Immunize ZDoggMD Video. Awesome Stuff.

ZDoggMD.  You are a creative genius. Life is quite simple, really.  Parents.  Immunize your kids.  Kids.  Listen to your parents.  And last but most importantly, we should all avoid Oprah.  Any questions?  For other great ZDoggMD humor, check out his hilarious hospitalist anthem video.  You'll pee your pants. 

Charity Shamrock For Jerry's Kids (Picture). Marty and Cooper Would Give Up Biscuits To Help Others.

What can I say?   Marty and Cooper have a soft spot for Jerry's Kids.  They donated a dollar to the Muscular Dystrophy Association and in return they got their very own charity shamrock.  If they could donate a box of their favorite biscuits to the kids, they would.  That's how special they are. Straight from the heart those two.   They live to give.

Now, how do you teach your kids to be generous instead of writing  fake doctor notes and accepting them too.

Hospital Clocks: Taking Delirium To The Next Level

I've taught you about reorientation techniques for traumatic brain injury patients.  I've even taught you about the 5Ps of hourly rounding for nurses.  I now present to you the next generation tool in nursing plans of care:  The three armed hospital clock.

I took this picture of this giant three armed hospital clock stuck to the wall of my patient's room.  I was kind of taken back by the monstrosity of it all.  This thing is huge.  

Happy:  What the heck is that thing?

Nurse:  It's something we started a few weeks ago.

Happy:  It's a three armed clock.

Nurse:  I know.

Happy:  You're going to make my confused patients really confused.

Nurse:  I know

Happy:  I don't get it.  What's the point of hanging a pediatric looking three armed clock in the rooms of elderly patients with dementia?  You're just going to agitate them and think they are looking a three armed clocks.

Nurse:  I know.

Happy:  What do all the arms mean?

Nurse:  The move arm is to remind us and the patient that it's time to move.  The pain arm is to let the patient know when their next pain pill is due.  And the toilet arm is to remind us to ask the patient if they need to use the restroom to prevent incontinence.

Happy:  You do this on all your patients?

Nurse:  Yes.  At least when I remember to move the arms.

So let me get this straight.  Between all the ridiculous computerized documentation requirements, hourly rounds, medication administration, answering call lights, communicating with other doctors, nurses, lab people, and taking lunch break,  we are now asking our nurses to remember to change the arrows on a three armed pediatric clock that will cause demented patients to question everything about their existence?

Rest in peace nurses.  Rest in peace.    It's time to apply for nurse practitioner school.  You can use  your hundreds of hours  of experience clocked in to independently  take care of patients who show up in clinic with undefined weakness and a chief complaint of not feeling well. Make sure you bring a clock with lots of arms.  As a reminder, you know, of the differential diagnosis. 

Worst Ways To Commit Suicide

There are good ways and bad ways to commit suicide. Jumping off a really high  bridge. Good Effective way. Threatening to commit suicide by not taking your coumadin?  Bad way. However.  One of the worst ways ever to commit suicide?  Threaten not to take  your HIV meds.  

Why is it the worst way to commit suicide. It won't work. 

• It's like a person with hypertension trying to commit suicide by not taking their ACE inhibitor
• It's like a person with hypercholesterolemia trying to commit suicide by not taking their statin
• It's like a person with diabetes trying to commit suicide by not taking their metformin.

If not taking your medication was a form of suicide, then most Americans would need committed for being a danger to themselves.  

Try getting that past the county attorney.  It ain't gonna happen.   What's the worst suicide attempt you've ever seen?

Philadelphia Side Car. Side em Up.

Ever wonder if  prisoners with a colostomy bag have sex?  Well, yes.  It's called the Philadelphia side car.  =

Blockbuster Store Closing (Picture): Rest In Peace. You're Just Not Too Big To Fail.

We used to go to Hollywood video, until the store  went out of business.  Then we went down the block to the Blockbuster  video store.  We lived through their late fees, then no late fees, then late fees again.  But in the end,  not their late fees nor the Pillow Pet store renting videos  it had become could keep Blockbuster alive. 

Mrs Happy and I went to rent a movie the other day and we were greeted with the giant going out of business sign.

Everything for sale. Nothing for rent. They tried to get us to sign up for their online service by telling us we would get $20 in free merchandise to buy that night and we could cancel their online service before we ever got our first bill.

We didn't take advantage of it and left empty handed.  We are now left without a full service video store chain anywhere within ten miles. That's OK though. One of the best parts about getting the movie is going for a relaxing ride to get the movie.

Heck. Half the time we rent a movie, we fall asleep with Marty and Cooper snuggled in close and return it without ever seeing the end. 

One To One Monitoring In The Hospital: Good Humor

One to one monitoring is a term used in the hospital when confused patients require a babysitter to sit in their room all night long and make sure they don't pull out their IV or their feeding tubes or their telemetry cardiac monitoring leads. 

I was standing outside a confused patient's room the other that had a one to one sitter.  All of the sudden the guy opened up his eyes, looked at the sitter and said:

Are you staring at me?

I guess he doesn't need a sitter any more. That's just good hospital humor right there. 

Quick and Covert Grand Rounds

Dr Rich gives us his austerity version of Grand Rounds this week.  Head on over to check out this week's best offerings. 

H.I.T. Positive Antibody (SRA Confirmed) Thrombocytopenia With Arixtra, Suspected

I received a call from a physician who may be doing a  case report on a patient I once saw, so I won't spoil the discussion here.   Needless to say the event  raises some interesting discussion on how we treat our patients.    It turns out I once cared for a patient who had a  heparin induced thrombocytopenia (HIT) positive antibody, confirmed with a positive SRA, who developed  an impressive acute thrombocytopenia that resolved after discontinuation of Arixtra and placement on Argatroban.  Confirmation was made as to the lack of exposure to any heparin or Lovenox over a prior six month period. What does this mean?  Is this a case of Arixtra induced HIT?  Is it all coincidence?  If true, it could have significant implications in how we treat our patients.

I won't get into the details of HIT antibody syndrome, except to say it can be nasty a thing to have.  Patients receiving heparin or Lovenox can develop antibody  complexes against these medications that promotes clot formation resulting in potentially life threatening deep venous thrombosis or pulmonary embolism.   These are very effective blood thinners, but if you get HIT from their use, you are at very high risk of developing blood clots.  

The treatment of HIT with clot requires the use of Argatroban, another horribly expensive anticoagulant.  Some folks use Arixtra to treat HIT antibody positivity without documented clot.  I'm not aware if this use has received an FDA indication or not.  You can understand the dilemma this causes. Would we want to treat a HIT patient with a drug that could potentially contribute to the antibody process?  Does this change everything?

At Happy's hospital, we  have hospital safety protocols, government approved of course, in place to monitor for HIT as part of our anticoagulation safety initiatives.  Part of that protocol involves monitoring platelet counts every other day on patients being given heparin or Lovenox for the sole purpose of discovering patients who may develop HIT antibody syndrome in the hospital.  This protocol excludes platelet monitoring with Arixtra because Arixtra is not thought to be associated with HIT syndrome. 

Now, the question is, does this change everything?  I use Arixtra, often, as medical VTE prophylaxis (off label but no reason to suspect ineffective) so I don't have to have my patients stuck every other day for platelet checks.

As far as I know, there is only one prior case report of Arixtra associated with HIT syndrome.

What now?

RVU E/M 2011, 2012 Work (wRVU) and Total (tRVU) List For Common Hospitalist CPT Codes

A reader asked me if I could explain what the most common hospitalist evaluation and management (E/M) codes were and provide a list of their RVU values.  Here is the question:

I recently found your website and love it.  I am finishing up my last few months of residency and starting as a Hospitalist July 1.  I was just curious if you could send a revised list of the most common RVUs used on a day to day basis.  Have they changed since Nov 2010?  I am having to learn all inpatient billing/coding/RVU on my own and I've learned a ton from your site.  I still have 4 months to learn as much as I can before actually start handing in my charges.  I was also wondering if you could email or send me a link to your card thing you carry around that lets you add up point for decision making.  Thanks for creating your site.

Here is a basic understanding of how the obnoxious RVU madness works:

• Read How Doctors Get Paid
• Read What Is An RVU
• Read RVU Explained 
• Hospitalist compensation/wRVU.  Understand what you're worth.
• Read all of 'em at my lectures on  Medical billing and coding
• hospitalist salary vs productivity

Now for why you're here.  Here is an updated  list of the most common evaluation and management CPT® codes you will use and the RVU value (work and total) for each code. These are updated for 2011.  There are some changes for 2010 vs 2011, but the changes mostly have to do with an increase in the practice expense component of the RVU total.

Remember,  your progress notes will be filled with diagnoses (ICD codes).  You link the ICD codes (a maximum of four ICD codes will be submitted for billing) to your E/M  CPT® code (as below) .  The CPT® codes are the E/M codes.  Each E/M code is worth a specific number of total relative value units (RVUs).  The total RVU for each E/M code (CPT® code) is a sum of the workRVU + malpractice RVU + practice expense RVU.

There are published hospitalist benchmarks with regards to RVU embedded in the 2010 SHM/MGMA Hospitalist Salary Compensation Survey which can give you a great sense of what you are worth as can the 2011 Hospitalist Salary Survey by Today's Hospitalist.

When you are applying for a job and your compensation is dependent on production, most programs will use RVUs as their marker of production.  You want an apples to apples comparison between programs.  Make sure you understand what you're reading in  your contract.    You want to know if your productivity benchmarks are in total RVUs or work RVUs, because there is a huge difference in these values.  

With that said, here are your 2011 values for the most commonly used E/M hospitalist CPT® codes and their RVU values, both totalRVU (tRVU) and workRVU (wRVU).

CPT® description  2011 TABLE	CPT®	(wRVU)	(tRVU)
low level in-patient admit	99221	1.92	2.86
mid level in-patient admit	99222	2.61	3.89
high level in-patient admit	99223	3.86	5.71
low level observation admit	99218	1.28	1.90
mid level observation admit	99219	2.14	3.17
high level observation admit	99220	2.99	4.43
low level admit/dc same date	99234	2.56	3.88
mid level admit/dc same date	99235	3.41	5.07
high level admit/dc same date	99236	4.26	6.30
low level in-patient consult	99253	2.27	3.26
mid level in-patient consult	99254	3.29	4.70
high level in-patient consult	99255	4.0	5.68
low level in-patient follow-up	99231	0.76	1.13
mid level in-patient follow-up	99232	1.39	2.05
high level in-patient follow-up	99233	2.0	2.94
low level observation follow-up	99224	0.54	0.82
mid level observation  follow-up	99225	0.96	1.45
high level observation follow-up	99226	1.44	2.17
<30 minutes in-patient discharge	99238	1.28	2.04
>30 minutes in-patient discharge	99239	1.9	2.99
observation discharge	99217	1.28	2.04
critical care initial	99291	4.5	6.4
critical care add on	99292	2.25	3.21
prolonged service initial in-patient	99356	1.71	2.57
prolonged service add on in-patient	99357	1.71	2.58
central line	36556	2.5	3.61
paracentesis	49080	1.35	2.05
lumbar puncture	62270	1.37	2.32
thoracentesis	32421	1.54	2.28
CPR/Resuscitation	92950	3.79	5.14
smoking cessation counseling 3-10 min	99406	0.24	0.35
smoking cessation counseling > 10 min	99407	0.5	0.73

CPT® description   2012 TABLE	CPT®	(wRVU)	(tRVU)
low level in-patient admit	99221	1.92	2.92
mid level in-patient admit	99222	2.61	3.96
high level in-patient admit	99223	3.86	5.
low level observation admit	99218	1.92	2.85
mid level observation admit	99219	2.60	3.90
high level observation admit	99220	3.56	5.32
low level admit/dc same date	99234	2.56	3.88
mid level admit/dc same date	99235	3.24	4.86
high level admit/dc same date	99236	4.20	6.27
low level in-patient consult	99253	2.27	3.26
mid level in-patient consult	99254	3.29	4.70
high level in-patient consult	99255	4.0	5.68
low level in-patient follow-up	99231	0.76	1.13
mid level in-patient follow-up	99232	1.39	2.07
high level in-patient follow-up	99233	2.0	2.97
low level observation follow-up	99224	0.76	1.14
mid level observation  follow-up	99225	1.39	2.06
high level observation follow-up	99226	2.0	2.96
<30 minutes in-patient discharge	99238	1.28	2.07
>30 minutes in-patient discharge	99239	1.9	3.07
observation discharge	99217	1.28	2.08
critical care initial	99291	4.5	6.42
critical care add on	99292	2.25	3.22
prolonged service initial in-patient	99356	1.71	2.64
prolonged service add on in-patient	99357	1.71	2.61
central line	36556	2.5	3.61
paracentesis	49082	1.24	2.05
lumbar puncture	62270	1.37	2.29
thoracentesis	32421	1.54	2.22
CPR/Resuscitation	92950	4.0	5.39
smoking cessation counseling 3-10 min	99406	0.24	0.35
smoking cessation counseling > 10 min	99407	0.5	0.74

LINK TO E/M POCKET REFERENCE CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital: (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic: (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high def view

EMR Comparison

Successful software implementation starts with choosing the right system. This  checklist contains over 50 of the most important features to look for when evaluating:

• electronic medical records
• medical billing software 
• scheduling software
• technology, security and certifications

Download now and get started today Other useful information is available at my EHR Resource Center.

White Male Nurses Wanted.

I wrote recently about the rates of medical school acceptance by race.  If you are a white male and you are competing with other white males, you will be accepted on your merits.  If you are a white male and you are competing for a slot with less qualified black and Hispanic males (based on objective scored data), the data says you are less likely to get accepted.  I didn't make it up. That's what the data says. 

I brought this data up to a colleague recently.  Here's how that conversation went

Happy:  Did you know that being white is a disadvantage when applying to medical school?  If you have great scores and great MCATs, your rates of acceptance are much lower than black or Hispanic candidates with lower scores and a lower grade point average.  Much lower.

Colleague:  That's interesting.  I have a relative who's white son is thinking of applying to nursing school.  His mother told him it might be kind of hard to get in since there is a waiting list.  And you know what he told her?  "

"Mom, I'm a man.  Nursing schools want men.  I don't think I'm going to have any problem getting in."

So.  If you are a white male and you can't get accepted into medical school because you're white, think about nursing school.  They're looking for a few good men.  I think the reverse holds true too.  If you are a female and you can't get into nursing school, try applying to medical school.  They're always looking for a few good women too.  But it helps to be black or Hispanic and a women.

Wisconsin Doctors Protest Rally Fallout: Shocking Revelations Revealed!

What happened to those Wisconsin doctors caught on YouTube writing all those  doctor notes?  What was the fallout of their actions at the union protest rally?  As you know, a bunch of Wisconsin doctors were caught on video handing out doctor notes to give government union workers an excuse not to show up for work, then with some claiming patient-doctor confidentiality.  I find that disturbing. 

Nothing is confidential in the world of cell phones and  YouTube.  These are a new bread of  policians ,part politician, part physician.  All the actions of these Wisconsin policians have been caught on video tape for the Wisconsin Department of Regulation and Licensing to see. 

Unlikely Hospitalist at Pundit Press gives us the scoop:

While this peddles slowly along, some of profiles are being scrubbed clean. The profiles of xxx remain, while xxxx have all been expunged from the Department of Family Medicine Faculty and Staff Directory page.

We learn that one  physician's focus is on  "resident physician professional development".  That's interesting.  I wonder if  teaching residents how to write doctor notes at Union rallies is a part of  the teaching curriculum for professional development of residents.  

The question is why?  Why would a University system, with union employees no doubt, be doing this?  Is it because they have been relieved of their duties?  Is it an attempt to suppress information and protect the privacy of these doctors? 

I think not.  In fact, The Happy Hospitalist has learned the truth about what's going in in Wisconsin. The profiles of these Family Medicine physicians have been expunged from the staff directory page not because they've been fired and released of their duties.  In fact, all these policians have been promoted to leadership positions in the newest residency training program to hit the Wisconsin University campus.    It's called the  Political Medicine Specialty and it's going to revolutionize the way doctors in Wisconsin practice medicine. 

That's right folk Dr XXX YYYY MD PMS a former residency director of the Madison Family Medicine program has been promoted to department head of the new Political Medicine Specialty program. As head  of the PMS college, she has been given just one directive:

•  To work closely with government unions to fund new covert methods of helping patients steal time and resources from their government employers.  

In a leaked email obtained by The Happy Hospitalist, we learn that Dr XXX YYYY MD, PMS already has many excellent ideas to take PMS  to the next level of respect.  Part of her  teaching curriculum has been exposed in this email obtained by The Happy Hospitalist's inside sources. 

Physician methods to help patients avoid going to work and get paid.

• Cough and use a fake sick voice when you call in sick.  Proceed to doctor for sick note.
• Get one of those iPhone Apps that list a bunch of excuses for missing work.  You can use a different excuse everyday.  Proceed to doctor for sick note.
• Tell them you had a family emergency.  Proceed to doctor for sick note.   
• Tell them your neighbor is coming over for barbecue.  Proceed to doctor for sick note.  
• Tell them your car wouldn't start.  Proceed to doctor for sick note.
• Tell them your grandmother died two months ago.  Proceed to doctor for sick note.
• Tell them you overslept.  Proceed to doctor for sick note.
• Tell them the NBA playoffs are on.  Proceed to doctor for sick note.
• Tell them you just got back from a weeks vacation.  Proceed to doctor for sick note.
• Show up at protest rally.  Proceed to doctor for sick note.  

(Just in case you had any doubts and couldn't tell the difference between real and fake because your teachers didn't show up to teach you  and instead went to protest the loss of their obnoxious benefit plans, none of this is true.   I made it all up, at least the part about PMS.  The rest of it is documented elsewhere in the Internets, which is where students have to go now to get their edumacation in Wisconsin, now that none of the teachers show up for work.)

(This is satire.  Please take none of this seriously.  Thank you)

AMA Position On Physician Activities During Wisconsin Union Protest Explained

Wouldn't you know it.  A press release explaining the AMA position on  all those disturbing physicians writing doctor notes during the Wisconsin public service rallies has been leaked. 

For immediate release:
February 22, 2011

Washington, D.C. – The American Medical Association (AMA) announced late last night that it wholeheartedly supports the pro-union protest activities of certain physicians from the University of Wisconsin School of Medicine’s Department of Family Medicine.

 Go read the rest.  It's delightful. (It's not real.  Don't worry.  It' humor)

DDT Sprayed In India Hospitals. Now. What Do YOU Want To Complain About Today?

A colleague of mine recently returned from an investigational medical trip to some of the poorest parts of India to help understand how health care is delivered to some of the poorest people in this world. The answer is, it isn't. I heard him discuss his experience the other day. It was fascinating to listen to. 

India has public health clinics, but none of the natives trust them. They lack staffing and supplies. In fact, he discovered many of the physicians only show up for a couple hours a week. The rest of the time they are providing private services for people who can pay under the table.

He showed pictures of birthing tables filled with blood, already cleaned and preped for the next delivery. And this picture especially caught my eye.  This was a slide showing a wall marked up with a bunch of symbols.  This image describes the D.D.T ( dichlorodiphenyltrichloroethane) that is sprayed in the public hospitals twice a year in an effort to reduce the spread of disease such as malaria and leishmaniasis.

Remember DDT?  It's that synthetic pesticide that was banned from the USA in 1972 after a large public outcry about environmental and public health concerns.  

Fascinating stuff. The poorest people in America are like the middle class anywhere else in this world. And here we have Wisconsin teachers pulling in $100,000 a year in wages and benefits striking on the streets at the expense of children and doctors playing along with fake doctor notes. How shameful are we.

If you want to see poor people, you need to leave America. We don't have poor people  in America.   Our poorest people, by far, would be considered strongly middle class in any worldy comparison.   How do I know that? Because I have never, in eight years as a hospitalist, admitted a single patient to the hospital for starvation. And admitting people to the hospital  is what I do for a living.  In a country where anyone, anytime, can go to the emergency room and receive all the free meals and healthcare they so desire, they never show up in a state of starvation.

They may be hungry, but they aren't  in starvation.  There is a huge difference.   They come complaining that the cost of cigarettes are too high or that their Medicare wouldn't pay for their toe nail trimming.

How telling that is of America's truth.   We are not poor.  We are just poorer than our neighbors and we don't like it.   Poor is going to a country that sanitizes their hospital with DDT.  You want poor.  Go to India.  

Now stop complaining and be grateful for what you have. 

Getting Linked By Instapundit Is Like Being Invited To See Johnny Carson

Yesterday, I got linked by blogging behemoth Instapundit.com  (35 million page views a month) for my post about the fake doctor notes in Wisconsin.    

Ten thousand page views in one day. Not bad. Not bad at all. As one reader says, getting linked by Instapundit is the equivalent of getting invited to see Johnny Carson.  I better go shopping for an outfit. 

Heeeeeeeerrrrrrrrreeeeeeessssss  Happy! 

How To Write a Progress Note In The Hospital: Just Assume Nobody Cares.

You've all heard the saying, if you didn't document it, it didn't happen.  Right?  Wrong.  If I had a bowl movement today and didn't write about it, it still happened.  But a lawyer will try to tell you otherwise.  With that in mind, a reader of The Happy Hospitalist brought up an interesting point of discussion.  What should be documented in a hospital progress note and what is a waste of time?   How should we be writing progress notes in the hospital?  Here is the reader's question in full:

Happy,

I'm a 3rd year resident in internal medicine, going on to be a full time hospitalist when I graduate this year. I had a question about documentation that we've struggled with at my residency program and one which I've failed to get a consistent answer to, even from my otherwise brilliant program director.

As medical students, we get trained to write reams and reams of stuff in our assessment and plan section, and as interns and residents, the amount we are expected to write is reduced, but I for one have not received proper direction as to how much the narrative should be whittled down. Let me give you an example:

A/P:
1. Febrile state with new onset murmur: At the time, infective endocarditis needs to be ruled out. Blood cultures from yesterday still pending. TTE ordered today. Vancomycin Day two started for empiric treatment. Patient currently presumed septic based on fever and white count. otherwise VSS. Will order TEE if TTE negative. Will consider ID consult.

That is one way to say it, and our program did not discourage this verbosity, and indeed I know residents that would have written even more. Another way to say it is as follows:

1. Suspected IE: Vanco D2. Await Echo, CX.

Here you have to extremes of documentation. In my residency program, the patient load has more than doubled in the 2 and a half years I've been here and our program is struggling to keep up. One of the places I feel we need more direction on is what the appropriate amount of documentation needed is. I don't mean from a billing perspective, I mean from the perspective of effective communication to other members of the health care team. Our hospital is a big one, and we don't always run into the other members of the medical team and so need to put our thoughts down in a communicable way.

What is your take on how much detail needs to go into notes to communicate well? As a hospitalist, I need to figure out how to do this efficiently.

regards,

Most doctors have been trained on how to write a S.O.A.P. note for their hospital rounds.  

Subjective

Objective

Assessment

Plan.

You can find a good explanation in my original coding post on  billing a CPT 99231.   If you think the chart is a way for doctors to communicate with each other, you are sadly mistaken.  Those years have long disappeared.  The chart is for lawyers and insurance companies.  You will soon learn out in the real world that reading another physician's charting is a mystery in and of itself.  There is no point.  If you have a question, call them.

My suggestion to you?  Get in the habit of writing "See orders" as your plan.  That is your plan.  That is all that matters.   That's all you need to write.  It takes care of the insurance companies by linking your orders as your medical decision making component of your complexity.   Regarding all the other garbage being written?

1. Nobody is going to read it
2. Nobody cares.  See #1.

Make it simple.  If I need a reminder of my thought process going forward, I may write little comments about "consider x or evaluate y if no better". But I write it for me, not others.  Because I know  nobody else really cares what I write and if they have questions or concerns about my management plan, they will call me directly. 

Your orders ARE your plan. Forget all the other nonsense.   You are just killing trees and wasting your time.

What Is The RUC? If You Don't Know, You Should, Because It Defines American Health Care

What is the RUC?  If you don't know, you need to educate yourself, now.  It defines how we deliver healthcare services to all Americans.    And once you understand what the RUC is, you'll understand why it needs to be abolished in its current form. To learn more, go over and check out ReplacetheRUC.org.

If interested, you can  find a bunch on The Happy Hospitalist as well by using my search bar at the top of the page to search for "RUC" and "RVU". 

The Happy Hospitalist Is Now Published In Hardback. Get Your Copy Today!

It's official.  The Happy Hospitalist has now officially been published in hardback and is available from Amazon via the latest and greatest look at American healthcare.  It's called  Overhauling America's Healthcare Machine:   Stop the Bleeding and Save Trillions, by Douglas Perednia, MD.  My copy of the book is in the mail so I can't give you my take, yet.  

Says one Amazon reviewer

This is NOT a book about ObamaCare. It is a book presenting facts about health care that SHOULD HAVE BEEN REVIEWED AND EXTENSIVELY DEBATED BY CONGRESS before it crafted legislation and voted. 

Get your own copy today, if for no other reason than to let Happy tuck you in at night with a fascinating look at the reality of American healthcare.  

You can read more about Dr Perednia at his blog The Road To Hellth. 

Med School In a Box: Now That's Thinking Inside The Box, Obamastyle.

Is it hard to get into medical school?  Well, it used to be.  But not anymore.  Obamacare is revolutionizing the way we train our future doctors.  After hours of deliberation and internal conflict discussing how to train the future doctors of America, a member of Obama's staff happened upon The Happy Hospitalist and learned about the current nursing education requirements sweeping across America. 

He decided to apply these standards of excellence to medical education as well.  What was Obama's final decision? With a massive shortage of doctors on the horizon, Obama has decided to team up with the experts at Mental Floss to bring us the future of health care education.  I present to you Med School in a Box:  All the Prestige For a Fraction of the Price.  Forget Harvard.  Forget Yale.  Your future doctor is going to be trained at home, on the Internets.  It even comes with fake doctor notes. 

Obamacare defined:  Thinking inside the box for generations to come.

Doctor Notes at Wisconsin Union Protest Rally (Video and Commentary) of These Obnoxious Citizens.

UPDATE:  February 20th, 2011:  UW Madison Family Medicine Residency Director  says teachers "have no choice" 

If you haven't heard about the 14 disgraceful Democrats who abandoned their duty  as public employees to cross state lines on taxpayers'  time instead of showing up for work to vote on a bill that would strip many unreasonable protections public unions have enjoyed for decades, you have now.  These people are an embarrassment to their profession and to their fellow citizens and probably felons for stealing taxpayer time  money and crossing state lines in the process. 

And now we learn a bunch of doctors are writing  medical notes to give rally protesters to excuse them from work and give them protection from employers  (such as the government supported with tax dollars) who don't find it acceptable for their employees to go spend valuable company/government time protesting their political views.  I believe this might be an abuse  of power by doctors who hide behind their cloak of doctor-patient confidentiality in the name of political motivation.   

Over at the Pundit Press, Unlikely Hospitalist gives us his take on the doctor's notes being handed out at the Wisconsin Teacher's Union rally:  Here's a  second follow up article to the doctor note story:

YouTube Video

If I was an employer who received one of these sick notes, I would demand proof of a billing statement from the doctor's office before I would let it slide.  There is no place  for this in the work place.  And those doctors should be investigated by their state certifying organizations  for not  possibly having adequate documentation of their confidential patient interactions.

To make matters even worse, what we have here might be theft of state taxpayers' money.  Every protester who doesn't show up for work but brings back a sick note is stealing money from the government.  In fact, the 14 Democrats who left state lines on the clock might  even be considered felons for stealing their salaries and crossing state lines.

And you wonder why the government is going bankrupt.  It is a systemic sense of entitlement and dishonesty that has made public service the golden ticket for those in the club and the road to ruin for everyone else paying their bill.  With just about every state in this Union being threatened with unfunded  and unsustainable pension liabilities, I commend Wisconsin for taking the bold step to keeping Wisconsin in the game for years to come.  Everyone who feels threatened by their actions should feel threatened.  

The Game Is Over.  Your Government Lied to You.  They Promised You More Than They Could Deliver.  

Move On.

CPT® 99222/99219/99235: How To Bill Mid Level Hospital In-Patient, Observation and Same Day Admit/Discharge Free E&M Coding Clinic

This is my coding lecture on how to bill the mid level hospital  in-patient admission, observation admission  and same day admit/discharge evaluation and management (E/M) codes.  These are CPT® codes 99222, 99219 and 99235 respectively.  What do these codes represent and why can I group them all together in one free coding lecture?  All three codes have the exact same documentation requirements.  Deciding on which code to use is dependent on what the status of the patient is with regards to their hospital admission. Just answer this two questions: 

Is the patient inpatient or observation status and is their admit and discharge on the same or different calendar day (using midnight as the cut off)?

Once you answer these two questions  (which your utilization review folks need to  help answer for you) you can figure out which group of codes to use and then, using my teaching here, decide if your codes meet criteria for these mid level E/M CPT® billing codes.  I'm going to spend a little time here explaining when to use each group of codes, then I'll tell you how to meet the basic minimum requirements necessary not to be accused of Medicare fraud when billing these codes.

CPT® 99222 is the mid level hospital admission code we use for our initial visit if the patient is considered in-patient status.  In addition to  billing critical care codes CPT®  99291 and 99292 on admission, the only three  evaluation and management codes we can use for the initial in-patient hospital admission process are CPT® 99221 (low level), CPT® 99222 (mid level) or CPT® 99223 (high level).   Which code you pick is dependent on what your documentation supports.  Keep reading below to learn the basics of CPT® 99222 coding.

Last year, CMS stopped paying for all in-patient consultation codes (CPT® 99251-99255).

This card below is my E/M pocket reference card I created, based on my interpretations of the 1995 and 1997 CMS guidelines.

What  does that mean for physicians caring for Medicare patients? It means, if you aren't billing critical care for your initial visit on a hospital in-patient, you must use CPT® 99221, CPT® 99222 or CPT® 99223 as your initial billing code even if you didn't admit the patient as the attending physician.    All physicians, attending and consultative, should be using CPT® codes 99221-99223 on their initial in-patient evaluation.

CPT® code 99219 is the mid level initial evaluation visit used for patients under observation status in the hospital.   The choices here are CPT® 99218 ( low level), CPT® 99219 (mid level) and CPT® 99220 (high level).    Which code you pick is dependent on what your documentation supports which I will teach you below.  Unlike the inpatient codes above, only the attending physician (known also as the admitting physician) can use this code for the initial visit during an observation admission.  Consultants who have been asked to see an observation patient should be billing the outpatient consultation codes, CPT® 99241-99245.  

But here is where it gets complication.  Medicare no longer recognizes any consultation codes, including outpatient consultation  codes 99241-99245.  Therefore, physicians who are seeing Medicare patients as consultants during a hospital observation stay should be billing the new patient outpatient evaluation codes 99201-99205.  

However, here is where it gets even more complicated.  If that Medicare patient has been seen anytime in the last three years (even one time)  by anyone in your group of physicians, you cannot bill a new patient outpatient evaluation for that patient in the hospital under observation status.  You must bill the established outpatient follow up codes (CPT® 99211-99215), even if you've never seen the patient before.  Basically, all you can bill for is a progress note, the lowest of low in terms of reimbursement, even if you've never seen the patient before.  And if you don't even submit the right code, you won't get paid at all!  I'm sure very few physicians understand this complicated differential diagnosis of their billing decision tree.   How many lawyers do you think would put up with this in nonsense in their billing department?

As you can see, the whole game of evaluation and management (E/M) borders on comedy if physicians weren't at risk for being thrown in jail and fined tens of thousands of dollars every time they billed  the wrong code for the wrong status. This is the tens of billions of dollars your government considers waste and fraud.  Honest physicians trying to figure the whole thing out and getting it wrong because the rules make getting it right nearly impossible.

The last set of mid level codes fall into the inpatient or observation admit and discharge same calendar day category. The three possible codes here are CPT® 99234 (low level), CPT® 99235 (mid level) and CPT® 99236 (high level) admit/discharge same calendar day (using midnight-to-midnight as the cut offs).  Again, these codes shall only be used by the admitting/attending physician and not a physician evaluating the patient in consultation.

Which code you choose is dependent on what your documentation supports which you will learn by continuing your coding journey to the bottom of this post.   You've come this far, why stop now?  You're almost there!  Here is my understanding of these three codes.  Find out what calendar day your hospital has listed as the day the patient is admitted observation or in-patient status.  If the day they are admitted is the same calendar day you discharged  them, the attending physician  must use either CPT® 99234, 99235 or 99236 as the global admit and discharge physician evaluation and management code.  No other E/M codes can be billed for the hospital stay.  These are a global admit and discharge code for both in-patient and observation stays.  But make sure the patient spends at least eight hours in the hospital, because Medicare won't pay the hospital or the doctor for any work if you discharge the patient before eight hours.  The solution is simple.  Round on them last.  And take an extra long lunch break if you have to.

CPT® 99234, 99235 and 99236 apply to patients whether they are observation or in-patient status.   Occasionally I will do a full in-patient admit and discharge on the same day using a critical care code as  my admission billing code (drug overdose on the ventilator that is admitted at 1 am and discharged at noon on the same day).  In these situations I will bill a critical care code 99291 on admission  and a discharge code CPT® 999238 or 99239) for discharge on the same calendar day, which goes against everything I've been taught with regards to getting paid for an E/M code performed AFTER a critical care code, on the same calendar day.

I'm beginning to believe, however, that I could use the add on critical care code 99292 to get paid for discharge work provided since most payers won't pay for an E/M code after a critical care code, but will pay for the add on code 99292 when used in conjunction with a 99291.  However, it gets more complicated when one considers the 99292 might be billed by a physician other than the doctor who billed the 99291 and may or may not get paid either. 

So hopefully you've got the basics down.  Is the patient's admit and discharge on the same calendar day using midnight at the cut off marker?  If so, use CPT® codes 99234, 99235 or 99236 for your global admit/discharge code, but make sure the patient lingers for at least eight hours by rounding on them last and taking an extra long lunch break if you have to.   Once you've determined that the patient's admit and discharge date fall on different calendar days,  determine if the patient is in-patient or observation status.  If the patient is  inpatient status, choose CPT® 99221, 99222 or 99223 as your initial evaluation code.  You will eventually bill a  99238 or 99239  for the discharge code.   If the patient is observation status chose CPT® 99218, 99219 or 99220 as your initial evaluation code of choice.  When you eventually discharge the patient, the only code available is CPT® 99217.

Now for why you're here.  What are the bare minimum requirements necessary to meet Medicare muster for billing a CPT® 99222, 99219 or 99235 evaluation and management initial admission code?   Before I explain, read my disclaimer:

I am not a licensed  coding compliance officer. I am a hospitalist physician with years of experience studying this stuff.  Read at your own risk.  My interpretations here are based on my review of the 1995 and 1997 guidelines and the CMS E/M guide along with the Marshfield Clinic point system for medical decision making.

The Marshfield Clinic point system  is voluntary for Medicare carriers but has become the standard in most parts of the country.  However, you should check with your own  Medicare carrier in your state to verify whether or not they use a different standard than that for which I have presented here on my free educational discussion.

Some carriers in some states utilize the  Trailblazer EM tool.   There are a few key differences with Trailblazer vs Marshfield in how Medicare carriers are to interpret evaluation and management documentation.  Here is asummary of those key differences.  Here is  the actual link to the Trailblazer E/M Audit reference pdf.  If your carrier uses Trailblazer, this discussion may help you, but these additional resources should be reviewed as well for clarity.
.

How does the AMA define a 99222/99219/99235?

Initial hospital care (or observation care), per day, for the evaluation and management of a patient, which requires these three key components:  a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity.  Counseling and /or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.  Usually, the problem(s) requiring admission are of moderate severity.  Physicians typically spend 50 minutes at the bedside and on the patient's hospital floor or unit.

I rarely, if ever bill a 99222, 99219 or 99235.  Why?  Because a patient that meets criteria for the mid level admission codes will almost ALWAYS meet criteria for the high level codes 99223, 99220 and 99236.  I know this because I know exactly what qualifies for a CPT® medical coding level 3 admit. Almost all of my patients that would meet level 2 (99222/99129/99235) would meet criteria for a high level 3 admit (99223/99220/99236). 

Last year I billed a total of ZERO level two admits. Why? Because, if they qualify for a two, they  will qualify for a three with good documentation. I know if my patient doesn't qualify for a level three, it has a 99% chance of being a level one admit (99221/99218/99234) because the requirements to get from a level two to a level three are minimal, but the requirements to get from a level one to a level  two are huge.

See how easy this is? Well, the following is the exact bare minimum you must do in order to qualify for a mid level admit code 99222/99219/99235 and ward off the fraud police.  So here it is. The 99222/99219/99235. You need history, physical AND decision making to qualify in their respective levels, unlike hospital follow up visits that need just 2 out of 3 areas.

History (You need all three of these components)

1. 4 elements of the HPI (character, onset, location, duration, associated signs etc. OR status of 3 chronic medical conditions. AND
2. 10+ review of systems AND
3. All 3 areas documented:  Past History (things like medical, medications, allergies) AND Family History  AND  Social History

AND

Exam

1. 1995 Guidelines:  8 or more systems documented
2. 1997 Guidelines:  9 areas with two bullets each

It's really complicated and I almost NEVER base my billing on physical exam.

AND

Decision Making (moderate decision making)

There are three components to deciding the level of decision making complexity. You only need to meet moderate decision making criteria for two out of the three.  They are based on a point system.  What are they?

1. Number of diagnoses and management options:  3 points
2. amount and complexity of data to be reviewed:  3 points
3. Table of risk:  Moderate risk.

These rules are obnoxious.   And you thought working through a differential diagnosis was complicated. Take a look at these two picture files below filled with all the specifics rules that determine what level of decision making must be applied for every single E/M code we bill for every single patient encounter.  We have to implement this rule set every patient encounter, every time, if we want to get it right and not be accused of fraud.  The first picture highlights the point system me must all use.  The second is a larger version of the risk table, one of the components of the medical decision making tree.   You can click on either to enlarge or print.  I highly encourage you print it and study it if you don't want to end up in federal prison for Medicare fraud.

So here is a note for a mid level  admission 99222/99219/99235.  I  rarely, if ever, bill the mid level codes. because if they meet criteria for a mid level, they will almost always meet criteria for a high level code, if you document correctly. 

C/C: My leg is red

HPI

28 yo Male with 3 day history left calf pain. 6/10, dull, constant. Associated edema, erythema. (4 HPI)

PMFSH

On no meds.  Smoker, Mother with eczema,  (3 components)

ROS

Except as dictated above, all other systems were reviewed and otherwise negative (10+ROS)

Exam

120/80 85 102.7 temp, well appearing (3 vitals equals one component)

(HENT):  Normal

Eyes:  Normal

CV:  Normal

Respiratory:  Normal

GI:  Normal

Psychiatric:  Normal

Skin:  Edema, warmth, redness right leg, lines consistent with cellulitis, marked with skin marker.

Labs

WBC 13K ( one point for documenting lab in complexity of data decision making)

Impression

1. Cellulitis (new problem) (4 points for number of diagnosis for medical decision making)

Plan

Antibiotics.  Reviewed with ER physician.  (2 points fro documenting discussion of case with another health care provider). 

In this case we meet all the requirements for history and physical  to bill a  mid level admission code (which are the same for a high level admission).  The history and physical documentation requirements for the mid level admission codes are the same as the high level (99223/99220/99236) admission codes.  The only difference between a high level admission code and a mid level admission code lies  in the decision making component.

My documentation supports a mid level medical decision making component.  While I got four points for a new diagnosis (considered high level with 4 points), I only got three points in the data section (documenting one lab and discussing with the ER physician is worth 3 total points).   My risk table is moderate with prescription management.  My overall medical decision making is moderate (highest 2 out of three).  

For a mid level code you need moderate decision making.  For a high level admission you need a high level decision making.  And that's where the value of good documentation lies  and why  I use coding card every day to help me decide between the different decision making levels of care.

That's all you need folks.  I hope you never bill a mid level admission code.  Because if you are, you are screwing yourself out of tens of thousands of dollars a year.  If  a patient meets criteria for a level two admission, they will almost ALWAYS meet criteria for a level three high level admission.  ALWAYS!  That's what my experience tells me.   In my state, the difference between a mid level admission 99222 and a high level admission 99223 is $125 vs $180.  That's $45 per admission. If you aren't billing a high level admission, you are screwing yourself.  Just learn some very simple basic coding rules and you can dramatically increase your billing performance and your take home pay.

Several notes. On history and physical examination, you can write "normal" and it constitutes a full exam of that body area. You cannot write "abnormal".    You can document a sentence stating "a full review of systems was performed and otherwise negative" without having to write out an essay on your negative review of systems by organ systems.  Of course, make sure you do a full review of systems. 

You can read more about coding at at my free lectures on  medical billing and coding with all my previous coding posts.  As any great hospitalist knows, what CPT® code you bill is entirely dependent on how you document, not how much you document.

LINK TO E/M POCKET REFERENCE CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital: (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic: (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high def view

EMR Comparison

Successful software implementation starts with choosing the right system. This  checklist contains over 50 of the most important features to look for when evaluating:

• electronic medical records
• medical billing software 
• scheduling software
• technology, security and certifications

Download now and get started today Other useful information is available at my EHR Resource Center.