Practice Economics

Providers typically rely on the “key components” (history, exam, medical decision-making) when documenting in the medical record. However, there are instances when the majority of the encounter constitutes counseling/coordination of care (C/CC). Physicians might only document a brief history and exam, or nothing at all. Utilizing time-based billing principles allows a physician to disregard the “key component” requirements and select a visit level reflective of this effort.

For example, a 64-year-old female is hospitalized with newly diagnosed diabetes and requires extensive counseling regarding disease management, lifestyle modification, and medication regime, as well as coordination of care for outpatient programs and services. The hospitalist reviews some of the pertinent information with the patient and leaves the room to coordinate the patient’s ongoing care (25 minutes). The hospitalist then asks a resident to assist with the remaining counseling efforts (20 minutes). Code 99232 (inpatient visit, 25 minutes total visit time) would be appropriate to report.

Counseling, Coordination of Care

Time may be used as the determining factor for the visit level, if more than 50% of the total visit time involves C/CC.¹ Time is not used for visit-level selection if C/CC is minimal or absent from the patient encounter. Total visit time is acknowledged as the physician’s face-to-face (i.e. bedside) time combined with time spent on the unit/floor reviewing data, obtaining relevant patient information, and discussing the individual case with other involved healthcare providers.

Time associated with activities performed outside of the patient’s unit/floor is not considered when calculating total visit time. Time associated with teaching students/interns also is excluded; only the attending physician’s time counts.

When the requirements have been met, the physician selects the visit level that corresponds with the documented total visit time (see Table 1). In the scenario above, the visit level is chosen based on the attending physician’s documented time (25 minutes). The resident’s time cannot be included.

click for large version

Documentation Requirements

Physicians must document the interaction during the patient encounter: history and exam, if updated or performed; discussion points; and patient response, if applicable. The medical record entry must contain both the C/CC time and the total visit time.² “Total visit time=35 minutes; >50% spent counseling/coordinating care” or “20 of 35 minutes spent counseling/coordinating care.”

A payor may prefer one documentation style over another. It is always best to ask about the payor’s policy and review local documentation standards to ensure compliance.

Family Discussions

Physicians are always involved in family discussions. It is appropriate to count this as C/CC time. In the event that the family discussion takes place without the patient present, only count this as C/CC time if:

• The patient is unable or clinically incompetent to participate in discussions;
• The time is spent on the unit/floor with the family members or surrogate decision-makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment; and
• The conversation bears directly on the management of the patient.⁴

The medical record should reflect these criteria. Do not consider the time if the discussion takes place in an area outside of the patient’s unit/floor, or if the time is spent counseling family members through their grieving process.

It is not uncommon for the family discussion to take place later in the day, after the physician has made earlier rounds. If the earlier encounter involved C/CC, the physician would report the cumulative time spent for that service date. If the earlier encounter was a typical patient evaluation (i.e. history update and physical) and management service (i.e. care plan review/revision), this second encounter might be regarded as a prolonged care service.

Prolonged Care

Prolonged care codes exist for both outpatient and inpatient services. A hospitalists’ focus involves the inpatient code series:

99356: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, first hour; and

99357: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, each additional 30 minutes.

click for large version

Code 99356 is reported during the first hour of prolonged services, after the initial 30 minutes is reached; code 99357 is reported for each additional 30 minutes of prolonged care beyond the first hour, after the first 15 minutes of each additional segment. Both are “add on” codes and cannot be reported alone on a claim form; a “primary” code must be reported. Similarly, 99357 cannot be reported without 99356, and 99356 must be reported with one of the following inpatient service (primary) codes: 99218-99220, 99221-99223, 99231-99233, 99251-99255, 99304-99310. Only one unit of 99356 may be reported per patient per physician group per day, whereas multiple units of 99357 may be reported in a single day.

The CPT definition of prolonged care varies from that of the Centers for Medicare & Medicaid Services (CMS). Since 2009, CPT recognizes the total duration spent by a physician on a given date, even if the time spent by the physician on that date is not continuous; the time involves both face-to-face time and unit/floor time.⁵ CMS only attributes direct face-to-face time between the physician and the patient toward prolonged care billing. Time spent reviewing charts or discussion of a patient with house medical staff, waiting for test results, waiting for changes in the patient’s condition, waiting for end of a therapy session, or waiting for use of facilities cannot be billed as prolonged services.5 This is in direct opposition to its policy for C/CC services, and makes prolonged care services inefficient.

Medicare also identifies “threshold” time (see Table 2). The total physician visit time must exceed the time requirements associated with the “primary” codes by a 30-minute threshold (e.g. 99221+99356=30 minutes+30 minutes=60 minutes threshold time). The physician must document the total face-to-face time spent in separate notes throughout the day or, more realistically, in one cumulative note.

When two providers from the same group and same specialty perform services on the same date (e.g. physician A saw the patient during morning rounds, and physician B spoke with the patient/family in the afternoon), only one physician can report the cumulative service.⁶ As always, query payors for coverage, because some non-Medicare insurers do not recognize these codes.

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. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
2. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.1C. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
3. Centers for Medicare & Medicaid Services (CMS). Medicare National Coverage Determinations Manual: Chapter 1, Section 70.1. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed Jan. 8, 2012.
4. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
5. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:7-21.
6. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.5. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.

Providers typically rely on the “key components” (history, exam, medical decision-making) when documenting in the medical record. However, there are instances when the majority of the encounter constitutes counseling/coordination of care (C/CC). Physicians might only document a brief history and exam, or nothing at all. Utilizing time-based billing principles allows a physician to disregard the “key component” requirements and select a visit level reflective of this effort.

For example, a 64-year-old female is hospitalized with newly diagnosed diabetes and requires extensive counseling regarding disease management, lifestyle modification, and medication regime, as well as coordination of care for outpatient programs and services. The hospitalist reviews some of the pertinent information with the patient and leaves the room to coordinate the patient’s ongoing care (25 minutes). The hospitalist then asks a resident to assist with the remaining counseling efforts (20 minutes). Code 99232 (inpatient visit, 25 minutes total visit time) would be appropriate to report.

Counseling, Coordination of Care

Time may be used as the determining factor for the visit level, if more than 50% of the total visit time involves C/CC.¹ Time is not used for visit-level selection if C/CC is minimal or absent from the patient encounter. Total visit time is acknowledged as the physician’s face-to-face (i.e. bedside) time combined with time spent on the unit/floor reviewing data, obtaining relevant patient information, and discussing the individual case with other involved healthcare providers.

Time associated with activities performed outside of the patient’s unit/floor is not considered when calculating total visit time. Time associated with teaching students/interns also is excluded; only the attending physician’s time counts.

When the requirements have been met, the physician selects the visit level that corresponds with the documented total visit time (see Table 1). In the scenario above, the visit level is chosen based on the attending physician’s documented time (25 minutes). The resident’s time cannot be included.

click for large version

Documentation Requirements

Physicians must document the interaction during the patient encounter: history and exam, if updated or performed; discussion points; and patient response, if applicable. The medical record entry must contain both the C/CC time and the total visit time.² “Total visit time=35 minutes; >50% spent counseling/coordinating care” or “20 of 35 minutes spent counseling/coordinating care.”

A payor may prefer one documentation style over another. It is always best to ask about the payor’s policy and review local documentation standards to ensure compliance.

Family Discussions

Physicians are always involved in family discussions. It is appropriate to count this as C/CC time. In the event that the family discussion takes place without the patient present, only count this as C/CC time if:

• The patient is unable or clinically incompetent to participate in discussions;
• The time is spent on the unit/floor with the family members or surrogate decision-makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment; and
• The conversation bears directly on the management of the patient.⁴

The medical record should reflect these criteria. Do not consider the time if the discussion takes place in an area outside of the patient’s unit/floor, or if the time is spent counseling family members through their grieving process.

It is not uncommon for the family discussion to take place later in the day, after the physician has made earlier rounds. If the earlier encounter involved C/CC, the physician would report the cumulative time spent for that service date. If the earlier encounter was a typical patient evaluation (i.e. history update and physical) and management service (i.e. care plan review/revision), this second encounter might be regarded as a prolonged care service.

Prolonged Care

Prolonged care codes exist for both outpatient and inpatient services. A hospitalists’ focus involves the inpatient code series:

99356: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, first hour; and

99357: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, each additional 30 minutes.

click for large version

Code 99356 is reported during the first hour of prolonged services, after the initial 30 minutes is reached; code 99357 is reported for each additional 30 minutes of prolonged care beyond the first hour, after the first 15 minutes of each additional segment. Both are “add on” codes and cannot be reported alone on a claim form; a “primary” code must be reported. Similarly, 99357 cannot be reported without 99356, and 99356 must be reported with one of the following inpatient service (primary) codes: 99218-99220, 99221-99223, 99231-99233, 99251-99255, 99304-99310. Only one unit of 99356 may be reported per patient per physician group per day, whereas multiple units of 99357 may be reported in a single day.

The CPT definition of prolonged care varies from that of the Centers for Medicare & Medicaid Services (CMS). Since 2009, CPT recognizes the total duration spent by a physician on a given date, even if the time spent by the physician on that date is not continuous; the time involves both face-to-face time and unit/floor time.⁵ CMS only attributes direct face-to-face time between the physician and the patient toward prolonged care billing. Time spent reviewing charts or discussion of a patient with house medical staff, waiting for test results, waiting for changes in the patient’s condition, waiting for end of a therapy session, or waiting for use of facilities cannot be billed as prolonged services.5 This is in direct opposition to its policy for C/CC services, and makes prolonged care services inefficient.

Medicare also identifies “threshold” time (see Table 2). The total physician visit time must exceed the time requirements associated with the “primary” codes by a 30-minute threshold (e.g. 99221+99356=30 minutes+30 minutes=60 minutes threshold time). The physician must document the total face-to-face time spent in separate notes throughout the day or, more realistically, in one cumulative note.

When two providers from the same group and same specialty perform services on the same date (e.g. physician A saw the patient during morning rounds, and physician B spoke with the patient/family in the afternoon), only one physician can report the cumulative service.⁶ As always, query payors for coverage, because some non-Medicare insurers do not recognize these codes.

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. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
2. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.1C. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
3. Centers for Medicare & Medicaid Services (CMS). Medicare National Coverage Determinations Manual: Chapter 1, Section 70.1. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed Jan. 8, 2012.
4. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
5. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:7-21.
6. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.5. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.

Providers typically rely on the “key components” (history, exam, medical decision-making) when documenting in the medical record. However, there are instances when the majority of the encounter constitutes counseling/coordination of care (C/CC). Physicians might only document a brief history and exam, or nothing at all. Utilizing time-based billing principles allows a physician to disregard the “key component” requirements and select a visit level reflective of this effort.

For example, a 64-year-old female is hospitalized with newly diagnosed diabetes and requires extensive counseling regarding disease management, lifestyle modification, and medication regime, as well as coordination of care for outpatient programs and services. The hospitalist reviews some of the pertinent information with the patient and leaves the room to coordinate the patient’s ongoing care (25 minutes). The hospitalist then asks a resident to assist with the remaining counseling efforts (20 minutes). Code 99232 (inpatient visit, 25 minutes total visit time) would be appropriate to report.

Counseling, Coordination of Care

Time may be used as the determining factor for the visit level, if more than 50% of the total visit time involves C/CC.¹ Time is not used for visit-level selection if C/CC is minimal or absent from the patient encounter. Total visit time is acknowledged as the physician’s face-to-face (i.e. bedside) time combined with time spent on the unit/floor reviewing data, obtaining relevant patient information, and discussing the individual case with other involved healthcare providers.

Time associated with activities performed outside of the patient’s unit/floor is not considered when calculating total visit time. Time associated with teaching students/interns also is excluded; only the attending physician’s time counts.

When the requirements have been met, the physician selects the visit level that corresponds with the documented total visit time (see Table 1). In the scenario above, the visit level is chosen based on the attending physician’s documented time (25 minutes). The resident’s time cannot be included.

click for large version

Documentation Requirements

Physicians must document the interaction during the patient encounter: history and exam, if updated or performed; discussion points; and patient response, if applicable. The medical record entry must contain both the C/CC time and the total visit time.² “Total visit time=35 minutes; >50% spent counseling/coordinating care” or “20 of 35 minutes spent counseling/coordinating care.”

A payor may prefer one documentation style over another. It is always best to ask about the payor’s policy and review local documentation standards to ensure compliance.

Family Discussions

Physicians are always involved in family discussions. It is appropriate to count this as C/CC time. In the event that the family discussion takes place without the patient present, only count this as C/CC time if:

• The patient is unable or clinically incompetent to participate in discussions;
• The time is spent on the unit/floor with the family members or surrogate decision-makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment; and
• The conversation bears directly on the management of the patient.⁴

The medical record should reflect these criteria. Do not consider the time if the discussion takes place in an area outside of the patient’s unit/floor, or if the time is spent counseling family members through their grieving process.

It is not uncommon for the family discussion to take place later in the day, after the physician has made earlier rounds. If the earlier encounter involved C/CC, the physician would report the cumulative time spent for that service date. If the earlier encounter was a typical patient evaluation (i.e. history update and physical) and management service (i.e. care plan review/revision), this second encounter might be regarded as a prolonged care service.

Prolonged Care

Prolonged care codes exist for both outpatient and inpatient services. A hospitalists’ focus involves the inpatient code series:

99356: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, first hour; and

99357: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, each additional 30 minutes.

click for large version

Code 99356 is reported during the first hour of prolonged services, after the initial 30 minutes is reached; code 99357 is reported for each additional 30 minutes of prolonged care beyond the first hour, after the first 15 minutes of each additional segment. Both are “add on” codes and cannot be reported alone on a claim form; a “primary” code must be reported. Similarly, 99357 cannot be reported without 99356, and 99356 must be reported with one of the following inpatient service (primary) codes: 99218-99220, 99221-99223, 99231-99233, 99251-99255, 99304-99310. Only one unit of 99356 may be reported per patient per physician group per day, whereas multiple units of 99357 may be reported in a single day.

The CPT definition of prolonged care varies from that of the Centers for Medicare & Medicaid Services (CMS). Since 2009, CPT recognizes the total duration spent by a physician on a given date, even if the time spent by the physician on that date is not continuous; the time involves both face-to-face time and unit/floor time.⁵ CMS only attributes direct face-to-face time between the physician and the patient toward prolonged care billing. Time spent reviewing charts or discussion of a patient with house medical staff, waiting for test results, waiting for changes in the patient’s condition, waiting for end of a therapy session, or waiting for use of facilities cannot be billed as prolonged services.5 This is in direct opposition to its policy for C/CC services, and makes prolonged care services inefficient.

Medicare also identifies “threshold” time (see Table 2). The total physician visit time must exceed the time requirements associated with the “primary” codes by a 30-minute threshold (e.g. 99221+99356=30 minutes+30 minutes=60 minutes threshold time). The physician must document the total face-to-face time spent in separate notes throughout the day or, more realistically, in one cumulative note.

When two providers from the same group and same specialty perform services on the same date (e.g. physician A saw the patient during morning rounds, and physician B spoke with the patient/family in the afternoon), only one physician can report the cumulative service.⁶ As always, query payors for coverage, because some non-Medicare insurers do not recognize these codes.

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. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
2. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.1C. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
3. Centers for Medicare & Medicaid Services (CMS). Medicare National Coverage Determinations Manual: Chapter 1, Section 70.1. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed Jan. 8, 2012.
4. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
5. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:7-21.
6. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.5. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.

click for large version

click for large version

click for large version

Physicians should formulate a complete and accurate description of a patient’s condition with an equivalent plan of care for each encounter. While acuity and severity can be inferred by healthcare professionals without excessive detail or repetitive documentation of previously entered information, adequate documentation for every service date assists in conveying patient complexity during medical record review.

Regardless of how complex a patient’s condition might be, physicians tend to undervalue their services. This is due, in part, to the routine nature of patient care for seasoned physicians; it is also due in part to a general lack of understanding with respect to the documentation guidelines.

Consider the following scenario: A 68-year-old male with diabetes and a history of chronic obstructive bronchitis was hospitalized after a five-day history of progressive cough with increasing purulent sputum, shortness of breath, and fever. He was treated for an exacerbation of chronic bronchitis within the past six weeks. Upon admission, the patient had an increased temperature (102°F), increased heart rate (96 beats per minute), and increased respiratory rate (28 shallow breaths per minute). His breath sounds included in the right lower lobe rhonchi, and his pulse oximetry was 89% on room air. Chest X-ray confirmed right lower lobe infiltrates along with chronic changes.

Although some physicians would consider this “low complexity” due to the frequency in which they encounter this type of case, others will more appropriately identify this as moderately complex.

MDM Categories

Medical decision-making (MDM) remains consistent in both the 1995 and 1997 guidelines.^1,2 Complexity is categorized as straightforward, low, moderate, or high, based on the content of physician documentation. Each visit level is associated with a particular level of complexity. Only the care plan for a given date of service is considered when assigning MDM complexity. For each encounter, the physician receives credit for the number of diagnoses and/or treatment options, the amount and/or complexity of data ordered/reviewed, and the risk of complications/morbidity/mortality (see Table 1).

Number of diagnoses or treatment options. Physicians should document problems addressed and managed daily despite any changes to the treatment plan. Credit is provided for each problem with an associated plan, even if the plan states “continue treatment.” Credit also depends upon the quantity of problems addressed, as well as the problem type. An established problem in which the care plan has been established by the physician or group practice member during the current hospitalization is less complex than a new problem for which a diagnosis, prognosis, or plan has not been determined. Severity of the problem affects the weight of complexity. A worsening problem is more complex than an improving problem. Physician documentation should:

• Identify all problems managed or addressed during each encounter;
• Identify problems as stable or progressing, when appropriate;
• Indicate differential diagnoses when the problem remains undefined;
• Indicate the management/treatment option(s) for each problem; and
• When documentation indicates a continuation of current management options (e.g. “continue meds”), be sure that the management options to be continued are noted somewhere in the progress note for that encounter (e.g. medication list).

The plan of care outlines problems that the physician personally manages and those that impact management options, even if another physician directly oversees the problem. For example, the hospitalist might primarily manage diabetes, while the pulmonologist manages pneumonia. Since the pneumonia may impact the hospitalist’s plan for diabetic management, the hospitalist can receive credit for the pneumonia diagnosis if there is a non-overlapping, hospitalist-related care plan or comment about the pneumonia.

Amount and/or complexity of data ordered/reviewed. “Data” is classified as pathology/laboratory testing, radiology, and medicine-based diagnostics. Pertinent orders or results could be noted in the visit record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:

• Specify tests ordered and rationale in the physician’s progress note or make an entry that refers to another auditor-accessible location for ordered tests and studies;
• Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”);
• Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary;
• Indicate when images, tracings, or specimens are “personally reviewed”; and
• Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.

Risks of complication and/or morbidity or mortality. Risk involves the patient’s presenting problem, diagnostic procedures ordered, and management options selected. It is measured as minimal, low, moderate, or high when compared with corresponding items assigned to each risk level (see Table 2). The highest individual item detected on the table determines the overall patient risk for that encounter.

Chronic conditions and invasive procedures pose more risk than acute, uncomplicated illnesses or non-invasive procedures. Stable or improving problems are not as menacing as progressing problems; minor exacerbations are less hazardous than severe exacerbations; and medication risk varies with the type and potential for adverse effects. A patient maintains the same level of risk for a given medication whether the dosage is increased, decreased, or continued without change. Physicians should:

• Status all problems in the plan of care; identify them as stable, worsening, exacerbating (mild or severe), when applicable;
• Document all diagnostic or therapeutic procedures considered;
• Identify surgical risk factors involving comorbid conditions, when appropriate; and
• Associate the labs ordered to monitor for toxicity with the corresponding medication (e.g. “Continue Coumadin, monitor PT/INR”).

Determining complexity of medical decision-making. The final complexity of MDM depends upon the second-highest MDM category. The physician does not have to meet the requirements for all three MDM categories. For example, if a physician satisfies the requirements for a “multiple” number of diagnoses/treatment options, “limited” data, and “high” risk, the physician achieves moderate complexity decision-making (see Table 3). Remember that decision-making is just one of three components in evaluation and management services, along with history and exam.

Beware of payor variation, as it could have a significant impact on visit-level selection.³ Become acquainted with rules applicable to the geographical area. Review insurer websites for guidelines, policies, and “frequently asked questions” that can help improve documentation skills and support billing practices.

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. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf. Accessed Nov. 14, 2011.
2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed Nov. 14, 2011.
3. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, IL: American College of Chest Physicians, 2009; 87-118.
4. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011:1-20.

click for large version

click for large version

click for large version

Physicians should formulate a complete and accurate description of a patient’s condition with an equivalent plan of care for each encounter. While acuity and severity can be inferred by healthcare professionals without excessive detail or repetitive documentation of previously entered information, adequate documentation for every service date assists in conveying patient complexity during medical record review.

Regardless of how complex a patient’s condition might be, physicians tend to undervalue their services. This is due, in part, to the routine nature of patient care for seasoned physicians; it is also due in part to a general lack of understanding with respect to the documentation guidelines.

Consider the following scenario: A 68-year-old male with diabetes and a history of chronic obstructive bronchitis was hospitalized after a five-day history of progressive cough with increasing purulent sputum, shortness of breath, and fever. He was treated for an exacerbation of chronic bronchitis within the past six weeks. Upon admission, the patient had an increased temperature (102°F), increased heart rate (96 beats per minute), and increased respiratory rate (28 shallow breaths per minute). His breath sounds included in the right lower lobe rhonchi, and his pulse oximetry was 89% on room air. Chest X-ray confirmed right lower lobe infiltrates along with chronic changes.

Although some physicians would consider this “low complexity” due to the frequency in which they encounter this type of case, others will more appropriately identify this as moderately complex.

MDM Categories

Medical decision-making (MDM) remains consistent in both the 1995 and 1997 guidelines.^1,2 Complexity is categorized as straightforward, low, moderate, or high, based on the content of physician documentation. Each visit level is associated with a particular level of complexity. Only the care plan for a given date of service is considered when assigning MDM complexity. For each encounter, the physician receives credit for the number of diagnoses and/or treatment options, the amount and/or complexity of data ordered/reviewed, and the risk of complications/morbidity/mortality (see Table 1).

Number of diagnoses or treatment options. Physicians should document problems addressed and managed daily despite any changes to the treatment plan. Credit is provided for each problem with an associated plan, even if the plan states “continue treatment.” Credit also depends upon the quantity of problems addressed, as well as the problem type. An established problem in which the care plan has been established by the physician or group practice member during the current hospitalization is less complex than a new problem for which a diagnosis, prognosis, or plan has not been determined. Severity of the problem affects the weight of complexity. A worsening problem is more complex than an improving problem. Physician documentation should:

• Identify all problems managed or addressed during each encounter;
• Identify problems as stable or progressing, when appropriate;
• Indicate differential diagnoses when the problem remains undefined;
• Indicate the management/treatment option(s) for each problem; and
• When documentation indicates a continuation of current management options (e.g. “continue meds”), be sure that the management options to be continued are noted somewhere in the progress note for that encounter (e.g. medication list).

The plan of care outlines problems that the physician personally manages and those that impact management options, even if another physician directly oversees the problem. For example, the hospitalist might primarily manage diabetes, while the pulmonologist manages pneumonia. Since the pneumonia may impact the hospitalist’s plan for diabetic management, the hospitalist can receive credit for the pneumonia diagnosis if there is a non-overlapping, hospitalist-related care plan or comment about the pneumonia.

Amount and/or complexity of data ordered/reviewed. “Data” is classified as pathology/laboratory testing, radiology, and medicine-based diagnostics. Pertinent orders or results could be noted in the visit record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:

• Specify tests ordered and rationale in the physician’s progress note or make an entry that refers to another auditor-accessible location for ordered tests and studies;
• Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”);
• Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary;
• Indicate when images, tracings, or specimens are “personally reviewed”; and
• Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.

Risks of complication and/or morbidity or mortality. Risk involves the patient’s presenting problem, diagnostic procedures ordered, and management options selected. It is measured as minimal, low, moderate, or high when compared with corresponding items assigned to each risk level (see Table 2). The highest individual item detected on the table determines the overall patient risk for that encounter.

Chronic conditions and invasive procedures pose more risk than acute, uncomplicated illnesses or non-invasive procedures. Stable or improving problems are not as menacing as progressing problems; minor exacerbations are less hazardous than severe exacerbations; and medication risk varies with the type and potential for adverse effects. A patient maintains the same level of risk for a given medication whether the dosage is increased, decreased, or continued without change. Physicians should:

• Status all problems in the plan of care; identify them as stable, worsening, exacerbating (mild or severe), when applicable;
• Document all diagnostic or therapeutic procedures considered;
• Identify surgical risk factors involving comorbid conditions, when appropriate; and
• Associate the labs ordered to monitor for toxicity with the corresponding medication (e.g. “Continue Coumadin, monitor PT/INR”).

Determining complexity of medical decision-making. The final complexity of MDM depends upon the second-highest MDM category. The physician does not have to meet the requirements for all three MDM categories. For example, if a physician satisfies the requirements for a “multiple” number of diagnoses/treatment options, “limited” data, and “high” risk, the physician achieves moderate complexity decision-making (see Table 3). Remember that decision-making is just one of three components in evaluation and management services, along with history and exam.

Beware of payor variation, as it could have a significant impact on visit-level selection.³ Become acquainted with rules applicable to the geographical area. Review insurer websites for guidelines, policies, and “frequently asked questions” that can help improve documentation skills and support billing practices.

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. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf. Accessed Nov. 14, 2011.
2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed Nov. 14, 2011.
3. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, IL: American College of Chest Physicians, 2009; 87-118.
4. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011:1-20.

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Physicians should formulate a complete and accurate description of a patient’s condition with an equivalent plan of care for each encounter. While acuity and severity can be inferred by healthcare professionals without excessive detail or repetitive documentation of previously entered information, adequate documentation for every service date assists in conveying patient complexity during medical record review.

Regardless of how complex a patient’s condition might be, physicians tend to undervalue their services. This is due, in part, to the routine nature of patient care for seasoned physicians; it is also due in part to a general lack of understanding with respect to the documentation guidelines.

Consider the following scenario: A 68-year-old male with diabetes and a history of chronic obstructive bronchitis was hospitalized after a five-day history of progressive cough with increasing purulent sputum, shortness of breath, and fever. He was treated for an exacerbation of chronic bronchitis within the past six weeks. Upon admission, the patient had an increased temperature (102°F), increased heart rate (96 beats per minute), and increased respiratory rate (28 shallow breaths per minute). His breath sounds included in the right lower lobe rhonchi, and his pulse oximetry was 89% on room air. Chest X-ray confirmed right lower lobe infiltrates along with chronic changes.

Although some physicians would consider this “low complexity” due to the frequency in which they encounter this type of case, others will more appropriately identify this as moderately complex.

MDM Categories

Medical decision-making (MDM) remains consistent in both the 1995 and 1997 guidelines.^1,2 Complexity is categorized as straightforward, low, moderate, or high, based on the content of physician documentation. Each visit level is associated with a particular level of complexity. Only the care plan for a given date of service is considered when assigning MDM complexity. For each encounter, the physician receives credit for the number of diagnoses and/or treatment options, the amount and/or complexity of data ordered/reviewed, and the risk of complications/morbidity/mortality (see Table 1).

Number of diagnoses or treatment options. Physicians should document problems addressed and managed daily despite any changes to the treatment plan. Credit is provided for each problem with an associated plan, even if the plan states “continue treatment.” Credit also depends upon the quantity of problems addressed, as well as the problem type. An established problem in which the care plan has been established by the physician or group practice member during the current hospitalization is less complex than a new problem for which a diagnosis, prognosis, or plan has not been determined. Severity of the problem affects the weight of complexity. A worsening problem is more complex than an improving problem. Physician documentation should:

• Identify all problems managed or addressed during each encounter;
• Identify problems as stable or progressing, when appropriate;
• Indicate differential diagnoses when the problem remains undefined;
• Indicate the management/treatment option(s) for each problem; and
• When documentation indicates a continuation of current management options (e.g. “continue meds”), be sure that the management options to be continued are noted somewhere in the progress note for that encounter (e.g. medication list).

The plan of care outlines problems that the physician personally manages and those that impact management options, even if another physician directly oversees the problem. For example, the hospitalist might primarily manage diabetes, while the pulmonologist manages pneumonia. Since the pneumonia may impact the hospitalist’s plan for diabetic management, the hospitalist can receive credit for the pneumonia diagnosis if there is a non-overlapping, hospitalist-related care plan or comment about the pneumonia.

Amount and/or complexity of data ordered/reviewed. “Data” is classified as pathology/laboratory testing, radiology, and medicine-based diagnostics. Pertinent orders or results could be noted in the visit record, but most of the background interactions and communications involving testing are undetected when reviewing the progress note. To receive credit:

• Specify tests ordered and rationale in the physician’s progress note or make an entry that refers to another auditor-accessible location for ordered tests and studies;
• Document test review by including a brief entry in the progress note (e.g. “elevated glucose levels” or “CXR shows RLL infiltrates”);
• Summarize key points when reviewing old records or obtaining history from someone other than the patient, as necessary;
• Indicate when images, tracings, or specimens are “personally reviewed”; and
• Summarize any discussions of unexpected or contradictory test results with the physician performing the procedure or diagnostic study.

Risks of complication and/or morbidity or mortality. Risk involves the patient’s presenting problem, diagnostic procedures ordered, and management options selected. It is measured as minimal, low, moderate, or high when compared with corresponding items assigned to each risk level (see Table 2). The highest individual item detected on the table determines the overall patient risk for that encounter.

Chronic conditions and invasive procedures pose more risk than acute, uncomplicated illnesses or non-invasive procedures. Stable or improving problems are not as menacing as progressing problems; minor exacerbations are less hazardous than severe exacerbations; and medication risk varies with the type and potential for adverse effects. A patient maintains the same level of risk for a given medication whether the dosage is increased, decreased, or continued without change. Physicians should:

• Status all problems in the plan of care; identify them as stable, worsening, exacerbating (mild or severe), when applicable;
• Document all diagnostic or therapeutic procedures considered;
• Identify surgical risk factors involving comorbid conditions, when appropriate; and
• Associate the labs ordered to monitor for toxicity with the corresponding medication (e.g. “Continue Coumadin, monitor PT/INR”).

Determining complexity of medical decision-making. The final complexity of MDM depends upon the second-highest MDM category. The physician does not have to meet the requirements for all three MDM categories. For example, if a physician satisfies the requirements for a “multiple” number of diagnoses/treatment options, “limited” data, and “high” risk, the physician achieves moderate complexity decision-making (see Table 3). Remember that decision-making is just one of three components in evaluation and management services, along with history and exam.

Beware of payor variation, as it could have a significant impact on visit-level selection.³ Become acquainted with rules applicable to the geographical area. Review insurer websites for guidelines, policies, and “frequently asked questions” that can help improve documentation skills and support billing practices.

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. Centers for Medicare and Medicaid Services. 1995 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf. Accessed Nov. 14, 2011.
2. Centers for Medicare and Medicaid Services. 1997 Documentation Guidelines for Evaluation & Management Services. Available at: http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf. Accessed Nov. 14, 2011.
3. Pohlig, C. Documentation and Coding Evaluation and Management Services. In: Coding for Chest Medicine 2010. Northbrook, IL: American College of Chest Physicians, 2009; 87-118.
4. Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology Professional Edition. Chicago: American Medical Association Press; 2011:1-20.

The 2011 State of Hospital Medicine report offers some tantalizing insights into the operation of academic hospital medicine practices and how they compare with their nonacademic peers. Some results are not surprising, such as the fact that academic hospital medicine groups tend to be larger than nonacademic groups, and that compensation and clinical-FTE-adjusted productivity both tend to be lower for academic hospitalists. Interestingly, turnover rates were about the same in academic and nonacademic practices.

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Among the more unexpected findings, however, is that academic HM practices tend to employ a higher proportion of women (44%) than nonacademic practices (35%). In addition, academic practices employed a wider range of staffing models, with only 43% of practices using shift-based staffing, compared with 78% of nonacademic respondents. Similarly, only 47% of academic groups provided on-site coverage at night, compared with 81% of nonacademic groups.

Additional differences between the way academic and nonacademic HM groups staff their programs are shown in the table, “Other Staffing Arrangements.” While the use of nurse practitioners and physician assistants (PA) was similar for academic and nonacademic practices, academic groups were much less likely to utilize nocturnists, and far more likely to have a nonphysician first responder at night (resident, nonphysician provider/PA, or other) than nonacademic groups.

It will be interesting to follow these trends over time. Because of new resident work-hour limits that went into effect in July, SHM Practice Analysis Committee (PAC) member Andrew White, MD, expects that there will be very few places that continue to use residents to cross-cover at night. “I suspect most academic centers have or will hire nocturnists,” he says, “but we’ll see.”

On the other hand, PAC member Scarlett Blue, RN, believes that continued growth in HM, coupled with a competitive job market, could result in increased use of nonphysician first responders at night—and in general. “Hospital medicine group leaders who are looking for alternative ways to meet the supply-demand conundrum may find a blended physician-NP/PA team to be one such answer,” she says.

Finally, the clinical services provided by academic HM groups vary from their nonacademic counterparts in some other important ways. Only 25% of academic practices provide care for ICU patients, compared with 78% of nonacademic practices, while 75% of academic groups perform procedures, compared with only 52% of nonacademic groups. And while the overwhelming majority of both academic and nonacademic practices provide surgical comanagement, academic practices were more than twice as likely to provide comanagement for medical subspecialty patients (45%, compared with 20% for nonacademic practices).

PAC member Troy Ahlstrom, MD, explains, tongue-in-cheek, that “academic hospitalists don’t do procedures because they have oodles of residents, fellows, and interventional radiologists to do them instead, and academics do more medical comanagement because the subspecialist who only does Waldenstrom’s macroglobulinemia probably doesn’t do diabetes.”

Whatever the reason, there are meaningful differences between academic and nonacademic HM practices that bear watching over time. You can help us identify and track these differences by ensuring that your group participates in SHM’s annual State of Hospital Medicine survey, launching this month.

The 2011 State of Hospital Medicine report offers some tantalizing insights into the operation of academic hospital medicine practices and how they compare with their nonacademic peers. Some results are not surprising, such as the fact that academic hospital medicine groups tend to be larger than nonacademic groups, and that compensation and clinical-FTE-adjusted productivity both tend to be lower for academic hospitalists. Interestingly, turnover rates were about the same in academic and nonacademic practices.

click for large version

Among the more unexpected findings, however, is that academic HM practices tend to employ a higher proportion of women (44%) than nonacademic practices (35%). In addition, academic practices employed a wider range of staffing models, with only 43% of practices using shift-based staffing, compared with 78% of nonacademic respondents. Similarly, only 47% of academic groups provided on-site coverage at night, compared with 81% of nonacademic groups.

Additional differences between the way academic and nonacademic HM groups staff their programs are shown in the table, “Other Staffing Arrangements.” While the use of nurse practitioners and physician assistants (PA) was similar for academic and nonacademic practices, academic groups were much less likely to utilize nocturnists, and far more likely to have a nonphysician first responder at night (resident, nonphysician provider/PA, or other) than nonacademic groups.

It will be interesting to follow these trends over time. Because of new resident work-hour limits that went into effect in July, SHM Practice Analysis Committee (PAC) member Andrew White, MD, expects that there will be very few places that continue to use residents to cross-cover at night. “I suspect most academic centers have or will hire nocturnists,” he says, “but we’ll see.”

On the other hand, PAC member Scarlett Blue, RN, believes that continued growth in HM, coupled with a competitive job market, could result in increased use of nonphysician first responders at night—and in general. “Hospital medicine group leaders who are looking for alternative ways to meet the supply-demand conundrum may find a blended physician-NP/PA team to be one such answer,” she says.

Finally, the clinical services provided by academic HM groups vary from their nonacademic counterparts in some other important ways. Only 25% of academic practices provide care for ICU patients, compared with 78% of nonacademic practices, while 75% of academic groups perform procedures, compared with only 52% of nonacademic groups. And while the overwhelming majority of both academic and nonacademic practices provide surgical comanagement, academic practices were more than twice as likely to provide comanagement for medical subspecialty patients (45%, compared with 20% for nonacademic practices).

PAC member Troy Ahlstrom, MD, explains, tongue-in-cheek, that “academic hospitalists don’t do procedures because they have oodles of residents, fellows, and interventional radiologists to do them instead, and academics do more medical comanagement because the subspecialist who only does Waldenstrom’s macroglobulinemia probably doesn’t do diabetes.”

Whatever the reason, there are meaningful differences between academic and nonacademic HM practices that bear watching over time. You can help us identify and track these differences by ensuring that your group participates in SHM’s annual State of Hospital Medicine survey, launching this month.

The 2011 State of Hospital Medicine report offers some tantalizing insights into the operation of academic hospital medicine practices and how they compare with their nonacademic peers. Some results are not surprising, such as the fact that academic hospital medicine groups tend to be larger than nonacademic groups, and that compensation and clinical-FTE-adjusted productivity both tend to be lower for academic hospitalists. Interestingly, turnover rates were about the same in academic and nonacademic practices.

click for large version

Among the more unexpected findings, however, is that academic HM practices tend to employ a higher proportion of women (44%) than nonacademic practices (35%). In addition, academic practices employed a wider range of staffing models, with only 43% of practices using shift-based staffing, compared with 78% of nonacademic respondents. Similarly, only 47% of academic groups provided on-site coverage at night, compared with 81% of nonacademic groups.

Additional differences between the way academic and nonacademic HM groups staff their programs are shown in the table, “Other Staffing Arrangements.” While the use of nurse practitioners and physician assistants (PA) was similar for academic and nonacademic practices, academic groups were much less likely to utilize nocturnists, and far more likely to have a nonphysician first responder at night (resident, nonphysician provider/PA, or other) than nonacademic groups.

It will be interesting to follow these trends over time. Because of new resident work-hour limits that went into effect in July, SHM Practice Analysis Committee (PAC) member Andrew White, MD, expects that there will be very few places that continue to use residents to cross-cover at night. “I suspect most academic centers have or will hire nocturnists,” he says, “but we’ll see.”

On the other hand, PAC member Scarlett Blue, RN, believes that continued growth in HM, coupled with a competitive job market, could result in increased use of nonphysician first responders at night—and in general. “Hospital medicine group leaders who are looking for alternative ways to meet the supply-demand conundrum may find a blended physician-NP/PA team to be one such answer,” she says.

Finally, the clinical services provided by academic HM groups vary from their nonacademic counterparts in some other important ways. Only 25% of academic practices provide care for ICU patients, compared with 78% of nonacademic practices, while 75% of academic groups perform procedures, compared with only 52% of nonacademic groups. And while the overwhelming majority of both academic and nonacademic practices provide surgical comanagement, academic practices were more than twice as likely to provide comanagement for medical subspecialty patients (45%, compared with 20% for nonacademic practices).

PAC member Troy Ahlstrom, MD, explains, tongue-in-cheek, that “academic hospitalists don’t do procedures because they have oodles of residents, fellows, and interventional radiologists to do them instead, and academics do more medical comanagement because the subspecialist who only does Waldenstrom’s macroglobulinemia probably doesn’t do diabetes.”

Whatever the reason, there are meaningful differences between academic and nonacademic HM practices that bear watching over time. You can help us identify and track these differences by ensuring that your group participates in SHM’s annual State of Hospital Medicine survey, launching this month.

A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.

The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.

“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”

HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.

For the full survey, please visit www.antheliohealth.com and search “survey.”

A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.

The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.

“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”

HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.

For the full survey, please visit www.antheliohealth.com and search “survey.”

A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.

The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.

“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”

HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.

For the full survey, please visit www.antheliohealth.com and search “survey.”

It’s that time of year again. A new year is upon us. It’s resolution time.

I must admit, somewhat sheepishly, that I am a bit of “resolver.” What can I say? I like to resolve. I like to think about resolutions. I like to plan resolutions. I like to regale my uninterested wife with my resolutions. And I am, in fact, actually quite good at all phases of resolving, with one small exception—the follow-through.

You see, while I love to plan changes in my life, I’m horrible at making changes in my life. There’s nothing too shocking about that, I suppose. Most people fail when change is required. What is interesting, though, is that years of failure have yet to imbue me with the sense to stop resolving. I mean, how many times can a man fail at resolutions before he stumbles upon a resolution to stop resolving—a resolution I’d surely fail at?

But what are perhaps even more interesting are the things I’ve apparently resolved to do. I say “apparently” because not only do I typically not remember making the resolutions, but most often I also can’t even fathom why I’d resolve such things in the first place. But clearly I do. In fact, every year, I commit to about 10-20 resolutions. I actually write them down, threaten to make my wife read them, then stow them safely in my desk drawer, only to unearth them a year later to discover that I actually resolved to write a children’s book. True story; I just reviewed my resolutions from last year. I don’t remember why I put that on the list. But I did. And, of course, I failed—but I did, in fact, read a children’s book. Maybe that’s what I meant.

Over the years I’ve also resolved to make a hole-in-one, get better hair, and read War and Peace (on the toilet, during medical school). Fail, fail, and fail. The last one’s a great example of good intentions and no follow-through. Driven by the numerology (1,296 pages+1,296 days of medical school, excluding the last semester, of course, as most of us did=one page per day!) and the symbolism (medical school+grueling+war=challenging, long, grueling book about war) of the goal, I was ultimately undone by an inability to reliably differentiate a Bezukhov from a Bolkonsky, and constipation.

I bring this all up because it is time again for New Year’s resolutions. So here, in no particular order, are my 2012 resolutions.

Oh, That’s How Full Feels!

In 2012, I resolve to finally have a fully staffed HM group. From our group’s origins in 2003 to our current 30-member group, we have been intermittently understaffed to various degrees—a feeling I know most of you have experienced. For a couple of years we were fully staffed, but recent hospital expansions again place us at risk of being understaffed. As most of you know, it is exceedingly difficult to move the clinical, quality, and efficiency goals of a group forward without enough boots on the ground. So, if you’re in the market, the skiing in Colorado can’t be beat!

Appreciate VBP

I resolve to position our hospitalist group for the coming value-based purchasing world. We all know that the future belongs to those who can provide fundamental value—that is, higher-quality care at lower cost. This has been HM’s mantra the past decade. 2012 is the year I resolve to see our group fully realize this.

Leave the Cave

I resolve to (really) learn how to use Epic. We implemented our new Epic electronic health record in 2011. I’m a big proponent, but also a Luddite. I tinker around the edges of what is a truly powerful tool in advancing clinical care. I resolve to move past casual to highly functional user.

Make “10” Perfect

I resolve to figure out this new ICD-10 system. OK, technically it’s not “new.” It’s been complete since 1992 and in use in many countries for the better part of a decade. This is not a simple update of the ICD-9 system; rather, this is an entire overhaul that adds two more digits to the system. This takes the number of possible codes from 13,000 (ICD-9) to 68,000 (ICD-10). This allows for much more specificity and laterality—that is, you could have cellulitis of the right or left foot.

These changes are more than just job security for coders. The issue monetizes as payors decide not to pay for readmissions. Consider a patient who had a right-foot cellulitis, only to be admitted two weeks later with a left-foot cellulitis. ICD-9 does not have laterality, such that both stays would have the same code and the second admit could be denied as a 30-day readmission.

Twitter With Excitement

I resolve to figure out social media. I must admit that this is a red-alert, high-risk-of-failure resolution, partly because I don’t Facebook, tweet, or blog; heck, I’m not even LinkedIn! Additionally, I don’t have any friends. And finally, I just don’t get it. Then again, I didn’t get “The Simpsons” when they first came out. D’oh!

Get Hipper

And I resolve to re-enter the pop culture world in general. My social and cultural life came to a screeching halt near midnight on Sept. 29, 2007: One moment I was innocently watching the Colorado Rockies battle into their first playoffs in 12 years, and the next I was blasted onto a four-year hyper-blur of crying, spoon-feeding, and diaper-changing—for the non-parent readers, I’m describing child-rearing, not residency training, which is admittedly often marked by these same mileposts. Now 4 and 2 years old, my kiddos have finally reached the stages of self-care that allow for my gradual re-entry into the outside world.

As such, I resolve to go to a movie (in the theater) again. The last two movies we saw in the theatre in 2007 were chosen by my pregnant wife and contained an uncomfortable subliminal theme—Knocked Up (pregnant woman hates impregnating sloth of a man), Juno (pregnant woman has love-hate relationship with pasty, impregnating nerd in tight gym shorts).

I’m also interested to see what’s on TV and on the radio. When I last turned off the cathodes, “Lost” was big; ditto “The Sopranos.” And in a clearly ill-fated second season, “Dancing with the Stars” was well on its way to its undeniable cancellation. Musically, Britney was shaving her head and Jordin Sparks was edging out Sanjaya’s faux-hawk on “Idol.”

I’m also looking forward to learning what a Kardashian is (a sweater?), explaining the strange pull toward vampire romances, and discovering the difference between a Pippa and a Snooki. Should be fun. I just hope I don’t catch “Bieber Fever.”

Aspire To “Be The Cup”

Finally, in 2012, I resolve to live up to the coffee cup—you know, the Father’s Day 2011 gift emblazoned with “World’s Best Dad.” I’m sure you all feel this in your own way—that constant tension between work and life. In 2011, work won a few too many of the tug-o’-wars. Too many missed gymnastics lessons, soccer practices, parent events at daycare, and late dinners. 2012 will be different.

I resolve to teach my son the art of hitting a curveball (even if it’s off a tee) and my daughter her letters and numbers. The dogs will get more tennis balls, the wife fewer resolutions to review.

In fact, this year is going to be totally different. This is the year my to-do list doesn’t once again end as an “undid list.” This is the year I will accomplish my resolutions … not just one or two, but all of my resolutions.

And I might just write a children’s book for good measure.

Dr. Glasheen is The Hospitalist’s physician editor.

It’s that time of year again. A new year is upon us. It’s resolution time.

I must admit, somewhat sheepishly, that I am a bit of “resolver.” What can I say? I like to resolve. I like to think about resolutions. I like to plan resolutions. I like to regale my uninterested wife with my resolutions. And I am, in fact, actually quite good at all phases of resolving, with one small exception—the follow-through.

You see, while I love to plan changes in my life, I’m horrible at making changes in my life. There’s nothing too shocking about that, I suppose. Most people fail when change is required. What is interesting, though, is that years of failure have yet to imbue me with the sense to stop resolving. I mean, how many times can a man fail at resolutions before he stumbles upon a resolution to stop resolving—a resolution I’d surely fail at?

But what are perhaps even more interesting are the things I’ve apparently resolved to do. I say “apparently” because not only do I typically not remember making the resolutions, but most often I also can’t even fathom why I’d resolve such things in the first place. But clearly I do. In fact, every year, I commit to about 10-20 resolutions. I actually write them down, threaten to make my wife read them, then stow them safely in my desk drawer, only to unearth them a year later to discover that I actually resolved to write a children’s book. True story; I just reviewed my resolutions from last year. I don’t remember why I put that on the list. But I did. And, of course, I failed—but I did, in fact, read a children’s book. Maybe that’s what I meant.

Over the years I’ve also resolved to make a hole-in-one, get better hair, and read War and Peace (on the toilet, during medical school). Fail, fail, and fail. The last one’s a great example of good intentions and no follow-through. Driven by the numerology (1,296 pages+1,296 days of medical school, excluding the last semester, of course, as most of us did=one page per day!) and the symbolism (medical school+grueling+war=challenging, long, grueling book about war) of the goal, I was ultimately undone by an inability to reliably differentiate a Bezukhov from a Bolkonsky, and constipation.

I bring this all up because it is time again for New Year’s resolutions. So here, in no particular order, are my 2012 resolutions.

Oh, That’s How Full Feels!

In 2012, I resolve to finally have a fully staffed HM group. From our group’s origins in 2003 to our current 30-member group, we have been intermittently understaffed to various degrees—a feeling I know most of you have experienced. For a couple of years we were fully staffed, but recent hospital expansions again place us at risk of being understaffed. As most of you know, it is exceedingly difficult to move the clinical, quality, and efficiency goals of a group forward without enough boots on the ground. So, if you’re in the market, the skiing in Colorado can’t be beat!

Appreciate VBP

I resolve to position our hospitalist group for the coming value-based purchasing world. We all know that the future belongs to those who can provide fundamental value—that is, higher-quality care at lower cost. This has been HM’s mantra the past decade. 2012 is the year I resolve to see our group fully realize this.

Leave the Cave

I resolve to (really) learn how to use Epic. We implemented our new Epic electronic health record in 2011. I’m a big proponent, but also a Luddite. I tinker around the edges of what is a truly powerful tool in advancing clinical care. I resolve to move past casual to highly functional user.

Make “10” Perfect

I resolve to figure out this new ICD-10 system. OK, technically it’s not “new.” It’s been complete since 1992 and in use in many countries for the better part of a decade. This is not a simple update of the ICD-9 system; rather, this is an entire overhaul that adds two more digits to the system. This takes the number of possible codes from 13,000 (ICD-9) to 68,000 (ICD-10). This allows for much more specificity and laterality—that is, you could have cellulitis of the right or left foot.

These changes are more than just job security for coders. The issue monetizes as payors decide not to pay for readmissions. Consider a patient who had a right-foot cellulitis, only to be admitted two weeks later with a left-foot cellulitis. ICD-9 does not have laterality, such that both stays would have the same code and the second admit could be denied as a 30-day readmission.

Twitter With Excitement

I resolve to figure out social media. I must admit that this is a red-alert, high-risk-of-failure resolution, partly because I don’t Facebook, tweet, or blog; heck, I’m not even LinkedIn! Additionally, I don’t have any friends. And finally, I just don’t get it. Then again, I didn’t get “The Simpsons” when they first came out. D’oh!

Get Hipper

And I resolve to re-enter the pop culture world in general. My social and cultural life came to a screeching halt near midnight on Sept. 29, 2007: One moment I was innocently watching the Colorado Rockies battle into their first playoffs in 12 years, and the next I was blasted onto a four-year hyper-blur of crying, spoon-feeding, and diaper-changing—for the non-parent readers, I’m describing child-rearing, not residency training, which is admittedly often marked by these same mileposts. Now 4 and 2 years old, my kiddos have finally reached the stages of self-care that allow for my gradual re-entry into the outside world.

As such, I resolve to go to a movie (in the theater) again. The last two movies we saw in the theatre in 2007 were chosen by my pregnant wife and contained an uncomfortable subliminal theme—Knocked Up (pregnant woman hates impregnating sloth of a man), Juno (pregnant woman has love-hate relationship with pasty, impregnating nerd in tight gym shorts).

I’m also interested to see what’s on TV and on the radio. When I last turned off the cathodes, “Lost” was big; ditto “The Sopranos.” And in a clearly ill-fated second season, “Dancing with the Stars” was well on its way to its undeniable cancellation. Musically, Britney was shaving her head and Jordin Sparks was edging out Sanjaya’s faux-hawk on “Idol.”

I’m also looking forward to learning what a Kardashian is (a sweater?), explaining the strange pull toward vampire romances, and discovering the difference between a Pippa and a Snooki. Should be fun. I just hope I don’t catch “Bieber Fever.”

Aspire To “Be The Cup”

Finally, in 2012, I resolve to live up to the coffee cup—you know, the Father’s Day 2011 gift emblazoned with “World’s Best Dad.” I’m sure you all feel this in your own way—that constant tension between work and life. In 2011, work won a few too many of the tug-o’-wars. Too many missed gymnastics lessons, soccer practices, parent events at daycare, and late dinners. 2012 will be different.

I resolve to teach my son the art of hitting a curveball (even if it’s off a tee) and my daughter her letters and numbers. The dogs will get more tennis balls, the wife fewer resolutions to review.

In fact, this year is going to be totally different. This is the year my to-do list doesn’t once again end as an “undid list.” This is the year I will accomplish my resolutions … not just one or two, but all of my resolutions.

And I might just write a children’s book for good measure.

Dr. Glasheen is The Hospitalist’s physician editor.

It’s that time of year again. A new year is upon us. It’s resolution time.

I must admit, somewhat sheepishly, that I am a bit of “resolver.” What can I say? I like to resolve. I like to think about resolutions. I like to plan resolutions. I like to regale my uninterested wife with my resolutions. And I am, in fact, actually quite good at all phases of resolving, with one small exception—the follow-through.

You see, while I love to plan changes in my life, I’m horrible at making changes in my life. There’s nothing too shocking about that, I suppose. Most people fail when change is required. What is interesting, though, is that years of failure have yet to imbue me with the sense to stop resolving. I mean, how many times can a man fail at resolutions before he stumbles upon a resolution to stop resolving—a resolution I’d surely fail at?

But what are perhaps even more interesting are the things I’ve apparently resolved to do. I say “apparently” because not only do I typically not remember making the resolutions, but most often I also can’t even fathom why I’d resolve such things in the first place. But clearly I do. In fact, every year, I commit to about 10-20 resolutions. I actually write them down, threaten to make my wife read them, then stow them safely in my desk drawer, only to unearth them a year later to discover that I actually resolved to write a children’s book. True story; I just reviewed my resolutions from last year. I don’t remember why I put that on the list. But I did. And, of course, I failed—but I did, in fact, read a children’s book. Maybe that’s what I meant.

Over the years I’ve also resolved to make a hole-in-one, get better hair, and read War and Peace (on the toilet, during medical school). Fail, fail, and fail. The last one’s a great example of good intentions and no follow-through. Driven by the numerology (1,296 pages+1,296 days of medical school, excluding the last semester, of course, as most of us did=one page per day!) and the symbolism (medical school+grueling+war=challenging, long, grueling book about war) of the goal, I was ultimately undone by an inability to reliably differentiate a Bezukhov from a Bolkonsky, and constipation.

I bring this all up because it is time again for New Year’s resolutions. So here, in no particular order, are my 2012 resolutions.

Oh, That’s How Full Feels!

In 2012, I resolve to finally have a fully staffed HM group. From our group’s origins in 2003 to our current 30-member group, we have been intermittently understaffed to various degrees—a feeling I know most of you have experienced. For a couple of years we were fully staffed, but recent hospital expansions again place us at risk of being understaffed. As most of you know, it is exceedingly difficult to move the clinical, quality, and efficiency goals of a group forward without enough boots on the ground. So, if you’re in the market, the skiing in Colorado can’t be beat!

Appreciate VBP

I resolve to position our hospitalist group for the coming value-based purchasing world. We all know that the future belongs to those who can provide fundamental value—that is, higher-quality care at lower cost. This has been HM’s mantra the past decade. 2012 is the year I resolve to see our group fully realize this.

Leave the Cave

I resolve to (really) learn how to use Epic. We implemented our new Epic electronic health record in 2011. I’m a big proponent, but also a Luddite. I tinker around the edges of what is a truly powerful tool in advancing clinical care. I resolve to move past casual to highly functional user.

Make “10” Perfect

I resolve to figure out this new ICD-10 system. OK, technically it’s not “new.” It’s been complete since 1992 and in use in many countries for the better part of a decade. This is not a simple update of the ICD-9 system; rather, this is an entire overhaul that adds two more digits to the system. This takes the number of possible codes from 13,000 (ICD-9) to 68,000 (ICD-10). This allows for much more specificity and laterality—that is, you could have cellulitis of the right or left foot.

These changes are more than just job security for coders. The issue monetizes as payors decide not to pay for readmissions. Consider a patient who had a right-foot cellulitis, only to be admitted two weeks later with a left-foot cellulitis. ICD-9 does not have laterality, such that both stays would have the same code and the second admit could be denied as a 30-day readmission.

Twitter With Excitement

I resolve to figure out social media. I must admit that this is a red-alert, high-risk-of-failure resolution, partly because I don’t Facebook, tweet, or blog; heck, I’m not even LinkedIn! Additionally, I don’t have any friends. And finally, I just don’t get it. Then again, I didn’t get “The Simpsons” when they first came out. D’oh!

Get Hipper

And I resolve to re-enter the pop culture world in general. My social and cultural life came to a screeching halt near midnight on Sept. 29, 2007: One moment I was innocently watching the Colorado Rockies battle into their first playoffs in 12 years, and the next I was blasted onto a four-year hyper-blur of crying, spoon-feeding, and diaper-changing—for the non-parent readers, I’m describing child-rearing, not residency training, which is admittedly often marked by these same mileposts. Now 4 and 2 years old, my kiddos have finally reached the stages of self-care that allow for my gradual re-entry into the outside world.

As such, I resolve to go to a movie (in the theater) again. The last two movies we saw in the theatre in 2007 were chosen by my pregnant wife and contained an uncomfortable subliminal theme—Knocked Up (pregnant woman hates impregnating sloth of a man), Juno (pregnant woman has love-hate relationship with pasty, impregnating nerd in tight gym shorts).

I’m also interested to see what’s on TV and on the radio. When I last turned off the cathodes, “Lost” was big; ditto “The Sopranos.” And in a clearly ill-fated second season, “Dancing with the Stars” was well on its way to its undeniable cancellation. Musically, Britney was shaving her head and Jordin Sparks was edging out Sanjaya’s faux-hawk on “Idol.”

I’m also looking forward to learning what a Kardashian is (a sweater?), explaining the strange pull toward vampire romances, and discovering the difference between a Pippa and a Snooki. Should be fun. I just hope I don’t catch “Bieber Fever.”

Aspire To “Be The Cup”

Finally, in 2012, I resolve to live up to the coffee cup—you know, the Father’s Day 2011 gift emblazoned with “World’s Best Dad.” I’m sure you all feel this in your own way—that constant tension between work and life. In 2011, work won a few too many of the tug-o’-wars. Too many missed gymnastics lessons, soccer practices, parent events at daycare, and late dinners. 2012 will be different.

I resolve to teach my son the art of hitting a curveball (even if it’s off a tee) and my daughter her letters and numbers. The dogs will get more tennis balls, the wife fewer resolutions to review.

In fact, this year is going to be totally different. This is the year my to-do list doesn’t once again end as an “undid list.” This is the year I will accomplish my resolutions … not just one or two, but all of my resolutions.

And I might just write a children’s book for good measure.

Dr. Glasheen is The Hospitalist’s physician editor.

Doctors shouldn’t have to worry about financial issues. The welfare of our patients should be our only concern.

We should be able to devote our full attention to studying how best to serve the needs of the people we care for. We shouldn’t need to spend time learning about healthcare reform or things like ICD-9 (or ICD-10!)—things that don’t help us provide better care to patients.

But these are pie-in-the-sky dreams. As far as I can tell, all healthcare systems require caregivers to attend to economics and data management that aren’t directly tied to clinical care. Our system depends on all caregivers devoting some time to learn how the system is organized, and keeping up with how it evolves. And the crisis in runaway costs in U.S. healthcare only increases the need for all who work in healthcare to devote significant time (too much) to the operational (nonclinical side) of healthcare.

Hospitalist practice is a much simpler business to manage and operate than most forms of clinical practice. There usually is no building to rent, few nonclinical employees to manage, and a comparatively simple financial model. And if employed by a hospital or other large entity, nonclinicians handle most of the “business management.” So when it comes to the number of brain cells diverted to business rather than clinical concerns, hospitalists start with an advantage over most other specialties.

Still, we have a lot of nonclinical stuff to keep up with. Consider the concept of “managing to Medicare reimbursement.” This means managing a practice or hospital in a way that minimizes the failure to capture all appropriate Medicare reimbursement dollars. Even if you’ve never heard of this concept before, there are probably a lot of people at your hospital who have this as their main responsibility, and clinicians should know something about it.

So in an effort to distract the fewest brain cells away from clinical matters, here is a very simple overview of some components of managing to Medicare reimbursement relevant to hospitalists. This isn’t a comprehensive list, only some hospitalist-relevant highlights.

Medicare Reimbursement Today

Accurate determination of inpatient vs. observation status. Wow, this can get complicated. Most hospitals have people who devote significant time to doing this for patients every day, and even those experts sometimes disagree on the appropriate status. But all hospitalists should have a basic understanding of how this works and a willingness to answer questions from the hospital’s experts, and, when appropriate, write additional information in the chart to clarify the appropriate status.

Optimal resource utilization, including length of stay. Because Medicare pays an essentially fixed amount based on the diagnoses for each inpatient admission, managing costs is critical to a hospital’s financial well-being. Hospitalists have a huge role in this. And regardless of how Medicare reimburses for services, there is clinical rationale for being careful about resources used and how long someone stays in a hospital. In many cases, more is not better—and it even could be worse—for the patient.

Optimal clinical documentation and accurate DRG assignment. Good documentation is important for clinical care, but beyond that, the precise way things are documented can have significant influence on Medicare reimbursement. Low potassium might in some cases lead to higher reimbursement, but a doctor must write “hypokalemia”; simply writing K+ means the hospital can’t include hypokalemia as a diagnosis. (A doctor, nurse practitioner, or physician assistant must write out “hypokalemia” only once for Medicare purposes; it would then be fine to use K+ in the chart every other time.)

Say you have a patient with a UTI and sepsis. Write only “urosepsis,” and the hospital must bill for cystitis—low reimbursement. Write “urinary tract infection with sepsis,” and the hospital can bill for higher reimbursement.

There should be people at your hospital who are experts at this, and all hospitalists should work with them to learn appropriate documentation language to describe illnesses correctly for billing purposes. Many hospitals use a system of “DRG queries,” which hospitalists should always respond to (though they should agree with the issue raised, such as “was the pneumonia likely due to aspiration?” only when clinically appropriate).

Change Is Coming

Don’t make the mistake of thinking Medicare reimbursement is a static phenomenon. It is undergoing rapid and significant evolution. For example, the Affordable Care Act, aka healthcare reform legislation, provides for a number of changes hospitalists need to understand.

I suggest that you make sure to understand your hospital’s or medical group’s position on accountable-care organizations (ACOs). It is a pretty complicated program that, in the first few years, has modest impact on reimbursement. If the ACO performs well, the additional reimbursement to an organization might pay for little more than the staff salaries of the staff that managed the considerable complexity of enrolling in and reporting for the program. And there is a risk the organization could lose money if it doesn’t perform well. So many organizations have decided not to pursue participation as an ACO, but they may decide to put in place most of the elements of an ACO without enrolling in the program. Some refer to this as an “aco” rather than an “ACO.”

Value-based purchasing (VBP) is set to influence hospital reimbursement rates starting in 2013 based on a hospital’s performance in 2012. SHM has a terrific VBP toolkit available online.

Bundled payments and financial penalties for readmissions also take effect in 2013. Now is the time ensure that you understand the implications of these programs; they are designed so that the financial impact to most organizations will be modest.

Reimbursement penalties for a specified list of hospital-acquired conditions (HACs) will begin in 2015. Conditions most relevant for hospitalists include vascular catheter-related bloodstream infections, catheter-related urinary infection, or manifestations of poor glycemic control (HONK, DKA, hypo-/hyperglycemia).

I plan to address some of these programs in greater detail in future practice management columns.

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Doctors shouldn’t have to worry about financial issues. The welfare of our patients should be our only concern.

We should be able to devote our full attention to studying how best to serve the needs of the people we care for. We shouldn’t need to spend time learning about healthcare reform or things like ICD-9 (or ICD-10!)—things that don’t help us provide better care to patients.

But these are pie-in-the-sky dreams. As far as I can tell, all healthcare systems require caregivers to attend to economics and data management that aren’t directly tied to clinical care. Our system depends on all caregivers devoting some time to learn how the system is organized, and keeping up with how it evolves. And the crisis in runaway costs in U.S. healthcare only increases the need for all who work in healthcare to devote significant time (too much) to the operational (nonclinical side) of healthcare.

Hospitalist practice is a much simpler business to manage and operate than most forms of clinical practice. There usually is no building to rent, few nonclinical employees to manage, and a comparatively simple financial model. And if employed by a hospital or other large entity, nonclinicians handle most of the “business management.” So when it comes to the number of brain cells diverted to business rather than clinical concerns, hospitalists start with an advantage over most other specialties.

Still, we have a lot of nonclinical stuff to keep up with. Consider the concept of “managing to Medicare reimbursement.” This means managing a practice or hospital in a way that minimizes the failure to capture all appropriate Medicare reimbursement dollars. Even if you’ve never heard of this concept before, there are probably a lot of people at your hospital who have this as their main responsibility, and clinicians should know something about it.

So in an effort to distract the fewest brain cells away from clinical matters, here is a very simple overview of some components of managing to Medicare reimbursement relevant to hospitalists. This isn’t a comprehensive list, only some hospitalist-relevant highlights.

Medicare Reimbursement Today

Accurate determination of inpatient vs. observation status. Wow, this can get complicated. Most hospitals have people who devote significant time to doing this for patients every day, and even those experts sometimes disagree on the appropriate status. But all hospitalists should have a basic understanding of how this works and a willingness to answer questions from the hospital’s experts, and, when appropriate, write additional information in the chart to clarify the appropriate status.

Optimal resource utilization, including length of stay. Because Medicare pays an essentially fixed amount based on the diagnoses for each inpatient admission, managing costs is critical to a hospital’s financial well-being. Hospitalists have a huge role in this. And regardless of how Medicare reimburses for services, there is clinical rationale for being careful about resources used and how long someone stays in a hospital. In many cases, more is not better—and it even could be worse—for the patient.

Optimal clinical documentation and accurate DRG assignment. Good documentation is important for clinical care, but beyond that, the precise way things are documented can have significant influence on Medicare reimbursement. Low potassium might in some cases lead to higher reimbursement, but a doctor must write “hypokalemia”; simply writing K+ means the hospital can’t include hypokalemia as a diagnosis. (A doctor, nurse practitioner, or physician assistant must write out “hypokalemia” only once for Medicare purposes; it would then be fine to use K+ in the chart every other time.)

Say you have a patient with a UTI and sepsis. Write only “urosepsis,” and the hospital must bill for cystitis—low reimbursement. Write “urinary tract infection with sepsis,” and the hospital can bill for higher reimbursement.

There should be people at your hospital who are experts at this, and all hospitalists should work with them to learn appropriate documentation language to describe illnesses correctly for billing purposes. Many hospitals use a system of “DRG queries,” which hospitalists should always respond to (though they should agree with the issue raised, such as “was the pneumonia likely due to aspiration?” only when clinically appropriate).

Change Is Coming

Don’t make the mistake of thinking Medicare reimbursement is a static phenomenon. It is undergoing rapid and significant evolution. For example, the Affordable Care Act, aka healthcare reform legislation, provides for a number of changes hospitalists need to understand.

I suggest that you make sure to understand your hospital’s or medical group’s position on accountable-care organizations (ACOs). It is a pretty complicated program that, in the first few years, has modest impact on reimbursement. If the ACO performs well, the additional reimbursement to an organization might pay for little more than the staff salaries of the staff that managed the considerable complexity of enrolling in and reporting for the program. And there is a risk the organization could lose money if it doesn’t perform well. So many organizations have decided not to pursue participation as an ACO, but they may decide to put in place most of the elements of an ACO without enrolling in the program. Some refer to this as an “aco” rather than an “ACO.”

Value-based purchasing (VBP) is set to influence hospital reimbursement rates starting in 2013 based on a hospital’s performance in 2012. SHM has a terrific VBP toolkit available online.

Bundled payments and financial penalties for readmissions also take effect in 2013. Now is the time ensure that you understand the implications of these programs; they are designed so that the financial impact to most organizations will be modest.

Reimbursement penalties for a specified list of hospital-acquired conditions (HACs) will begin in 2015. Conditions most relevant for hospitalists include vascular catheter-related bloodstream infections, catheter-related urinary infection, or manifestations of poor glycemic control (HONK, DKA, hypo-/hyperglycemia).

I plan to address some of these programs in greater detail in future practice management columns.

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Doctors shouldn’t have to worry about financial issues. The welfare of our patients should be our only concern.

We should be able to devote our full attention to studying how best to serve the needs of the people we care for. We shouldn’t need to spend time learning about healthcare reform or things like ICD-9 (or ICD-10!)—things that don’t help us provide better care to patients.

But these are pie-in-the-sky dreams. As far as I can tell, all healthcare systems require caregivers to attend to economics and data management that aren’t directly tied to clinical care. Our system depends on all caregivers devoting some time to learn how the system is organized, and keeping up with how it evolves. And the crisis in runaway costs in U.S. healthcare only increases the need for all who work in healthcare to devote significant time (too much) to the operational (nonclinical side) of healthcare.

Hospitalist practice is a much simpler business to manage and operate than most forms of clinical practice. There usually is no building to rent, few nonclinical employees to manage, and a comparatively simple financial model. And if employed by a hospital or other large entity, nonclinicians handle most of the “business management.” So when it comes to the number of brain cells diverted to business rather than clinical concerns, hospitalists start with an advantage over most other specialties.

Still, we have a lot of nonclinical stuff to keep up with. Consider the concept of “managing to Medicare reimbursement.” This means managing a practice or hospital in a way that minimizes the failure to capture all appropriate Medicare reimbursement dollars. Even if you’ve never heard of this concept before, there are probably a lot of people at your hospital who have this as their main responsibility, and clinicians should know something about it.

So in an effort to distract the fewest brain cells away from clinical matters, here is a very simple overview of some components of managing to Medicare reimbursement relevant to hospitalists. This isn’t a comprehensive list, only some hospitalist-relevant highlights.

Medicare Reimbursement Today

Accurate determination of inpatient vs. observation status. Wow, this can get complicated. Most hospitals have people who devote significant time to doing this for patients every day, and even those experts sometimes disagree on the appropriate status. But all hospitalists should have a basic understanding of how this works and a willingness to answer questions from the hospital’s experts, and, when appropriate, write additional information in the chart to clarify the appropriate status.

Optimal resource utilization, including length of stay. Because Medicare pays an essentially fixed amount based on the diagnoses for each inpatient admission, managing costs is critical to a hospital’s financial well-being. Hospitalists have a huge role in this. And regardless of how Medicare reimburses for services, there is clinical rationale for being careful about resources used and how long someone stays in a hospital. In many cases, more is not better—and it even could be worse—for the patient.

Optimal clinical documentation and accurate DRG assignment. Good documentation is important for clinical care, but beyond that, the precise way things are documented can have significant influence on Medicare reimbursement. Low potassium might in some cases lead to higher reimbursement, but a doctor must write “hypokalemia”; simply writing K+ means the hospital can’t include hypokalemia as a diagnosis. (A doctor, nurse practitioner, or physician assistant must write out “hypokalemia” only once for Medicare purposes; it would then be fine to use K+ in the chart every other time.)

Say you have a patient with a UTI and sepsis. Write only “urosepsis,” and the hospital must bill for cystitis—low reimbursement. Write “urinary tract infection with sepsis,” and the hospital can bill for higher reimbursement.

There should be people at your hospital who are experts at this, and all hospitalists should work with them to learn appropriate documentation language to describe illnesses correctly for billing purposes. Many hospitals use a system of “DRG queries,” which hospitalists should always respond to (though they should agree with the issue raised, such as “was the pneumonia likely due to aspiration?” only when clinically appropriate).

Change Is Coming

Don’t make the mistake of thinking Medicare reimbursement is a static phenomenon. It is undergoing rapid and significant evolution. For example, the Affordable Care Act, aka healthcare reform legislation, provides for a number of changes hospitalists need to understand.

I suggest that you make sure to understand your hospital’s or medical group’s position on accountable-care organizations (ACOs). It is a pretty complicated program that, in the first few years, has modest impact on reimbursement. If the ACO performs well, the additional reimbursement to an organization might pay for little more than the staff salaries of the staff that managed the considerable complexity of enrolling in and reporting for the program. And there is a risk the organization could lose money if it doesn’t perform well. So many organizations have decided not to pursue participation as an ACO, but they may decide to put in place most of the elements of an ACO without enrolling in the program. Some refer to this as an “aco” rather than an “ACO.”

Value-based purchasing (VBP) is set to influence hospital reimbursement rates starting in 2013 based on a hospital’s performance in 2012. SHM has a terrific VBP toolkit available online.

Bundled payments and financial penalties for readmissions also take effect in 2013. Now is the time ensure that you understand the implications of these programs; they are designed so that the financial impact to most organizations will be modest.

Reimbursement penalties for a specified list of hospital-acquired conditions (HACs) will begin in 2015. Conditions most relevant for hospitalists include vascular catheter-related bloodstream infections, catheter-related urinary infection, or manifestations of poor glycemic control (HONK, DKA, hypo-/hyperglycemia).

I plan to address some of these programs in greater detail in future practice management columns.

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.