29 November 2008

Holiday Cheer

And so it begins:

Lotsa other christmas cards for geeks courtesy of The Telegraph.

Bioscientists like BethV should be sure to check out #9.

(Via Americablog)

27 November 2008

Happy Turkey Day

Been unplugged for a while. Exploring the analog world and reacquainting myself with my family.

Have a nice holiday and enjoy your turkey. I know I will!

23 November 2008


No, not the good kind, blowing stuff up and all that. The Washington Post takes a shot at the Five Myths about US healthcare. It's a nice start, for a traditional media source and a general audience. For health policy wonks and readers of med blogs, probably not too much new there.

I don't have time to fisk it in depth, but a couple of quick observations:

Myth One: America has the best health care in the world.
This is basically a rehash of the OECD data showing the US lagging in outcomes such as life expectancy and infant mortality, while spending 50% more than our nearest comparison. While the OECD numbers have come in for a lot of criticism, and there's a lot more to the outcomes than the quality of the health care system, the authors make one point very well: the cost/expense of medical care does not correlate well with outcomes or quality. This is, in fact, an important point to make. Also, I like the fact that the Post is tackling the zombie myth that the US is the M*A*S*H 4077, the "Best Care Anywhere," since that perception is a significant impediment to reform.

Myth Three: We would save a lot if we could cut the administrative waste of private insurance.
Interesting point to make. While I'm not entirely sure that their point is bullet-proof, the inclusion of this point seems intended to stymie the arguments from the single-payer zealots that we should just get rid of all the insurance companies. Inasmuch as this article represents the zeitgeist of the Villagers in the Beltway at this time, I think it may fairly be inferred that the CW is that a market-based solution is preferable to a single-payer option. Fortunately.

Myth Four: Health-care reform is going to cost a bundle.
I don't have a clever insight to offer here, but I'm still glad that Senator Wyden's plan is still part of the debate.

Myth Five: Americans aren't ready for a major overhaul of the health-care system.
Don't know that this is currently a widely-accepted myth, but it's good to make the point. If it ever will be, the time is now, and the stars may be aligning.

Declining Patient Volumes?

WhiteCoat notes a 7% decline in patient volumes in his ED, which he attributes to the poor economy. My initial though was that a poor economy would do the opposite: more people would lose insurance and meaningful access to healthcare, so they would have to turn to Our Awesome Safety Net [tm] of the ER for their care. WhiteCoat does mention the migrant labor population as being in some way related, so I suppose that might make sense: as jobs dry up, workers leave. That got me wondering whether we might see something of the same effect in the Great, Damp Northwest. So I ran our most recent numbers, compared against last year:So I guess that'd be a "no." Volumes are up a few percent over last year, consistent with the year-over-year increases we've been seeing this decade. Not much evidence for any short-term effect over the last couple of months, either. I suppose that as the economy coninutes to crater, and we start to see the downstream effect of job losses, we may get a drop-off in volume. I kinda doubt it, though. We don't have a significant migrant population in our area, so we shouldn't see the demographic shifts Whitecoat describes. I do think the bad economy will further drive up our volumes.

The bad news for us will be that there will be fewer commercially insured patients, and more Medicaid and uninsured patients. This will drive our reimbursement down significantly, I suspect. I'm not complaing about that, mind you -- our losses will be a tiny fraction of the suffering of those who wind up unemployed, foreclosed or what-have-you in this impending recession.

Only time will tell, but I have a sinking feeling that this recession will be long and deep. I hope I'm wrong, or that Obama and his team are clever enough to figure out something to fix the economy. But the fundamentals are looking pretty grim just now, and I don't see any governmental intervention having much effect for quite a while.

Boy, this post took an unintended depresasing turn. Sorry about that. Wait, I know just what will cheer you all up: Puppies!

21 November 2008


An article with some CT images was published earlier today.   Unfortunately, not all patient identifying information was removed from the images.   Thanks to an alert reader who notified me of this error.

The post has been taken down and will not be republished.  I regret the error.

19 November 2008

Lost in Transition

I remember a bad hand-off once, long ago. It was the classic admitted patient, long forgotten two shifts after a bed had been ordered, but hanging out in the ER waiting for the assigned bed to be vacated and cleaned. It was a chest pain admission, a "low-risk rule-out," meaning that the patient was to get a blood tests to rule out a heart attack and then a stress test. Turns out the diagnosis was quite wrong: it was an aortic dissection, and when the patient crashed, there was chaos because nobody remembered why the patient was there and who was responsible for him.

In that case, there were other problems: the nurses in the ED had been quite content to ignore the patient while he slept. No vital signs were obtained, at one point the cardiac monitoring had been discontinued for the patient to go to the bathroom, and the schedule of blood tests designed to detect an evolving heart attack were not drawn.

The outcome was bad, and we as an organization learned a lot from it.

Doctor RW writes about this topic today, linking to an interesting article in Today's Hospitalist. RW's recommendation is good, but does not go far enough:

Hospitalist groups should meet with their emergency medicine colleagues regularly to discuss cases, offer feedback and improve professional relationships.
To be sure, this is necessary and I won't disagree with it. But the fact is this: if the patient is physically in your ED after "admission," they remain your responsibility, and as a department, you must have procedures in place to ensure the patient will continue to receive excellent care during the transition.

Key points which such procedures must address include:
  • There must be an ED physician who is the designated responsible provider and who is aware of the patient. This is pretty standard and is easily accomplished with most patient tracking system, be they simple grease boards or sophisticated EMRs.
  • Transfer of care to the hospitalist does not take place until the patient has either left the ED or until the hospitalist has physically seen the patient in the ED.
  • The ED doc must perform interval assessments of the "boarding" patients in the ED, regardless of whether the hospitalist has seen them. If they're in the ED, they're still your responsibility. Generally, stable patients don't take much attention, but sicker patients, ICU admits, etc will require this assessment. If nothing else, it can add to your critical care time!
  • Once the hospitalist has seen the "boarded" patient, they are the primary caregiver, and simple questions or non-urgent issues can be directed to them. But the ED doc must remain available for urgent issues and to keep tabs on the patient's condition.
  • Inpatient admitting orders should be written at the time the patient is designated as "admitted." The ED nursing staff need to follow these orders as if the patient were in their inpatient bed, especially if the patient will be boarding more than a couple of hours.
  • If you are in the enviable position of sending patients upstairs before the admitting doc has seen them, you need to write adequate holding orders.
For some reason, this last point has been controversial in EM. The AAEM, I think, particularly crusades against this practice. I cannot understand why. Sending patients upstairs to languish until the hospitalists see them is a clear extension of liability for the ER doc. Yeah, it would be great if all admits were seen within ten minutes of arrival to the floor, but that's not reality. There's a persistent idea that writing admitting or holding orders somehow increases the ER docs' liability and muddies the question of who bears responsibility for the inpatient.

My opinion is that by writing good holding orders, the ER docs improve patient care, help the hospitalists, and reduce everybody's risk. The key is that these orders do not need to be comprehensive, but they do need to be adequate. In my opinion, the minimum acceptable holding order set includes:
  • The name of the responsible admitting doc.
  • A clear statement that for problems, questions, or changes in condition, the admitting doc should be promptly notified.
  • A defined time during which your holding orders are valid (i.e. an expiration time for your orders, by which time the admitting doc needs to have seen the patient).
  • Any critical patient safety information (ie allergies, NPO, fall precautions, etc)
  • Any scheduled tests or treatments which will forseeably be needed before the patient may be seen (serial enzymes, nebs, pain meds, blood sugars, e.g.)
  • Parameters to notify the admitting doc (vitals, test results, etc)
When well done, this practice can improve patient care and safety and foster the sense of collaboration between the hospitalists and the ER docs. Standardization is your friend; we have a pre-printed "holding order" set which is very useful and help ensure nothing important is omitted. As hospital-based medicine is a team sport, it is also useful to have joint committees set up between the ER and hospitalist teams. Working together regularly outside of the clinical setting also helps foster a sense of collegiality, and to dispel the "us-vs-them" sentiment that is engendered in the trenches.

This is a pretty important topic. Change of shift is the most dangerous time in any ER, and the transfer of care is fraught with risk. It's curious, now that I think about it, that this has received so little attention in the evolving culture of patient safety and the Quality measures being developed. Look for this to gain prominence in coming years.

18 November 2008

Parlor Games

I've never been much interested in playing the breathless speculation "Who's going to be Secretary of xxxxxxx," games that so consume the Beltway types.  But for what it's worth, Obama could do worse than former Governor John Kitzhaber of Oregon for Secretary of Health and Human Services.  He's an Emergency Physician who developed and implemented a universal health care plan in his state, and since leaving office has advocated tirelessly for national health care reform.

I've attended a few speaking engagements with Dr Kitzhaber, and have come away impressed at his knowledge of health policy and his pragmatic and value-driven approach to reform.   He'd be a good guy to have on the team.

17 November 2008

Private payers: the unlevel playing field

Kevin linked to an interesting article in the Boston Globe. It has way too many words, and as usual when the media tries to write about health care economics, completely misses the point. In fact, the authors, bless them for trying, can't even bring themselves to ask the right questions.
A brief summary:

  • Brigham & Women's Hospital, Mass General, and other well-known hospitals ("Partners HealthCare") get reimbursed 15-60% more than less-elite institutions in and near Boston.
  • The quality of care at all these institutions is comparable.
  • Partners HealthCare are extorting patients by leveraging their market power to demand higher compensation from commercial insurance companies.
That's it. The whole 5,000 word bowel movement, distilled in all its ineffable ignorance to under sixty words.

Now the first impenetrably stupid thing the authors do is begin with the assumption that compensation for services in medicine is linked to quality. I can understand their desire to believe this to be so, and I can understand their error, given the publicity given to the various quality initiatives and Medicare's P4P programs. But it is not so. Quality measurement is in its infancy and at this time the financial linkage of quality to compensation is something on the order of 2% of medicare revenues and a few small pilot programs by commercial payers. If the authors wished to write an editorial arguing that we should link quality to compensation on a grand scale, that would be a fair matter for debate. But they assumed their conclusion, and proceeded to lambaste the Partners health system without ever once considering the bigger picture.

In fact, I have to wonder if they even read their own article.

In context, readers need to understand that health care (especially the hospital business) is not a lucrative business. The typical hospital's profit margin is about 1.75%, and fluctuates wildly year to year in the throes of economic cycles and federal budgetary shortfalls. The pressure is ever downwards, from Medicare and Medicaid especially. Hospitals, especially those with significant charity care costs, must cost-shift, which is to say they must charge private patients more than the actual cost of their care in order to subsidize the care provided at a loss to the government-insured and uninsured patients.

Insurers, understandably, do not like this, and will fight tooth and nail to drive down the amount they will pay for their patients to be served at a given facility. Those that are able to negotiate favorable contract terms will do well. Those that cannot will wind up like this:
[T]he state's second-largest hospital chain, Caritas Christi, had to borrow money this year to pay for basics, like oxygen tanks.
This is, mind you, from the same article which strongly stated that Partners was making too much money, and that they were overcharging patients for sub-par services. (At least Partners hospitals have oxygen tanks, though! Hahaha.) The authors stated outright that the greed and lasciviousness of the Partners system was a key force in the explosion of premium costs for Massachusetts residents. Partners clearly should back off and charge reasonable rates, like the rest of Mass. hospitals. Say, how are they doing, anyway? Let's go to the same damn article:
Massachusetts hospitals are losing money. Many of them would be profitable if they had even a fraction of Partners' contract clout. Caritas Norwood Hospital, for instance, could erase the $242,347 deficit it reported through the third quarter of this fiscal year if the hospital were paid Partners rates for the babies it delivers.
I'm sorry, my irony gland is hurting. I'm not sure I read that right. So, if the other hospitals were able to get compensated for their services at the Partner's rates, they would be making money. Instead, the insurance companies underpay when they can get away with it, and all the rest of the hospitals are losing money. And Partners is the bad guy? What about the insurance companies who are conspiring to depress the prices paid to the hospitals? (To say nothing of the government which underpays everybody.)

So how much is Partners fleecing the Boston public for? Let's see:
Partners' favorable insurance contracts have helped the company to reap $1.7 billion in profits since 2004, reflecting a profit rate that is average compared with the nationally known hospitals the company considers its peers.
Average, huh? That doesn't sound too bad. But what's average? Well, according to the Fitch bond rating agency, Partners posted a 2.2% operating margin for 2006 (the 2006 Fitch average was 2.8%) with $132 million "profit" (which isn't actually a profit but can be re-invested into the organization). Fitch also expresses concern about:
"Partners' high Medicaid mix and increased charity care at certain facilities, the concentration of three large managed care organizations that control a significant 80% of the managed care payer market, the competitive Boston market, and future capital needs. Partners has incurred significant losses in Medicaid and uncompensated care, which has hindered overall profitability."
What I see here is a well-run institution which manages, despite a mission which includes charity care for indigent patients, to market itself effectively and sustain itself, and to renew and grow the organization. The victims in this scenario are the regional centers which manage to deliver excellent care (as measured by the rather crude statistical metrics) despite being undercapitalized and under-reimbursed by the insurance companies.

And what about those insurance companies, anyway? How did they figure into this piece of investigative journamalism? The Globe reports:
Private insurance data obtained by the Globe's Spotlight Team show that the Brigham, Mass. General, Children's Hospital, and a few others are, on average, paid about 15 percent to 60 percent more than their rivals by insurance companies such as Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care. [Emphasis added]
Hmmmm. How do you think The Globe just happened to chance upon the very closely-guarded data cited here? What player would be in a position to know how much BCBS pays all the local hospitals? Let me think . . . waitaminit! It's BCBS! How else would The Globe happen to obtain the complete (or selected?) fee schedules for all the regional hospitals if it was not deliberately leaked to the media? And why would the insurance companies want to do this? Maybe they are sick of having to pay higher rates to Partners, and decided to leak embarrassing information to gullible journalists to make Partners look bad. Maybe it'll help BCBS in their next contract negotiation, and if not, at least it's a finger in the eye of their hated enemy.

Make no mistake, this bit of "investigative journalism" is nothing more than a hit job on Partners HealthCare by the insurance companies, abetted by the naivete of poorly-informed journalist-stenographers who eagerly gobbled up the data they were spoon-fed and happliy ran with the prefabricated narrative they were handed by Blue Cross Blue Shield, with some bonus snark thrown in by Partners' jealous competitors, and layered with a veneer of concern for quality of care.

And we wonder why the traditional media is losing credibility.

Disclosure: I have never set foot in Boston and have no relationship to or brief for the Partners system. My own facility is itself in a tense struggle with the local high-profile, better funded regional giant. I, however, do not blame them any more than I blame Microsoft for selling a lot of copies of Office. It's market economics. We are playing at a disadvantage and we will only prosper if we can run a leaner operation, deliver excellent care, and find our own leverage with private payers.

11 November 2008

A Time for Change, Finally

Dr. Michael Copass, "legendary" director of the ER at Seattle's Harborview Medical Center, is finally being put out to pasture.

A little background: Copass, trained in neurology, has been running the ER for thirty-some years. He has run his fiefdom with an iron fist and a cult of personality striking in large part for his antipathy towards the field of Emergency Medicine as a specialty. The University of Washington has become something of a local embarrassment, being the last of the top ten medical schools in the US (actually, the last of the top fifty!) not to have a training program in Emergency Medicine. Copass has sworn, apocraphally, that it will be over his dead body that there will be an EM program in "his" ER.

The consequence is that over the last twenty years, with regard to emergency care and training, UW has slowly slipped further and further behind other mainstream university medical centers. The political environment has been toxic, with even UW faculty members decrying the insitutional hostility towards EM. Matters came to a head a few years back when the ACGME decertified Harborview's EM training program, a move which resulted in the EM residency at Madigan pulling its residents from Harborview, citing "inadequate supervision," specifically a lack of supervision from trained Emergency Physicians. (Others have alleged that supervision at all in Harborview's ER is "nominal.") Madigan now sends its residents to Emanuel in Portland for their trauma training. Seattle, the 15th largest metro area in the US, does not have a dedicated training program in EM; most cities this size have two or three.

The University was, I think, highly embarrassed by the fiasco. Since that time, they have recruited for and hired a number of trained and certified Emergency Physicians. (Some of whom are good friends of mine.) The word on the street is that the UW is finally intent on starting a training program in EM, which would be a welcome and long overdue development. If Copass was encouraged to retire in order to remove one of the last remaining obstacles, it would be an ironic capstone on a career which has in some respects been dedicated to opposing the development of EM as a specialty.

Still, there's going to be yeoman's work to be done at Harborview. The insitutional bias against EM may run deep, and the faculty who take over the reins of the department will have their work cut out to establish control over the department and autonomy of their operations. I admire and respect those colleagues who have signed up to bring about the needed change. It's thankless work, fighting these turf battles. Most of the work to establish EM as an independent specialty was done in the '80s and '90s: it seems very weird and anachronistic to have to go back and revisit those battles. I will be cheering them on, and I look forward to a time not too far in the future when I may have the opportunity to work with UW residents, or to hire graduates from a local program.

I should stipulate here, that I have never worked at UW, did not train there, and have never met Copass. I do not doubt that he has been a dedicated physician and educator. If I have misstated his positions here, I will be only too happy to publicly apologize. However, his reputation is that of a divisive persona who has persisted in fighting one of the last bitter turf battles in the house of medicine. To the degree that is true, he will not be missed.

10 November 2008

Critical Care

The practice of medicine, as a business, is a challenging model. You have minimal control over your prices, no ability to negotiate with your biggest payers (the governmental ones, that is), and limited leverage to contract with commercial payers. In our specialty, you also know that a certain significant but unpredictable fraction of your patients will not be paying you at all, and you have to staff to an expected patient volume, but you have no real ability to control your volume. Compensation for services from all payers is perpetually squeezed downward, and given the narrow focus of our specialty, it is difficult to diversify the business model.

So, if you want to run a profitable and successful practice, you need to focus on the internal efficiencies to maximize your revenue. The universal inefficiency in EM practices is physician documentation; this inefficiency is, of course, also an opportunity to improve, and thereby increase your revenue. For most practices, 85% of revenue can be accounted for with only seven codes: 9928x and 9929x in coding jargon, commonly referred to as the Evaluation and Management (E/M) codes and Critical Care (CC). A lot of attention is paid to the E/M coding requirements, as they are onerous and failure to comply will absolutely sink your business. But Critical Care is often overlooked, and this underutilized code can provide a significant profit margin for your practice.

As you can see, one hour of Critical Care is worth about 25% more, per case, than a Level 5 E/M charge. Of course, your experience may vary depending on your payer mix, collection rate, and current coding levels, but optimizing your CC coding has the potential to add 2-5% to your total revenue. That may not sound like much, but those are totally "free" dollars -- there is no added cost to generate that additional revenue, so it goes directly to provider compensation. Depending on your practice's overhead, that may increase physician compensation by 3-9%.

So why don't Emergency Physicians routinely code for CC time? Well, many do, and the frequency with which this code is utilized in the ED has been steadily increasing:

(Source: BESS data, representing Medicare patients only.) Some of this increase, however, may be due to the increasing practice of "boarding" critical patients in the ER waiting for inpatient beds. Some may be due to the increasing age, complexity, and acuity of patients in the ER. But it is undeniable that Emergency Physicians are catching on to the value of appropriate utilization of the CC code.

Many challenges remain to widespread adoption of this code. Many EPs are just unaware of the value of this code and the opportunity it represents. Emergency Medicine residencies do a terrible job of educating their physicians in this area, which puts young physicians at risk of losing income as they get up to speed with the business of medicine. Additionally, many EPs are a bit jaded and undervalue their services, not recognizing when they have provided critical care.

Furthermore, CC is a unique code in that it requires a break in the routine documentation flow. Unlike almost every other procedural code used in the ER, for CC, the physician must explicitly and affirmatively ask for it. For every other code, the professional coder can infer from the record what was done and apply the appropriate codes, but CC requires that the EP remember to claim it, and document in a very specific manner what was done in order to compliantly receive credit for the service provided. Critical care requires that the doctor record the time spent, the "unbundled" associated procedures, and a defensible summary of the critical illness and interventions. While not difficult, these requirements are different from those for the other 90% of patients seen in the ED, and require the EP to approach the record in a different manner that they otherwise do.

So what is "Critical Care" anyway?
The nice thing is that Medicare provided a very loose and vague definition, and left it to physicians to decide on a case by case basis. According to the most recent Medicare definition (PDF) : Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

There are a three key requirements which must be met for critical care:
  • Time.
  • Medical Necessity/Criticality.
  • Interventions.
Let's address these individually.

This is a time-based code; the physician must document the total time spent in the care of this patient. The first 30-60 minutes will be billed as code 99291, and subsequent half hours will each be billed as a 99292. The time element is the most commonly missed. Frequently physicians will provide wonderful documentation of their critical care services, but failure to explicitly record the time spent will result in the case reverting to an E/M code. Coders are not allow to infer from the record how much critical care time the patient received.

The time requirement is cumulative, meaning it need not be continuous. So if the patient is in the Department for six hours, but you spent 90 minutes over this time frame devoted to the patient's care, you may bill for 90 minutes of critical care. This does includes time not at the bedside, and explicitly includes activities such as lab review, consultations, family decision-making, and documentation. You do not need to explicitly break down a line-item summary of the activities you engaged in.

A key requirement is that you must be "immediately available" to the patient during this time. For this reason, time spent off the unit cannot be included in CC time. This effectively means that providing prehospital control to EMS can not count towards the total time.

This is the huge subjective element in CC today, and may represent the greatest opportunity (as well as the greatest risk) for your practice. CPT provides examples of critical care which are intended to represent the "mid-range" of CC services. However, CPT also provides examples of Level 5 E/M cases which appear to meet the definition of critical care as it is currently understood. For example, any patient who experiences acute respiratory or circulatory failure requiring ventilatory support or vasopressors is clearly critical. However, a patient with unstable angina requiring intravenous nitrates, beta blockers, and anticoagulants certainly also meets the definition. Or a patient with a GI bleed requiring fluids resuscitation and transfusion. For that matter, the current definition of sepsis/SIRS is quite broad, and patients with SIRS, even early SIRS, meet the broad definition of "high probability of deterioration."

The key here is to recognize that criticality extends far beyond the intubated patient to a wide variety of conditions.

In order to fully justify the service you are claiming, it is necessary to have done something for the patient. That may include anything from heroic life-sustaining measures to very simple measures such as crystalloid fluid resuscitation, so long as the criticality requirements are met. The CPT definition clearly includes complex decision-making as meeting this requirement. It is, however, more justifiable when there is a tangible and clearly identifiable intervention was performed which can be said to have averted or treated the patient's actual or potential deterioration.

What's not required for critical care is almost as important as what is required. The standard E/M components of HPI, ROS, Past/Family/Social History, etc are not required. While you omit them at your peril (from a medical liability point of view), these are not required elements of a critical care chart from a coding and billing perspective.

It is important to understand that a variety of procedures are included, or "bundled" into CC. These are: blood draws, peripheral IV placement, blood gas interpretation, NG placement, Pulse oximeter interpretation, ventilator management, transcutaneous pacing, and CXR interpretation. You may not bill separately for these items on a critical care patient. However, all other procedures still may be billed separately, including but not limited to: intubation, central line placement, EKG interpretation, cardioversion, tube thoracostomy, laceration repair, fracture care, lumbar puncture, etc etc etc. Be aware that CPR supervision is a separately billed service, and CPR time bust therefore be subtracted from your total Critical Care time. It is very important to explicitly note that the time you spent providing critical care services was "exclusive of all other separately billed services." Memorize that phrase and be certain to use it in every critical care dictation you do!

Compliance and Risk:
As Medicare's RAC process turns its attention to professional billing, it is predictable that this will draw its attention and that audits will result, especially in light of the increase in the utilization in these codes. As the standards are somewhat loose, how to demonstrate compliance is on everybody's mind. The key is, I think, to set standards in advance and consistently apply them, and to document explicitly the nature of the patient's criticality. In almost every critical care case, I include the statement that I felt the patient was at high risk of "X" to make it very clear to the coder (and any auditor) why I felt the patient was critical. Auditors generally give a fair amount of latitude to the judgment of the provider, so long as you explain your thoughts.

Supporting evidence of criticality which is helpful to highlight in your documentation might include:
  • Obvious problems like respiratory failure or circulatory failure.
  • Any organ system which has acutely failed (or may fail).
  • Significantly abnormal vital signs.
  • Shock, even early shock.
  • Acidosis.
  • Need for interventions such as central venous access, thoracostomy, cardioversion/defibrillation, transfusion of blood products, or the "ACLS" suite of IV medications.
  • Multi-system diagnoses (aka, your "Train wrecks") requiring highly complex medical decision-making.
  • Trauma patients with serious injuries.
  • Patients requiring ICU admission.
ICU admission may support the criticality of the patient, but is alone not sufficient, especially if the patient is admitted as an overflow patient, or as a chronic ventilator patient.

There is some debate regarding whether Critical Care may be justified based on the presentation alone, or whether an actual critical illness need be present. Consider, for example, a trauma patient whose injuries turn out to be non-life-threatening. Some claim that the patient, prospectively, was an unknown and had a high potential for deterioration. However, the guidelines state that "both the illness or injury and the treatment must meet the requirements." This requires that the patient has an actual illness/injury, not a potential one.

Conversely, there may be cases in which the patient is manifestly critically ill, but the EP does not actually provide direct treatment. For example, consider the stable patient who comes in with a cerebral hemorrhage. If all the EP does is order the CT and call the neurosurgeon, there was no critical care provided. If the patient required urgent blood pressure control, that would be different, but absent some intervention, Critical Care is not appropriate.

And there are some patients who are critical but do not meet the time requirements. In my institution, ST-Elevation MI's go very quickly to the cath lab, and are often in the ED for only fifteen or twenty minutes. While the illness is critical, and the intensity of service provided in that time is high, the time requirement is absolute, and these patients must be coded out as level 5's. (Using the "patient acuity" caveat for the ROS, of course.)

Frequently Asked Questions:
Can you code Critical Care on a patient who is subsequently discharged home?
Yes, but be cautious. A compliant chart would make it quite clear that the patient was indeed critical and that there was an intervention which changed the course of their illness. An auditor would likely be skeptical of CC on a discharged patient, so I would recommend that your documentation be bullet-proof in these events. The most common example I can think of would be an overdose requiring temporary airway management, and things of that sort.

Can Critical Care be billed as a shared service between physicians?
No. If two physicians of the same specialty within the same group both provide 30+ minutes of critical care on the same day, the first must be billed as 99291, with subsequent increments of 99292 as appropriate. If each physician accounts for only 15 minutes of time, it may not be combined.

Can an ER physician bill for an E/M service and Critical Care on the same calendar date?
Not for Medicare patients. CMS specifically prohibits this, for the ER E/M codes only. CPT guidelines will permit this, so long as the services provided are separately identifiable and discrete. Some commercial payers may recognize this, but it is fairly uncommon and often will be rejected by payers. If the patient presents prior to midnight and receives 30+ minutes of critical care both prior to and after midnight, two units of 99291 may be billed.

Can an attending bill for teaching time, or time spent by resident physicians?
Teaching time may not count towards Critical Care. However, the attending may bill for time spent supervising the resident so long as the attending is physically in the room with thepatient while the services are being provided, and documents: "(1) the time the teaching physician spent providing critical care, (2) that the patient was critically ill during the time the teaching physician saw the patient, (3) what made the patient critically ill, and (4) the nature of the treatment and management provided by the teaching physician." The attending may reference the resident's documentation for details.

Can a PA or Nurse Practitioner bill Critical Care time?
Yes, provided all the other guidelines are met. As with Physicians, this may not be billed as a shared service.

In summary, Critical Care is a valuable service which we provide to our patients, and it is correspondingly well-reimbursed. Most Emergency Department practices still do not utilize it as fully as is allowed, and optimizing your critical care coding can provide a valuable profit margin to your practice's bottom line. However, given the increasing attention to this code, future audits are all-but-certain, and it is essential to consider the compliance elements of this code and be certain that your documentation supports the value of the services you are providing to your patients.

06 November 2008

My Life is Empty

Obama Win Causes Obsessive Supporters To Realize How Empty Their Lives Are

Oh, boy, they've got me.

In Which I am Asked to Back up my Assertions

GruntDoc takes me to task for a couple of statements I made in this previous post. Fair enough, I am happy to provide some supporting data. First, I wrote that "over the last century, economic prosperity has been the hallmark of Democratic administrations," which Allen described as "failing any reasonableness test." I think that GDP growth and Job Growth are generally accepted as indices of prosperity; here are the average, annual numbers for GDP Growth and Employment Growth, respectively, broken down by President, from the Eisenhower administration on:

Note that the Carter administration was not as bad as generally remembered. It started out very well, and ended very badly. However, note that there is fairly strict segregation between high and low growth periods by party in control of the White House. Now, if you want to make an argument that these are accidents of happenstance and bear as much relation to reality as the winner of the Redskins game before the election, that's a fair point to make, and an argument I'm not smart enough to engage in. But I stand by the general statement that Democrats have generally been better for the economy than republicans. But we all know that past performance is no guarantee of future results...

The other statement, which is, I admit, more arguable, was that the republican party is "reduced to a regional party based in the south." Allen refered me to this map which shows a Red America with small islands of blue. I actually think this supports my point quite nicely, as it reflects the southern boundaries of the GOP quite clearly (extending up through Appalachia).I offer, as supplemental evidence, this cartograph of the recent election, broken down by state and weighted by the population of that state:
Or, if you prefer a more granular level of detail, here's the same graph, broken down by county.
Mostly I just wanted an excuse to post these cool pictures. I love these graphical displays. While it is true that the republicans retain some strength in the Mountain West in addition to the Old Confederacy, the Democrats own the entire Midwest, Northeast, Mid-Atlantic, and Pacific Coasts.

I admit that the whole thing is oversimplified, and that there's truly a lot of purple areas out there. Fair enough. But the original point is valid: unless the republicans can learn to compete in the large metropolitan areas of the country, they are at risk of becoming progressively more marginalized as a rural/regional party.

Obama to outlaw Designated Hitter!

A First 100 Days we can believe in!


Failure to Blow Election Stuns Democrats
Party Faithful Mourn End to Losing Tradition

Just minutes after their party's longstanding losing tradition lay in tatters on the ground, millions of shell-shocked Democrats stared at their television screens in disbelief, asking themselves what went right.

For Democrats, who have become accustomed to their party blowing an election even when it seemed like a sure thing, Tuesday night's results were a bitter pill to swallow.

The head-shaking and finger-pointing over the demise of the Democrats' losing streak, which many of the party faithful had worn like a badge of honor, reached all the way to the upper echelons of the Democratic National Committee.

"Believe me, I'm as shocked by these results as anybody," said DNC chief Howard Dean, who indicated he has received hundreds of calls from incredulous party members. "We did everything in our power to screw this thing up."

Credit: Andy Borowitz

The day after the day after

Still kinda emotionally exhausted. Can't bring myself to get too deep into the electoral post-mortems. Rahm for Chief of Staff? Groovy. Palin for Ambassador to Russia? Great -- she can see it from her house. Rove tells me that despite the fact that Obama got more votes than Bush ever did that this is not a "mandate" and America remains a center-right country. Riiiight.

I'd love for this to be the dawn of a new Progressive Era in governance, but it's not going to be. Despite the National Journal's bullshit about Obama being the most liberal senator, (Really? More liberal than avowed socialist Bernie Sanders?) this is likely to be a cautious and centrist administration. Emmanuel himself is notorious for being something of a Blue Dog.

But let's make no mistake here: Americans, by and large, share the core values of the progressive movement. End the war in Iraq. Universal healthcare. Minimum wages. Equality of opportunity. Personal privacy and civil rights. Progressive taxation. The Republican party, only four years removed from crowing about its "permanent majority," is now firmly reduced to a regional party based in the south. Once, the "party of ideas," the conservative movement has nothing left but a hollow anti-tax, gay-hatin' demagoguery. I don't think that the democratic majority will be "permanent." This is their opportunity, however, in partnership with a Democratic president, to show the country what competence in government looks like, and to remind them that over the last century, economic prosperity has been the hallmark of Democratic administrations. If they succeed in that objective, and if Obama's administration is as well-run as his campaign was, then there is a possibility that Democratic control of congress may be enduring. And that would be a good thing.

05 November 2008


Is America fixed yet?

04 November 2008

Change Has Come

Historic. Unbelievable.

Yes. We. Did.

Holy Fucking Shit.

This is for real, right? I mean, they can't take it back? We are Democrats after all. Don't underestimate us -- we can still manage to screw it up.

I feel strange. We won. That's an odd thing for me to say. Let me try it again. We won. I kind of like the sound of it.

I think I like winning. You know, it's better than losing.

It's sort of an unfamiliar sensation. I'm not sure I'm suited for it.

What a day. I just sat on the sofa with my six-year-old son, and I told him to remember this moment the rest of his life. This is up there with July 20, 1969. I'm so glad I got a chance to see this.

Change has come.

Vote Quimby!

Just a comment on process. Where I live, all voting is by mail. It's awesome -- you get a ballot in the mail two weeks before the election, and you get to fill it out in the privacy of your own home, at your own leisure, and send it back in by mail (or if you choose, drop it off at a polling station). It's like NetFlix took over the secretary of state's office!

It's truly the greatest thing ever.

No lines, no hassles, no waiting. All the obstacles to voting are just gone. No worries about child care or having to work. If you don't get your ballot or if there is some trouble with your registration, you find out about it before election day, so you have time to straighten it out.

Better yet, you can actually think about and research your vote before hand. Sure, we all know who we're going to vote for, for President, before we go to the polls. But what about the confusing array of initiatives and down-ticket races? (Apparently we have a Lieutenant Governor! Who knew?) So if you need to google I-985 to find out what it will really do to traffic congestion, you have that opportunity, which you really don't have at the polls (unless you are foresighted enough to research the whole ballot in advance).

And best yet, it is so incredibly inclusive. The turnout of eligible voters in our area is somewhere over 90%, I think. No state with voting in person can boast that kind of participation, and I've got to believe that full participation strengthens the democracy.

The only downside is that it robs election day of its drama. Half the state's already voted, so in most races pollsters can figure out who's won beforehand. But in a marginally close race, the late mail-in returns can drag it out forever. So not as fun. But the convenience so outweighs that factor. If you're reading this post on your blackberry while standing in a six-hour line to vote, maybe you should sponsor an initiative in your state to go to all mail voting...

Yes we can

Still gives me chills:

"In the unlikely story that is America, there has never been anything false about hope."

Know Hope.

03 November 2008

One Day More!

One more day before the storm,
At the barricades of freedom.
When our ranks begin to form,
Will you take your place with me?

Tomorrow we'll be far away,
Tomorrow is the judgment day,
Tomorrow we'll discover what our Lord in heaven has in store:
One more dawn,
One more day,
One day more!

Still gives me chills after all these years.

An, ahem, more authentic version is here.

Say, how'd it turn out for those idealistic young revolutionaries, anyway?

How do you compare?

The 2007 BESS data has been released. It's pretty hard to come by, as CMS makes it very difficult to access and interpret. Here's the breakdown for Emergency Medicine's E/M distribution, nationally:

Bear in mind that these are Medicare patients only, so there is an inherent right skew to this distribution. If you want to compare apples to apples, you'll need to suss out your own Medicare patients. Understand that Medicare uses this data, in part, to identify practices which are outliers and possibly noncompliantly coding their ED patients. So unless you are a unique practice (i.e. trauma center, etc), you do not want to be too far off the averages. "The nail that stands up gets hammered down," as the old saying goes.

There's state-by-state information published over at HealthCare Business Resources. Much thanks to them for taking the time and effort to pull out this information, and for generously sharing it with us.

How fast is fast?

Our ED is a pretty high-acuity, intense place to work. We staff it to a level of about 2 patients per physician per hour, which is more or less in line with the ACEP practice management recommendations. In the lower-acuity areas ("Fast Track"), there are PAs who see somewhat more: 2.5-3 pph.

I'm one of the faster physicians in our group. I can see 2.5-3 pph without too much trouble, though that certainly requires a high-energy day for me. I average more like 2.25-2.5 over the longer run. The fastest doc we have ever employed averaged about 2.7 pph, and frankly, I worried that he was a little too fast for my comfort.

So I was at ACEP recently and talked to some docs from other areas of the country. They tossed around numbers like 3-4 pph as if it were no big deal. Due to the setting, I was not able to closely question them on how they achieved those numbers, which quite frankly stretch credulity. But it got me thinking. With our ED, and our acuity, and our doctors, numbers like that actually seem impossible.

How about you, O My Readers? What sort of volumes do you or your docs generally see per hour? If it's a higher number, 3+, what factors allow you to achieve such efficiency? Do you work in a high-volume shop which sacrifices safety for speed? I'm curious to know.

So what's your experience?

Stream of Consciousness

A slightly surreal, stream of consciousness summary of This Fucking Election.

Almost over now.

01 November 2008

Taking a stand

Okay, pure horse-race politics here. It's just three days away (finally) and it's time to put my chips on the table. Here's my predictions for Tuesday night. I may be hysterically wrong, or prophetic, but's that's the fun of predicting, right?


  • Obama-Biden 379 EVs
  • McCain-Palin 159 EVs
Popular vote:
  • Turnout: 130,000,000 votes
  • 70,000,000 Obama
  • 60,000,000 McCain
  • or Obama 54%-46% (neglecting third parties)

State-by state results:

Obama keeps all the other Kerry states and wins the "battleground" states of: FL, NC, VA, GA, OH, PA, MI, WI, MN, IA, MO, CO, NM, NV
GA is my long-shot pick. CW is it's out of reach, but turnout there may surprise us. Obama has made plays for IN, WV, AZ, and has a chance at LA, MT and the Dakotas, but I predict all of those will narrowly stay in the McCain column.

Here's my predicted map:


Dem 58
Rep 42

This includes Lieberman and Sanders in the Dem caucus, for the sake of argument.
Dem Pickups:
  • VA Warner (open)
  • NH Shaheen (Sununu)
  • NM Udall (open)
  • CO Udall (open)
  • AK Begich (Stevens)
  • OR Merkley (Smith)
  • NC Hagan (Dole)
I predict that Franken will fall short in MN, and none of our outside-shot seats in GA, KY, or MS will materialize. Landrieu in LA seems safe, and there are no other pickup opportunities for the GOP as far as I know. Note that I am contradicting myself a bit: if Obama does pull off the upset in GA, then Martin will probably also beat Chambliss. Bah. Who needs consistency?


Let's say a net Dem pickup of 20 seats for a Congress composed of 256 Dem to 178 Rep. That's a conservative estimate, but there have been a few setbacks in the House races recently. A big Obama night could conceivably run the Dems up to as much as 270 seats. That really would require running the table.


The cool map up there is courtesy of the Daily Kos Political Scoreboard. I don't care if you think DKos is a bunch of lefty haters, you've got to go check out the scoreboard. It's the coolest toy ever for a political junkie. You can of course play with the EV map, but you can also drill down to the state level, graphically looking at county-by county results, or individual congressional district results historically, all of which will be updated in real time on Tuesday. It's very very cool. Also, 538.com has a wealth of data on the current state of the races, and NBC's political guru Chuck Todd has a nice state-by-state walkthrough as well.

Okay, there it is. Now you all know that I am terribly, terribly wrong. Tell me where, and why. And be nice about it. We're all grown-ups here.