, many hospitalists I have talked to seem to believe that the requirement/expectation of imaging in the performance of more and more invasive procedures—now a standard of care— has increasingly driven procedures to specialized areas of the hospital such as imaging/radiology departments. There may also be a net decrease in the number of procedures performed as more noninvasive diagnostic modalities provide satisfactory information.

As hospitalists may become focused on throughput (admissions discharges and transfers), the interruption to perform procedures may decrease the net value of the hospitalist to the institution. It may make sense for others to be doing procedures. Whatever the cause, my guess is these two trends may continue.

Diving deeper into the granularity of the report will lead the reader to discover subtle differences and trends. Academics, pediatric hospitalists, and independent HMGs all have some nuances, not to mention regional variation. You will have to dig into the report yourself to explore.

Just as there is a freshness to every new sports season, there is a freshness to reviewing the information from the SOHM reports, and evaluating the scope of service is always an exciting moment.

Dr. Landis is medical director of Wellspan Hospitalists in York, Pa., and a member of SHM’s Practice Analysis Committee.