PSOTBLOG

Billing and Coding

my has pointed out that there are two hospital observation codes depending on whether or not the patient discharge is a calendar day later than the admission these are amended to the hospital billing sheet which is amended and attached. Medicos frequentlyuses these codes for false labor admissions of Tenncare  patients.
 
Second topic---Below I think Amy suggests that Medicos is losing potential revenue by starting the OB chart and intitiating the global fee too early. We need to review this at a meeting.
 
Meanwhile, for Tenncare patients, I suggest Medicos physicians use the amenorrhea, pelvic pain/ vaginal bleed codes to do a level four medical visit with US, UPT, CBC, and gyn ultrasound[probably complete 76857 which willl be a new code added to the encounter form.]
 
The Tenncare patients are different from the Latino uninsured. These patients are bringing  more risk, more doctor shopping, fragmented care, and psychosocial issues. It is true that these pregnat paitents should be placed onto the database at detection, but this does not constitute acceptance for prenatal care. Some patients do not return. Some return three months later. Therefore immediate intitiation of the global fee is inappropriate.
 
It is OK to send an OB panel in addition to the CBC/urine/other lab at these medical amenorrhea visits. Twenty percent of these women have a Hgb less than 10, and they need to leave with iron today. Waiting for the OB panel is not good enough.
 
Amy refers to creation of the OB chart as an item which triggers the global fee protocol. This confuses me. I do not believe audits of Medicos' paper charts lead to reclaiming of medical visit revenue. Medicos has had more problems with a failure to creat OB charts, but it may well be that charts are opened on the day of an amennorrhea. I don't see this as a problem, but it may be that we should annotate in the paper chart that the first date was a medical visit.
 
Additionally, Medicos is experiencing the need for unexpected high risk visits which occur after an OB chart has been started. These V23.89 visits require a second code but almost always are level 4 or 5 with the need for blood tests, urine, ultrasound, and some NST's.
 
Memphis is now carrying a prenatal list of over 330 women, with over 60 of them dropped for unacceptably high risk. Memphis has transitioned from 75% uninsured OB to 75% Tenncare. Physicians will have to remain ethical, but bill aggressively to meet the overhead of the cliinical operation.
 
 
AMY WRITES--BOTH FACILITIES ARE DOING THIS...
 
NEW PREGNANCY COMES IN WITH UNCONFIRMED PREGNANCY. THE DOCTORS ARE IMMEDIATELY STARTING HER PRENATAL CHART AND VISIT ON THIS FIRST DATE SEEN. I CANT BILL OFFICE VISIT FOR LACK OF MENSES WHEN OB CHART IS STARTED. RECOMMENDATION IS TO SEE HER FOR THE MEDICAL CONDITION, LACK OF MENSES, WITH PREGNANCY TEST AND WELL VISIT IF NEEDS ONE PERFORMED. THEN HAVE PATIENT RETURN AS NEW OB WITH DOING ALL LABS ON THAT VISIT. HOWEVER, IF PATIENT IS LATE PRENATAL CARE OR TRANSFER OB THEN WE MUST START THE OB CHART. THIS HASN'T BEEN THE CASE THOUGH.
 
EXAMPLES:
MS. JANE DOE COMES IN FOR LACK OF MENSES. LMP 1/19/09. HER LAST PAP WAS 1 YEAR AGO. WE CAN DO A PAP, PREGNANCY TEST AND ULTRASOUND IF YOU LIKE. BILL PREVENTATIVE VISIT (99384-99386 FOR NEW PT) (99394-99396 FOR ESTABLISHED) DX-V72.31, URINE PREGNANCY TEST (81025) FOR LACK OF MENSES DX-626.8 OR AMENORHEA 626.0 AND IF YOU DO ULTRASOUND THEN USE GYN (76830 OR 76857) DX-626.8 OR 626.0. LABS DONE TO CHECK QHCG THEN CHARGE VENIPUNCTURE FOR DX-626.8 OR 626.0
 
MS. JOANNA DOE COMES IN FOR LACK OF MENSES. LMP 2/10/09. LAST PAP WAS 2-3 MONTHS AGO SO SHE DOESN'T NEED ANOTHER. WE CAN CHARGE E&M OFFICE VISIT (99212-99214) FOR LACK OF MENSES OR AMENORRHEA. YOU CAN DO ULTRASOUND IF YOU LIKE BUT CHARGE THE GYN U.S., ETC.
 
IF PATIENT IS NOT OUR OB PATIENT BUT SHE COMES HERE FOR MEDICAL TREATMENT AND WE DECIDE TO SEE HER FOR SOME REASON THEN CODE THE MEDICAL AND NOT THE OBSTETRICS.
 
THANK YOU FOR YOUR TIME,
AMY

Index--Quick form List; b illing observation admits, billing office OB

Lost Revenue Due to MD Code Errors

MEDICOS IS NOT A "FQHC(government clinic)". Medicos is testing the theory that physicians will want to manage their own offices, and that they will be paid for it.
 
Physicians will live and die by their collections. Failure to bill correctly is a major cause of primary care failure. Shelby-billing has pointed out that dental care codes are not billable for insurance patients, and the use of a code such as  "Toothache" will not be billable. The note should deal with some medical aspect such as head pain(headache, lower jaw).
 
Almost all of our patients have other comorbities and it is desirable(and ethical) to mention them in every note. Remember Medicos' policy for listing the Problems/Issues each time. The electronic medical record does this with 4-5 keystrokes. Undercoding for lack of mentioning comorbidities remains the number #1 cause of lost revenue, and Tenncare-Medicaid patients need this coordinated care for moral reasons. To sustain the financial viability of the office in which they are seen, this care MUST BE documented.
 
If this is done correctly by the physicians, there is no need to have front desk policies turning away patients complaining of tooth pain. Truthful coding will lead to appropriate charges in 95% of patients.
 
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville, rural
www.psot.com
(TheProcedural Skills and Office Technology Project)

Index--How physicians lose money on Medicaid patients
A potential column for the American Journal of Clinical Medicine

Student Comments

 

Dear Dr. Rodney:

Thank you. I've had a wonderful time at Medicos, both in Nashville and Memphis Feb 2009.

I wish every Meharry student would take advantage of the opportunity to experience Medicos Memphis. I personally have never seen a more dynamic, well-functioning clinic anywhere. To me, it represents the epitome of what family medicine could be and provides an elegant and sustainable model for primary care in this country. Medicos Nashville certainly has this potential and is headed in the right direction, but is not yet as multi-faceted or multi-dimensional.

I'd like to see Meharry students have the opportunity to do one week of their Junior Family Medicine rotation in Memphis. As far as I know, this is not presented as an option at the beginning of the rotation. If it were I believe interested students would come forward, especially if gas and lodging were included, and a steady stream of students would cycle through. Students who were not interested in "going away" for a week could then be assigned to local clinics, as they are now. Provisions could be made for the weekly classroom time that junior students would miss during their week in Memphis. What do you think?

Maureen Seitz Meharry Medical College 2009

Index--student comments

Cesarean Article From Phoenix Group

Mark and Bill:

As I get going on the nitty gritty of doing this maternity care article, I am asking if you have easy access to some of the literature/references of family medicine maternity care that may be relevant to our project.  I will be having our librarian do my own literature search as well, but recognize that you two are a wealth of knowledge.

If you would be so kind and to send me a list of some references, or direct me to them, I would really appreciate it.

Aline Coonrod

REPLY (WMR):

I have a review of Mark's article from the OB literature, and it states in writing that the only OB data, as of 1960-1970, was that they tried to have the average OB-Gyn resident complete at least 40 Cesareans for "competence." Last month I met with a now retired former Chair of OB who said that he had completed 12. In Italy may still do less than that now. International medical education contains many strange set of inconsistencies. Here in the USA, it is the same.

Deutchman M, Connor P, Gobbo R, FitzSimmons R. 

Outcomes of cesarean  sections performed by family physicians and the training they received: a 15-year retrospective study.  J Am Bd Fam Pract 1995; 8(2):81-90.      

Heider A, Neely B, Bell L. Cesarean delivery results in a family medicine residency  using a specific training model. Fam Med 2006;38: 103-109.

I have the world's literature reviewed for the the 1989 AAFP Task Force and then updated it 1994, 1999, 2004, and fairly current now. Exhaustive references may not help that much, on the other hand there is very little on the central question. The central question is about curriculum and the lack of outcome based studies on the definition of competence for Cesarean section. I havve a lot of material on this topic, but I would prefer to start with some  general issues and possibly helpful published studies. Cearean section is a lightning rod issue because, if family medicne can teach this procedure, it rewrites some of the fundamental assumptions currently undergirding the American system of medical education.
 
When I was on the AMA ad hoc committee on credentialing, we decided to avoid the term "competence" because it lacked a hard definition. We settled on language like, "education, training, experience, and proven ability" Roughly this meant MD/DO, specialty neutral-any reasonable residency , number of cases or something like it, and proctorship during the time of provisional privileges in the hospital.
 
A second point to be made in this paper is similar to the paper I published on the question of GI endsocopy credentialing in 1998.
 
Rodney WM.  Will virtual reality simulators end the credentialing arms race in gastrointestinal endoscopy or the need for family physician faculty with endoscopic skills?     JABFP 1998; 11(6):492-495.
 
In this paper I outlined the various numbers suggested as having face validity on the basis of "expert opinion".
 
Operationally our Family Medicine Obsterics fellowship trainees have to survive the hospital credentials committtees in various urban, suburban, and rural envirionments. The same is true for those who train in a residency without a fellowship, but we invented our fellowship as a "political device" after all attempts at logic and reason had failed.
 
Legally there is but one national standard for competence, or the lack of, but it's settled case by case in the malpractice courts whenever there is a bad outcome.
 
In Tennessee the absolute number of needed cases to obtain Cesarean privileges is " a one year fellowship" and a case log. Cases required range from 20 to 100, but there are some hospitals who refuse to even discuss the question. I believe this is an accurate summary of the current situation nationally.
 
I have suggested that the surgically equipped proceduralist FP is a "disruptive technology" requiring well entrenched sub-specialty medicine to reconsider its paradigm. Yes , the dreaded paradigm shift. Additionally our fellowships have liberally imported the use of ultrasound. This changes everything in terms of improved risk management. There are huge implications for timely Cesarean with detection of placenta previa, breech, transvers, and we are finishing a study on the diagnosis of OP presentations as the cause of delayed second stage labor.
 
 
Hahn R., Ornstein S, Davies TC, Roi L, Rodney WM, Garr D, et al. Obstetric ultrasound training for family physicians: Results from a multi-site study.  J Fam Pract 1988; 26:553-558.

Morgan WC, Rodney WM, Garr DA, Hahn RG. Ultrasound for the primary care physician:  Applications in family-centered obstetrics.  Postgrad Med, 1988; 83(2):103-107.

Rodney WM, Prislin MD, Orientale E, McConnell M, Hahn RG. Family practice obstetrical ultrasound in an urban community health center: Birth outcomes and examination accuracy of the initial 227 cases.  J Fam Pract 1990; 30:163-168.

Rodney WM, Deutchman ME, Hartman KJ, Hahn RG.  Obstetric ultrasound by family physicians.  J Fam Pract 1992; 34(2):186-200.

Connor PD, Deutchman ME, Hahn RG.  Training in obstetric sonography in family medicine residency programs: results of a nationwide survey and suggestions for a teaching strategy.  JABFP 1994; 7(2):124-129.

Deutchman EM, Connor P, Hahn RG, Rodney WM.  Maternal gallbladder assessment during obstetrical ultrasound: results, significance, and technique.  J Fam Pract 1994; 39:33-37.

Dresang LT. Rodney WM, Dees J. Teaching prenatal ultrasound to family medicine residents. Fam Med 2004; 36: 98-107.

Dresang L, Rodney WM, Koch P, Leeman L, Palencio M. ALSO in Ecuador:Teaching the Teachers. J Am Board Fam Practice 2004;17(4): 276-282. http://www.jabfp.org/cgi/content/full/17/4/276  

Dresang L, Rodney WM, Rodney KMMR. Prenatal ultrasound: A tale of two cities.   J Nat Med Assoc Feb 2006; 98[2]: 161-171

http://www.nmanet.org/JMNA_Journal_Articles/feb-06-jnma/OC167.pdf

Thus the Cesarean procedure is the visible tip of a larger iceberg wherein the entire body of sophisticated women's health care resides. This is particularly vital for developing coutries and underserved communities with limited resources. We imported hysteroscopy and laparoscopy into our family medicne center circa 1994, but were visciously attacked by those who thought we were going "too far". Can you say "Ensure" as it replaces the far more invasive and much more expensive old technology of bilateral tubal ligation.

Rodney WM, Deutchman ME, Hahn RG. Advanced Procedures in Family  Medicine: The Cutting Edge or the Lunatic Fringe? J Fam Pract 2004; 53:209-212.

The Cesarean capable family physician is emerging as the generalist model with the actual credibility to provide twice the service at half the cost 24/7-365

Rodney WM, Hardison D, McKenzie L, Rodney-Arnold KM. Impact of  Deliveries  on Office Hours and Sleep Cycle. J Nat Med Association October 2006; 98: 1685-1690.

Sorry for the weird puctuation. I am old and computer limited.

With best wishes for your professional success,
 

 
Wm MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural
www.psot.com

Index--Cesarean training