One At A Time Please. Sharing Is Caring.

I know. I know. He's irresistible.  You're just going to have to take turns.

Doctor-Nurse Communication Tools and Techniques

I've discovered the perfect tool to improve doctor-nurse communication skills.  Let's see.  Hundreds of nurses.  Dozens of floors.  Day shifts.  Night shifts. This pin pretty much sums it up. Any questions?

Dogs Are From Heaven, Sent As Angels And I Have Picture Proof.

I always knew dogs were from Heaven, sent as  Angels to rescue us.  And I have picture proof.  Here's Princess Angel Marty in all his Heavenly glory.  

Angel Marty protecting his squeaker

For more Marty and Cooper action, you can read all their blog posts, catch them at their YouTube channel  or watch their two beautiful slide show presentations, the full color slide show and the all black and white slide show, both available for viewing in my side bar as well.

The folks at Second Life, the newest upscale resale Atlanta thrift are returning the favor by saving our discarded pets in order for them to complete their life long mission as Angels.  If you're in the Avondale Estates area, go check them out.  Meet Lucky, their inspirational Chief Smile Officer.  He's a 16 year old Dalmatian that will give you one heck of a smile.


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Baby Sneezing (Cute Video). If You Don't Like Cute, Close Your Eyes.

If you  don't like cute baby videos, stop right there.  Otherwise, watch baby Zach sneezing.  He'd look pretty  cute in the baby blue vinyl of that Memorial Day ride.   

Memorial Day Ride In Convertible Style (Picture)

I'm not an expert in cars by any means , but I think this stylish Memorial Day super sport  ride is a 1966 Impala SS 390 horsepower 427 cubic-inch pile of manliness.  I love the baby blue vinyl interior.

Reference Cards (E&M) Based on CMS Guidelines and Marshfield Clinic Point Audit (Hospital and Clinic)

These are  E&M bedside pocket reference  cards I created and use myself for both hospital based and clinic based evaluation and management.   These cards are based on my review and interpretation of CMS guidelines  and offer a quick as well as easy to understand reference  of the E&M rules applied to real life documentation requirements.  I've written a whole lecture series on the ins and outs of hospital based coding.  You can find all my experience and understanding at my free medical billing and coding lectures.

Here are your purchase choices:

• A two sided hospital based pocket card with reference my interpretations of CMS guidelines for the admit/consult rules on one side and the hospital follow up  rules on the other side for $10 + $2 S&H.  The card seen below represents one side of this card.
• A two sided office based pocket card with reference to my interpretations of the new patient/consult rules on one side and the established patient rules on the other side in the exact same format as above for $10 + $2 S&H.
• You can have two cards, in any combination for $16 + $2 S&H
• You can have two hospital based cards and two office based cards for $29 + $2 S&H.

The cards come with  high quality commercial grade print and crisp easy to read text.  The inpatient card comes in lemon yellow with black text and the outpatient coding card comes in lime green with black text.   Both two sided pocket CMS reference cards  have high quality commercial grade lamination.  If you are a hospitalist  or any doctor that uses evaluation and management and your livelihood depends on accurate documentation, these quick reference bedside pocket cards  can help you understand what your documentation supports.

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

Carnival Ring Game Practice (Video): Become a Cola Ring Master.

You know that carnival ring game where you have to lift a bottle with a hanging ring on a stick without having the cola bottle tip back over?  I've discovered the perfect method where practice makes perfect.  If you happen to have a baby laying around your house,  which we do, just watch this video I made demonstrating with Zachary how to master the carnival cola ring game.  A few hundred times and you'll be cleaning house at your State Fair.   

Any questions?

Football Pacifier NUK (Picture): Zacher the Linebacker Preparing For Sports.

Here he is. Zacher the linebacker. We figured if he's going to play football we had to start training him now while he's still willing to listen to our suggestions. Zachary is a boy. We are not going to raise him like that lady not telling friends or family the sex of their child, and naming it Storm. And because he's a boy, we're going to stuff him full of football pacifiers.

You can see, in this case, he's wearing his baby shower NUK football pacifier gift while praying he makes the football team.   You can find a whole assortment of NUK pacifiers from their Amazon store.

Thank you God for giving me the strength to play linebacker.

After a short stint in the corporate world with his onesie tie business attire, we decide to guide him back to what he loves best: Talking sports while eating and hanging out with his Brest Friend. And what better way than to indulge his desires for physical activity than to give him a taste of the leather with his very own football pacifier.  We promised, however, not to tell his friends about treating his blocked tears ducts with breast milk.  That's just too embarrassing for the little fella.  If his hands turn out to be as big as his newborn baby feet ink feet pictures, he's going to make one heck of a linebacker.

We had our one month postpartum check up with the midwives the other day.  They thought the football pacifier was great.  With Medicaid going bankrupt, I told them they should expand their business model and start selling football pacifiers and other irresistible merchandise for mothers coming in after their delivery or for soon to be mothers looking to have the cutest baby in the world.  

We all know new mothers would spend hundreds of dollars on cute stuff for their baby, Medicaid or not.  I learned first hand what patients were and weren't willing to pay for with my hospitalist efficiency idea.  

With such a captive audience, selling football pacifiers to new mothers would almost be like stealing candy from a baby.  

New Happy Hospitalist Blog Logo Poll. Tell Me What You Think.

I've settled on a new logo for my blog here at The Happy Hospitalist.  Look above or below and tell me what you think.

Chest Pain Clinic Observation E&M CPT® Billing and Coding Answers

A cardiologist recently asked me a question on how to bill his chest pain clinic observation patients.  While this post is in response to the chest pain clinic observation patients, it can be applied to any observation patient.

I have a E/M question that I haven't been able to figure out. I'm a cardiologist and our hospital recently opened up an observation unit so we're running into all the observation issues more frequently. If a regular patient of my practice goes to the ER, is seen by the ED doc, who requests I see him to decide on admit/discharge and I decide to put him in observation and do the orders/H&P, can I bill for an observation admission or do I still bill for an outpatient follow up since the ER doc has already billed an E/M code for ER care? If I discharge the patient the next day can I bill for that?  Thanks in advance!

Here is my response:

Good morning. What the ER bills has no bearing on what can bill. You are independent from their practice.  If you are the attending of record when you bring a patient into the hospital as an observation, you bill either the 99218, 99219 or 99220 (low, medium, high) observation admit codes.  You must be the attending.  Different codes and rules apply if you are not.  Again.  These rules only apply if you are the attending/admitting physician.  

If the patient is discharged on the same calendar day you must cancel using the 99218, 99219 or 99220 codes and instead use just the bundled admit/discharge same calendar day code 99234, 99235, or 99236 (low, medium, or high) admit/discharge same day code.

If the patient is admitted observation one calendar day and discharged the next calendar day, you bill the 99218, 99219 or 99220 on the first calendar day and the only code you can use for the discharge is the observation discharge code 99217.

So here are the three scenarios:

You are the attending on record and bring someone in observation on June 1st and discharge them June 2nd

June 1st:   Bill CPT® 99218 or 99219 or 99220 (low, medium and high codes).  Pick which ever code your documentation supports.
June 2nd:  Bill CPT® 99217. This is the only option. There are no other codes.

You are the attending on record and you bring someone in observation June 1st and discharge them June 1st

You must submit a bundled admit/discharge same day code 99234 or 99235 or 99236 (low, medium or high).  Pick which ever code your documentation supports.

You are the attending on record and bring someone in observation on June 1st and discharge them June 3rd.

June 1st:  Bill CPT® 99128 or 99219 or 99220 (low, medium or high codes).  Pick which ever code your documentation supports.
June 2nd:  Bill the new 2011 observation follow up CPT® codes 99224 or 99225 or 99226 (low, medium or high codes).  Pick which ever code your documentation supports.
June 3rd:  Bill CPT® 99217 observation discharge.  This is the only option.  There are no other codes.  

Whether you bill the low, medium or high codes is dependent on what your documentation supports.

That's how you bill your E&M CPT® codes for an observation stay in the chest pain clinic, if you are the attending on record.  But, what if you aren't the attending/admitting physician?  How are you supposed to bill your daily visits on a chest pain clinic observation admission, or any observation admission for that matter?  Read on.

If you are the consultant on an observation patient admitted by say, the hospitalist, none of the above applies because you aren't the attending physician.  These CPT® codes (99218, 99219, 99220, 99217, 99234, 99235, 99236, 99224, 99225, 99226) are only to be used by the attending physician.

If you are a cardiologist or oncologist or nephrologist or even a hospitalist asked to consult on an observation patient that was admitted by another physician that patient is considered outpatient  so you have to use the outpatient consult codes.  But here is where it gets complicated.

If the patient is a Medicare patient, outpatient consult codes no longer exist.   So, if you are asked to consult on an observation patient admitted by another service and that patient is a Medicare patient,  you are to use the follwing rules

• If the patient has not been seen by you or any of your partners (of similar specialty)  in the last three years, and you have been asked to consult on an observation patient, on your initial evaluation, bill the new patient outpatient clinic codes (99201-99205).  Your follow up visits should be billed as the established patient outpatient codes (99211-99215).  On the day the patient is released from their observation stay, continue to bill the established outpatient codes (99211-99215).  Only the attending/admitting physician can bill the observation discharge code 99217.
• If the patient has been seen by you or any of your partners (of similar specialty)  in the last three years and you have been asked to consult on an observation patient, on your initial evaluation, you can only bill the established outpatient clinic codes (99211-99215).  Continue to bill these codes for all your daily evaluations. 

If the patient is not a Medicare patient and you are asked to consult on an observation patient, then you should bill the outpatient consult codes (99241-99245) as your initial visit and use the outpatient established clinic codes (99211-99215) for additional hospital days. Now, the difficult part is knowing whether or not the patient has Medicare and which insurance companies still accept consult codes and which don't.  I can usually find out pretty easily using my iPad for hospitalist rounds if the patient has Medicare or not.  But I never know what the rules are for the private insurance companies.

For our group, I still bill consult codes when in doubt about whether they will get paid when I am asked to consult on an inpatient or whether I am asked to consult on an observation patient and then I let our billing company change the code to the correct code based on what the insurance allows.

I hope this helps.  This is a classic example of the E&M "Evaluation and Madness" we have to go through in order to get paid for the work provided.  And if we don't get it right, every time, thousands of times a year, we don't get paid and even worse, Obama will accuse us of Medicare fraud.  

Hope that helps!

You can read more about coding at at my  free lectures on medical billing and coding.  

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.

Best Panoramic Photo Maker Free iPhone App Ever. (Cool Picture Example)

If you have an iPhone and you love taking cool pictures, I've discovered Photosynth, a free app that will stich together as many pictures and in what ever design you'd like as you're taking the pictures.  Have a scene too wide or too tall for your iPhone camera angle?  Just open Photosynth and create your panoramic picture through their app.   It will  stich together your pictures and generate the panoramic picture for you and save it into your photo album for you to share with anyone. It is one of the few 5 star reviewed apps I've seen.

And it's completely free. It's definitely the best panoramic photo iPhone app I've seen.   It gets my two huge thumbs up.  Here is what a 360 degree view of my 2010-2011 home remodel.  Can you find Marty and Cooper?

Photosynth iPhone Panorama iPhone App Photo Maker (click to enlarge)

I think it would be really cool to get a 360 degree panoramic view of a real life code trauma in action in the ED.  Now that would be cool.  Then sell them to the patient on discharge.

If they survive.     With Medicaid going bankrupt and Medicare struggling to survive, this is just one other way hospital profit margins from Medicare can be supplemented with a little extra cash to the bottom line.

I'm sure we could find an out of work photographer willing to work on the cheap in this economy.

Picture of Parkinson's Disease (Bathroom Counter View)

Here's a picture of Parkinson's Disease few people can appreciate.  I take one medication on a daily basis and trying to decide if  I can take synthroid at night is the toughest question I can come up with. It's not like Parkinson's Disease.

Definitely not.    

Technology in Medicine.

medGadget  discusses technology in this week's Grand Rounds technology edition.  They have some great stuff on that site.  Go check it out.  

Dog Poop Disposal Method With Babies on the Run.

I snapped this picture showing how to solve the problem of picking up dog poop on a friendly afternoon jog but having no where to take it home.    Now that we have baby Zachary, our methods have changed.  It took a little thinking outside the box, but this dog poop disposal method is the cleanest, easiest and safest dog poop disposal method we could come up with.

As all good pet owners know, picking up after your dog is the right thing to do.  And when you have a little Zachary, you take advantage of your new found dog poop disposal method at your service.  With Zach sleeping quietly with his new football pacifier, simply tie the poop to your jogging stroller  and off you go.

One baby.  Two dogs.  Two poops. Forget this hospitalist stuff.   I'm thinking about maybe customizing some   accessory side hooks for the B.O.B jogging stroller and selling them on Amazon as an after-market dog poop disposal system for all the jogging moms and dads out there.

Any questions?

Onesie Tie Business Attire (Picture): One Day In The Real World Was Enough For Zachary!

We are already realizing how quickly the little ones grow up. Zach is already a month old and he's had enough experiences to last him a lifetime. Way back when, we learned about the treatment of blocked tear ducts using natural nonprescription methods.  We learned all about Zach's desire to join the baby dates personal ad circuit behind our backs and his wish to be the  spokesbaby for the Brest Friend Pillow.

Back when he was little, we learned  how fast the BiliBlanket works to clear up newborn jaundice.   Zachary has even helped us learn  how to lose weight after pregnancy.  

Not to mention in football pacifier.  So many experiences.  Where did all the time go?  He's already had his opportunity in the business world.  We bought him this onesie tie business attire to take the world by storm.  But as you can see, it only took him one day to  in the real world to throw his arms up in disgust.  That was the end of that. 

It only took Zachary one day in the business world to throw his arms up in disgust. 

And with that he decided, instead,  to sell his newborn breastfeeding poses  to help pay for his high gas bills.  He took off his onesie tie business attire for good and traded them in for his funny still living at home onesie.

For other great onesie ideas visit

• Funny Halloween onesie:  I want my MUMMY!
• Camouflage onesie
• Future Potbelly! onesie
• Tax deduction onesie
• My favorite custom made onesie  
• Young buck onesie
• Handsome like daddy onesie
• Still living at home funny onesie
• Laughing my diaper off (LMDO) onesie
• Moose onesie with a hoodie

Chantix Lawsuits, Here We Come. What Are The FDA and Pfizer Smoking?

Chantix lawsuits here we come.  I've been prescribing Chantix and helping fill out forms for free Chantix for my patients for several years now.  Chantix is one medicine used to help get patients to quit smoking right now.  In fact, I even had a case presentation of a woman I warned to quit smoking for good or face a lifetime of being cross eyed.

Does Chantix help to quit smoking?  Yes it does.  It helps to take the cravings away in folks who use it.  If you smoke, you should want to quit, based on my discussions with a tobacco farming insider.  If nothing has helped, Chantix might be your last hope.  As a hospitalist, I always offer Chantix therapy as part of my smoking lecture (that I bill out as smoking cessation CPT 99406 or 99407)

With the average cost of cigarettes going through the roof, the percentage of Americans who smoke has come down.  For those still hanging on, taking Chantix to help quit seems like a perfect opportunity to put down the cancer sticks forever.  Until the nicotine vaccine becomes widely available I just don't think we have that many other options available.  

But now it seems like Chantix lawsuits may be the next greatest get rich scheme for smokers every where.  On May 19th, 2011 the FDA responded to a report from the QuarterWatch: 2010 Quarter 3  Institute of Safe Medication Practices report regarding the safety profile of Chantix .  You can view the Chantix information on this pdf file starting on page 14.     Pfizer sent the FDA information  on several thousand  Chantix adverse  drug events (ADEs) resubmitted to the FDA'a Adverse Events Reporting System in July 2010 at the FDA's  request.  These events reportedly had been previously submitted in a form that did not allow for a comprehensive evaluation.

These included 150 completed suicides dating back to 2007 along with hundreds of incidents of psychosis, depression and attempted suicide.    In the third quarter of 2010, varenicline had  1,055 serious adverse drug events reported, more than any other drug the ISMP montitors and Chantix ranked first with twice as many deaths reported related to Chantix exposure. 

Pfizer said they were unable to repond to the findings of the ISMP because of their possible involvement in future legal cases.  Here is the FDA response statement to the ISMP QuarterWatch report:

In 2006, the Pfizer product, Chantix (varenicline), was FDA-approved as a smoking cessation aid. Soon after marketing, FDA became aware through its postmarketing surveillance system, the Adverse Events Reporting System or AERS, of the potential for serious neuropsychiatric events in patients taking Chantix. Subsequently, FDA began communicating about these potential risks with health professionals and patients. A list of previous safety communications can be found on the Chantix Information page.

Amid continuing adverse event reports, in July 2009, the FDA required that Pfizer update the Chantix label with the most restrictive safety labeling - a boxed warning – describing the risk for neuropsychiatric events. This warning was directly related to the association of Chantix with suicidal thoughts and aggressive behavior. In addition, in 2008, FDA required a mandatory medication guide for patients describing this risk.

In July 2010, Pfizer, at the request of FDA, resubmitted a large number of adverse event reports that were initially sent to the Agency in a way that did not allow for comprehensive evaluation. Although this resubmission included thousands of reports of potential adverse events, these events were spread out over a number of years, and had been reported to the agency periodically in summary safety reports. These reports confirm what we already knew about Chantix and would not have changed the Agency's position on the drug's risks and benefits, given that the data in these reports were consistent with those that led to the 2009 labeling change. At this point, based on the data, FDA does not have any new safety concerns with Chantix, though those that have been established remain under active review.

The Agency takes seriously the adverse events associated with all drugs, including Chantix. FDA continues to monitor for serious and unexpected events associated with Chantix. FDA has initiated additional postmarket safety activities. Specifically, it has required the manufacturer of Chantix to conduct a large, comparative, postmarket clinical trial assessing the safety of Chantix among other smoking cessation aids. FDA has also initiated two observational safety studies on Chantix, one with the Veterans Administration and one with the Department of Defense.

Last year, FDA became aware that a few manufacturers were submitting adverse events reports to FDA through improper channels. At that time, FDA clarified its instructions to drug manufacturers, including Pfizer, to submit adverse event reports through a channel that would allow for the adverse event reports to be entered into FDA's Adverse Event Reporting System, a database of postmarketing adverse event reports that allows for review by the Agency's safety staff. These instructions were clarified and put on the FDA website for AERS Electronic Submissions2.

FDA will continue to monitor the postmarket safety of Chantix and will communicate any new information as it becomes available. The Agency remains committed to monitoring the safety of drugs as they are used in the postmarket, real-world setting.

Chantix lawsuits, here we come. I think all hospitalists should be aware of these significant findings.  Should we stop prescribing the drug?  I think I'm done with it.  I'd rather have my patients die a slow and painful death filled with morbid disability spread over many years than to have one claim I tried to knock them off with a little  bloodless surgery.

Pick your poison, I guess. There's always cold turkey available too.

Bloodless Surgery Skills In Our Next Generation of Surgeons. Think Psychosis.

Bloodless surgery refers to to desire to avoid transfused blood or blood related products.  If you talk to most surgeons, I think most believe they have the skills to provide bloodless surgery to all of their patients, most of the time.  If their patient bleeds and they require a blood transfusion, more than likely the bleeding was caused by a non surgical complication induced by the hospitalist's desire to prevent a life threatening venous thromboembolism with anticoagulants.   .  

I'm not a surgeon.  But I have seen my fair share of operative reports showing 10 cubic centimeters of blood loss after an  eight hour surgical marathon.  In these situations I am left without an explanation for the six gram/deciliter drop in hemoglobin concentration. It is a hospitalist mystery that I see day in and day out.   It seems like a job the Society of Hospital Medicine should tackle

Ten cubic centimeters isn't much, but there is always room for improvement.   I've discovered the latest and greatest in bloodless surgery.  The skills of these future  surgeons are like no other.  Where are we going to get our next generation of surgeons?  You may think I'm crazy, but I can see the writing on the wall.  They are not surgeons by trade.  They are cutters.  That's right.  Cutters.  Cutters are those psychiatric folks who use cutting of their wrists and ankles as 

• A way of releasing whatever tensions they have
• Gaining attention
• Seeking help
• Feeling alive.

That sounds like a surgeon to me.  These cutters  have no idea how skilled they are.  To be able to cut themselves hundreds of times, day after day, year after year with the skill of a surgeon, avoiding the intricate network of nerves and arteries that supply blood to the hands and feet, and to be able to do all this without the grueling surgical residency, these are surgeon savants.   These are the people I want operating on me.

Happy:  I saw this patient once that had dozens of superficial cuts on both their hands and ankles.
ED Doc:  Oh, you mean those scratches?  We see that all the time.  Those are cutters.
Happy:  They must be really good at cutting to have that many marks and have no major complication.  They look so clean.  I can't imagine they're actually trying to commit suicide.
Happy's Partner:  I wonder what that operative report would look.   Total estimated blood loss of  4 RBCs.

4 RBCs.  It doesn't get anymore bloodless than that. If  you want bloodless surgery, we should stop trying to train surgeons that come from our medical schools filled with high anxiety high achievers looking to impress people who do nothing but try to impress each other all day long  and start looking in the psychiatric wards for our laid back cutters with skills.  Now that I think about it, picking our next generation of surgeons from the psychiatric population of cutters makes perfect sense.  You'd have to be a little psychotic, in the midst of  visual hallucinations,  to try and convince the hospitalist that the six gram drop in hemoglobin wasn't related to the six hour operation with a documented 10cc of blood loss.    Psychosis is the only explanation. 

By the way,   How do you hide $100 from a surgeon?  

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.

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 definition view

Medical Slang Vocabulary in the ICU: Speaking Trachonese.

I heard this ICU medical slang today.  You can dramatically increase your hospitalist vocabulary by just keeping your ears open on a daily basis.  According to this nurse, she speaks trachonese.

Trachonese:  The art of understanding the language of trach patients.  Similar to vent speak, but without the ventilator.

Used in a sentence:  Holly soon realized the only way she would survive as an ICU nurse was to learn trachonese.

Someday the MARTI interpreter may be able to provide translation for this population of patients.  

Medical slang at its finest.  And for a finale, check out the best respiratory slogan ever. 

Pain Patch Lidoderm Preauthorization Madness.

I had the opportunity to take care of a patient with unexplainable chest wall  pain of three weeks duration.  I had no idea why they were having pain.  They had a complete CT scan of their chest that essentially ruled out a pulmonary embolism with high probability.  They had a full series cervical through lumbar MRI.  They had an entirely normal laboratory work up with no evidence of inflammation.  They had no red flag symptoms that would suggest the need for further workup

Like so many patients I see, the diagnosis remains a mystery and I'm forced to explain to the patient that things that remain unexplained will either

1. Go away on their own or
2. Eventually declare themselves one way or another

Day in and day out I explain to patients that when the work up has been done and no red flag symptoms are present, time is our best diagnostic and therapeutic treatment.  

What did I do with this patient?  I sent them home with a cocktail of pain medications and the only thing that seemed to help before discharge  a Lidoderm pain patch.

Lidoderm is a topical transdermal delivery system for lidocaine.  It's expensive and some insurance companies require pain patch Lidoderm preauthorization.  Heres' how that played out.  I received a text at almost 5pm on a Wednesday afternoon  to call a 1-800 number  to preauthorize a Lidoderm pain patch I had ordered upon discharge two days previously.  Apparently, the pharmacy couldn't fill the script without preauthorization.

I called the number while driving to Walmart to pick up diapers.  Here's how that conversation went.

Pain Patch Lidoderm Preauthorization rep:  Hello, thank you for calling.  May I have your name?
Happy:  Dr Happy.
Pain Patch Lidoderm Preauthorization rep:  Thank you.  Can I have your national provider number?
Happy:  I don't know what you're talking about
Pain Patch Lidoderm Preauthorization rep:  Your NPI number.
Happy:  I don't know what you're talking about.
Pain Patch Lidoderm Preauthorization rep:  Can I get your DEA number?
Happy:  Yes.  XXXXXXXX
Pain Patch Lidoderm Preauthorization rep:  I'm sorry, I'm not finding you
Happy:  This is Dr Happy.  I'm the only one.
Pain Patch Lidoderm Preauthorization Rep:  Can I have your DEA number again?
Happy:  Yes. XXXXXXX
Pain Patch Lidoderm Preauthorization Rep:  OK I found you.  Can I have the patient's name?
Happy:  Let me check my text.  OK.  It's Jane Doe.
Pain Patch Lidoderm Preauthorization Rep:  Do you have her date of birth?
Happy:  No.  I'm driving to Walmart.  All I have is a name.  Jane Doe.
Pain Patch Lidoderm Preauthorization Rep:  OK, I think we can figure this out.  There she is.  What can I do for you?
Happy:  I was asked to call to preauthorize a Lidoderm pain patch.
Pain Patch Lidoderm Preauthorization Rep:  OK.  I just need to ask you a few questions.  Does the patient have neuropathic pain?
Happy:  I don't know.  She has pain that responded to a Lidoderm patch in the ER.  I don't know the cause of her pain.
Pain Patch Lidoderm Preauthorization Rep:  Is that a yes or a no?
Happy:  I don't know.  She has pain that responded to a Lidoderm patch in the ER.  I don't know the cause of her pain.  It could be neuropathic or it could be muscular-skeletal in nature.  I just don't know.
Pain Patch Lidoderm Preauthorization Rep:  I'm sorry.  I cannot approve your patch.  I will have to send it on to a pharmacist for additional review.  It may take several business days to complete.
Happy:  No.  We aren't playing this game.  I'm sitting in a Walmart parking lot waiting to get diapers and I'm not working for another week, so we are going to settle this now.
Pain Patch Lidoderm Preauthorization Rep:  OK, I'll place you on hold and speak with our pharmacist
On hold....five minutes laterPain Patch Lidoderm Preauthorization Rep:  I spoke with our pharmacist.  We can not approve your patient's Lidoderm pain patch with the current diagnosis of pain.
Happy:  That's OK.  Just let me know what anesthetic pain patch you can preauthorize so my patient can get relief from her pain.
Pain Patch Lidoderm Preauthorization Rep:  clicking away on a keyboard.  It looks like we can approve a Flector patch for her pain.
Happy:  Flector is a nonsteroidal.  My patient has already failed a trial of nonsteroidals.  Would you please tell me what anesthetic patch you can approve so my patient can continue to get relief from her pain.
Pain Patch Lidoderm Preauthorization Rep:  I'm sorry.  We cannot approve an anesthetic patch at this time based on your diagnosis of pain.  Does your patient have neuropathic pain.
Happy:  OK.  How about yes.  Yes they do.  They have neuropathic pain.
Pain Patch Lidoderm Preauthorization Rep:  OK doctor.  We have now approved your patient's Lidoderm patch.  Her copay will be $50 for a daily one month supply.  Is there anything else I can help you with?
Happy:  No.  Thank you.  

And this is the preauthorization madness we deal with every day.   It's a good thing I have people that shield me from this madness.  It took me 20 minutes on my day off driving to Walmart to pick up diapers on a late afternoon to get the therapy approved for my patient.  I can't even imagine what it's like doing this 50x a day in an office setting.  

But I learned something important that day.  If I ever have a patient with pain and they need  a Lidoderm patch prescribed, they may have neuropathic pain until proven otherwise, even though I can't exclude   fibromyalgia pain, musculo-skeletal pain, or psychosomatic pain. 

And this is why concierge medicine is going to expand by leaps and bounds.  It's not just Medicaid preauthorization for vitamins madness that is degrading the doctor-patient relationship.   It's all third party insurance rules and radiology management madness.  As physicians get squeezed with uncompensated busy work, either the patient is going to pay an administrative fee for the right to be  their insurance company's liaison or the insurance company will pay.  And guess who's going to lose that battle. Doctors are charging for emails, phone calls and filling out disability and FMLA paperwork.  Good for them.  It's time preauthorization was a compensated administrative fee.  

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.

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 definition view

Taking Care of Older Dogs: Love and Sweet Potatoes

If you have ever owned a senior dog, this essay is meant for you.  Taking care of older dogs is about love and nothing else.  Dog owners understand.  People without dogs will  think you're crazy.  They lack understanding.  

At 16 years old, Lucky is an old guy….a senior  geriatric dog.   Seeing him struggle with the ailments of old age is one of the hardest things to watch.  I feel so helpless knowing I cannot ease his pain.  I can give him medications, but the arthritis will continue to make his legs weaker.  I can shower him with love after his accidents and his confused eyes plead for forgiveness – but I cannot make them stop.  I can take him on short walks, but I know we will never again spend hours exploring our favorite spots at Stone Mountain Park.

For the rest of the this story about caring for elderly dogs, visit Love and Sweet Potatoes on Lucky's Blog.  Lucky is the inspiration behind Atlanta's best thrift store,  Second Life, a non profit 501c that benefits animal rescue organizations.  If you're ever in the area, make sure you stop by and meet Lucky.   You'll be lucky you did.  

Patient Perspective on Rounds

Grand rounds that is.  Go check out this weeks best offerings from the Internet Universe.  

Treatment of Blocked Tear Ducts With Breast Milk? Boobs Are Magic.

Little Zachary had been cruising right along.  He had huge newborn baby ink feet pictures.  His BiliBlanket got sent home with the home health care nurses and we were able to snap a really cute picture of him in a newborn feeding pose.  

He's been feeding so well and gaining so much weight that we let our Iggy's use his special pillow for their enjoyment.  Marty and Cooper gave their Brest Friend pillow review two paws up.  

Then it hit him.  In just one day, Zach had an eye full of mattering thick yellow goop.  Here's a picture of his face.

Mrs Happy did what most mothers would do these days and she did a Google search that suggested the possibility of a blocked tear duct.  How did some websites suggest treating the blocked tear duct in an infant or newborn?  By putting a drop or two of breast milk  in the area of the blocked tear duct.

Before heading to the doctor's office for confirmation of Google, MD, we stopped by a local store that assists women with their breast feeding needs.  With Zach at her side complete with his football pacifier, Mrs Happy mentioned the mattering and the possibility that his think secretions might be a blocked tear duct and the folks there said that sometimes breast milk can be used to help clear up a blocked tear duct.  They couldn't really explain why.  But I found independent confirmation of therapy for blocked and obstructed tear ducts in babies 

With that said, we headed to the pediatrician.  The pediatrician listened to Zach's heart and lungs, while carrying on full  conversation with us.  I was impressed, as this skill isn't taught in medical school.  She agreed with Dr Google  but indicated there wasn't much that could be done.  Sometimes blocked tear ducts could last 4-6 months and sometimes required surgery if they don't open on their own.

Mrs Happy indicated that breast milk may help open the ducts.  The pediatrician said she'd never heard of this therapy but to let her know how it worked.

So we did.  A couple squirts of breast milk and less than 24 hours later?

Zach is a new boy.  Just in time for his dating baby personal ad.  So, if you think you'r infant or newborn has a blocked tear duct and your pediatrician agrees, try a little breast milk.  It does the body good.  And you don't even need a prescription.  

(This is not medical advice.  I don't know anything about treating kids.)

Hand Sanitizer (Purell™) Use Study and Testing Positive For Alcohol Use. 2011 Florida Research Study Findings Confirm What I Already Knew. To Be A Good Doctor or Nurse, You Have To Be Drunk.

The cat is out of the bag and research from The University of Florida, and published in the March 2011 Journal of Analytical Toxicology confirms what I already knew.  To be a good doctor or nurse in the hospital these days following diligent  handwashing hygiene, you have to be drunk.  In an evidence based world, anyone seeking out a role in health care will be required to undergo forced alcohol tolerance training.

These findings are going to change how hospitals perform their physician credentialing and how states license their physicians as well as offer up a  new defense opportunity angle for Lindsay Lohan.  I'm going to have to start answering yes when asked if I have a drug or alcohol problem.  Because it turns out to be a good evidence based doctor or nurse these days, we have to take care of patients while drunk.

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.

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 definition view

How say you Happy?   What's the premise of the research?  University of Florida research began their evidence based quest to prove the relationship between hand sanitizer and urinary alcohol levels by forcing willing participants to cleanse their hands every five minutes over a ten hour period for three consecutive days.

They argue this is equivalent to good handwashing technique for a routine daily nursing experience.  That works out to 120 daily episodes of exposure to hand sanitizer (Purell™) in a normal nursing shift.

They wished to test alcohol absorption from the frequent use of hand sanitizer in the expected working world of health care professionals.  One can check blood alcohol levels (here's the highest blood alcohol concentration ever), by breathlizer (here's that famous picture of man arrested for drunk driving while wearing a breathalyzer costume making him the funniest criminal arrest of the year) or by urine.

Many alcoholic beverages contain ethyl alcohol, the same alcohol used in many hand sanitizers.  Does our body absorb this alcohol through the skin in measurable amounts?  That's what these researchers decided to find out.  

In the case of urine testing for positive alcohol exposure, several metabolites can be tested including ethyl glucuronide (EtG) and  ethyl sulfate (EtS).  Ethyl glucuronide is most commonly used in testing exposure to alcohol in the work place or court system.  While blood and breathalyzer testing only tests for the acute exposure to alcohol, urine testing of these metabolites can be used to search for longer term alcohol exposure as the metabolites remain long after the acute alcohol exposure has ended.  It's the same concept as testing one for cotinine after smoking, a compound that can be detected for up to a month or more in the urine long after the nicotine has been metabolized.

How did our germ free participants do?  Nearly all participants had levels of alcohol metabolites consistent with drinking moderate amounts of alcohol.  That means Lindsay Lohan or the disruptive physician accused of being drunk by an angry Night Nurse RN, MSN, M'M, PRN may have an alibi. They were  just being a diligent germ free doctor and trying to protect their patients from VRSA.  

The researchers, however, did clarify their findings by suggesting that ehtyl sulfate levels did not rise significantly in hand sanitizer exposure as they did with alcohol beverage consumption, and in fact, this test may be much more important in clarifying positive urine testing from beverage versus hand sanitizer exposure than the more commonly used ethyl glucuronide.  

Regardless of whether the doctors and nurses get drunk during their lunch break or during the normal daily exposure to hand sanitizer,  I think the take home message remains.  If you want to practice good evidence based medicine, your going to have to be drunk to do so. 

Which means, in this new era of CMS physician pay for performance PQRI madness where we measure compliance instead of outcomes, I formally submit to CMS that we start a program of measuring alcohol levels in all physicians and nurses to verify that we are in fact all practicing drunk.  

One other thing.  For you ER nurses and doctors, instead of calling the hospitalist to admit an alcohol withdrawal patient that is too weak to go home,  just slather on a full body hand sanitizer bath and send them on their way. The more the merrier.  

Who's with me? 

• You can watch the  University of Florida video about their hand sanitizer study.
• Read the University of Florida press release about the study.

What Is The Most Durable Cell Phone Ever? (Picture). It Survived Fire and Wild Animals.

What is the most durable cell phone ever?  I think I've found it.  Check this out.  So I'm at a birthday party this evening when one of the teenage family members pulls out his incredibly abused cell phone by LG. Teenagers love their cell phones.  It's a statement of who they are.

So you can understand how floored I was when I saw this thing.  He says it survived a fire.   I think it might have even survived a few wild animals.  It looks to me like something or someone tried to eat it.  I saw this crazy working phone with my own eyes.  It still works, shockingly enough.

To me it says he's full of fire, he's one heck of a survivor or he's just really hungry all the time.

Here's what I don't get. I know most cell phones are free these days.  But, you can get a 3G iPhone smart phone for $49.  Slap a case on it and turn your smart phone into the most durable cell phone ever made.  

Or keep your LG and lay claim to the most durable cell phone ever made.  This guy needs to contact LG and let them know that their cell phone took a licking and kept on clicking.  I bet he could get his own commercial out of the deal.  

If you've seen a more durable cell phone, I'd like to see it.  I don't think another more durable cell phone exists in this world. 

It's a good thing i have an iPhone.  I wouldn't have a clue on how to text with this monstrosity.  Although, If I did have this cell phone in the hospital, I'd have a good excuse why I didn't return any of my calls in a timely fashion.  Little would they know it's probably the most durable cell phone ever.

Miniature Horse Physical Therapy In the Hospital (Picture). You Heard It Here First.

It's amazing what a little breeding will do to the animal kingdom. I took this picture of a standing miniature horse at the local county fair last year.

What a waste of a good miniature horse.  He's just standing there.  I've got better plans for this thing. Hospital pony rides.   Miniature horses may be the next big thing in hospital based physical therapy. What better way to get grandma going again after her hip fracture than to saddle her up on the back of a miniature horse and make the horse run.  

After too much horsing around in his younger years,
Shorty asked that I  keep his identity secret to avoid
paying child support.

If she falls, it's not like she'll break her hip.  It's already broken.  It's time to put some fun and excitement back into the monotony of physical therapy.  I know all about that with my electrical stimulation shoulder therapy (which turned out to be a posterior labral tear).  

If you want, you can even put some tie dye horse ankle support braces on to spice things up and to  prevent from having to care for a miniature horse with a broken or sprained ankle.  You just want to make sure grandma doesn't have some weird allergy to horses.  If she does, horse penicillin isn't going to save her.  She'll need to see her rheumatologist for acute exacerbation of her systemic  fibromyallergia after she tells you she's allergic to prednisone and diet products too.  

Now that I think about it, perhaps sending grandma home with her own miniature horse could perhaps be the key to preventing 30 day readmissions for Medicare patients.  Sometimes thinking outside the box opens up a whole new opportunity for our patients.

Forget follow up with a nurse practitioner.  Just send granny home with her own miniature horse.