MD model.... 2 simultaneous cases. How to bill?

[sevoflurane]

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Post call today... in the cath lab doing a Sensi/Robotic A-fib ablation (like all robots there is a learning curve....)

Anyways, dude is cruising with 1% Sevo/LMA and some midaz. One of our adjacent cath labs has a STEMI next door and they are trying to stent the LAD + a coupla other vessels. Therapeutic Integrilin and Heparin on board. 150kg, short chin butterball dude goes into VFib arrest. Respiratory Therapy goes in and... drum roll please....

Muck’s up the AW.

My patient is comfortably cruising though his ablation. I get a hoard of nurses running into my peaceful cathlab asking for emergent AW management as the rest of our anesthesia team is tied up. I give specific instructions to my cathlab nurses and place one in front of my monitor. Tell my EP guy to stop for the moment. Go next door, stick in suction and follow the red sea bubbles into the trachea. BBS/ETCO2. I'm gone for 3 minutes.

2 questions for you guys out there in the biz.....


1) Would anybody have an issue with this? i.e. patient abandonment vs good samaritan?

http://en.wikipedia.org/wiki/Good_Samaritan_law

I think we’ve all had this discussion before but I don’t remember what the consensus was here on this forum.... What does the ASA say?

2) My question to you guys that are familiar with billing....

Can I bill for this emergent AW while I have another under GA going on immediately next door...? Or chalk it up as water under the bridge?

 

[rsgillmd]

...........

2 questions for you guys out there in the biz.....


1) Would anybody have an issue with this? i.e. patient abandonment vs good samaritan?

http://en.wikipedia.org/wiki/Good_Samaritan_law

I think we’ve all had this discussion before but I don’t remember what the consensus was here on this forum.... What does the ASA say?

2) My question to you guys that are familiar with billing....

Can I bill for this emergent AW while I have another under GA going on immediately next door...? Or chalk it up as water under the bridge?

I would have to go back and look, but I believe this OK, because you left someone to watch the monitor gave specific instructions. You also only left for an emergency.

However, I think if you bill for airway management, Good Samaritan laws go out the window.

 

[Consigliere]

You did the right thing. However, doing the right thing won't increase your compensation in this instance as you cannot bill for simultaneous procedures.

 

[Gimlet]

Not quite "in the biz" yet, so I'm not sure what the ASA and billing companies would say about this, but my gut tells me that if you're helping out on the prinicple of Good Samaritan-ship, you probably shouldn't try to bill for it. Could get you in trouble for leaving your first patient as someone could argue that seeking compensation for helping the second patient is evidence that you weren't truly acting as a Good Samaritan.

edit: whoops, slow typing today - these guys beat me to it.

 

[Mman]

Tough spot to be in. I agree that from a patient care point of view, you did the right thing. Your case was on cruise control and you were merely feet away with somebody staring at the monitors to alert you if anything was amiss.


HOWEVER

If anything bad did happen in the room you left, you'd be hung out to dry for abandoning the patient.

You definitely can't bill for something concurrent for a case that you are the sole provider on. I also am fairly certain that the letter of the law says you can't leave the room unless being relieved by a qualifed person (MD relieving you on case or CRNA you are supervising). There is no chance that leaving an RN in front of the monitor would pass muster on a review of a critical event.




So I think you did the right thing to help save a life. I just don't think you attention brought to it. I think the Good Samaritan stuff only comes into play when you volunteer to enter a bad situation and offer assistance. It doesn't pertain to leaving the care of someone you are responsible for to do it.

 

[wine thief]

Thanks to trial lawyers:
Bill? Screwed.
Don't bill? Screwed.

I was just talking about this with a group of guys after work. Looked it up when I got home.

In Chamley v. Khokha (2007), a patient undergoing kidney surgery began bleeding during the operation. The surgeon believed that the source of the bleeding was kidney vessels and requested the assistance of a vascular surgeon to help stop the bleeding. A vascular surgeon came emergently to assist in the surgery and helped remove the patient’s kidney. The patient’s vena cava was punctured during the surgery and was also repaired by the vascular surgeon. Later, the patient’s condition deteriorated, she was transferred to another hospital and she died the following day.

In a subsequent lawsuit, the vascular surgeon claimed the “Good Samaritan” defense and was dismissed from the case.

The North Dakota Supreme Court noted that while North Dakota’s Good Samaritan statute immunized liability for emergency assistance provided to another person unless intentional misconduct or gross negligence was proven, the immunity did not apply to those rendering aid or assistance with an “expectation of remuneration.” Because the vascular surgeon was employed by the hospital to provide surgical services to patients, because the patient was in the hospital when the incident occurred, and because the surgeon billed for his services, the court held that the Good Samaritan statute did not apply.


In Hernandez v. Alexian Brothers Health System (Ill. App., 2008), a patient undergoing a biopsy in a radiology suite suffered a cardiac arrest and was immediately transferred to the emergency department where “any available cardiologist” was paged over the intercom to come and render care. A staff cardiologist responded and arrived to find the patient intubated and asystolic. He inserted a femoral central line, performed a bedside echocardiogram, and made several attempts at a pericardiocentisis. The patient ultimately died.

The cardiologist and hospital were sued. In response, the cardiologist alleged that the Good Samaritan statute should apply because he had no pre-existing duty to care for the patient, because the patient was in the midst of a medical emergency, and because he did not bill for his medical care.

The plaintiff’s family alleged that the cardiologist’s failure to bill for his medical care was not made in good faith. During discovery, the cardiologist was asked to identify all of the patients that he had not billed in the prior five years. The chief financial officer for the cardiologist’s corporation stated that she was “unaware of any other time” that the cardiologist had not submitted a bill for services he had provided to a patient.
In rejecting the Good Samaritan argument, the Illinois appellate court noted that Illinois’ Good Samaritan Act immunized the acts of a physician “who, in good faith, provides emergency care without fee.” According to the court, refraining from charging a fee simply to invoke Good Samaritan protection seemed to violate the “good faith” requirement, particularly if the decision not to charge a fee was made following treatment that could potentially expose a doctor to liability.

 

[deleted126335]

Thanks to trial lawyers:
Bill? Screwed.
Don't bill? Screwed.

I was just talking about this with a group of guys after work. Looked it up when I got home.

In Chamley v. Khokha (2007), a patient undergoing kidney surgery began bleeding during the operation. The surgeon believed that the source of the bleeding was kidney vessels and requested the assistance of a vascular surgeon to help stop the bleeding. A vascular surgeon came emergently to assist in the surgery and helped remove the patient’s kidney. The patient’s vena cava was punctured during the surgery and was also repaired by the vascular surgeon. Later, the patient’s condition deteriorated, she was transferred to another hospital and she died the following day.

In a subsequent lawsuit, the vascular surgeon claimed the “Good Samaritan” defense and was dismissed from the case.

The North Dakota Supreme Court noted that while North Dakota’s Good Samaritan statute immunized liability for emergency assistance provided to another person unless intentional misconduct or gross negligence was proven, the immunity did not apply to those rendering aid or assistance with an “expectation of remuneration.” Because the vascular surgeon was employed by the hospital to provide surgical services to patients, because the patient was in the hospital when the incident occurred, and because the surgeon billed for his services, the court held that the Good Samaritan statute did not apply.


In Hernandez v. Alexian Brothers Health System (Ill. App., 2008), a patient undergoing a biopsy in a radiology suite suffered a cardiac arrest and was immediately transferred to the emergency department where “any available cardiologist” was paged over the intercom to come and render care. A staff cardiologist responded and arrived to find the patient intubated and asystolic. He inserted a femoral central line, performed a bedside echocardiogram, and made several attempts at a pericardiocentisis. The patient ultimately died.

The cardiologist and hospital were sued. In response, the cardiologist alleged that the Good Samaritan statute should apply because he had no pre-existing duty to care for the patient, because the patient was in the midst of a medical emergency, and because he did not bill for his medical care.

The plaintiff’s family alleged that the cardiologist’s failure to bill for his medical care was not made in good faith. During discovery, the cardiologist was asked to identify all of the patients that he had not billed in the prior five years. The chief financial officer for the cardiologist’s corporation stated that she was “unaware of any other time” that the cardiologist had not submitted a bill for services he had provided to a patient.
In rejecting the Good Samaritan argument, the Illinois appellate court noted that Illinois’ Good Samaritan Act immunized the acts of a physician “who, in good faith, provides emergency care without fee.” According to the court, refraining from charging a fee simply to invoke Good Samaritan protection seemed to violate the “good faith” requirement, particularly if the decision not to charge a fee was made following treatment that could potentially expose a doctor to liability.

Not a lawyer, but a good samaritan defense for care rendered in a hospital where you have privileges is almost never going to fly. Even if "off duty".

 

[deleted126335]

The original poster violated standard 1 of the ASA standards for Basic anesthesia monitoring. Doesn't mean that it wasn't the right thing to do. You do what you have to. Doesn't meant that you won't be crucified for it.

 

[IlDestriero]

Expect more of this with independent CRNA rescue. Funny how I wouldn't expect to get sued helping my physician colleague if they have an emergency.🙄
When they off a few people the surgeons will wise up. My hospital is decreasing nurse "sedation" services across the board, they suck and the surgeons, GI, and IR folks now want us for most cases. They woke up to reality.

 

[IlDestriero]

BTW, don't bill, and consider it a near miss. I hope the card service and Resp therapy are looking at it as well. You don't need to be put in that position again.

 

[proman]

1) Would anybody have an issue with this? i.e. patient abandonment vs good samaritan?

http://en.wikipedia.org/wiki/Good_Samaritan_law

I think we've all had this discussion before but I don't remember what the consensus was here on this forum.... What does the ASA say?

2) My question to you guys that are familiar with billing....

Can I bill for this emergent AW while I have another under GA going on immediately next door...? Or chalk it up as water under the bridge?

I thought we had previously established that it's ok to leave a stable anesthetized patient to care for an emergency of short duration (analagous to leaving c-section to care for the infant). It's not a violation of ASA standards.
You could probably bill for a lowest level consult (I guess new patient now) evaluation. The reason: airway management. Requesting: cardiologist. Emergent. Write a brief airway note and send it to billing. I don't think it's a concurrent issue since intubation is not anesthesia. It's how we billed for our emergency out-of-OR intubations in residency.

BTW strong work.

 

[jetproppilot]

Post call today... in the cath lab doing a Sensi/Robotic A-fib ablation (like all robots there is a learning curve....)

Anyways, dude is cruising with 1% Sevo/LMA and some midaz. One of our adjacent cath labs has a STEMI next door and they are trying to stent the LAD + a coupla other vessels. Therapeutic Integrilin and Heparin on board. 150kg, short chin butterball dude goes into VFib arrest. Respiratory Therapy goes in and... drum roll please....

Muck’s up the AW.

My patient is comfortably cruising though his ablation. I get a hoard of nurses running into my peaceful cathlab asking for emergent AW management as the rest of our anesthesia team is tied up. I give specific instructions to my cathlab nurses and place one in front of my monitor. Tell my EP guy to stop for the moment. Go next door, stick in suction and follow the red sea bubbles into the trachea. BBS/ETCO2. I'm gone for 3 minutes.

2 questions for you guys out there in the biz.....


1) Would anybody have an issue with this? i.e. patient abandonment vs good samaritan?

http://en.wikipedia.org/wiki/Good_Samaritan_law

I think we’ve all had this discussion before but I don’t remember what the consensus was here on this forum.... What does the ASA say?

2) My question to you guys that are familiar with billing....

Can I bill for this emergent AW while I have another under GA going on immediately next door...? Or chalk it up as water under the bridge?

I think you did a GREAT thing.

I wouldn't bill for it.

 

[Pietrantonio]

Great post. I have no Anesthesia experience so I can't chime in with a reply specific to your question.

If you don't mind me asking, I would like to ask a learning question. As a new RT, I was curious to know how the RT's could have performed better? Currently, I am not signed off to perform intubations, however, I'm always willing to learn and this sounds like a good opportunity - especially from those of you who specialize in advanced airway procedures.

 

[IN2B8R]

Do not bill for it. And do not do anything cute to make it appear that it was not a concurrency to others. You will likely regret doing that: the government is on a witch hunt! When it comes to billing, you should avoid anything that even looks remotely incriminating. The poor collection that you may get from this medicare/medicaid patient is not even worth it. You did the right thing, but be careful with sticking your neck on the line. No such thing as "Good Sam laws" within a hospital, do not chance it--your livelihood is at stake, bro'.... Let those arse-hole cardiologists who elected to start this case without anesthesia's help deal with their own mess: even an STEMI can be somewhat better planned than have respiratory therapy f*ck things up even further (thus worsening the MI) during a cath lab case.... Poor planing = poor outcomes. Try to avoid those situations, you are better off.👍

 

[Oggg]

Unless you have anesthesia standby for every cath lab case, this kind of thing will keep happening. And nobody will agree to anesthesia standby

 

[sevoflurane]

I appreciate all the comments. Interesting replies and certainly something to think about as most of us will encounter something like this at least a couple of times in our careers (especially those in MD models). It’s like a massive CO2 embolism from pneumoperitoneum during trocar placement. You need to have a reflex plan in your head ready to go if it happens (cardiac bypass in the laparoscopic room). Not having the issues worked out ahead of time can lead you to make a poor decision.

I was fortunate in the sense that my patient was breathing spontaneously and extremely stable + I was able to get a definitive AW quickly. I would like to know what the ASA says about these situations as here in the US we live under the scrutiny of lawyers (more so than most all other countries). It is frustrating to find ourselves in a position to perform life saving maneuvers and yet at the same time be reluctant to do so in light of the possible medico-legal repercussions. These situations test the morality of us as physician professionals.

As for billing... well, I wrote an intubation note in the chart. I will have to go to billing and have them flag the chart so the patient doesn’t get charged. This seems to be the consensus and it’s not like it’s a big loss to our department.

Interventional Cards was extremely thankful and as such makes our department look strong and valuable. So it’s not a total loss.

I have a feeling that most of us would do the same if presented with the same scenario. But what if the patient was quasi-stable (after all we had a catheter in the coronary sinus right?) or the intubation was taking longer than expected. These issues become increasingly grey as the line between right and wrong start to become blurry.

Again, thanks for all the replies. I found your responses extremely helpful.

👍

 

[sevoflurane]

Do not bill for it. And do not do anything cute to make it appear that it was not a concurrency to others. You will likely regret doing that: the government is on a witch hunt! When it comes to billing, you should avoid anything that even looks remotely incriminating. The poor collection that you may get from this medicare/medicaid patient is not even worth it. You did the right thing, but be careful with sticking your neck on the line. No such thing as "Good Sam laws" within a hospital, do not chance it--your livelihood is at stake, bro'.... Let those arse-hole cardiologists who elected to start this case without anesthesia's help deal with their own mess: even an STEMI can be somewhat better planned than have respiratory therapy f*ck things up even further (thus worsening the MI) during a cath lab case.... Poor planing = poor outcomes. Try to avoid those situations, you are better off.👍

You always have something good to say when it comes to the madico-legal arena. 👍

 

[foxtrot]

I appreciate all the comments. Interesting replies and certainly something to think about as most of us will encounter something like this at least a couple of times in our careers (especially those in MD models). It’s like a massive CO2 embolism from pneumoperitoneum during trocar placement. You need to have a reflex plan in your head ready to go if it happens (cardiac bypass in the laparoscopic room). Not having the issues worked out ahead of time can lead you to make a poor decision.

I was fortunate in the sense that my patient was breathing spontaneously and extremely stable + I was able to get a definitive AW quickly. I would like to know what the ASA says about these situations as here in the US we live under the scrutiny of lawyers (more so than most all other countries). It is frustrating to find ourselves in a position to perform life saving maneuvers and yet at the same time be reluctant to do so in light of the possible medico-legal repercussions. These situations test the morality of us as physician professionals.

As for billing... well, I wrote an intubation note in the chart. I will have to go to billing and have them flag the chart so the patient doesn’t get charged. This seems to be the consensus and it’s not like it’s a big loss to our department.

Interventional Cards was extremely thankful and as such makes our department look strong and valuable. So it’s not a total loss.

I have a feeling that most of us would do the same if presented with the same scenario. But what if the patient was quasi-stable (after all we had a catheter in the coronary sinus right?) or the intubation was taking longer than expected. These issues become increasingly grey as the line between right and wrong start to become blurry.

Again, thanks for all the replies. I found your responses extremely helpful.

👍

Great post. It is sad how the medicolegal environment has ruined medicine. Unfortunately, this will continue until trial lawyers no longer run the country.

 

[epidural man]

Great post. It is sad how the medicolegal environment has ruined medicine. Unfortunately, this will continue until trial lawyers no longer run the country.

It is preposterous that the same lawyers that say I can't get a sandwich from the Cleviprex rep so that I will listen to their data and hear how the drug works etc, will take un-godly amounts of money, trips, dinners, shows, from special interest groups that tell them how to vote.


Very upsetting...

cool post by the way.

 

[dhb]

I would like to know what the ASA says about these situations as here in the US we live under the scrutiny of lawyers (more so than most all other countries).

I'm not a stud on medico-legal issues but i'm pretty sure you would be hung out to dry in europe if you were to refuse care except if you can prove major instability of the patient you are taking care of.