Nursing Home Geriatrics

[JSizzles]

Hi Everyone,

I started new outpatient work and am slowly building a practice. In the meantime, I picked up an opportunity doing nursing home rounds 2 days a week. I was reluctant to take on the gig, because I have little geriatric experience. The medical director just said start low go slow, but thats not very reassuring. I brainstormed some questions if anyone wants to pipe in.

What codes do you use most frequently? 99308?

what diagnosis do I use? mostly dementia behavioral disturbance?

Can I add modifiers for medicare patients? like therapy add on 90833?

Now that MMSE is off the table are you using MOCA? are you doing this on every new eval for a baseline?

What do you do use for your go to prns?

When you round and the patient is in an activity do you pull them out?

An established patient all the sudden acts up? you think maybe something medical maybe UTI
do you order CBC, urine culture? Or have the nurse call medical tell them your recommendations so they manage?

I was thinking I would stick to:
mirtazapine: helps with depressive symptoms, sleep, appetite, blood pressure etc
celexa: maybe for less acute first line less interactions less qtc
ripserdone: second line maybe .25 at night to start add an afternoon dose if necessary
seroquel: maybe 25 at night for sleep and behavioral disturbances

Insomnia: are you guys using trazadone if mirtazapine isn't enough?

Anyone ever use topical ativan? which patients? maybe for a prn?

Do you still use onlazapine, abilify, geodon?

Thanks for the help! I will be seeing around 25-30 starting Monday...

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[hamstergang]

I was reluctant to take on the gig, because I have little geriatric experience. ...I will be seeing around 25-30 starting Monday...

I'm a little concerned that you knew about this job for a while but still don't know what to do. Will the medical director be able to provide you with support?

 

[JSizzles]

Pretty quick process credentialling took 4 days. All patients are established so I’m not anticipating much difficulty. Most of the stress is just anticipatory from going to a new setting. I’ll get by.

 

[birchswing]

Nuedexta for everyone!

Just kidding.

Very seriously, just kidding. Please don't do Nuedexta for everyone.

 

[splik]

Now that MMSE is off the table are you using MOCA? are you doing this on every new eval for a baseline?

there is no reason you can't use the MMSE, the whole copyright thing is completely unenforceable and has no legal standing since 1) the questions of the MMSE are basic parts of a diagnostic interview 2) the folsteins stole it from Henderson and Gillespie's textbook of psychiatry and 3) paul mchugh (one of the authors) said many years ago that the MMSE was like "babinski's sign" and thus could not be copyrighted, which of course did not stop them selling it to PAR.

the MoCA is primarily an instrument for screening mild cognitive impairment. it is less useful than the MMSE is more established/advanced dementia.

 

[WisNeuro]

the MoCA is primarily an instrument for screening mild cognitive impairment. it is less useful than the MMSE is more established/advanced dementia.

I can gather some info for you, but this is not quite correct. The MoCA is much more sensitive in many areas, both for more subcortical/vascular etiologies, as well as AD for detecting change. It's much better at detecting change from other variables (UTI, medication, etc). So, as a screening instrument, according to recent norms and data, I would say far superior. Either way, these are both merely screening instruments, and both pale in comparison to a comprehensive evaluation. Although, depending on the tier of the NH, may not be necessary when individuals reach a certain point on screening instruments if stable.

 

[zolof]

Pretty quick process credentialling took 4 days. All patients are established so I’m not anticipating much difficulty. Most of the stress is just anticipatory from going to a new setting. I’ll get by.

how did credentialing take so little time? are you already on a medicare panel in the facility? who is doing your billing, ?

 

[SpinDktr]

If you are seeing that many people, I'd be careful about billing for therapy services. In addition, you have to justify doing therapy in cognitively impaired individuals. You can do it, and there is good reason to, but you a) need time, and b) need to document it pretty extensively, which might be difficult with very brief appointments.

I do not do nursing home visits, but here is a snippet from a recent visit where I billed for therapy: I also do additional documentation for time start/stop and type of therapy used.

Since the last appointment, there has been a significant stressor. His wife passed away a week ago Tuesday. July 11th will have a service for her. He says it was a blessing; she was slowly forgetting more and more over the last few years and was eating and drinking less, to the point she had stopped. She was placed on hospice care for about a week. She was calm with the medications she was on. The last day was a quiet one. Discussed the process of grieving and death.

He says he wouldn't mind if he "cached out" bevore the service in July. He denies any acute intent or plan to end his life, but says he could go "the same way" as his wife (he means with morphine). However, he does not have access to this medication, and he has no other plans.

He says he is taking it "a day at a time". He wonders about the afterlife and thinks he would not be in the same condition he is in here; believes it will be better. Allowed him time to process these thoughts today.

Good luck; I see a lot of people pretending to be geriatric psychiatrists out there who are anything but.

 

[st2205]

If you are seeing that many people, I'd be careful about billing for therapy services. In addition, you have to justify doing therapy in cognitively impaired individuals. You can do it, and there is good reason to, but you a) need time, and b) need to document it pretty extensively, which might be difficult with very brief appointments.

I do not do nursing home visits, but here is a snippet from a recent visit where I billed for therapy: I also do additional documentation for time start/stop and type of therapy used.

Since the last appointment, there has been a significant stressor. His wife passed away a week ago Tuesday. July 11th will have a service for her. He says it was a blessing; she was slowly forgetting more and more over the last few years and was eating and drinking less, to the point she had stopped. She was placed on hospice care for about a week. She was calm with the medications she was on. The last day was a quiet one. Discussed the process of grieving and death.

He says he wouldn't mind if he "cached out" bevore the service in July. He denies any acute intent or plan to end his life, but says he could go "the same way" as his wife (he means with morphine). However, he does not have access to this medication, and he has no other plans.

He says he is taking it "a day at a time". He wonders about the afterlife and thinks he would not be in the same condition he is in here; believes it will be better. Allowed him time to process these thoughts today.

Good luck; I see a lot of people pretending to be geriatric psychiatrists out there who are anything but.

It’s fine you did that, but I don’t think that’s a good example as it’s way too much.

 

[JSizzles]

how did credentialing take so little time? are you already on a medicare panel in the facility? who is doing your billing, ?

Not quite sure to be honest. They told me it would take max a week and it was done on the short end. I have a template I made and I just submit it to the office when I'm done with the appropriate coding. The office takes care of the submission- I think they use a billing company, but I don't concern myself with that.

 

[Attending1985]

25-30 patients per day?

 

[JSizzles]

My roster will have 25-30 I round only one day a week, but a few patients may be out when I get there so I should expect low 20s. With established patients at 99308 I think this should be manageable. From other colleagues this seems to be the norm.

 

[TexasPhysician]

25-30 patients per day?

Not abnormal for structured, non-acute facilities seen weekly.

 

[SourceOfDenial]

Eeek, reading this thread makes me cringe. While you certainly don't need a fellowship to be a geriatric psychiatrist, you need a firm understanding of not only the the pharm and medical aspect, but also CMS and DPH regulations. How will you document/counsel risk of fall increase with psychotropics? With seeing 20-25 a day does that include calling family for informed consent to start psychotropics? Are you seeing everyone weekly or biweekly--how are you rounding on these patients so you can document/assess attempts to taper antipsychotics?

 

[futuredo32]

I did nursing home work for a brief period while the psychiatrist was on leave. Personally, I hated it. The patients were sedated to the max and the nurses loved it. I tapered them off little by little , the nurses complained - the patients weren't doing anything but asking to be cared for. I'm sure the regular psychiatrist just upped their meds and had them sedated 24/7 after I was gone. You DO need something while starting private practice, if you opt to stick with this I wish you well. I moonlight a weekend a month and get paid VERY well for it, I wish I could moonlight at this hospital every weekend . There's also telepsych or other one or two day a week jobs if you opt not to do this.

 

[JSizzles]

I did nursing home work for a brief period while the psychiatrist was on leave. Personally, I hated it. The patients were sedated to the max and the nurses loved it. I tapered them off little by little , the nurses complained - the patients weren't doing anything but asking to be cared for. I'm sure the regular psychiatrist just upped their meds and had them sedated 24/7 after I was gone. You DO need something while starting private practice, if you opt to stick with this I wish you well. I moonlight a weekend a month and get paid VERY well for it, I wish I could moonlight at this hospital every weekend . There's also telepsych or other one or two day a week jobs if you opt not to do this.

Private practice is taking a bit longer than expected. I have about 10-15 new evals a week. But the problem with hospital work is that they have their own affiliated outpatient clinics so it violates most non-competes. The additional nursing home work allows me to make something while I'm building. I'm at 70 percent of collections which I guess could be better could be worse

 

[JSizzles]

Eeek, reading this thread makes me cringe. While you certainly don't need a fellowship to be a geriatric psychiatrist, you need a firm understanding of not only the the pharm and medical aspect, but also CMS and DPH regulations. How will you document/counsel risk of fall increase with psychotropics? With seeing 20-25 a day does that include calling family for informed consent to start psychotropics? Are you seeing everyone weekly or biweekly--how are you rounding on these patients so you can document/assess attempts to taper antipsychotics?

These are established patients. I have a total census of 100 so I will round on 25 a week. I will be there anyway so if a patient needs to be seen earlier or there is an acute issue I'll take care of it.

 

[futuredo32]

Private practice is taking a bit longer than expected. I have about 10-15 new evals a week. But the problem with hospital work is that they have their own affiliated outpatient clinics so it violates most non-competes. The additional nursing home work allows me to make something while I'm building. I'm at 70 percent of collections which I guess could be better could be worse

I get it, ya gotta make ends meet. 10-15 new evals a week is good. Word will spread, patients will refer their friends.

 

[Attending1985]

These are established patients. I have a total census of 100 so I will round on 25 a week. I will be there anyway so if a patient needs to be seen earlier or there is an acute issue I'll take care of it.

do you mind me asking what kind of reimbursement you’re getting?

 

[JSizzles]

do you mind me asking what kind of reimbursement you’re getting?

70 percent of collections. That seems about average I have heard people between 60-80%. Does that sound accurate to you?

 

[Attending1985]

70 percent of collections. That seems about average I have heard people between 60-80%. Does that sound accurate to you?

I don’t know I do nursing home rounds but I’m salaried and only see like 13 per day

 

[st2205]

I don’t know I do nursing home rounds but I’m salaried and only see like 13 per day

Is this your full time gig or you’re just doing this like once per week? How does your salary per unit time stack up vs. other settings, if you don’t mind me asking?

 

[Attending1985]

Is this your full time gig or you’re just doing this like once per week? How does your salary per unit time stack up vs. other settings, if you don’t mind me asking?

I only do it once per month. They fill my schedule at the nursing home just as they do at the clinic 30 minute follow ups and 60 minute for evals plus some time for travel between nursing homes