Charting for RVU maximization

[BoardingDoc]

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Plus you still have to spend > 30 minutes of time with them to bill CC time.

You have to spend 30 minutes working on them, not physically with them. Ordering meds, charting, thinking about what you're going to do with them when you're at your desk etc etc etc all counts towards your total time.

 

[BoardingDoc]

The reason they often go to surgery post haste is because of the well documented risk of delayed appendectomy leading to perforation which increases morbidity and complications. (i.e. intraabdominal abscess, postoperative fistulas, etc..) OR time usually isn't an issue. Some hospitals have dedicated OR for emergent cases, almost all others have at least one OR available and on-call staff who are scheduled for unexpected surgeries.

Our surgeons will sometimes sit on them until morning (also evidence based (under 6 or 12h) and some take them right away. If they go right away, I call that emergent and I have no problem billing CC because they made a decision that the pt wasn't safe to wait until later or morning. Why wouldn't that qualify? That's a potentially life saving intervention on your part. You resuscitated them, identified a potentially life threatening diagnosis and facilitated timely definitive surgery for their condition.

As for the ARF. That's ARF by RIFLE classification. It's over 3 times baseline. Organ failure is organ failure. I didn't write the rules. Plus, why wouldn't that qualify as a potentially clinically significant OR life threatening deterioration? Most of the times these people have a bump in their K and/or an acidosis. You don't know if they are going to improve or not (even though most do...). They could code halfway through the night. This is from ACEP's website: "

Critical care services are defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure.

I totally get that you are being conservative with the definition and with your documentation, but I feel that many times we are desensitized to the emergent nature of our cases because we see them so often. If a PCP diagnosed an appy on a pt that he/she was able to squeeze into an imaging center that afternoon and called him with results telling him to go straight to ER... Most of those guys would be skipping and dancing talking about the pt they "saved". An emergency physician on the other hand? Meh....another appy, yawn... Another renal failure...yawn. Another stroke....yawn. Another alcohol withdrawal...yawn.(also qualifies in my book). I'm just a little more liberal with my definition and feel we under document CC.

I guarantee even if I got audited and anyone made an issue of it, I could mount an excellent defense of my charting and it would amount to nothing more than me either updating the chart with an appropriate addendum and/or dropping the charge. Hell, the guidelines are anything but crystal clear. They can't possibly expect everyone to code these at 100%.

Totally agree with the sentiment that as EM docs we get desensitized to emergencies and subsequently underbill CC time. I still don't personally agree with your appendicitis thing for reasons that I and other people have stated above.

As for the AKI patient... if they have hyperK as well and you're giving them insulin and D50, absolutely. If their K is 4.9 with a Cr of 4, I still don't see how you're arguing that it's CC time just because they might get worse. You could make the same argument about an untreated pneumonia with an O2 saturation of 90% but I don't think anyone here is billing CC time on those patients (I hope).

 

[Groove]

You could make the same argument about an untreated pneumonia with an O2 saturation of 90% but I don't think anyone here is billing CC time on those patients (I hope).

Agreed. For pneumonia, I usually don't bill CC unless they require bipap or tube, at which point I will generally add the diagnosis of "acute respiratory failure", which I think most of us would agree qualifies. If it's vanilla PNA, then no. If it's PNA with "sepsis" in the dx then yes.

Out of curiosity, if you say you don't have an issue billing CC for "sepsis", why not add the diagnosis to your appendicitis pt's? Most of them easily meet the definition. Would you have less of a problem billing CC if you called it "sepsis", in spite of their perceived clinical stability? I'm genuinely curious...

Are you billing CC for all sepsis or (severe sepsis/septic shock)?

 

[RustedFox]

Remember when the word "sepsis" used to mean something?

 

[TooMuchResearch]

Remember when the word "sepsis" used to mean something?

It meant something at the very very beginning of residency.
Now everything is sepsis. Even the ones without definite infection.

 

[Groove]

We've got a sepsis coordinator nazi at work who will peer review anyone not conforming to sepsis bundle management. I've had to write three peer review evaluation/responses for our director whom she dinged for not giving the fluid bolus (clear contraindications in each case). They called me again recently to evaluate an additional two more...it's wearing me out. Everyone ordering lactates in triage, "code sepsis" being blared overhead every 10 minutes. I hate sepsis these days.

 

[GatorCHOMPions]

What do you guys think about a "moderate" asthma exacerbation that gets duo-nebs followed by reeval, still not looking the best but not terrible (let's say mild increased work of breathing, still diffuse wheezing and you document such)? Then you give a continuous albuterol over an hour, steroids and +/- magnesium. Document other reevaluations and maybe they turn around and are discharged or maybe they need to stay in the obs unit or something. I've been billing that as CC because others told me they have, but not sure this would pass an audit as is mentioned above. I haven't been told by coders that these have been down-coded.

 

[southerndoc]

Unfortunately here to stay until CMS decides to not bundle sepsis "quality" measures with reimbursement.

Generally, if IV fluids are contraindicated, we take the hit and don't even notify the doc. There are some times where appropriate care is not to follow the measure. Giving 30 mL/kg bolus to someone in active heart failure is just bad care.

 

[Groove]

What do you guys think about a "moderate" asthma exacerbation that gets duo-nebs followed by reeval, still not looking the best but not terrible (let's say mild increased work of breathing, still diffuse wheezing and you document such)? Then you give a continuous albuterol over an hour, steroids and +/- magnesium. Document other reevaluations and maybe they turn around and are discharged or maybe they need to stay in the obs unit or something. I've been billing that as CC because others told me they have, but not sure this would pass an audit as is mentioned above. I haven't been told by coders that these have been down-coded.

I think it depends on how you document it. For the moderate asthma exacerbations with > 1h albuterol nebs and multiple meds where I am documenting "respiratory distress" on the exam, I'll generally document CC (I feel it is justified). Including the dx of "acute respiratory distress" or "acute respiratory distress syndrome" or "acute respiratory failure" (if qualifies) also helps justify it. Even with the ones where I am documenting distress, documenting CC appropriately and dx with mere "acute asthma exacerbation"...I am not aware of any incidences where these cases are being downcoded.

 

[RoyBasch]

Are you billing CC for all sepsis or (severe sepsis/septic shock)?

Only severe sepsis and septic shock for me.

 

[thegenius]

Unfortunately here to stay until CMS decides to not bundle sepsis "quality" measures with reimbursement.

Generally, if IV fluids are contraindicated, we take the hit and don't even notify the doc. There are some times where appropriate care is not to follow the measure. Giving 30 mL/kg bolus to someone in active heart failure is just bad care.

We were told that if the physician documents a reason why the patient should not get 30 ml / kg, then that is sufficient and there won’t be a fallout.

 

[deleted109597]

We were told that if the physician documents a reason why the patient should not get 30 ml / kg, then that is sufficient and there won’t be a fallout.

You were told wrong

 

[southerndoc]

You were told wrong

It's still a fallout for the SEP-1 measure, but definitely not inappropriate care if they are volume overloaded. Research suggests that septic dialysis patients are often volume depleted and underresuscitated. I've only seen a few become volume overloaded with a 30 mL/kg bolus when septic (true sepsis with hypotension and not just has a pneumonia and gets a 30 mL/kg bolus unnecessarily).

I think the confusion is SEP-1 vs MIPS sepsis measures. SEP-1 does not allow an exclusion for CHF, dialysis, etc. MIPS does. MIPS also doesn't specify the amount of fluid to be given. You can give 100 mL and be compliant with MIPS, but not with SEP-1.

 

[BoardingDoc]

Agreed. For pneumonia, I usually don't bill CC unless they require bipap or tube, at which point I will generally add the diagnosis of "acute respiratory failure", which I think most of us would agree qualifies. If it's vanilla PNA, then no. If it's PNA with "sepsis" in the dx then yes.

Out of curiosity, if you say you don't have an issue billing CC for "sepsis", why not add the diagnosis to your appendicitis pt's? Most of them easily meet the definition. Would you have less of a problem billing CC if you called it "sepsis", in spite of their perceived clinical stability? I'm genuinely curious...

Are you billing CC for all sepsis or (severe sepsis/septic shock)?

I should have clarified. I'm only billing cc for patients with severe sepsis/septic shock. If your HR is 92 and you have a fever alongside your pneumonia and/or your pyelo I'm generally not billing cc time. Hell, I'm probably not even admitting you (yes, I know you don't need to admit to bill for cc time).

 

[BoardingDoc]

What do you guys think about a "moderate" asthma exacerbation that gets duo-nebs followed by reeval, still not looking the best but not terrible (let's say mild increased work of breathing, still diffuse wheezing and you document such)? Then you give a continuous albuterol over an hour, steroids and +/- magnesium. Document other reevaluations and maybe they turn around and are discharged or maybe they need to stay in the obs unit or something. I've been billing that as CC because others told me they have, but not sure this would pass an audit as is mentioned above. I haven't been told by coders that these have been down-coded.

Virtually all of my asthmatics get a stack of 3 duonebs and steroids. If they still have significant respiratory distress and need another stack of nebs... maybe. If they need mag, and/or I'm worried enough about their respiratory status to physically go back into the room a few times to check on them... yes.

 

[EsTxDr]

This thread has been very helpful, this is something I have been trying to improve lately. Still pretty confused, but getting better.

 

[migm]

Re appendicitis: if the surgeon is telling the anesthesiologist this case is emergent, I'm putting critical care on it if it qualifies from a time perspective. If you're in renal failure, I think it's only justifiable if there is an acidosis or electrolyte imbalance enough that you have to act upon it. I'm billing critical care for sepsis if me not doing anything would lead to your significant morbidity in 1 day's time. I bill critical care for any IV pushes of medication - there is way too much risk and your doctor's office is NOT doing that, I don't care if it's 5mg of metop or not, if it meets criteria, I bill it. I'm at around 14% - no audits and zero concerns. we see some sick people (we being collective EM docs) - bill appropriately.

 

[lymphocyte]

As for the ARF. That's ARF by RIFLE classification. It's over 3 times baseline. Organ failure is organ failure. I didn't write the rules. Plus, why wouldn't that qualify as a potentially clinically significant OR life threatening deterioration? Most of the times these people have a bump in their K and/or an acidosis. You don't know if they are going to improve or not (even though most do...). They could code halfway through the night. This is from ACEP's website: "

Critical care services are defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition. Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure.

I totally get that you are being conservative with the definition and with your documentation, but I feel that many times we are desensitized to the emergent nature of our cases because we see them so often. If a PCP diagnosed an appy on a pt that he/she was able to squeeze into an imaging center that afternoon and called him with results telling him to go straight to ER... Most of those guys would be skipping and dancing talking about the pt they "saved". An emergency physician on the other hand? Meh....another appy, yawn... Another renal failure...yawn. Another stroke....yawn. Another alcohol withdrawal...yawn.(also qualifies in my book). I'm just a little more liberal with my definition and feel we under document CC.

I guarantee even if I got audited and anyone made an issue of it, I could mount an excellent defense of my charting and it would amount to nothing more than me either updating the chart with an appropriate addendum and/or dropping the charge. Hell, the guidelines are anything but crystal clear. They can't possibly expect everyone to code these at 100%.

You're consistently referencing medicine that was vogue in the 2000s, like RIFLE and hypertensive urgency. I just want to inject some dogmalysis.

ARF is not ARF until “after an optimal state of hydration has been achieved.” That's one of the major contributions of the AKIN modification to RIFLE. Otherwise, the Cr bump should really be called acute renal success, because the kidneys are appropriately not wasting free water to clear Cr in the face of hypovolemia. Elevated Cr that resolves with a volume challenge is not life-threatening organ dysfunction. It's literally the opposite -- life-preserving organ function.

"Hypertensive urgency" is a phrase coined in the 2003 JNC-7 Hypertension Guidelines -- that phrase is nowhere to be found come 2013 in JNC-8. I contest that it's still a valid diagnostic entity.

Headache in the absence of visual disturbances, confusion, seizure, or focal neurological deficit is NOT symptomatic of a hypertensive emergency, where emergent blood pressure control will make any sort of difference to anything in the short run.

In fact, the immediate risk of stroke from acutely lowering their blood pressure is higher than the immediate risk of stroke from just letting their BP ride high and correcting it over the course of a day or two. This is what kills me when I see interns chart PRN hydralazine on the ward (and hydralazine is an awfully unpredictable drug).

The safest strategy by far is to give them their usual oral anti-hypertensives and tell them to see their GP.

Bertel O, Marx BE, Conen D. Effects of antihypertensive treatment on cerebral perfusion. Am J Med 1987;82:29-36.

Rhoney DH, et al. Effect of vasoactive therapy on cerebral circulation. Crit Care Clin 2006;22:221-43.

Vuylsteke A, et al. Characteristics, practice patterns, and outcomes in patients with acute hypertension: European Registry for Studying the Treatment of Acute Hypertension (EuroSTAT). Crit Care 2011;15:R271.

 

[southerndoc]

Giving parenteral agents to lower BP is considered critical care by most standards. This is taught in most billing and coding classes and is held true in audits.

Acute renal failure, acute kidney injury, or whatever the term du jour is in itself not critical care. One should only bill for critical care in renal failure when there are associated instability: hypotension, significant tachycardia (heart rate >140), hyperkalemia, etc.

 

[Groove]

You're consistently referencing medicine that was vogue in the 2000s, like RIFLE and hypertensive urgency. I just want to inject some dogmalysis.

ARF is not ARF until “after an optimal state of hydration has been achieved.” That's one of the major contributions of the AKIN modification to RIFLE. Otherwise, the Cr bump should really be called acute renal success, because the kidneys are appropriately not wasting free water to clear Cr in the face of hypovolemia. Elevated Cr that resolves with a volume challenge is not life-threatening organ dysfunction. It's literally the opposite -- life-preserving organ function.

"Hypertensive urgency" is a phrase coined in the 2003 JNC-7 Hypertension Guidelines -- that phrase is nowhere to be found come 2013 in JNC-8. I contest that it's still a valid diagnostic entity.

Headache in the absence of visual disturbances, confusion, seizure, or focal neurological deficit is NOT symptomatic of a hypertensive emergency, where emergent blood pressure control will make any sort of difference to anything in the short run.

In fact, the immediate risk of stroke from acutely lowering their blood pressure is higher than the immediate risk of stroke from just letting their BP ride high and correcting it over the course of a day or two. This is what kills me when I see interns chart PRN hydralazine on the ward (and hydralazine is an awfully unpredictable drug).

The safest strategy by far is to give them their usual oral anti-hypertensives and tell them to see their GP.

Bertel O, Marx BE, Conen D. Effects of antihypertensive treatment on cerebral perfusion. Am J Med 1987;82:29-36.

Rhoney DH, et al. Effect of vasoactive therapy on cerebral circulation. Crit Care Clin 2006;22:221-43.

Vuylsteke A, et al. Characteristics, practice patterns, and outcomes in patients with acute hypertension: European Registry for Studying the Treatment of Acute Hypertension (EuroSTAT). Crit Care 2011;15:R271.

You're a resident right?

I particularly enjoyed the dig about practicing medicine that was "vogue in the 2000s" (was it actually THAT long ago? Damn, I feel old..) and then you start quoting me a journal article from 1987 and 2006. Give me a second to LOL.

There's nothing wrong with RIFLE or AKIN. Period. Plenty of nephrologists use them. Both classification systems are well accepted in most medical communities.

RIFLE Criteria and AKIN Classification

AKI can be defined as an abrupt (1 to 7 days) and sustained (more than 24 hours) decrease in kidney function. The ADQI formulated the RIFLE criteria in 2004 to allow for AKI to be objectively and uniformly defined.

litfl.com

The RIFLE and AKIN classifications for acute kidney injury: a critical and comprehensive review - PMC

In May 2004, a new classification, the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) classification, was proposed in order to define and stratify the severity of acute kidney injury (AKI). This system relies on ...

www.ncbi.nlm.nih.gov

I'm well aware of the confusion in hypertensive definitions over the years. I wouldn't hang your hat on JNC-8. The term "hypertensive urgency" is anything but moribund and redundant. Along with JNC 7, you've still got 2013 ACEP and 2013 ESC/ESH HTN Guidelines, all of which relatively define hypertensive urgency. There's nothing magical about the word, btw. They are all conveying the same thing...elevated HTN without end organ damage. The problem in the real world, such as the ED, is that people take this term and run wild with it. There's no strict definition of upper limits of "safe to discharge" and people will take a 280/140 BP with "clean labs" and argue that they are asymptomatic and d/c them out the door stating ACEP guidelines. I would argue that the authors of these definitions and guidelines never intended patients with extreme BPs to be discharged with no anti-HTN therapy. Call up a cardiologist and ask them if it's safe for you to send home a 280/140 and he will laugh in your face over the phone. Anecdotally, for many of us dealing with pt's returning or presenting to the ED with HTN emergencies, this practice doesn't seem safe and I think that would be validated if a study were ever created to track pt's at the upper extremes of "HTN Urgency or Asymptomatic HTN" compared to ranges that were less extreme. It's also ridiculous from a real world and practical perspective for those of us that have been doing this awhile. Let's say we send out an extremely elevated BP to the PCP office. What does the PCP do? He calls the CMO or ED Dir and asks why his pt wasn't admitted that he sent over there for extremely elevated BP. You d/c them to see a cardiologist and he does the same...sends them right back to the ED for BP control. Unless you're a resident in the ED, you're probably not dealing with these patients as most floors would not even accept them with BPs in that range. If they are in the ICU, they are probably already on cardene gtt, etc..

"Kills me when I see interns do X" Again, massive eye roll when I glance at your posts and realize you are a resident who was chasing up with your attending a few weeks ago.

Look man, it's not that I don't mind the posts. Thanks for the contribution. It's just that many times on here I see residents post very authoritative dissertations about something they're anything but an expert on. Come find me and talk renal dysfunction classification systems and HTN emergencies after you've been in a few hospital systems and been practicing on your own for a few years and realize that these two topics are anything but black and white.

The whole point with renal "failure" is that it is a definition used in ACEP Facility Level Coding guidelines for CPT 99291. Any qualifier used in the definition is going to encourage clinicians to utilize classification systems that discretely define "renal failure", hence why I'm even using RIFLE.

 

[thegenius]

Virtually all of my asthmatics get a stack of 3 duonebs and steroids. If they still have significant respiratory distress and need another stack of nebs... maybe. If they need mag, and/or I'm worried enough about their respiratory status to physically go back into the room a few times to check on them... yes.

Continuous nebs for > 1 hr for asthma can be considered critical care.

Problem is I guve just about all asthma at least 7.5 mg of albuterol, often 10 mg as a continuous neb and it feels silly charging CC. I’ll charge for CC if they are tripoding or speaking 3 word sentences, or have significant retractions, or if I give them IV Mag.

 

[lymphocyte]

You're a resident right?

I particularly enjoyed the dig about practicing medicine that was "vogue in the 2000s" (was it actually THAT long ago? Damn, I feel old..) and then you start quoting me a journal article from 1987 and 2006. Give me a second to LOL.

There's nothing wrong with RIFLE or AKIN. Period. Plenty of nephrologists use them. Both classification systems are well accepted in most medical communities.

RIFLE Criteria and AKIN Classification

AKI can be defined as an abrupt (1 to 7 days) and sustained (more than 24 hours) decrease in kidney function. The ADQI formulated the RIFLE criteria in 2004 to allow for AKI to be objectively and uniformly defined.

litfl.com

The RIFLE and AKIN classifications for acute kidney injury: a critical and comprehensive review - PMC

In May 2004, a new classification, the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) classification, was proposed in order to define and stratify the severity of acute kidney injury (AKI). This system relies on ...

www.ncbi.nlm.nih.gov

I'm well aware of the confusion in hypertensive definitions over the years. I wouldn't hang your hat on JNC-8. The term "hypertensive urgency" is anything but moribund and redundant. Along with JNC 7, you've still got 2013 ACEP and 2013 ESC/ESH HTN Guidelines, all of which relatively define hypertensive urgency. There's nothing magical about the word, btw. They are all conveying the same thing...elevated HTN without end organ damage. The problem in the real world, such as the ED, is that people take this term and run wild with it. There's no strict definition of upper limits of "safe to discharge" and people will take a 280/140 BP with "clean labs" and argue that they are asymptomatic and d/c them out the door stating ACEP guidelines. I would argue that the authors of these definitions and guidelines never intended patients with extreme BPs to be discharged with no anti-HTN therapy. Call up a cardiologist and ask them if it's safe for you to send home a 280/140 and he will laugh in your face over the phone. Anecdotally, for many of us dealing with pt's returning or presenting to the ED with HTN emergencies, this practice doesn't seem safe and I think that would be validated if a study were ever created to track pt's at the upper extremes of "HTN Urgency or Asymptomatic HTN" compared to ranges that were less extreme. It's also ridiculous from a real world and practical perspective for those of us that have been doing this awhile. Let's say we send out an extremely elevated BP to the PCP office. What does the PCP do? He calls the CMO or ED Dir and asks why his pt wasn't admitted that he sent over there for extremely elevated BP. You d/c them to see a cardiologist and he does the same...sends them right back to the ED for BP control. Unless you're a resident in the ED, you're probably not dealing with these patients as most floors would not even accept them with BPs in that range. If they are in the ICU, they are probably already on cardene gtt, etc..

"Kills me when I see interns do X" Again, massive eye roll when I glance at your posts and realize you are a resident who was chasing up with your attending a few weeks ago.

Look man, it's not that I don't mind the posts. Thanks for the contribution. It's just that many times on here I see residents post very authoritative dissertations about something they're anything but an expert on. Come find me and talk renal dysfunction classification systems and HTN emergencies after you've been in a few hospital systems and been practicing on your own for a few years and realize that these two topics are anything but black and white.

The whole point with renal "failure" is that it is a definition used in ACEP Facility Level Coding guidelines for CPT 99291. Any qualifier used in the definition is going to encourage clinicians to utilize classification systems that discretely define "renal failure", hence why I'm even using RIFLE.

I'm an intensive care trainee, not a resident. I also do locum work in EM. I bow down to your street-smart attending awesomeness.

You're basically saying, "listen kid, let me tell you how things work in the real world," but what I see is 1) very questionable billing practices and 2) medicine designed to please dinosaur doctors.

Who cares if some outpatient cardiologist might laugh at you? Wouldn't they be more inclined to laugh at you because you're calling them to decide what's safe? You're the expert on emergencies making a decision based on guidelines promulgated by a society of emergency medicine experts. So let's stop the charade that high blood pressure alone constitutes an emergency nevermind one requiring critical care.

"There's nothing wrong with RIFLE or AKIN." I literally quoted the AKIN definition to you, which requires adequate hydration before assessing for kidney injury. IVF fixing (or diluting) a Cr bump does not demonstrate organ failure. Also, the whole point of finding biomarkers for AKI like cystatin C and NGAL is because RIFLE frankly sucks. Cr is like diagnosing NSTEMI based on the ejection fraction.

The work on cerebral perfusion is indeed pretty old, which is why it's such a pet peeve of mine when I see patients slammed with IV hydralazine. Why? To fix a number and nothing more at the risk of harming patients. It drives me nuts.

Anyways. Back to maximizing RVUs.

 

[Groove]

I'm an intensive care trainee, not a resident. I also do locum work in EM.

And the difference is...? This is you in May of 2018 (1 year ago).

PGY-2 with rotations in neurology, cardiology, ICU, pulm, 2 x ED, psychiatry, plus a few surgical terms. Nearly every consultant has called me the best resident they've ever worked with, and I think they mean it.

FM resident originally, correct? If you are doing much locums work in a high acuity ED, word of advice...you probably shouldn't be.

This part was cool:

You're basically saying, "listen kid, let me tell you how things work in the real world,"

Because I distinctly heard myself with the voice of Indiana Jones... More of that please. Now get back to those ICU studies Short Round. You've got more interns to eviscerate during morning rounds tomorrow.

 

[migm]

alright back to the thread

 

[deleted859535]

alright back to the thread

This. Dear God, this.

 

[DoubleBogey]

Anyone bill advance care planning with incoming hospice patients, after codes, declining patients etc?

 

[gutonc]

Anyone bill advance care planning with incoming hospice patients, after codes, declining patients etc?

This is one of those things that should be super simple and obvious, but isn't. You need to spend 16 minutes doing so (the first 15 are free advice apparently).

I'm an oncologist and have these discussions multiple times a day. I probably bill 1 or 2 of them a quarter.

 

[lymphocyte]

And the difference is...? This is you in May of 2018 (1 year ago).



FM resident originally, correct? If you are doing much locums work in a high acuity ED, word of advice...you probably shouldn't be.

This part was cool:



Because I distinctly heard myself with the voice of Indiana Jones... More of that please. Now get back to those ICU studies Short Round. You've got more interns to eviscerate during morning rounds tomorrow.

You didn't quote my board scores.

I eat, sleep, dream medicine and I'm not fun at parties. I've also been arguing with dinosaur attendings on SDN for a long time.

You can dig through my posts or you can can dig through the literature. Your posts speak for themselves.

I'm an ICU trainee, mostly definitely never an FM resident (though I respect good, evidence-based FM doctors). I love EM but only high acuity patients. So keep going with your "acute renal failure" to maximise billings while I slam in the Hickman's and get the job done.

 

[NITRAS]

Anyone bill advance care planning with incoming hospice patients, after codes, declining patients etc?

Yes, but remember you can't bill for critical care on the same encounter. And the times cannot be bundled in with your time for the admission or doing other stuff.

I look at billing as getting paid for work I actually do. I have opinions on doing things to bill more that doesn't actually influence patient care.

 

[jw3600]

You didn't quote my board scores.

I eat, sleep, dream medicine and I'm not fun at parties. I've also been arguing with dinosaur attendings on SDN for a long time.

You can dig through my posts or you can can dig through the literature. Your posts speak for themselves.

I'm an ICU trainee, mostly definitely never an FM resident (though I respect good, evidence-based FM doctors). I love EM but only high acuity patients. So keep going with your "acute renal failure" to maximise billings while I slam in the Hickman's and get the job done.

You’re ether trolling or are a complete tool. There is no other possibility.

 

[MechEDoc]

We've got a sepsis coordinator nazi at work who will peer review anyone not conforming to sepsis bundle management. I've had to write three peer review evaluation/responses for our director whom she dinged for not giving the fluid bolus (clear contraindications in each case). They called me again recently to evaluate an additional two more...it's wearing me out. Everyone ordering lactates in triage, "code sepsis" being blared overhead every 10 minutes. I hate sepsis these days.

The Joint Commission considers disruptive and intimidating behavior to be a sentinel event worthy of reporting. You've got options...

 

[deleted859535]

You didn't quote my board scores.

I eat, sleep, dream medicine and I'm not fun at parties. I've also been arguing with dinosaur attendings on SDN for a long time.

You can dig through my posts or you can can dig through the literature. Your posts speak for themselves.

I'm an ICU trainee, mostly definitely never an FM resident (though I respect good, evidence-based FM doctors). I love EM but only high acuity patients. So keep going with your "acute renal failure" to maximise billings while I slam in the Hickman's and get the job done.

You bumped this thread for this?

 

[Makati2008]

You didn't quote my board scores.

I eat, sleep, dream medicine and I'm not fun at parties. I've also been arguing with dinosaur attendings on SDN for a long time.

You can dig through my posts or you can can dig through the literature. Your posts speak for themselves.

I'm an ICU trainee, mostly definitely never an FM resident (though I respect good, evidence-based FM doctors). I love EM but only high acuity patients. So keep going with your "acute renal failure" to maximise billings while I slam in the Hickman's and get the job done.

I’ve never heard the term ICU trainee? What was your residency before your fellowship? Are you EM? Or some other speciality such as IM/FM/etc

 

[southerndoc]

The Joint Commission considers disruptive and intimidating behavior to be a sentinel event worthy of reporting. You've got options...

Usually it ends in career displacement. Asking why you didn't comply with SEP-1 measures isn't disruptive and intimidating behavior. Most of the time it's because it wasn't documented clearly in a chart why someone wasn't given a 30 mL/kg bolus (patient hypervolemic, acute CHF, etc.). Docs assume it can be inferred, but the chart abstractors are not allowed to make assumptions. If it's not documented why you didn't do something, why they didn't meet criteria, etc., then it's a fall out. Frequent fall outs is a quality issue and could cost someone their job.

I would advise that you seriously consider what you're doing before you go the JC route.

 

[southerndoc]

We've got a sepsis coordinator nazi at work who will peer review anyone not conforming to sepsis bundle management. I've had to write three peer review evaluation/responses for our director whom she dinged for not giving the fluid bolus (clear contraindications in each case). They called me again recently to evaluate an additional two more...it's wearing me out. Everyone ordering lactates in triage, "code sepsis" being blared overhead every 10 minutes. I hate sepsis these days.

If the care is appropriate, why are you writing three peer review responses and why were individuals dinged?

Luckily I have a great sepsis coordinator where I'm AMD. She is a former critical care NP who gets it. She sends things like last week "This patient is a SEP-1 fallout because 30 mL/kg wasn't given, but they had active CHF as documented by the EP. I'm considering it appropriate care unless you disagree."

Makes my job easier when she does that. Nothing gets peer reviewed from the sepsis coordinator. If she thinks it's inappropriate, I review it. It's up to me to send it to the medical care evaluation (MCE/QA) committee or an admitting physician can refer it. This is extremely rare and almost never happens because of not giving fluids, antibiotics in time, etc. Usually I just send an email notifying them of the drop out.

 

[Groove]

If the care is appropriate, why are you writing three peer review responses and why were individuals dinged?

Luckily I have a great sepsis coordinator where I'm AMD. She is a former critical care NP who gets it. She sends things like last week "This patient is a SEP-1 fallout because 30 mL/kg wasn't given, but they had active CHF as documented by the EP. I'm considering it appropriate care unless you disagree."

Makes my job easier when she does that. Nothing gets peer reviewed from the sepsis coordinator. If she thinks it's inappropriate, I review it. It's up to me to send it to the medical care evaluation (MCE/QA) committee or an admitting physician can refer it. This is extremely rare and almost never happens because of not giving fluids, antibiotics in time, etc. Usually I just send an email notifying them of the drop out.

Why does anyone have to respond to these things? Virtually anyone can generate them. Nurses, MLPs, vindictive consultants. Most of the times the AFMD squashes them before they are brought up in peer review, but if the AFMD gets one then it's up to me to write a response. You're lucky in that you have a rational, logical sepsis coordinator. Ours is strictly by the book and unable to look outside fixed algorithms from CMS. She also seems to have a vendetta against our current AFMD because of some interactions in the ED. She likes me however, so I never get one. Luckily for us she recently got promoted and will no longer be in charge of sepsis so here's to hoping that someone inherits her position with a little more common sense.

Peer reviews are beyond ridiculous. I once got one from a NP in the psych ward d/t a patient I had admitted the day prior for schizophrenia with a normal EKG. He developed a Mobitz 1 (asympomatic..mind you) on day 2 and she generated a peer review because it had not been diagnosed the day prior. (Completely not present on admission EKG). Our old AFMD actually had me write a formal response to that one and it went on to peer review. Some of these things are beyond ridiculous and a complete waste of time.

 

[BoardingDoc]

I’ve never heard the term ICU trainee? What was your residency before your fellowship? Are you EM? Or some other speciality such as IM/FM/etc

They appear to be Australian, or at least lived there for some time and trained there based on their post history and UK English spelling of certain words like honor/honour. Not sure how training works over there but apparently it involves a different set of prereqs, one of which is pointless necrobumping proficiency.

 

[lymphocyte]

You’re ether trolling or are a complete tool. There is no other possibility.

They appear to be Australian, or at least lived there for some time and trained there based on their post history and UK English spelling of certain words like honor/honour. Not sure how training works over there but apparently it involves a different set of prereqs, one of which is pointless necrobumping proficiency.

I was away and found myself quoted. I therefore "bumped" this thread because aggressively treating asymptomatic hypertension (or elevated blood pressure with a headache) or calling easily reversible rises in SrCr an AKI are pet peeves -- especially labelling them "critical care." I also didn't appreciate someone digging through all my old posts to argue what should be a medical claim.

In fact, I've made several friends through SDN in real life who can verify whatever you'd like (including me being a tool). I also explained my background here, because Groove followed me onto other threads:

https://forums.studentdoctor.net/threads/the-rush.1379885/post-21044916

I get this thread is about maximising RVUs -- and I'm happy to explain how I know about RVUs better than you'd expect --but appendicitis with normal vital signs? Elevated blood pressure with a headache (not encephalopathic)? SrCr bumps without actual renal failure? And then the advice about billing smoking cessation. It all seems pretty dubious. Anyways. To each their own.