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Movers and Shakers in Hospital Medicine December 2015
John Carlile, MD, is the new medical director of pediatric hospitalist and intensivist services at Summerville (S.C.) Medical Center. Most recently, Dr. Carlile worked as a pediatric critical care specialist at Cox Medical Center in Springfield, Mo.
Elaine McElveen, RN, has been named director of the hospitalist program at McLeod Medical Center Dillon in Dillon, S.C. In her new role, McElveen also will oversee the case management department. She has been a practicing nurse for the McLeod Health system for 28 years.
Christine Wentt, PA, an adult hospitalist physician assistant, has been inducted into the VIP Woman of the Year Circle for 2015-2016 by the National Association of Professional Women (NAPW). Wentt works for Physicians Inpatient Care Specialists (MDICS), a private hospitalist group in Glen Burnie, Md. Wentt also serves as an adjunct professor in Drexel University’s physician assistant program.
Robert Zurcher, MD, has been appointed chief medical officer for emergency medicine at HNI Healthcare (formerly Hospitalists Now, Inc.), based in Austin, Texas. Dr. Zurcher comes to HNI Healthcare from IPC Healthcare, where he served as the administrative director for their Northwest Region. Dr. Zurcher has 27 years of practice experience and has founded and managed physician services companies in both hospital medicine and emergency medicine.
Business Moves
North Hollywood, Calif.-based IPC Healthcare recently announced its acquisition of Hospital Medicine Consultants, LLC, in Elgin, Ill., a locally owned practice serving several hospitals in the Chicago suburbs. IPC staffs hospitalist providers in more than 400 hospitals across the country.
The Schumacher Group, a private hospitalist and emergency medicine provider, announced the implementation of a new telehospitalist program at Abrom Kaplan Memorial and Acadia General Hospitals, both in Lafayette, La. The program will allow physicians to provide overnight care to the two facilities from a remote location. The Schumacher Group was founded in 1994 and currently serves more than four million patients per year.
Mike O’Neal is a freelance writer in New York City.
In Memoriam
Dr. Ayantuga completed his PhD thesis at Oxford University in less than three years, during which time he received the Bishop Frazer Prize for excellence in research in organic chemistry. Following his tenure at Oxford, Dr. Ayantuga obtained his medical degree from Cambridge University in 1994.
As his memorial site notes, “he continued until his death, to demonstrate dedication to quality and process involvement, illustrating commitment to active engagement in lifelong learning.”
John Carlile, MD, is the new medical director of pediatric hospitalist and intensivist services at Summerville (S.C.) Medical Center. Most recently, Dr. Carlile worked as a pediatric critical care specialist at Cox Medical Center in Springfield, Mo.
Elaine McElveen, RN, has been named director of the hospitalist program at McLeod Medical Center Dillon in Dillon, S.C. In her new role, McElveen also will oversee the case management department. She has been a practicing nurse for the McLeod Health system for 28 years.
Christine Wentt, PA, an adult hospitalist physician assistant, has been inducted into the VIP Woman of the Year Circle for 2015-2016 by the National Association of Professional Women (NAPW). Wentt works for Physicians Inpatient Care Specialists (MDICS), a private hospitalist group in Glen Burnie, Md. Wentt also serves as an adjunct professor in Drexel University’s physician assistant program.
Robert Zurcher, MD, has been appointed chief medical officer for emergency medicine at HNI Healthcare (formerly Hospitalists Now, Inc.), based in Austin, Texas. Dr. Zurcher comes to HNI Healthcare from IPC Healthcare, where he served as the administrative director for their Northwest Region. Dr. Zurcher has 27 years of practice experience and has founded and managed physician services companies in both hospital medicine and emergency medicine.
Business Moves
North Hollywood, Calif.-based IPC Healthcare recently announced its acquisition of Hospital Medicine Consultants, LLC, in Elgin, Ill., a locally owned practice serving several hospitals in the Chicago suburbs. IPC staffs hospitalist providers in more than 400 hospitals across the country.
The Schumacher Group, a private hospitalist and emergency medicine provider, announced the implementation of a new telehospitalist program at Abrom Kaplan Memorial and Acadia General Hospitals, both in Lafayette, La. The program will allow physicians to provide overnight care to the two facilities from a remote location. The Schumacher Group was founded in 1994 and currently serves more than four million patients per year.
Mike O’Neal is a freelance writer in New York City.
In Memoriam
Dr. Ayantuga completed his PhD thesis at Oxford University in less than three years, during which time he received the Bishop Frazer Prize for excellence in research in organic chemistry. Following his tenure at Oxford, Dr. Ayantuga obtained his medical degree from Cambridge University in 1994.
As his memorial site notes, “he continued until his death, to demonstrate dedication to quality and process involvement, illustrating commitment to active engagement in lifelong learning.”
John Carlile, MD, is the new medical director of pediatric hospitalist and intensivist services at Summerville (S.C.) Medical Center. Most recently, Dr. Carlile worked as a pediatric critical care specialist at Cox Medical Center in Springfield, Mo.
Elaine McElveen, RN, has been named director of the hospitalist program at McLeod Medical Center Dillon in Dillon, S.C. In her new role, McElveen also will oversee the case management department. She has been a practicing nurse for the McLeod Health system for 28 years.
Christine Wentt, PA, an adult hospitalist physician assistant, has been inducted into the VIP Woman of the Year Circle for 2015-2016 by the National Association of Professional Women (NAPW). Wentt works for Physicians Inpatient Care Specialists (MDICS), a private hospitalist group in Glen Burnie, Md. Wentt also serves as an adjunct professor in Drexel University’s physician assistant program.
Robert Zurcher, MD, has been appointed chief medical officer for emergency medicine at HNI Healthcare (formerly Hospitalists Now, Inc.), based in Austin, Texas. Dr. Zurcher comes to HNI Healthcare from IPC Healthcare, where he served as the administrative director for their Northwest Region. Dr. Zurcher has 27 years of practice experience and has founded and managed physician services companies in both hospital medicine and emergency medicine.
Business Moves
North Hollywood, Calif.-based IPC Healthcare recently announced its acquisition of Hospital Medicine Consultants, LLC, in Elgin, Ill., a locally owned practice serving several hospitals in the Chicago suburbs. IPC staffs hospitalist providers in more than 400 hospitals across the country.
The Schumacher Group, a private hospitalist and emergency medicine provider, announced the implementation of a new telehospitalist program at Abrom Kaplan Memorial and Acadia General Hospitals, both in Lafayette, La. The program will allow physicians to provide overnight care to the two facilities from a remote location. The Schumacher Group was founded in 1994 and currently serves more than four million patients per year.
Mike O’Neal is a freelance writer in New York City.
In Memoriam
Dr. Ayantuga completed his PhD thesis at Oxford University in less than three years, during which time he received the Bishop Frazer Prize for excellence in research in organic chemistry. Following his tenure at Oxford, Dr. Ayantuga obtained his medical degree from Cambridge University in 1994.
As his memorial site notes, “he continued until his death, to demonstrate dedication to quality and process involvement, illustrating commitment to active engagement in lifelong learning.”
Healthcare Policies Affecting Hospitalists, Hospitalized Patients Advance in 2015
Laws and regulations regularly impact hospitalists and hospitalized patients, which is why SHM’s Advocacy Department and Public Policy Committee (PPC) work on behalf of SHM membership, the hospital medicine movement, and its patients.
This year has seen significant positive movement within several key policy areas for all of these groups. Some of these issues have made headlines, while others happened under the radar, but SHM and its members have played an important role within each of them.
In general, observation care and related issues have received increased attention from lawmakers in no small part as a result of SHM’s efforts in this area. Early in the summer, the Centers for Medicare and Medicaid Services (CMS) responded to SHM’s efforts by proposing changes to the two-midnight rule—softening yet still retaining the rule. SHM commented positively on the proposed changes but signaled to both CMS and Congress that still more needs to be done to address problems inherent within observation policy.
As CMS and Congress work on a long-term solution to issues related to observation stays, SHM will play an important role in both proposing solutions and providing feedback for potential changes.
In July 2015, CMS proposed to pay for advance care planning (ACP). This proposal, assuming it is finalized at press time, is one that SHM has advocated for and supported for almost two years. Hospitalists should consider it a victory. The PPC, SHM members, and staff have consistently advocated for improved ACP policies in urging Medicare to recognize the value in ACP and reimburse for these critical services.
Hospitalists have also played a major part in the advocacy efforts on the Congressional level, dispelling misconceptions surrounding ACP by educating members of Congress and their staff and explaining the importance of these conversations within the healthcare system. Consistent advocacy and hospitalist involvement have led to a positive response that has been a long time coming.
These are just a few examples of areas in which SHM has seen tangible accomplishments, but there are also issues that have yet to play out and require SHM’s efforts to remain consistent in the coming years.
One of these issues is a hospitalist-specific problem within the meaningful use program. Hospital-based physicians are exempt from meaningful use and associated penalties based on their percentages of inpatient services; however, due to the way the law was written and changes in the healthcare landscape since passage, an unintended consequence has arisen.
Hospitalists who care for significant numbers of “observation” and skilled nursing facility patients (coded as outpatient services) do not qualify as hospital-based under the law and are finding themselves subject to unfair penalties. In response to SHM advocacy, CMS provided a limited hardship exception for hospitalists in 2015 and extended it into 2016. This exception saved numerous hospitalist groups an estimated $2,000 to $3,000 per hospitalist per year.
The temporary exception was limited in scope, however, and a legislative fix is needed to ensure a permanent solution. SHM will continue to meet with legislators to discuss this issue and garner interest in what we hope will result in a permanent resolution to this issue.
Finally, passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April 2015 was one of the most important laws impacting physicians to pass in years. While it finally repealed the broken sustainable growth rate, its passage was just the beginning of SHM’s advocacy efforts on the legislation.
MACRA will fundamentally change the way in which physicians are compensated and will accelerate the transition away from fee-for-service (FFS) by encouraging alternative payment model (APM) participation; however, many details remain unclear and are in need of hospitalist-specific clarification. SHM has already begun engaging with federal agencies and lawmakers as the regulations for MACRA are developed, including initiating multi-stakeholder conversations about problems facing facility-based providers in pay-for-performance programs.
SHM’s Performance Measurement and Reporting Committee has been working closely with the PPC to devise concrete proposals that will allow physician/hospital alignment within mandated quality reporting programs, and the PPC has launched an APM workgroup that is exploring the most effective avenues for hospitalists to move away from FFS and take advantage of incentives that will be available under MACRA.
Successful advocacy efforts often take time, persistence, and most importantly, patience; these victories demonstrate that endurance pays off.
SHM is clearly making headway on behalf of hospitalists and patients, and will build off of the momentum that these victories have generated. As SHM Public Policy Committee chair, Ron Greeno, stated after SHM’s most recent victories, “There are times when we all ask if our efforts are all worth it, and the clear message that we have heard in the past few weeks is a resounding ‘Yes!’”
Success does take time, however, and help from SHM members is a critical part of the equation. Your voice does make a difference.
To stay up to date and get involved with SHM’s advocacy efforts, connect with SHM’s Grassroots Network at www.hospitalmedicine.org/grassroots, and join the policy discussions in the Advocacy and Public Policy community on HMX.
Josh Boswell is SHM’s director of government relations.
Laws and regulations regularly impact hospitalists and hospitalized patients, which is why SHM’s Advocacy Department and Public Policy Committee (PPC) work on behalf of SHM membership, the hospital medicine movement, and its patients.
This year has seen significant positive movement within several key policy areas for all of these groups. Some of these issues have made headlines, while others happened under the radar, but SHM and its members have played an important role within each of them.
In general, observation care and related issues have received increased attention from lawmakers in no small part as a result of SHM’s efforts in this area. Early in the summer, the Centers for Medicare and Medicaid Services (CMS) responded to SHM’s efforts by proposing changes to the two-midnight rule—softening yet still retaining the rule. SHM commented positively on the proposed changes but signaled to both CMS and Congress that still more needs to be done to address problems inherent within observation policy.
As CMS and Congress work on a long-term solution to issues related to observation stays, SHM will play an important role in both proposing solutions and providing feedback for potential changes.
In July 2015, CMS proposed to pay for advance care planning (ACP). This proposal, assuming it is finalized at press time, is one that SHM has advocated for and supported for almost two years. Hospitalists should consider it a victory. The PPC, SHM members, and staff have consistently advocated for improved ACP policies in urging Medicare to recognize the value in ACP and reimburse for these critical services.
Hospitalists have also played a major part in the advocacy efforts on the Congressional level, dispelling misconceptions surrounding ACP by educating members of Congress and their staff and explaining the importance of these conversations within the healthcare system. Consistent advocacy and hospitalist involvement have led to a positive response that has been a long time coming.
These are just a few examples of areas in which SHM has seen tangible accomplishments, but there are also issues that have yet to play out and require SHM’s efforts to remain consistent in the coming years.
One of these issues is a hospitalist-specific problem within the meaningful use program. Hospital-based physicians are exempt from meaningful use and associated penalties based on their percentages of inpatient services; however, due to the way the law was written and changes in the healthcare landscape since passage, an unintended consequence has arisen.
Hospitalists who care for significant numbers of “observation” and skilled nursing facility patients (coded as outpatient services) do not qualify as hospital-based under the law and are finding themselves subject to unfair penalties. In response to SHM advocacy, CMS provided a limited hardship exception for hospitalists in 2015 and extended it into 2016. This exception saved numerous hospitalist groups an estimated $2,000 to $3,000 per hospitalist per year.
The temporary exception was limited in scope, however, and a legislative fix is needed to ensure a permanent solution. SHM will continue to meet with legislators to discuss this issue and garner interest in what we hope will result in a permanent resolution to this issue.
Finally, passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April 2015 was one of the most important laws impacting physicians to pass in years. While it finally repealed the broken sustainable growth rate, its passage was just the beginning of SHM’s advocacy efforts on the legislation.
MACRA will fundamentally change the way in which physicians are compensated and will accelerate the transition away from fee-for-service (FFS) by encouraging alternative payment model (APM) participation; however, many details remain unclear and are in need of hospitalist-specific clarification. SHM has already begun engaging with federal agencies and lawmakers as the regulations for MACRA are developed, including initiating multi-stakeholder conversations about problems facing facility-based providers in pay-for-performance programs.
SHM’s Performance Measurement and Reporting Committee has been working closely with the PPC to devise concrete proposals that will allow physician/hospital alignment within mandated quality reporting programs, and the PPC has launched an APM workgroup that is exploring the most effective avenues for hospitalists to move away from FFS and take advantage of incentives that will be available under MACRA.
Successful advocacy efforts often take time, persistence, and most importantly, patience; these victories demonstrate that endurance pays off.
SHM is clearly making headway on behalf of hospitalists and patients, and will build off of the momentum that these victories have generated. As SHM Public Policy Committee chair, Ron Greeno, stated after SHM’s most recent victories, “There are times when we all ask if our efforts are all worth it, and the clear message that we have heard in the past few weeks is a resounding ‘Yes!’”
Success does take time, however, and help from SHM members is a critical part of the equation. Your voice does make a difference.
To stay up to date and get involved with SHM’s advocacy efforts, connect with SHM’s Grassroots Network at www.hospitalmedicine.org/grassroots, and join the policy discussions in the Advocacy and Public Policy community on HMX.
Josh Boswell is SHM’s director of government relations.
Laws and regulations regularly impact hospitalists and hospitalized patients, which is why SHM’s Advocacy Department and Public Policy Committee (PPC) work on behalf of SHM membership, the hospital medicine movement, and its patients.
This year has seen significant positive movement within several key policy areas for all of these groups. Some of these issues have made headlines, while others happened under the radar, but SHM and its members have played an important role within each of them.
In general, observation care and related issues have received increased attention from lawmakers in no small part as a result of SHM’s efforts in this area. Early in the summer, the Centers for Medicare and Medicaid Services (CMS) responded to SHM’s efforts by proposing changes to the two-midnight rule—softening yet still retaining the rule. SHM commented positively on the proposed changes but signaled to both CMS and Congress that still more needs to be done to address problems inherent within observation policy.
As CMS and Congress work on a long-term solution to issues related to observation stays, SHM will play an important role in both proposing solutions and providing feedback for potential changes.
In July 2015, CMS proposed to pay for advance care planning (ACP). This proposal, assuming it is finalized at press time, is one that SHM has advocated for and supported for almost two years. Hospitalists should consider it a victory. The PPC, SHM members, and staff have consistently advocated for improved ACP policies in urging Medicare to recognize the value in ACP and reimburse for these critical services.
Hospitalists have also played a major part in the advocacy efforts on the Congressional level, dispelling misconceptions surrounding ACP by educating members of Congress and their staff and explaining the importance of these conversations within the healthcare system. Consistent advocacy and hospitalist involvement have led to a positive response that has been a long time coming.
These are just a few examples of areas in which SHM has seen tangible accomplishments, but there are also issues that have yet to play out and require SHM’s efforts to remain consistent in the coming years.
One of these issues is a hospitalist-specific problem within the meaningful use program. Hospital-based physicians are exempt from meaningful use and associated penalties based on their percentages of inpatient services; however, due to the way the law was written and changes in the healthcare landscape since passage, an unintended consequence has arisen.
Hospitalists who care for significant numbers of “observation” and skilled nursing facility patients (coded as outpatient services) do not qualify as hospital-based under the law and are finding themselves subject to unfair penalties. In response to SHM advocacy, CMS provided a limited hardship exception for hospitalists in 2015 and extended it into 2016. This exception saved numerous hospitalist groups an estimated $2,000 to $3,000 per hospitalist per year.
The temporary exception was limited in scope, however, and a legislative fix is needed to ensure a permanent solution. SHM will continue to meet with legislators to discuss this issue and garner interest in what we hope will result in a permanent resolution to this issue.
Finally, passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in April 2015 was one of the most important laws impacting physicians to pass in years. While it finally repealed the broken sustainable growth rate, its passage was just the beginning of SHM’s advocacy efforts on the legislation.
MACRA will fundamentally change the way in which physicians are compensated and will accelerate the transition away from fee-for-service (FFS) by encouraging alternative payment model (APM) participation; however, many details remain unclear and are in need of hospitalist-specific clarification. SHM has already begun engaging with federal agencies and lawmakers as the regulations for MACRA are developed, including initiating multi-stakeholder conversations about problems facing facility-based providers in pay-for-performance programs.
SHM’s Performance Measurement and Reporting Committee has been working closely with the PPC to devise concrete proposals that will allow physician/hospital alignment within mandated quality reporting programs, and the PPC has launched an APM workgroup that is exploring the most effective avenues for hospitalists to move away from FFS and take advantage of incentives that will be available under MACRA.
Successful advocacy efforts often take time, persistence, and most importantly, patience; these victories demonstrate that endurance pays off.
SHM is clearly making headway on behalf of hospitalists and patients, and will build off of the momentum that these victories have generated. As SHM Public Policy Committee chair, Ron Greeno, stated after SHM’s most recent victories, “There are times when we all ask if our efforts are all worth it, and the clear message that we have heard in the past few weeks is a resounding ‘Yes!’”
Success does take time, however, and help from SHM members is a critical part of the equation. Your voice does make a difference.
To stay up to date and get involved with SHM’s advocacy efforts, connect with SHM’s Grassroots Network at www.hospitalmedicine.org/grassroots, and join the policy discussions in the Advocacy and Public Policy community on HMX.
Josh Boswell is SHM’s director of government relations.
Top Trends at Society of Hospital Medicine for 2016
Ready or not, 2016 is almost here, and SHM is gearing up for another year jam packed with exciting, enriching opportunities for hospitalists and their teams. Here are 10 things to have on your radar as we head into the new year.
1 Hospital Medicine 2016: March 6–9, 2016
This year’s annual meeting in San Diego promises to be the biggest yet, with new tracks in Co-Management/Perioperative Medicine, Health IT for Hospitalists, and Post-Acute Care—and opportunities to connect and collaborate with a vibrant community of hospital medicine professionals from around the nation. Register before early bird rates end on Jan. 11, 2016!
2 The Year of the Hospitalist
In celebration of the 20-year anniversary of the coining of the word “hospitalist,” SHM is preparing for a yearlong series of special events, contests, and opportunities. Follow SHM on Twitter at @SHMLive, and visit Hospital Medicine for the latest news!
3 Get Engaged with Public Policy
Healthcare legislation is constantly evolving, and hospitalists play an important role in advocating for hospitalized patients and the hospital medicine movement. SHM is an active voice in many conversations on policy development and reform. Sign up for the Grassroots Network now to stay updated on developments in healthcare policy, share your experiences with healthcare programs, and even participate in policy forums.
4 Fight the Resistance Campaign to Promote Antibiotic Stewardship
SHM is partnering with the CDC to change hospital culture and, in turn, change antibiotic prescription behaviors to prevent antibiotic resistance. Learn how you can be a part of the campaign, and download the campaign posters—featuring striking designs inspired by 1940s propaganda posters.
5 2016 State of Hospital Medicine Survey
The 2016 State of Hospital Medicine survey will take place January through March, with the release of the report scheduled for September. The survey consists of comprehensive, current information crucial to understanding the hospital medicine landscape and making better decisions in the hospital. Visit SHM’s website to find out how you can participate.
6 Expansion of the Quality Improvement Portfolio
SHM’s Center for Hospital Innovation and Improvement continues to develop guides, toolkits, and programs to meet the evolving needs of hospital-based clinicians and improve the care of hospitalized patients. New additions to the portfolio include resources for VTE, chronic heart failure, delirium, anemia, and end-of-life care.
7 SHM Student Hospitalist Scholar Grant Applications
Student members of SHM could be eligible to apply for an SHM Student Hospitalist Scholar Grant, including funding to complete scholarly work with an active SHM mentor in a project related to patient safety, quality improvement, or other hospital medicine-related fields. The deadline to apply is Feb. 15, 2016.
8 Innovative Additions to SHM’s Digital Learning Offerings
In addition to SHM SPARK, an MOC preparation tool for the Focused Practice in Hospital Medicine exam, and SHMConsults, online modules for consultative and perioperative medicine, look for new SHM Learning Portal activities in 2016, like “Management of Postoperative Atrial Fibrillation,” “Managing Pain in Postoperative Patients: What the Hospitalist Needs to Know,” and “Perioperative Bridging of Anticoagulant Theory.”
9 Get #SHeMpowered on Social Media
Have a success story to share about how SHM helped you advance your career or enhance patient care in your hospital? Maybe you improved your clinical skills at the annual meeting or improved care transitions with Project BOOST? Shout it from the rooftops—tweet @SHMLive and use the hashtag #SHeMpowered. If you haven’t followed SHM on Twitter, head over to @SHMLive.
10 “Are You Number 15,000?”
This is a question you want to say “yes” to! SHM is poised to welcome its 15,000th member in early 2016 as part of the Year of the Hospitalist. The 15,000th member will receive an assortment of exciting prizes, including complimentary registration to Hospital Medicine 2016 in San Diego. Know someone who is interested in joining? Spread the word!
Brett Radler is SHM’s communications coordinator.
Ready or not, 2016 is almost here, and SHM is gearing up for another year jam packed with exciting, enriching opportunities for hospitalists and their teams. Here are 10 things to have on your radar as we head into the new year.
1 Hospital Medicine 2016: March 6–9, 2016
This year’s annual meeting in San Diego promises to be the biggest yet, with new tracks in Co-Management/Perioperative Medicine, Health IT for Hospitalists, and Post-Acute Care—and opportunities to connect and collaborate with a vibrant community of hospital medicine professionals from around the nation. Register before early bird rates end on Jan. 11, 2016!
2 The Year of the Hospitalist
In celebration of the 20-year anniversary of the coining of the word “hospitalist,” SHM is preparing for a yearlong series of special events, contests, and opportunities. Follow SHM on Twitter at @SHMLive, and visit Hospital Medicine for the latest news!
3 Get Engaged with Public Policy
Healthcare legislation is constantly evolving, and hospitalists play an important role in advocating for hospitalized patients and the hospital medicine movement. SHM is an active voice in many conversations on policy development and reform. Sign up for the Grassroots Network now to stay updated on developments in healthcare policy, share your experiences with healthcare programs, and even participate in policy forums.
4 Fight the Resistance Campaign to Promote Antibiotic Stewardship
SHM is partnering with the CDC to change hospital culture and, in turn, change antibiotic prescription behaviors to prevent antibiotic resistance. Learn how you can be a part of the campaign, and download the campaign posters—featuring striking designs inspired by 1940s propaganda posters.
5 2016 State of Hospital Medicine Survey
The 2016 State of Hospital Medicine survey will take place January through March, with the release of the report scheduled for September. The survey consists of comprehensive, current information crucial to understanding the hospital medicine landscape and making better decisions in the hospital. Visit SHM’s website to find out how you can participate.
6 Expansion of the Quality Improvement Portfolio
SHM’s Center for Hospital Innovation and Improvement continues to develop guides, toolkits, and programs to meet the evolving needs of hospital-based clinicians and improve the care of hospitalized patients. New additions to the portfolio include resources for VTE, chronic heart failure, delirium, anemia, and end-of-life care.
7 SHM Student Hospitalist Scholar Grant Applications
Student members of SHM could be eligible to apply for an SHM Student Hospitalist Scholar Grant, including funding to complete scholarly work with an active SHM mentor in a project related to patient safety, quality improvement, or other hospital medicine-related fields. The deadline to apply is Feb. 15, 2016.
8 Innovative Additions to SHM’s Digital Learning Offerings
In addition to SHM SPARK, an MOC preparation tool for the Focused Practice in Hospital Medicine exam, and SHMConsults, online modules for consultative and perioperative medicine, look for new SHM Learning Portal activities in 2016, like “Management of Postoperative Atrial Fibrillation,” “Managing Pain in Postoperative Patients: What the Hospitalist Needs to Know,” and “Perioperative Bridging of Anticoagulant Theory.”
9 Get #SHeMpowered on Social Media
Have a success story to share about how SHM helped you advance your career or enhance patient care in your hospital? Maybe you improved your clinical skills at the annual meeting or improved care transitions with Project BOOST? Shout it from the rooftops—tweet @SHMLive and use the hashtag #SHeMpowered. If you haven’t followed SHM on Twitter, head over to @SHMLive.
10 “Are You Number 15,000?”
This is a question you want to say “yes” to! SHM is poised to welcome its 15,000th member in early 2016 as part of the Year of the Hospitalist. The 15,000th member will receive an assortment of exciting prizes, including complimentary registration to Hospital Medicine 2016 in San Diego. Know someone who is interested in joining? Spread the word!
Brett Radler is SHM’s communications coordinator.
Ready or not, 2016 is almost here, and SHM is gearing up for another year jam packed with exciting, enriching opportunities for hospitalists and their teams. Here are 10 things to have on your radar as we head into the new year.
1 Hospital Medicine 2016: March 6–9, 2016
This year’s annual meeting in San Diego promises to be the biggest yet, with new tracks in Co-Management/Perioperative Medicine, Health IT for Hospitalists, and Post-Acute Care—and opportunities to connect and collaborate with a vibrant community of hospital medicine professionals from around the nation. Register before early bird rates end on Jan. 11, 2016!
2 The Year of the Hospitalist
In celebration of the 20-year anniversary of the coining of the word “hospitalist,” SHM is preparing for a yearlong series of special events, contests, and opportunities. Follow SHM on Twitter at @SHMLive, and visit Hospital Medicine for the latest news!
3 Get Engaged with Public Policy
Healthcare legislation is constantly evolving, and hospitalists play an important role in advocating for hospitalized patients and the hospital medicine movement. SHM is an active voice in many conversations on policy development and reform. Sign up for the Grassroots Network now to stay updated on developments in healthcare policy, share your experiences with healthcare programs, and even participate in policy forums.
4 Fight the Resistance Campaign to Promote Antibiotic Stewardship
SHM is partnering with the CDC to change hospital culture and, in turn, change antibiotic prescription behaviors to prevent antibiotic resistance. Learn how you can be a part of the campaign, and download the campaign posters—featuring striking designs inspired by 1940s propaganda posters.
5 2016 State of Hospital Medicine Survey
The 2016 State of Hospital Medicine survey will take place January through March, with the release of the report scheduled for September. The survey consists of comprehensive, current information crucial to understanding the hospital medicine landscape and making better decisions in the hospital. Visit SHM’s website to find out how you can participate.
6 Expansion of the Quality Improvement Portfolio
SHM’s Center for Hospital Innovation and Improvement continues to develop guides, toolkits, and programs to meet the evolving needs of hospital-based clinicians and improve the care of hospitalized patients. New additions to the portfolio include resources for VTE, chronic heart failure, delirium, anemia, and end-of-life care.
7 SHM Student Hospitalist Scholar Grant Applications
Student members of SHM could be eligible to apply for an SHM Student Hospitalist Scholar Grant, including funding to complete scholarly work with an active SHM mentor in a project related to patient safety, quality improvement, or other hospital medicine-related fields. The deadline to apply is Feb. 15, 2016.
8 Innovative Additions to SHM’s Digital Learning Offerings
In addition to SHM SPARK, an MOC preparation tool for the Focused Practice in Hospital Medicine exam, and SHMConsults, online modules for consultative and perioperative medicine, look for new SHM Learning Portal activities in 2016, like “Management of Postoperative Atrial Fibrillation,” “Managing Pain in Postoperative Patients: What the Hospitalist Needs to Know,” and “Perioperative Bridging of Anticoagulant Theory.”
9 Get #SHeMpowered on Social Media
Have a success story to share about how SHM helped you advance your career or enhance patient care in your hospital? Maybe you improved your clinical skills at the annual meeting or improved care transitions with Project BOOST? Shout it from the rooftops—tweet @SHMLive and use the hashtag #SHeMpowered. If you haven’t followed SHM on Twitter, head over to @SHMLive.
10 “Are You Number 15,000?”
This is a question you want to say “yes” to! SHM is poised to welcome its 15,000th member in early 2016 as part of the Year of the Hospitalist. The 15,000th member will receive an assortment of exciting prizes, including complimentary registration to Hospital Medicine 2016 in San Diego. Know someone who is interested in joining? Spread the word!
Brett Radler is SHM’s communications coordinator.
ICD-10 Flexibility Helps Transition to New Coding Systems, Principles, Payer Policy Requirements
Effective October 1, providers submit claims with ICD-10-CM codes. As they adapt to this new system, physicians, clinical staff, and billers should be relying on feedback from each other to achieve a successful transition. On July 6, the Centers for Medicare and Medicaid Services (CMS), in conjunction with the AMA, issued a letter to the provider community offering ICD-10-CM guidance. The joint announcement and guidance regarding ICD-10 flexibilities minimizes the anxiety that often accompanies change and clarifies a few key points about claim scrutiny.1
According to the correspondence, “CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD-10 code set.”1 The guidance specifies the flexibility that will be used during the first 12 months of ICD-10-CM use.
This “flexibility” is an opportunity and should not be disregarded. Physician practices can effectively use this time to become accustomed to the ICD-10-CM system, correct coding principles, and payer policy requirements. Internal audit and review processes should increase in order to correct or confirm appropriate coding and claim submission.
Valid Codes
Medicare review contractors are instructed “not to deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”2 This “flexibility” will only occur for the first 12 months of ICD-10-CM implementation; the ultimate goal is for providers to assign the correct diagnosis code and the appropriate level of specificity after one year.
The “family code” allowance should not be confused with provision of an incomplete or truncated diagnosis code; these types of codes will always result in claim denial. The ICD-10-CM code presented on the claim form must be carried out to the highest character available for that particular code.
For example, an initial encounter involving an infected peripherally inserted central catheter (PICC) is reported with ICD-10-CM T80.212A (local infection due to central venous catheter). An individual unfamiliar with ICD-10-CM nomenclature may not realize that the seventh extension character of the code is required to carry the code out to its highest level of specificity. If T880.212 is mistakenly reported because the encounter detail (i.e., initial encounter [A], subsequent encounter [D], or sequela [S]) was not documented or provided to the biller, the payers’ claim edit system will identify this as a truncated or invalid diagnosis and reject the claim. Therefore, the code is required to be complete. The “flexibility” refers to reporting the code that best reflects the documented condition. As long as the reported code comes from the same family of codes and is valid, the claim cannot be denied.
Code Families
Code families are “codes within a category [that] are clinically related and provide differences in capturing specific information on the type of condition.”3 Upon review, Medicare will allow ICD-10-CM codes from the same code family to be reported on the claim without penalty if the most accurate code is not selected.
For example, a patient with COPD with acute exacerbation is admitted to the hospital. During the 12-month “flexibility” period, the claim could include J44.9 (COPD, unspecified) without being considered erroneous. The most appropriate code, however, is J44.1 (COPD with acute exacerbation). During the course of the hospitalization, if the physician determines that the COPD exacerbation was caused by an acute lower respiratory infection, J44.0 (COPD with acute lower respiratory infection) is the best option.
The provider goal for this flexibility period is to identify all of the “unspecified codes” used on their claims, review the documentation, and determine the most appropriate code. The practice staff assigned to this task would then provide feedback to the physicians to enhance their future reporting strategies. Although “unspecified” codes are often reported by default, physicians and staff should attempt to reduce usage of this code type unless the patient’s condition is unable to be further specified or categorized at a given point in time.
For example, it would not be acceptable to report R10.8 (unspecified abdominal pain) when a more specific diagnosis code can be easily determined by patient history or exam findings (e.g. right upper quadrant abdominal pain, R10.11).
Affected Claims
As previously stated, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review.”3 The review contractors included are as follows:
- Medicare Administrative Contractors (MACs) process claims submitted by physicians, hospitals, and other healthcare professionals and submit payment to those providers according to Medicare rules and regulations (including identifying and correcting underpayments and overpayments);
- Recovery Auditors (RACs) review claims to identify potential underpayments and overpayments in Medicare fee-for-service, as part of the Recovery Audit Program;
- Zone Program Integrity Contractors (ZPICs) perform investigations that are unique and tailored to the specific circumstances and occur only in situations where there is potential fraud and take appropriate corrective actions; and
- Supplemental Medical Review Contractor (SMRCs) conduct nationwide medical review as directed by CMS (including identifying underpayments and overpayments).4
This instruction applies to claims that are typically selected for review due to the ICD-10-CM code used on the claim but does not affect claims that are selected for review for other reasons (e.g. modifier 25 [separately identifiable visit performed on the same day as another procedure or service], unbundling, service-specific current procedural terminology code). If a claim is selected for one of these other reasons and does not meet the corresponding criterion, the service will be denied. This instruction also excludes claims for services that correspond to an existing local coverage determination (LCD) or national coverage determination (NCD).
For example, an esophagogastroduodenoscopy (EGD) is not considered “medically necessary” when reported with R10.8 (unspecified abdominal pain) and would be denied. EGD requires a more specific diagnosis (e.g. right upper quadrant abdominal pain, R10.11) per Medicare LCD.
Non-Medicare Payer Considerations
Most payers that are required to convert to ICD-10-CM have also provided some guidance about claim submission. Although most do not address the audit and review process, payers will follow some basic principles:
- Claims submitted with service dates on or after October 1 must use ICD-10-CM codes.
- Claims submitted with service dates prior to October 1 must use ICD-9-CM codes; this includes claims that are initially submitted after October 1 or require correction and resubmission after October 1.
- Physician claims will be held to medical necessity guidelines identified by specific ICD-10-CM codes represented in existing payer policies.
- General equivalence mappings (GEMs) should only be used as a starting point to convert large databases and large code lists from ICD-9 to ICD-10. Many ICD-9-CM codes do not crosswalk directly to an ICD-10-CM code. Physician and staff should continue to use the ICD-10-CM coding books and resources to determine the most accurate code selection.
- “Unspecified” codes are only for use when the information in the medical record is insufficient to assign a more specific code.5,6,7
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is on the faculty of SHM’s inpatient coding course.
References
- Centers for Medicare and Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10. July 6, 2015. Accessed October 3, 2015.
- Centers for Medicare and Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10: frequently asked questions. Accessed October 3, 2015.
- Centers for Medicare and Medicaid Services. Clarifying questions and answers related to the July 6, 2015 CMS/AMA joint announcement and guidance regarding ICD-10 flexibilities. Accessed October 3, 2015.
- Centers for Medicare and Medicaid Services. Medicare Learning Network: Medicare claim review programs. May 2015. Accessed October 3, 2015.
- Aetna. Preparation for ICD-10-CM: frequently asked questions. Accessed October 3, 2015.
- Independence Blue Cross. Transition to ICD-10: frequently asked questions. Accessed October 3, 2015.
- Cigna. Ready, Set, Switch: Know Your ICD-10 Codes. Accessed November 16, 2015.
Effective October 1, providers submit claims with ICD-10-CM codes. As they adapt to this new system, physicians, clinical staff, and billers should be relying on feedback from each other to achieve a successful transition. On July 6, the Centers for Medicare and Medicaid Services (CMS), in conjunction with the AMA, issued a letter to the provider community offering ICD-10-CM guidance. The joint announcement and guidance regarding ICD-10 flexibilities minimizes the anxiety that often accompanies change and clarifies a few key points about claim scrutiny.1
According to the correspondence, “CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD-10 code set.”1 The guidance specifies the flexibility that will be used during the first 12 months of ICD-10-CM use.
This “flexibility” is an opportunity and should not be disregarded. Physician practices can effectively use this time to become accustomed to the ICD-10-CM system, correct coding principles, and payer policy requirements. Internal audit and review processes should increase in order to correct or confirm appropriate coding and claim submission.
Valid Codes
Medicare review contractors are instructed “not to deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”2 This “flexibility” will only occur for the first 12 months of ICD-10-CM implementation; the ultimate goal is for providers to assign the correct diagnosis code and the appropriate level of specificity after one year.
The “family code” allowance should not be confused with provision of an incomplete or truncated diagnosis code; these types of codes will always result in claim denial. The ICD-10-CM code presented on the claim form must be carried out to the highest character available for that particular code.
For example, an initial encounter involving an infected peripherally inserted central catheter (PICC) is reported with ICD-10-CM T80.212A (local infection due to central venous catheter). An individual unfamiliar with ICD-10-CM nomenclature may not realize that the seventh extension character of the code is required to carry the code out to its highest level of specificity. If T880.212 is mistakenly reported because the encounter detail (i.e., initial encounter [A], subsequent encounter [D], or sequela [S]) was not documented or provided to the biller, the payers’ claim edit system will identify this as a truncated or invalid diagnosis and reject the claim. Therefore, the code is required to be complete. The “flexibility” refers to reporting the code that best reflects the documented condition. As long as the reported code comes from the same family of codes and is valid, the claim cannot be denied.
Code Families
Code families are “codes within a category [that] are clinically related and provide differences in capturing specific information on the type of condition.”3 Upon review, Medicare will allow ICD-10-CM codes from the same code family to be reported on the claim without penalty if the most accurate code is not selected.
For example, a patient with COPD with acute exacerbation is admitted to the hospital. During the 12-month “flexibility” period, the claim could include J44.9 (COPD, unspecified) without being considered erroneous. The most appropriate code, however, is J44.1 (COPD with acute exacerbation). During the course of the hospitalization, if the physician determines that the COPD exacerbation was caused by an acute lower respiratory infection, J44.0 (COPD with acute lower respiratory infection) is the best option.
The provider goal for this flexibility period is to identify all of the “unspecified codes” used on their claims, review the documentation, and determine the most appropriate code. The practice staff assigned to this task would then provide feedback to the physicians to enhance their future reporting strategies. Although “unspecified” codes are often reported by default, physicians and staff should attempt to reduce usage of this code type unless the patient’s condition is unable to be further specified or categorized at a given point in time.
For example, it would not be acceptable to report R10.8 (unspecified abdominal pain) when a more specific diagnosis code can be easily determined by patient history or exam findings (e.g. right upper quadrant abdominal pain, R10.11).
Affected Claims
As previously stated, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review.”3 The review contractors included are as follows:
- Medicare Administrative Contractors (MACs) process claims submitted by physicians, hospitals, and other healthcare professionals and submit payment to those providers according to Medicare rules and regulations (including identifying and correcting underpayments and overpayments);
- Recovery Auditors (RACs) review claims to identify potential underpayments and overpayments in Medicare fee-for-service, as part of the Recovery Audit Program;
- Zone Program Integrity Contractors (ZPICs) perform investigations that are unique and tailored to the specific circumstances and occur only in situations where there is potential fraud and take appropriate corrective actions; and
- Supplemental Medical Review Contractor (SMRCs) conduct nationwide medical review as directed by CMS (including identifying underpayments and overpayments).4
This instruction applies to claims that are typically selected for review due to the ICD-10-CM code used on the claim but does not affect claims that are selected for review for other reasons (e.g. modifier 25 [separately identifiable visit performed on the same day as another procedure or service], unbundling, service-specific current procedural terminology code). If a claim is selected for one of these other reasons and does not meet the corresponding criterion, the service will be denied. This instruction also excludes claims for services that correspond to an existing local coverage determination (LCD) or national coverage determination (NCD).
For example, an esophagogastroduodenoscopy (EGD) is not considered “medically necessary” when reported with R10.8 (unspecified abdominal pain) and would be denied. EGD requires a more specific diagnosis (e.g. right upper quadrant abdominal pain, R10.11) per Medicare LCD.
Non-Medicare Payer Considerations
Most payers that are required to convert to ICD-10-CM have also provided some guidance about claim submission. Although most do not address the audit and review process, payers will follow some basic principles:
- Claims submitted with service dates on or after October 1 must use ICD-10-CM codes.
- Claims submitted with service dates prior to October 1 must use ICD-9-CM codes; this includes claims that are initially submitted after October 1 or require correction and resubmission after October 1.
- Physician claims will be held to medical necessity guidelines identified by specific ICD-10-CM codes represented in existing payer policies.
- General equivalence mappings (GEMs) should only be used as a starting point to convert large databases and large code lists from ICD-9 to ICD-10. Many ICD-9-CM codes do not crosswalk directly to an ICD-10-CM code. Physician and staff should continue to use the ICD-10-CM coding books and resources to determine the most accurate code selection.
- “Unspecified” codes are only for use when the information in the medical record is insufficient to assign a more specific code.5,6,7
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is on the faculty of SHM’s inpatient coding course.
References
- Centers for Medicare and Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10. July 6, 2015. Accessed October 3, 2015.
- Centers for Medicare and Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10: frequently asked questions. Accessed October 3, 2015.
- Centers for Medicare and Medicaid Services. Clarifying questions and answers related to the July 6, 2015 CMS/AMA joint announcement and guidance regarding ICD-10 flexibilities. Accessed October 3, 2015.
- Centers for Medicare and Medicaid Services. Medicare Learning Network: Medicare claim review programs. May 2015. Accessed October 3, 2015.
- Aetna. Preparation for ICD-10-CM: frequently asked questions. Accessed October 3, 2015.
- Independence Blue Cross. Transition to ICD-10: frequently asked questions. Accessed October 3, 2015.
- Cigna. Ready, Set, Switch: Know Your ICD-10 Codes. Accessed November 16, 2015.
Effective October 1, providers submit claims with ICD-10-CM codes. As they adapt to this new system, physicians, clinical staff, and billers should be relying on feedback from each other to achieve a successful transition. On July 6, the Centers for Medicare and Medicaid Services (CMS), in conjunction with the AMA, issued a letter to the provider community offering ICD-10-CM guidance. The joint announcement and guidance regarding ICD-10 flexibilities minimizes the anxiety that often accompanies change and clarifies a few key points about claim scrutiny.1
According to the correspondence, “CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD-10 code set.”1 The guidance specifies the flexibility that will be used during the first 12 months of ICD-10-CM use.
This “flexibility” is an opportunity and should not be disregarded. Physician practices can effectively use this time to become accustomed to the ICD-10-CM system, correct coding principles, and payer policy requirements. Internal audit and review processes should increase in order to correct or confirm appropriate coding and claim submission.
Valid Codes
Medicare review contractors are instructed “not to deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”2 This “flexibility” will only occur for the first 12 months of ICD-10-CM implementation; the ultimate goal is for providers to assign the correct diagnosis code and the appropriate level of specificity after one year.
The “family code” allowance should not be confused with provision of an incomplete or truncated diagnosis code; these types of codes will always result in claim denial. The ICD-10-CM code presented on the claim form must be carried out to the highest character available for that particular code.
For example, an initial encounter involving an infected peripherally inserted central catheter (PICC) is reported with ICD-10-CM T80.212A (local infection due to central venous catheter). An individual unfamiliar with ICD-10-CM nomenclature may not realize that the seventh extension character of the code is required to carry the code out to its highest level of specificity. If T880.212 is mistakenly reported because the encounter detail (i.e., initial encounter [A], subsequent encounter [D], or sequela [S]) was not documented or provided to the biller, the payers’ claim edit system will identify this as a truncated or invalid diagnosis and reject the claim. Therefore, the code is required to be complete. The “flexibility” refers to reporting the code that best reflects the documented condition. As long as the reported code comes from the same family of codes and is valid, the claim cannot be denied.
Code Families
Code families are “codes within a category [that] are clinically related and provide differences in capturing specific information on the type of condition.”3 Upon review, Medicare will allow ICD-10-CM codes from the same code family to be reported on the claim without penalty if the most accurate code is not selected.
For example, a patient with COPD with acute exacerbation is admitted to the hospital. During the 12-month “flexibility” period, the claim could include J44.9 (COPD, unspecified) without being considered erroneous. The most appropriate code, however, is J44.1 (COPD with acute exacerbation). During the course of the hospitalization, if the physician determines that the COPD exacerbation was caused by an acute lower respiratory infection, J44.0 (COPD with acute lower respiratory infection) is the best option.
The provider goal for this flexibility period is to identify all of the “unspecified codes” used on their claims, review the documentation, and determine the most appropriate code. The practice staff assigned to this task would then provide feedback to the physicians to enhance their future reporting strategies. Although “unspecified” codes are often reported by default, physicians and staff should attempt to reduce usage of this code type unless the patient’s condition is unable to be further specified or categorized at a given point in time.
For example, it would not be acceptable to report R10.8 (unspecified abdominal pain) when a more specific diagnosis code can be easily determined by patient history or exam findings (e.g. right upper quadrant abdominal pain, R10.11).
Affected Claims
As previously stated, “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review.”3 The review contractors included are as follows:
- Medicare Administrative Contractors (MACs) process claims submitted by physicians, hospitals, and other healthcare professionals and submit payment to those providers according to Medicare rules and regulations (including identifying and correcting underpayments and overpayments);
- Recovery Auditors (RACs) review claims to identify potential underpayments and overpayments in Medicare fee-for-service, as part of the Recovery Audit Program;
- Zone Program Integrity Contractors (ZPICs) perform investigations that are unique and tailored to the specific circumstances and occur only in situations where there is potential fraud and take appropriate corrective actions; and
- Supplemental Medical Review Contractor (SMRCs) conduct nationwide medical review as directed by CMS (including identifying underpayments and overpayments).4
This instruction applies to claims that are typically selected for review due to the ICD-10-CM code used on the claim but does not affect claims that are selected for review for other reasons (e.g. modifier 25 [separately identifiable visit performed on the same day as another procedure or service], unbundling, service-specific current procedural terminology code). If a claim is selected for one of these other reasons and does not meet the corresponding criterion, the service will be denied. This instruction also excludes claims for services that correspond to an existing local coverage determination (LCD) or national coverage determination (NCD).
For example, an esophagogastroduodenoscopy (EGD) is not considered “medically necessary” when reported with R10.8 (unspecified abdominal pain) and would be denied. EGD requires a more specific diagnosis (e.g. right upper quadrant abdominal pain, R10.11) per Medicare LCD.
Non-Medicare Payer Considerations
Most payers that are required to convert to ICD-10-CM have also provided some guidance about claim submission. Although most do not address the audit and review process, payers will follow some basic principles:
- Claims submitted with service dates on or after October 1 must use ICD-10-CM codes.
- Claims submitted with service dates prior to October 1 must use ICD-9-CM codes; this includes claims that are initially submitted after October 1 or require correction and resubmission after October 1.
- Physician claims will be held to medical necessity guidelines identified by specific ICD-10-CM codes represented in existing payer policies.
- General equivalence mappings (GEMs) should only be used as a starting point to convert large databases and large code lists from ICD-9 to ICD-10. Many ICD-9-CM codes do not crosswalk directly to an ICD-10-CM code. Physician and staff should continue to use the ICD-10-CM coding books and resources to determine the most accurate code selection.
- “Unspecified” codes are only for use when the information in the medical record is insufficient to assign a more specific code.5,6,7
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is on the faculty of SHM’s inpatient coding course.
References
- Centers for Medicare and Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10. July 6, 2015. Accessed October 3, 2015.
- Centers for Medicare and Medicaid Services. CMS and AMA announce efforts to help providers get ready for ICD-10: frequently asked questions. Accessed October 3, 2015.
- Centers for Medicare and Medicaid Services. Clarifying questions and answers related to the July 6, 2015 CMS/AMA joint announcement and guidance regarding ICD-10 flexibilities. Accessed October 3, 2015.
- Centers for Medicare and Medicaid Services. Medicare Learning Network: Medicare claim review programs. May 2015. Accessed October 3, 2015.
- Aetna. Preparation for ICD-10-CM: frequently asked questions. Accessed October 3, 2015.
- Independence Blue Cross. Transition to ICD-10: frequently asked questions. Accessed October 3, 2015.
- Cigna. Ready, Set, Switch: Know Your ICD-10 Codes. Accessed November 16, 2015.
Hospitalist Enjoys Mentoring Residents on Patient Care Practices
From 2003 to 2007, Joshua LaBrin, MD, FACP, SFHM, completed his residency in the University of Pittsburgh’s internal medicine/pediatrics program. In his chief resident year, he began to look at fellowships.
So he started thinking about who he considered role models in medicine.
“And they were the hospitalists,” Dr. LaBrin says. “They were the ones on the wards. I was able to see their compassion for their patients, their ability to teach and mentor residents such as myself.
“Those are the people I looked up to, and that’s who I wanted to be.”
And with that, his career in HM began. A fellowship in the specialty followed at the Mayo Clinic in Rochester, Minn. Then a teaching position there. Then one at Vanderbilt University School of Medicine in Nashville. And last year, he became an academic hospitalist and assistant professor at the University of Utah School of Medicine.
Now, he’s one of seven new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: What got you involved in medicine in the first place?
Answer: I remember my pediatrician … putting me at ease during the visits, and then when I was in high school and had appendicitis and had to go through surgery. ... Each of the physicians caring for me left a different impact and served as an inspiration for me to follow in their footsteps.
Q: What was it about those who treated you that struck a nerve?
A: The fact that they cared for me and were able to either keep me well or get me better. The surgeons helped me through a pretty scary part in my life. [They] treated me as a person, rather than just another patient, even meeting me where I was at at that point. That was the kind of thing that resonated with me, and I wanted to do that for people as well.
Q: Did you have a mentor?
A: I had more than one mentor in residency and fellowship where I was able to really learn many lessons from them. And I think among the things that I learned, beyond hospital medicine, was the value of work-life balance. I’ve definitely been able to talk with them, even beyond fellowship, as I have moved and changed positions. That’s something I’ve been able to reflect on regularly. Especially as my family has grown, I continue to communicate with them, so I have always been grateful for their mentorship.
Q: Have you looked to mentor others?
A: That’s one of the things I’ve definitely enjoyed. I have been given opportunities to provide mentorship for new faculty or for residents, and it’s been a humbling experience and it’s been an honor to be able to do that.
Q: In terms of personal satisfaction, what do you enjoy most about your job?
A: I really enjoy working with the trainees, walking with them in their development, seeing them on the wards caring for inpatients and thinking more about issues germane to their patients. Seeing them grow as doctors, as physicians. That’s something I don’t think I’ll ever get tired of doing.
Q: No job is perfect. What do you like least about your job?
A: The most frustrating issue for me is when you are caring for patients and you’re really unable to provide an ideal discharge plan for them due to a financial or technical issue. For example, the three-midnight rule with Medicare sometimes limits you in what you are able to provide for your patients ... so I think that’s probably one of the frustrating things.
Q: What are the biggest changes you’d like to see in the field?
A: One of the big things I have seen over this past year is the whole MOC (Maintenance of Certification) path debate. As nebulous as it has been for internal medicine, in general, I think it is even more so for hospitalists. So having a kind of clear, more practical path for hospitalists would be one of the biggest changes I would like to see. I think the current discussion is healthy. I think it provides a good forum for, hopefully, some positive changes, and I hope that also translates into positive changes for hospitalists as well.
Q: Academic HM can be a real time crunch, between clinical care and classes. How do you balance?
A: Balancing patient care with teaching is one of the big struggles that educators find nowadays, and I think you have to get creative. Obviously, the goal for me as an educator when I am on the wards is to help the trainees take better care of their patients.
So the more I can find ways to be able to provide great patient care, but do it in a way that also either allows the residents or students to learn to do that themselves or to be able to model that for them, then debrief with them afterwards, the more I can achieve that goal.
I have started to learn there are many different ways to be able to do that. And so being able to go into the day as prepared as you can be, and try to have a good plan in place with also plan B and plan C, if necessary, depending on how the day goes, I think is what has helped me.
From 2003 to 2007, Joshua LaBrin, MD, FACP, SFHM, completed his residency in the University of Pittsburgh’s internal medicine/pediatrics program. In his chief resident year, he began to look at fellowships.
So he started thinking about who he considered role models in medicine.
“And they were the hospitalists,” Dr. LaBrin says. “They were the ones on the wards. I was able to see their compassion for their patients, their ability to teach and mentor residents such as myself.
“Those are the people I looked up to, and that’s who I wanted to be.”
And with that, his career in HM began. A fellowship in the specialty followed at the Mayo Clinic in Rochester, Minn. Then a teaching position there. Then one at Vanderbilt University School of Medicine in Nashville. And last year, he became an academic hospitalist and assistant professor at the University of Utah School of Medicine.
Now, he’s one of seven new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: What got you involved in medicine in the first place?
Answer: I remember my pediatrician … putting me at ease during the visits, and then when I was in high school and had appendicitis and had to go through surgery. ... Each of the physicians caring for me left a different impact and served as an inspiration for me to follow in their footsteps.
Q: What was it about those who treated you that struck a nerve?
A: The fact that they cared for me and were able to either keep me well or get me better. The surgeons helped me through a pretty scary part in my life. [They] treated me as a person, rather than just another patient, even meeting me where I was at at that point. That was the kind of thing that resonated with me, and I wanted to do that for people as well.
Q: Did you have a mentor?
A: I had more than one mentor in residency and fellowship where I was able to really learn many lessons from them. And I think among the things that I learned, beyond hospital medicine, was the value of work-life balance. I’ve definitely been able to talk with them, even beyond fellowship, as I have moved and changed positions. That’s something I’ve been able to reflect on regularly. Especially as my family has grown, I continue to communicate with them, so I have always been grateful for their mentorship.
Q: Have you looked to mentor others?
A: That’s one of the things I’ve definitely enjoyed. I have been given opportunities to provide mentorship for new faculty or for residents, and it’s been a humbling experience and it’s been an honor to be able to do that.
Q: In terms of personal satisfaction, what do you enjoy most about your job?
A: I really enjoy working with the trainees, walking with them in their development, seeing them on the wards caring for inpatients and thinking more about issues germane to their patients. Seeing them grow as doctors, as physicians. That’s something I don’t think I’ll ever get tired of doing.
Q: No job is perfect. What do you like least about your job?
A: The most frustrating issue for me is when you are caring for patients and you’re really unable to provide an ideal discharge plan for them due to a financial or technical issue. For example, the three-midnight rule with Medicare sometimes limits you in what you are able to provide for your patients ... so I think that’s probably one of the frustrating things.
Q: What are the biggest changes you’d like to see in the field?
A: One of the big things I have seen over this past year is the whole MOC (Maintenance of Certification) path debate. As nebulous as it has been for internal medicine, in general, I think it is even more so for hospitalists. So having a kind of clear, more practical path for hospitalists would be one of the biggest changes I would like to see. I think the current discussion is healthy. I think it provides a good forum for, hopefully, some positive changes, and I hope that also translates into positive changes for hospitalists as well.
Q: Academic HM can be a real time crunch, between clinical care and classes. How do you balance?
A: Balancing patient care with teaching is one of the big struggles that educators find nowadays, and I think you have to get creative. Obviously, the goal for me as an educator when I am on the wards is to help the trainees take better care of their patients.
So the more I can find ways to be able to provide great patient care, but do it in a way that also either allows the residents or students to learn to do that themselves or to be able to model that for them, then debrief with them afterwards, the more I can achieve that goal.
I have started to learn there are many different ways to be able to do that. And so being able to go into the day as prepared as you can be, and try to have a good plan in place with also plan B and plan C, if necessary, depending on how the day goes, I think is what has helped me.
From 2003 to 2007, Joshua LaBrin, MD, FACP, SFHM, completed his residency in the University of Pittsburgh’s internal medicine/pediatrics program. In his chief resident year, he began to look at fellowships.
So he started thinking about who he considered role models in medicine.
“And they were the hospitalists,” Dr. LaBrin says. “They were the ones on the wards. I was able to see their compassion for their patients, their ability to teach and mentor residents such as myself.
“Those are the people I looked up to, and that’s who I wanted to be.”
And with that, his career in HM began. A fellowship in the specialty followed at the Mayo Clinic in Rochester, Minn. Then a teaching position there. Then one at Vanderbilt University School of Medicine in Nashville. And last year, he became an academic hospitalist and assistant professor at the University of Utah School of Medicine.
Now, he’s one of seven new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: What got you involved in medicine in the first place?
Answer: I remember my pediatrician … putting me at ease during the visits, and then when I was in high school and had appendicitis and had to go through surgery. ... Each of the physicians caring for me left a different impact and served as an inspiration for me to follow in their footsteps.
Q: What was it about those who treated you that struck a nerve?
A: The fact that they cared for me and were able to either keep me well or get me better. The surgeons helped me through a pretty scary part in my life. [They] treated me as a person, rather than just another patient, even meeting me where I was at at that point. That was the kind of thing that resonated with me, and I wanted to do that for people as well.
Q: Did you have a mentor?
A: I had more than one mentor in residency and fellowship where I was able to really learn many lessons from them. And I think among the things that I learned, beyond hospital medicine, was the value of work-life balance. I’ve definitely been able to talk with them, even beyond fellowship, as I have moved and changed positions. That’s something I’ve been able to reflect on regularly. Especially as my family has grown, I continue to communicate with them, so I have always been grateful for their mentorship.
Q: Have you looked to mentor others?
A: That’s one of the things I’ve definitely enjoyed. I have been given opportunities to provide mentorship for new faculty or for residents, and it’s been a humbling experience and it’s been an honor to be able to do that.
Q: In terms of personal satisfaction, what do you enjoy most about your job?
A: I really enjoy working with the trainees, walking with them in their development, seeing them on the wards caring for inpatients and thinking more about issues germane to their patients. Seeing them grow as doctors, as physicians. That’s something I don’t think I’ll ever get tired of doing.
Q: No job is perfect. What do you like least about your job?
A: The most frustrating issue for me is when you are caring for patients and you’re really unable to provide an ideal discharge plan for them due to a financial or technical issue. For example, the three-midnight rule with Medicare sometimes limits you in what you are able to provide for your patients ... so I think that’s probably one of the frustrating things.
Q: What are the biggest changes you’d like to see in the field?
A: One of the big things I have seen over this past year is the whole MOC (Maintenance of Certification) path debate. As nebulous as it has been for internal medicine, in general, I think it is even more so for hospitalists. So having a kind of clear, more practical path for hospitalists would be one of the biggest changes I would like to see. I think the current discussion is healthy. I think it provides a good forum for, hopefully, some positive changes, and I hope that also translates into positive changes for hospitalists as well.
Q: Academic HM can be a real time crunch, between clinical care and classes. How do you balance?
A: Balancing patient care with teaching is one of the big struggles that educators find nowadays, and I think you have to get creative. Obviously, the goal for me as an educator when I am on the wards is to help the trainees take better care of their patients.
So the more I can find ways to be able to provide great patient care, but do it in a way that also either allows the residents or students to learn to do that themselves or to be able to model that for them, then debrief with them afterwards, the more I can achieve that goal.
I have started to learn there are many different ways to be able to do that. And so being able to go into the day as prepared as you can be, and try to have a good plan in place with also plan B and plan C, if necessary, depending on how the day goes, I think is what has helped me.
Modified Valsalva Better than Standard Maneuver to Restore Sinus Rhythm
Clinical question: Does a postural modification to the Valsalva maneuver improve its effectiveness?
Background: The Valsalva maneuver, often used to treat supraventricular tachycardia, is rarely successful. A modification to the maneuver to increase relaxation phase venous return and vagal stimulation could improve its efficacy.
Study design: Multicenter, randomized controlled trial (RCT).
Setting: Ten emergency departments in England.
Synopsis: Four hundred thirty-three patients with stable supraventricular tachycardia (excluding atrial fibrillation or flutter) were randomized to use the Valsalva maneuver (control) or modified Valsalva maneuver (intervention). In the control group, strain was standardized using a manometer (40 mm Hg for 15 seconds). In the intervention group, patients underwent the same maneuver, followed by lying supine with passive leg raise to 45 degrees for 15 seconds. Participants could repeat the maneuver if it was initially unsuccessful. Randomization was stratified by center.
Using an intention-to-treat analysis, 43% of the intervention group achieved the primary outcome of sinus rhythm one minute after straining, compared with 17% of the control group (P<0.0001). The intervention group was less likely to receive adenosine (50% vs. 69%, P=0.0002) or any emergency, anti-arrhythmic treatment (80% vs. 57%, P<0.0001).
No significant differences were seen in hospital admissions, length of ED stay, or adverse events between groups.
Bottom line: In patients with stable supraventricular tachycardia, modifying the Valsalva maneuver is significantly more effective in restoring sinus rhythm.
Citation: Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial [published online ahead of print August 24, 2015]. Lancet. doi: 10.1016/S0140-6736(15)61485-4.
Clinical question: Does a postural modification to the Valsalva maneuver improve its effectiveness?
Background: The Valsalva maneuver, often used to treat supraventricular tachycardia, is rarely successful. A modification to the maneuver to increase relaxation phase venous return and vagal stimulation could improve its efficacy.
Study design: Multicenter, randomized controlled trial (RCT).
Setting: Ten emergency departments in England.
Synopsis: Four hundred thirty-three patients with stable supraventricular tachycardia (excluding atrial fibrillation or flutter) were randomized to use the Valsalva maneuver (control) or modified Valsalva maneuver (intervention). In the control group, strain was standardized using a manometer (40 mm Hg for 15 seconds). In the intervention group, patients underwent the same maneuver, followed by lying supine with passive leg raise to 45 degrees for 15 seconds. Participants could repeat the maneuver if it was initially unsuccessful. Randomization was stratified by center.
Using an intention-to-treat analysis, 43% of the intervention group achieved the primary outcome of sinus rhythm one minute after straining, compared with 17% of the control group (P<0.0001). The intervention group was less likely to receive adenosine (50% vs. 69%, P=0.0002) or any emergency, anti-arrhythmic treatment (80% vs. 57%, P<0.0001).
No significant differences were seen in hospital admissions, length of ED stay, or adverse events between groups.
Bottom line: In patients with stable supraventricular tachycardia, modifying the Valsalva maneuver is significantly more effective in restoring sinus rhythm.
Citation: Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial [published online ahead of print August 24, 2015]. Lancet. doi: 10.1016/S0140-6736(15)61485-4.
Clinical question: Does a postural modification to the Valsalva maneuver improve its effectiveness?
Background: The Valsalva maneuver, often used to treat supraventricular tachycardia, is rarely successful. A modification to the maneuver to increase relaxation phase venous return and vagal stimulation could improve its efficacy.
Study design: Multicenter, randomized controlled trial (RCT).
Setting: Ten emergency departments in England.
Synopsis: Four hundred thirty-three patients with stable supraventricular tachycardia (excluding atrial fibrillation or flutter) were randomized to use the Valsalva maneuver (control) or modified Valsalva maneuver (intervention). In the control group, strain was standardized using a manometer (40 mm Hg for 15 seconds). In the intervention group, patients underwent the same maneuver, followed by lying supine with passive leg raise to 45 degrees for 15 seconds. Participants could repeat the maneuver if it was initially unsuccessful. Randomization was stratified by center.
Using an intention-to-treat analysis, 43% of the intervention group achieved the primary outcome of sinus rhythm one minute after straining, compared with 17% of the control group (P<0.0001). The intervention group was less likely to receive adenosine (50% vs. 69%, P=0.0002) or any emergency, anti-arrhythmic treatment (80% vs. 57%, P<0.0001).
No significant differences were seen in hospital admissions, length of ED stay, or adverse events between groups.
Bottom line: In patients with stable supraventricular tachycardia, modifying the Valsalva maneuver is significantly more effective in restoring sinus rhythm.
Citation: Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial [published online ahead of print August 24, 2015]. Lancet. doi: 10.1016/S0140-6736(15)61485-4.
CHA2DS2-Vasc Score Modestly Predicts Stroke, Thromboembolism, Death
Clinical question: For patients with heart failure (HF), with and without concurrent Afib (AF), does the CHA2DS2-VASc score predict ischemic stroke, thromboembolism, and death?
Background: Factors in the CHA2DS2-VASc score predict increased risk of stroke, thromboembolism, and death, regardless of whether AF is present. It is unknown if this score can identify subgroups of patients with HF, with and without AF, at particularly high or low risk of these events.
Study design: Prospective, cohort study.
Setting: Three Danish registries, 2000-2012.
Synopsis: Among 42,987 patients 50 years and older with incident HF not on anticoagulation, the absolute risk of stroke among patients without AF was 1.5% per year or higher with a CHA2DS2-VASc score of two or higher. The absolute risk of stroke was 4% or higher at five years. Risks were higher in the 21.9% of patients with AF. The CHA2DS2-VASc score modestly predicted endpoints and had an approximately 90% negative predictive value for stroke, thromboembolism, and death at one-year follow-up, regardless of whether or not AF was present.
In this large study, HF patients in a non-diverse population were studied, and some patients may have had undiagnosed AF. Functional status and ejection fraction in patients with HF could not be categorized; however, reported five-year results may be generalizable to patients with chronic HF. Select patients with HF without AF, who have two or more factors of the score besides HF, might benefit from anticoagulation.
Bottom line: The CHA2DS2-VASc score modestly predicts stroke, thromboembolism, and death among patients with HF, but further studies are needed to determine its clinical usefulness.
Citation: Melgaard L, Gorst-Rasmussen A, Lane DA, Rasmussen LH, Larsen TB, Lip GY. Assessment of the CHA2DS2-VASc Score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. JAMA. 2015;314(10):1030-1038.
Clinical question: For patients with heart failure (HF), with and without concurrent Afib (AF), does the CHA2DS2-VASc score predict ischemic stroke, thromboembolism, and death?
Background: Factors in the CHA2DS2-VASc score predict increased risk of stroke, thromboembolism, and death, regardless of whether AF is present. It is unknown if this score can identify subgroups of patients with HF, with and without AF, at particularly high or low risk of these events.
Study design: Prospective, cohort study.
Setting: Three Danish registries, 2000-2012.
Synopsis: Among 42,987 patients 50 years and older with incident HF not on anticoagulation, the absolute risk of stroke among patients without AF was 1.5% per year or higher with a CHA2DS2-VASc score of two or higher. The absolute risk of stroke was 4% or higher at five years. Risks were higher in the 21.9% of patients with AF. The CHA2DS2-VASc score modestly predicted endpoints and had an approximately 90% negative predictive value for stroke, thromboembolism, and death at one-year follow-up, regardless of whether or not AF was present.
In this large study, HF patients in a non-diverse population were studied, and some patients may have had undiagnosed AF. Functional status and ejection fraction in patients with HF could not be categorized; however, reported five-year results may be generalizable to patients with chronic HF. Select patients with HF without AF, who have two or more factors of the score besides HF, might benefit from anticoagulation.
Bottom line: The CHA2DS2-VASc score modestly predicts stroke, thromboembolism, and death among patients with HF, but further studies are needed to determine its clinical usefulness.
Citation: Melgaard L, Gorst-Rasmussen A, Lane DA, Rasmussen LH, Larsen TB, Lip GY. Assessment of the CHA2DS2-VASc Score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. JAMA. 2015;314(10):1030-1038.
Clinical question: For patients with heart failure (HF), with and without concurrent Afib (AF), does the CHA2DS2-VASc score predict ischemic stroke, thromboembolism, and death?
Background: Factors in the CHA2DS2-VASc score predict increased risk of stroke, thromboembolism, and death, regardless of whether AF is present. It is unknown if this score can identify subgroups of patients with HF, with and without AF, at particularly high or low risk of these events.
Study design: Prospective, cohort study.
Setting: Three Danish registries, 2000-2012.
Synopsis: Among 42,987 patients 50 years and older with incident HF not on anticoagulation, the absolute risk of stroke among patients without AF was 1.5% per year or higher with a CHA2DS2-VASc score of two or higher. The absolute risk of stroke was 4% or higher at five years. Risks were higher in the 21.9% of patients with AF. The CHA2DS2-VASc score modestly predicted endpoints and had an approximately 90% negative predictive value for stroke, thromboembolism, and death at one-year follow-up, regardless of whether or not AF was present.
In this large study, HF patients in a non-diverse population were studied, and some patients may have had undiagnosed AF. Functional status and ejection fraction in patients with HF could not be categorized; however, reported five-year results may be generalizable to patients with chronic HF. Select patients with HF without AF, who have two or more factors of the score besides HF, might benefit from anticoagulation.
Bottom line: The CHA2DS2-VASc score modestly predicts stroke, thromboembolism, and death among patients with HF, but further studies are needed to determine its clinical usefulness.
Citation: Melgaard L, Gorst-Rasmussen A, Lane DA, Rasmussen LH, Larsen TB, Lip GY. Assessment of the CHA2DS2-VASc Score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. JAMA. 2015;314(10):1030-1038.
Intraoperative Hypotension Predicts Postoperative Mortality
Clinical question: What blood pressure deviations during surgery are predictive of mortality?
Background: Despite the widely assumed importance of blood pressure (BP) management on postoperative outcomes, there are no accepted thresholds requiring intervention.
Study design: Retrospective cohort.
Setting: Six Veterans’ Affairs hospitals, 2001-2008.
Synopsis: Intraoperative BP data from 18,756 patients undergoing major noncardiac surgery were linked with procedure, patient-related risk factors, and 30-day mortality data from the VA Surgical Quality Improvement Program database. Overall 30-day mortality was 1.8%. Using three different methods for defining hyper- or hypotension (based on standard deviations from the mean in this population, absolute thresholds suggested by medical literature, or by changes from baseline BP), no measure of hypertension predicted mortality; however, after adjusting for 10 preoperative patient-related risk factors, extremely low BP for five minutes or more (whether defined as systolic BP <70 mmHg, mean arterial pressure <49 mmHg, or diastolic BP <30 mmHg) was associated with 30-day mortality, with statistically significant odds ratios in the 2.4-3.2 range.
Because this is an observational study, no causal relationship can be established from these data. Low BPs could be markers for sicker patients with increased mortality, despite researchers’ efforts to adjust for known preoperative risks.
Bottom line: Intraoperative hypotension lasting five minutes or more, but not intraoperative hypertension, predicts 30-day mortality.
Citation: Monk TG, Bronsert MR, Henderson WG, et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology. 2015;123(2):307-319.
Clinical question: What blood pressure deviations during surgery are predictive of mortality?
Background: Despite the widely assumed importance of blood pressure (BP) management on postoperative outcomes, there are no accepted thresholds requiring intervention.
Study design: Retrospective cohort.
Setting: Six Veterans’ Affairs hospitals, 2001-2008.
Synopsis: Intraoperative BP data from 18,756 patients undergoing major noncardiac surgery were linked with procedure, patient-related risk factors, and 30-day mortality data from the VA Surgical Quality Improvement Program database. Overall 30-day mortality was 1.8%. Using three different methods for defining hyper- or hypotension (based on standard deviations from the mean in this population, absolute thresholds suggested by medical literature, or by changes from baseline BP), no measure of hypertension predicted mortality; however, after adjusting for 10 preoperative patient-related risk factors, extremely low BP for five minutes or more (whether defined as systolic BP <70 mmHg, mean arterial pressure <49 mmHg, or diastolic BP <30 mmHg) was associated with 30-day mortality, with statistically significant odds ratios in the 2.4-3.2 range.
Because this is an observational study, no causal relationship can be established from these data. Low BPs could be markers for sicker patients with increased mortality, despite researchers’ efforts to adjust for known preoperative risks.
Bottom line: Intraoperative hypotension lasting five minutes or more, but not intraoperative hypertension, predicts 30-day mortality.
Citation: Monk TG, Bronsert MR, Henderson WG, et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology. 2015;123(2):307-319.
Clinical question: What blood pressure deviations during surgery are predictive of mortality?
Background: Despite the widely assumed importance of blood pressure (BP) management on postoperative outcomes, there are no accepted thresholds requiring intervention.
Study design: Retrospective cohort.
Setting: Six Veterans’ Affairs hospitals, 2001-2008.
Synopsis: Intraoperative BP data from 18,756 patients undergoing major noncardiac surgery were linked with procedure, patient-related risk factors, and 30-day mortality data from the VA Surgical Quality Improvement Program database. Overall 30-day mortality was 1.8%. Using three different methods for defining hyper- or hypotension (based on standard deviations from the mean in this population, absolute thresholds suggested by medical literature, or by changes from baseline BP), no measure of hypertension predicted mortality; however, after adjusting for 10 preoperative patient-related risk factors, extremely low BP for five minutes or more (whether defined as systolic BP <70 mmHg, mean arterial pressure <49 mmHg, or diastolic BP <30 mmHg) was associated with 30-day mortality, with statistically significant odds ratios in the 2.4-3.2 range.
Because this is an observational study, no causal relationship can be established from these data. Low BPs could be markers for sicker patients with increased mortality, despite researchers’ efforts to adjust for known preoperative risks.
Bottom line: Intraoperative hypotension lasting five minutes or more, but not intraoperative hypertension, predicts 30-day mortality.
Citation: Monk TG, Bronsert MR, Henderson WG, et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology. 2015;123(2):307-319.
Caprini Risk Assessment Tool Can Distinguish High Risk of VTE in Critically Ill Surgical Patients
Clinical question: Is the Caprini Risk Assessment Model for VTE risk valid in critically ill surgical patients?
Background: Critically ill surgical patients are at increased risk of developing VTE. Chemoprophylaxis decreases VTE risk, but benefits must be balanced against bleeding risk. Rapid and accurate risk stratification supports decisions about prophylaxis; however, data regarding appropriate risk stratification are limited.
Study design: Retrospective, cohort study.
Setting: Surgical ICU (SICU) at a single, U.S. academic medical center, 2007-2013.
Synopsis: Among 4,844 consecutive admissions, the in-hospital VTE rate was 7.5% (364). Using a previously validated, computer-generated, retrospective risk score based on the 2005 Caprini model, patients were most commonly at moderate risk for VTE upon ICU admission (32%). Fifteen percent (723) were extremely high risk. VTE incidence increased linearly with increasing Caprini scores. Data were abstracted from multiple electronic sources.
Younger age, recent sepsis or pneumonia, central venous access on ICU admission, personal VTE history, and operative procedure were significantly associated with inpatient VTE events. The proportion of patients who received chemoprophylaxis postoperatively was similar regardless of VTE risk. Patients at higher risk were more likely to receive chemoprophylaxis preoperatively.
Results from this retrospective, single-center study suggest that Caprini is a valid tool to predict inpatient VTE risk in this population. Inclusion of multiple risk factors may make calculation of this score prohibitive in other settings unless it can be computer generated.
Bottom line: Caprini risk scores accurately distinguish critically ill surgical patients at high risk of VTE from those at lower risk.
Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948. doi:10.1001/jamasurg.2015.1841.
Clinical question: Is the Caprini Risk Assessment Model for VTE risk valid in critically ill surgical patients?
Background: Critically ill surgical patients are at increased risk of developing VTE. Chemoprophylaxis decreases VTE risk, but benefits must be balanced against bleeding risk. Rapid and accurate risk stratification supports decisions about prophylaxis; however, data regarding appropriate risk stratification are limited.
Study design: Retrospective, cohort study.
Setting: Surgical ICU (SICU) at a single, U.S. academic medical center, 2007-2013.
Synopsis: Among 4,844 consecutive admissions, the in-hospital VTE rate was 7.5% (364). Using a previously validated, computer-generated, retrospective risk score based on the 2005 Caprini model, patients were most commonly at moderate risk for VTE upon ICU admission (32%). Fifteen percent (723) were extremely high risk. VTE incidence increased linearly with increasing Caprini scores. Data were abstracted from multiple electronic sources.
Younger age, recent sepsis or pneumonia, central venous access on ICU admission, personal VTE history, and operative procedure were significantly associated with inpatient VTE events. The proportion of patients who received chemoprophylaxis postoperatively was similar regardless of VTE risk. Patients at higher risk were more likely to receive chemoprophylaxis preoperatively.
Results from this retrospective, single-center study suggest that Caprini is a valid tool to predict inpatient VTE risk in this population. Inclusion of multiple risk factors may make calculation of this score prohibitive in other settings unless it can be computer generated.
Bottom line: Caprini risk scores accurately distinguish critically ill surgical patients at high risk of VTE from those at lower risk.
Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948. doi:10.1001/jamasurg.2015.1841.
Clinical question: Is the Caprini Risk Assessment Model for VTE risk valid in critically ill surgical patients?
Background: Critically ill surgical patients are at increased risk of developing VTE. Chemoprophylaxis decreases VTE risk, but benefits must be balanced against bleeding risk. Rapid and accurate risk stratification supports decisions about prophylaxis; however, data regarding appropriate risk stratification are limited.
Study design: Retrospective, cohort study.
Setting: Surgical ICU (SICU) at a single, U.S. academic medical center, 2007-2013.
Synopsis: Among 4,844 consecutive admissions, the in-hospital VTE rate was 7.5% (364). Using a previously validated, computer-generated, retrospective risk score based on the 2005 Caprini model, patients were most commonly at moderate risk for VTE upon ICU admission (32%). Fifteen percent (723) were extremely high risk. VTE incidence increased linearly with increasing Caprini scores. Data were abstracted from multiple electronic sources.
Younger age, recent sepsis or pneumonia, central venous access on ICU admission, personal VTE history, and operative procedure were significantly associated with inpatient VTE events. The proportion of patients who received chemoprophylaxis postoperatively was similar regardless of VTE risk. Patients at higher risk were more likely to receive chemoprophylaxis preoperatively.
Results from this retrospective, single-center study suggest that Caprini is a valid tool to predict inpatient VTE risk in this population. Inclusion of multiple risk factors may make calculation of this score prohibitive in other settings unless it can be computer generated.
Bottom line: Caprini risk scores accurately distinguish critically ill surgical patients at high risk of VTE from those at lower risk.
Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948. doi:10.1001/jamasurg.2015.1841.
Adherence to Restrictive Red Blood Cell Transfusion Guidelines Improved with Peer Feedback
Clinical question: Can a multifaceted approach involving clinician education, peer email feedback, and monthly audit data improve adherence to restrictive red blood cell (RBC) transfusion guidelines?
Background: Randomized controlled trials and professional society guidelines support adoption of RBC transfusion strategies in stable, low-risk patients. Studies suggest that education and feedback from specialists may decrease inappropriate transfusion practices, but peer-to-peer feedback has not yet been explored.
Study design: Prospective, interventional study.
Setting: Tertiary care center SICU, single U.S. academic center.
Synopsis: All stable, low-risk SICU patients receiving RBC transfusions were included in this study. Intervention consisted of educational lectures to clinicians, dissemination of monthly aggregate audit transfusion data, and direct email feedback from a colleague to clinicians ordering transfusions outside of guidelines. Six-month intervention data were compared with six months of pre-intervention data.
During the intervention, total transfusions decreased by 36%, from 284 units to 181 units, and percentage of transfusions outside restrictive guidelines decreased to 2% from 25% (P<0.001). Six months after the end of the intervention period, transfusions outside restrictive guidelines increased back to 17%, suggesting a lack of permanent change in transfusion practices.
Bottom line: A multifaceted approach involving education, peer-to-peer feedback, and monthly audits improved adherence to restrictive RBC transfusion guidelines; however, changes were not sustained.
Citation: Yeh DD, Naraghi L, Larentzakis A, et al. Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit. J Trauma Acute Care Surg. 2015;79(1):65-70.
Clinical question: Can a multifaceted approach involving clinician education, peer email feedback, and monthly audit data improve adherence to restrictive red blood cell (RBC) transfusion guidelines?
Background: Randomized controlled trials and professional society guidelines support adoption of RBC transfusion strategies in stable, low-risk patients. Studies suggest that education and feedback from specialists may decrease inappropriate transfusion practices, but peer-to-peer feedback has not yet been explored.
Study design: Prospective, interventional study.
Setting: Tertiary care center SICU, single U.S. academic center.
Synopsis: All stable, low-risk SICU patients receiving RBC transfusions were included in this study. Intervention consisted of educational lectures to clinicians, dissemination of monthly aggregate audit transfusion data, and direct email feedback from a colleague to clinicians ordering transfusions outside of guidelines. Six-month intervention data were compared with six months of pre-intervention data.
During the intervention, total transfusions decreased by 36%, from 284 units to 181 units, and percentage of transfusions outside restrictive guidelines decreased to 2% from 25% (P<0.001). Six months after the end of the intervention period, transfusions outside restrictive guidelines increased back to 17%, suggesting a lack of permanent change in transfusion practices.
Bottom line: A multifaceted approach involving education, peer-to-peer feedback, and monthly audits improved adherence to restrictive RBC transfusion guidelines; however, changes were not sustained.
Citation: Yeh DD, Naraghi L, Larentzakis A, et al. Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit. J Trauma Acute Care Surg. 2015;79(1):65-70.
Clinical question: Can a multifaceted approach involving clinician education, peer email feedback, and monthly audit data improve adherence to restrictive red blood cell (RBC) transfusion guidelines?
Background: Randomized controlled trials and professional society guidelines support adoption of RBC transfusion strategies in stable, low-risk patients. Studies suggest that education and feedback from specialists may decrease inappropriate transfusion practices, but peer-to-peer feedback has not yet been explored.
Study design: Prospective, interventional study.
Setting: Tertiary care center SICU, single U.S. academic center.
Synopsis: All stable, low-risk SICU patients receiving RBC transfusions were included in this study. Intervention consisted of educational lectures to clinicians, dissemination of monthly aggregate audit transfusion data, and direct email feedback from a colleague to clinicians ordering transfusions outside of guidelines. Six-month intervention data were compared with six months of pre-intervention data.
During the intervention, total transfusions decreased by 36%, from 284 units to 181 units, and percentage of transfusions outside restrictive guidelines decreased to 2% from 25% (P<0.001). Six months after the end of the intervention period, transfusions outside restrictive guidelines increased back to 17%, suggesting a lack of permanent change in transfusion practices.
Bottom line: A multifaceted approach involving education, peer-to-peer feedback, and monthly audits improved adherence to restrictive RBC transfusion guidelines; however, changes were not sustained.
Citation: Yeh DD, Naraghi L, Larentzakis A, et al. Peer-to-peer physician feedback improves adherence to blood transfusion guidelines in the surgical intensive care unit. J Trauma Acute Care Surg. 2015;79(1):65-70.