Unobtainable ROS: A Benefit of Alzheimer's Dementia in the Hospital

The policy wonks are always talking about the costs of Alzheimer's dementia on society and in hospitalized patients.  As a hospitalist, I take care of many folks in the hospital with Alzheimer's dementia.  Many doctors won't admit it in public, but I'm the Happy Hospitalist and I'm here to help you drink from the fountain of truth and wisdom. The truth is, most doctors would love to have a service of filled to the brim with Alzheimer's patients.  Why is that you ask?  How could a demented Alzheimer's patient actually come with such benefits?  Despite the terrible emotional toll Alzheimer's disease takes on friends and family, it actually comes with one major benefit for the doctors who care for them:  It's called the unobtainable 12 point review of systems (ROS).  If you aren't a doctor, you have no idea what I'm talking about, but it's the truth none the less.

The unobtainable ROS is a gold mine for maximizing the RVU/time ratio under evaluation and management  (E&M) guidelines.  You see, in the fee for service payment system doctors are forced to operate under time is money.  The more patients you can see in a fixed period of time, the  more revenue and profit your office or hospitalist practice can generate.  That's just a reality of the payment model we practice in, especially a declining payment environment.  The review of systems is one of the requirements in the documentation game of medical billing and coding.  For patients with dementia, a ROS of systems cannot be reliably obtained. What does that mean clinically?   The E&M coding guidelines as defined by the Medicare National Bank state that an unobtainable ROS is equivalent to a full review of systems.  An unobtainable history is equivalent to a fully documented history. 

What does that mean for doctors?  That means doctors get credit for the highest level of care for a history component on any hospital or office based E&M code if the patient cannot reliably give their history.  What does that mean for the hospital follow up billing codes or the admit codes?  It means doctors spend no time taking a history  and can complete their evaluation in 1/10 of the time and can claim credit for the highest level of care for the history component.   What did that mean for Happy?  It meant he was able to round on six patients in one hour by writing the following note six times on six patients who presented with the exact same diagnosis.  Here's how a hospitalist can round on six patients in under an hour and bill a level three 99233 hospital follow up on every single one of them:
S) ROS unreliable secondary to dementia.
0) 120/80 80 98.6
PT INR 1.1
A) 1) Dementia-stable with no changes planned
     2) pick your chronic disease- stable with no changes planned
     3) pick your chronic disease-stable with no changes planned
     4) pick your chronic disease-stable with no changes planned
     5) anticoagulation management --follow INR (high risk drug management)
     6) Hip fracture
That's your 12 minute, high risk, $90 level three 99233.  Now that's the type of  service most hospitalists would kill for.  I take that back.  That's the kind of service most doctors would kill  for. If your mother or father has dementia, I guarantee to you that your doctor loves taking care of them and that's why you come to The Happy Hospitalist.  To hear truths nobody else is willing to discuss.


EM Pocket Reference Cards Using Marshfield Clinic Point Audit

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Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.

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