This patient represents my fastest patient exam ever. She'd been hospitalized for over two months awaiting placement in a nursing home. Nobody wanted her because she represented too great a risk to other nursing home patients. It's interesting that a hospital with an emergency department can be forced to see every patient that comes through their doors, but every nursing home in this universe can refuse to accept any patient at any time.
This is an example of one of those patients that can take days, weeks, sometimes months to place. They aren't safe to go home because they lack even the capacity to make poor medical decisions. Their family abandons them with the mentality that it isn't their problem to fix. The nursing homes don't care. They have every right to pick and choose, just like doctors do as an outpatient. No insurance? That's a problem. Bad insurance? Bad disease? Sorry, that's the hospital's problem.
A while back a patient was sued by a hospital because they refused to go to the only nursing home that would accept them. The patient instead wished to stay in the hospital, I suspect forever. Fortunately, the hospital isn't an appropriate place for long term management of stable disease.
In this case, every morning this patient would pull her sheets over her head and sleep in peaceful seclusion. Every morning she'd have nothing to say. Every morning I would wake her up and interrupt her peaceful dreams. Why? Every morning I am required to write a note on her because hospital bylaws require a daily evaluation by the attending physician. That' me, the hospitalist. So every day I am required to do an evaluation, the depth of which is determined by me. I can choose how much or how little I wish to do. I let the circumstances guide my decision making process.
After two months in the hospital, it becomes painfully silly for me to wake her up every morning, pull the sheets off her head and ask her if she slept well last night. So this time I didn't. I asked the nurse if the patient had any issues or concerns. I looked at the patient sleeping under her blanket from the bedside and I wrote my low level 99231 hospital follow up note
126/78 * 72 * 20 * 98.6Dementia, awaiting placement
That's my evaluation and it meets every lawful requirement necessary to be paid for by the Medicare National Bank for a CPT® 99231 evaluation without being accused of fraud (which is why a hospitalist should almost NEVER bill a 99231) and it meets every requirement necessary by Happy's hospital bylaws. And it pays about $35 from the MNB.
At least they aren't dead. And I know this because dead people don't pull their own sheets over their head. Although, as a resident working in the VA, I once had the privilege have being present when an RN documented stable vital signs on a patient that head been stiff dead for hours and hours and hours.
In that case, the RN failed to do a physical exam. In my case, this was the fastest patient exam ever.
You can find more about medical billing and coding in my hospital based coding lecture series.
You can find more about medical billing and coding in my hospital based coding lecture series.
