Attending attestations, variability, and billing

[da8s0859q]

Was discussing something with a friend the other day.

The quick version: we all know variance in the chart (resident or midlevel sees and says one thing, attending sees and says another) can be an issue in the wrong circumstances.

I'm leaving residency in a couple months. I'll be working with residents and midlevels. From both a billing and clinical thoroughness perspective, is it acceptable to explicitly acknowledge differences that sometimes appear (wheezes heard by one person and not another; historical alternans) and refer to your own addendum as the most recent eval seeing as how conditions can change with treatment and time in the ED?

And while we're at it, anyone have any big things that have cost you / your group reimbursement besides missing too many HPI elements, improper ROS, or overlooked CCT?

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[WilcoWorld]

Totally OK to acknowledge discrepancies. If you do so, and address it in your MDM I would expect that it strengthens your chart, rather than weakening it.

 

[Janders]

Just image a lay person in a jury reading your chart (and your mid-level / residents).

Absolutely nothing wrong with variances, but preferably should be acknowledged and discussed if meaningful.

With our mid-levels, any goofy exam findings we discuss and get on the same page before charting. If they happen to chart something I don't find, I just acknowledge and explain said finding (wheezes come and go, belly tender improves or worsens, etc).

 

[Janders]

As far as billing, they don't care at all about variances.... they just care about level of chart, and the fact you saw the patient and examined them, or not...

 

[Angry Birds]

When I was a resident, I remember this one chart bounced back to me twice as "incomplete." Each time I wrote a note that "I did not see this patient because she left before being seen by either myself or the attending physician." Each time I signed the chart, the attending--who was our EM chair and otherwise a great doctor lol--immediately co-signed the chart with a standard "smart" phrase, which basically said that he saw the patient with me, agrees with my history and physical exam, plan, etc. etc. It was my smoking gun that he doesn't read any of our notes and just signs them.

 

[shookwell]

Doesn't matter for billing, but I agree so explicitly acknowledge when you are disagreeing with a mid-level if it's anything important. For example, I recently had a resident write in the chart that a patient with knee pain was "non-ambulatory" and I wrote in my chart "agree with the resident, etc. . . except that the patient was observed ambulating by me around the ED and walking outside to smoke."

If it's minor things like an incidental heart murmur on exam I just note my findings on my chart and leave it like that.

 

[emergentmd]

As a matter of practicality, do you guys really read all of the midlevel's charts? I know I don't. I read the Chief complaint and age. I will read more indepth if its an oldie with a complex complaint.

But I get 20 charts to sign daily and I would spend an extra hr reading and correcting things. Plus it would probably scare the $hit out of me.

 

[RustedFox]

As a matter of practicality, do you guys really read all of the midlevel's charts? I know I don't. I read the Chief complaint and age. I will read more indepth if its an oldie with a complex complaint.

But I get 20 charts to sign daily and I would spend an extra hr reading and correcting things. Plus it would probably scare the $hit out of me.

Dude, I read EVERY FREAKING CHART.

You're in Teh-has, so your liability environment is way better; but I just posted that I have to chase down patients on an almost daily basis because of some of these MLPs.

They may have been taught how to evaluate things correctly; but they sure as $hit don't know how to document to support their work.

MDM? Forget it. I have to include x-ray results for them, EKG results for them, basic-assh things.

Be warned, amigo.

 

[emergentmd]

Dude, I read EVERY FREAKING CHART.

You're in Teh-has, so your liability environment is way better; but I just posted that I have to chase down patients on an almost daily basis because of some of these MLPs.

They may have been taught how to evaluate things correctly; but they sure as $hit don't know how to document to support their work.

MDM? Forget it. I have to include x-ray results for them, EKG results for them, basic-assh things.

Be warned, amigo.

Man, I get you. I review, the CC. Review the labs. If everything looks fine, then I feel like its a go. Should I read every chart, and go through it with a fine tooth comb? Probably. But if I did, I would spend an extra hr a shift or 175 hrs a yr reviewing charts. That doesn't even include callin the pts back.

That is over a month's worth of extra unpaid work. I guess I will continue to roll the dice.

 

[gro2001]

Dude, I read EVERY FREAKING CHART.

You're in Teh-has, so your liability environment is way better; but I just posted that I have to chase down patients on an almost daily basis because of some of these MLPs.

They may have been taught how to evaluate things correctly; but they sure as $hit don't know how to document to support their work.

MDM? Forget it. I have to include x-ray results for them, EKG results for them, basic-assh things.

Be warned, amigo.

I am going to risk revealing my ignorance, but I have a question: is you having to past in XR results an artifact of a really bad EMR? Don't the radiology reads also become part of the record automatically? Or do you feel it adds something to the chart to have it in your own note? Or are you adding your own reads, independent of radiology ones? If so, what's the point?

Also, with ECGs... if it's abnormal, or if it's a chest pain complaint, I get the need to describe it in detail, but do you do this on every ECG? What about the random ECGs from triage?

 

[shookwell]

I am going to risk revealing my ignorance, but I have a question: is you having to past in XR results an artifact of a really bad EMR? Don't the radiology reads also become part of the record automatically? Or do you feel it adds something to the chart to have it in your own note? Or are you adding your own reads, independent of radiology ones? If so, what's the point?

Also, with ECGs... if it's abnormal, or if it's a chest pain complaint, I get the need to describe it in detail, but do you do this on every ECG? What about the random ECGs from triage?

I always document an ECG if I interpret it. Even if they hand me an ECG from a different area because I'm the nearest attending, I will place in the chart "ECG NSR, no ischemic changes" or whatever. If you do the work you should document it.

 

[da8s0859q]

Bumping my own thread to ask a related question.

My upcoming attending position includes productivity. I don't feel like I have a good grasp on what I should expect to see with (a) additional charts, and (b) procedures.

My group's inner workings is one thing, but for example, if department flow allows, is it more worthwhile to jump-start the process and place a central line in a critical patient whose outcome would be the same if the ICU put the line in upstairs as opposed to picking up another chart which would bill as a level 5? Little unclear about facility versus non-facility differences looking at the CMS site for CPT codes, for one.

 

[Daiphon]

Bumping my own thread to ask a related question.

My upcoming attending position includes productivity. I don't feel like I have a good grasp on what I should expect to see with (a) additional charts, and (b) procedures.

My group's inner workings is one thing, but for example, if department flow allows, is it more worthwhile to jump-start the process and place a central line in a critical patient whose outcome would be the same if the ICU put the line in upstairs as opposed to picking up another chart which would bill as a level 5? Little unclear about facility versus non-facility differences looking at the CMS site for CPT codes, for one.

IIRC, a few years back central lines were 2.5 RVU. A 99285 is closer to 4, not counting 99291 time if applicable.

Unless they *really* need it, I'd avoid. Plus, an IO works just as well & is faster to place. Plus if you place the line & they develop an infection, the ding may come down on you & your department which hurts your reimbursement.

So, I'd argue pick up the chart & forgo the line.

Feel free to correct me, though, if anyone has newer data.

Cheers!
-d

Semper Brunneis Pallium

 

[Janders]

(1) Do what is right for the patient.
(2) Do what is right for the department (i.e. move the meat if someone else can easily place the CVL upstairs, and the patient is stable without).

Generally you want to look at the wRVU to gauge how much you'll make from a procedure/patient.
https://www.acep.org/Clinical---Practice-Management/Top-20-ED-Reimbursement-Codes-2016/

The best bang for your buck as far as increasing reimbursement is not doing more procedures. It is documenting thoroughly yet efficiently so you don't get down coded but you also don't waste time writings novels on every chart. Next, I'd tell you do make sure you always document your procedures. Finally I'd tell you to learn about proper critical care coding, and be rather aggressive documenting your critical care time (most EPs under-code this by a lot...).

CVL placement is CPT code 36556 giving you about 3.5 RVU total more like 2.5 wRVU; level 5 is CPT 99825 giving about 4.9 RVU total more like 3.8 wRVU

Read through the articles on charting/billing/coding on the ACEP website.

 

[Janders]

Oh and if you want easy access to all the CPT-->RVU stuff for your curiosity...

 

[shookwell]

IIRC, a few years back central lines were 2.5 RVU. A 99285 is closer to 4, not counting 99291 time if applicable.

Unless they *really* need it, I'd avoid. Plus, an IO works just as well & is faster to place. Plus if you place the line & they develop an infection, the ding may come down on you & your department which hurts your reimbursement.

So, I'd argue pick up the chart & forgo the line.

Feel free to correct me, though, if anyone has newer data.

Cheers!
-d

Semper Brunneis Pallium

Tell a senior resident to walk a junior resident though the line . . . see 3 ankle sprains and med refills meanwhile

 

[goodoldalky]

Bumping my own thread to ask a related question.

My upcoming attending position includes productivity. I don't feel like I have a good grasp on what I should expect to see with (a) additional charts, and (b) procedures.

My group's inner workings is one thing, but for example, if department flow allows, is it more worthwhile to jump-start the process and place a central line in a critical patient whose outcome would be the same if the ICU put the line in upstairs as opposed to picking up another chart which would bill as a level 5? Little unclear about facility versus non-facility differences looking at the CMS site for CPT codes, for one.

This depends on the flow of your dept. if it is perfectly efficient and there are other patients to see right now, it probably is worth your RVU to see a patient instead.
However most departments are not like that. If you have a few admitted pts, couple rooms turning over, and your nurses can get some stuff started on the new Next two patients that come back with chest pain, then it's probably worth it to put the line in, then circle back around and then see the two cps that have their labs running etc.

It really depends on your flow and it may vary shift to shift.. Same deal w any procedure your flow will dictate the best time to do it..

 

[Daiphon]

Tell a senior resident to walk a junior resident though the line . . . see 3 ankle sprains and med refills meanwhile

Oh absolutely. This approacy won't work in non-teaching community though...

Semper Brunneis Pallium