Physicians who consider themselves religious are not more likely to care for the poor than doctors with no religious affiliation, according to a new study. "The most religious are no more likely to care for the underserved than are the least religious. That to me was both a surprise and a disappointment," said lead author Farr A. Curlin, MD, assistant professor of medicine at the University of Chicago.
This article from the Washington Post provides an account of one physician's trip to the ER for a simple case of shingles, and the $9,000 hospital bill that followed. Jack Coulehan, MD, had already diagnosed himself when he went in, and even had a treatment plan in mind, but by the time he got out of the ER he had consults with an ophthalmologist an neurologist, two MRIs, and a CT scan—all of which were unnecessary, Coulehan states.
For physician practice coders, the transition to ICD-10 in 2013 might not be as bad as anticipated. Why? The most obvious reason is that physician practice coders don't have to worry about procedure codes, as physician practices will continue to report CPT codes for procedures. These coders only need to check for annual CPT updates, which is what they currently do. However, one major change will be the superbills update that will include ICD-10 codes that represent the most commonly used diagnoses for the practice's patient populations.
Because of CMS, providers have access to free resources to help them prepare for the transition to ICD-10. CMS and the CDC have created a set of tables that crosswalk the two versions of disease classifications. The tables, called general equivalence mappings (GEM), are text files that include information coders need to get acquainted with how common diagnosis codes will translate to ICD-10. Access the GEM and additional information about how to use them on CMS' Web site.
Although many crosswalks exist, some ICD-10 codes do not have a predecessor in ICD-9. Although this is the exception rather than the rule, CMS reminds coders that this means the GEM tables won't serve as an all-encompassing resource. Coders must continue to rely on coding books and adhere to coding rules.
To receive guidance on commonly used codes in ICD-9 versus ICD-10 and more, access HCPro's ICD-10 Watch blog at http://blogs.hcpro.com/icd-10.
The American Health Information Management Association offers many free and valuable tools for physician practices on its Web site, www.ahima.org.
The American Academy of Professional Coders Web site, www.aapc.com, offers additional resources, including an example of a 'before and after' superbill created by the American Academy of Family Practitioners.
The transition to ICD-10 is finally going to happen. Fortunately, coders have three years to prepare for the conversion and resources are readily available. Coders should seize the opportunity to take a sneak peek at what the changes will look like for their practice.
This article was adapted from one that originally appeared in the November 2009 issue ofThe Doctor's Office, a HealthLeaders Media publication.
When several patients needing urgent or emergent surgery arrive at a hospital simultaneously, who decides which case gets into the OR first? For true emergencies, the decision is generally straightforward, with the patient rushed into the first available room.
But in many other situations, the decision is not as clear: Should the patient with an open fracture go first; should it be the patient with an ectopic pregnancy, or perhaps the patient with an intestinal obstruction? Does the most senior surgeon get the first available OR slot? Should the decision be made on the basis of first-come, first-served? Or maybe the most assertive surgeon gets his or her case in first?
Often the decision falls to the anesthesiologist of the day in the OR. But no matter who makes the decision, the competition between surgeons over this matter, and the daily arguments with anesthesiologists, cause frustrations to both surgeons and anesthesiologists. And at times, patients end up waiting for surgery longer than is clinically optimal.
Ideally, the decision should be based on an objective measure that reflects the clinical needs of the patient and gives surgeons, anesthesiologists, and OR staff a predictable and fair system for prioritizing their cases.
An Innovative Approach
Wellstar Kennestone Hospital, a 600-bed hospital in Marietta, GA, working with Press Ganey, developed an innovative approach to this problem. As part of a significant initiative to improve patient flow through the OR, the surgical services committee—a committee composed of well-respected surgeons and anesthesiologists representing different services—developed criteria for classifying all emergent and urgent cases based on the medical needs of the patient.
The classification system was then used to determine the order in which cases were taken into the OR. It created a system that was fair, predictable and based on clinically-defined criteria. The clinical urgency system was used in conjunction with other patient flow improvement initiatives, including designating separate ORs for these add-on cases.
The surgical services committee decided to use five categories to classify its urgent and emergent cases. Time limits were set for each category, defining the maximum amount of time that should pass between the time a case was posted and when the patient was taken into the OR. Each specialty reviewed its common procedures and placed them into the category into which they would most commonly fall.
The five categories, and their corresponding time limits, were:
A. Acute life and death emergencies (30 - 60 minutes). Examples: Massive bleeding and airway emergencies.
B. Emergent but not immediately life threatening (< 2 hours). Examples: Acute spinal cord compression, bladder rupture, ectopic pregnancy.
C. Urgent cases (< 4 hours). Examples: Asymptomatic foreign body, appendicitis with sepsis/rapid progression, biliary obstruction, open fracture.
D. Semi-urgent (< 8 hours). Examples: Appendicitis, closed reduction of fracture, empyema.
Once the categories were developed and accepted by the surgeons, they began to use them to specify the urgency of add-on cases as they posted them. The system works in the following way:
When a surgeon posts a case, he or she classifies its urgency by using one of the five categories based on the needs of the patient. The appropriateness of the classification is never questioned at the time the case is posted but may be reviewed by the committee retrospectively. The order in which add-on urgent/emergent cases are then scheduled into the OR is based on the urgency of the case and the amount of time that has passed since the case was posted. If two cases within the same category arrive close together, they are taken in order of first-come, first-served.
The surgeon booking the case is responsible for categorizing the case, based on his or her knowledge of the clinical needs of the patient. For example, a surgeon can call an appendicitis case a 'B' case if he thinks that the patient's condition warrants surgery within two hours, even though most appendicitis cases are usually considered to be in the D (within eight hours) category. At the time of booking, no one can question the surgeon on this decision since it is assumed that he or she is the one with the most accurate assessment of the situation.
Monitoring Compliance
Like any system, this one can be manipulated, and oversight is necessary to maintain consistency and monitor compliance with the urgency categories. At WellStar Kennestone Hospital, the surgical services committee took on this role. Each month, the committee reviewed all 'A' cases and any other cases where the appropriateness of the urgency classification was questioned by another surgeon, an anesthesiologist, or surgical staff.
If further review appeared necessary, a member of the committee would talk with the surgeon in question, and if systematic or frequent problems occurred, the surgeon would be asked to appear before the committee to discuss the cases. This peer review system is critical to maintain accurate categorization and to avoid any gaming of the system. The review can also lead to revisions to the category guidelines over time.
Results
With the implementation of this approach to scheduling urgent/emergent cases into designated ORs, waiting times for these cases declined by 18% overall at WellStar Kennestone Hospital. For urgent and semi-urgent cases—types of cases that typically get delayed—the decreases in waiting time were even more dramatic, with waiting times decreasing 77% for C cases (maximum wait of four hours) and 33% for D cases (maximum wait of eight hours). In addition, E (non-urgent same day) cases no longer got pushed into nighttime hours—from 11 p.m. until 7 a.m.—because there was more time during the day to get these cases completed. The number of staff needed at night was reduced since it had only to care for more urgent cases.
The surgeons were pleased that their patients were getting into the OR more quickly. Surgeons, anesthesiologists and OR staff appreciated the transparency of the system. "Since we are able to get critical cases done more quickly we end up with less of a backlog during the day, and no longer find ourselves doing hip fractures at midnight," said an anesthesiologist at WellStar Kennestone.
Osnat Levtzion-Korach M.D, MHA is a senior medical consultant with Press Ganey Associates; Kenneth G. Murphy, MD, is president of Georgia Anesthesiologists, PC; Susan Madden, MS, is vice president for analytics with Press Ganey; and Christina Dempsey, RN, CNOR, MBA, is senior vice president for clinical operations with Press Ganey.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
Under pressure from moderate-to-conservative members of the House Democratic caucus, Speaker Nancy Pelosi has decided to propose a government-run insurance plan that would negotiate rates with doctors and hospitals rather than using prices set by the government. Pelosi said the public plan would compete with private insurers. The bill from members of the House Democratic leadership team would provide coverage to 35 million or 36 million people at a 10-year cost of expanding coverage that would be less than the $900 billion ceiling suggested by President Obama.
As U.S. lawmakers engage in a debate over healthcare reform, Chinese authorities are also attempting to fix their system. Over the past five years, the government has tried to provide coverage to more of its 1.4 billion people. But even people covered by a minimal health insurance program are often left with big hospital bills and must pay for most outpatient services and medication. In addition, more than 300 million people do not have any health insurance. The gap in the quality of care has been steadily growing, too, the Washington Post reports.