1. Consider volume purchasing. If you have adequate storage space, you may be able to save a considerable sum by buying items you use in large quantities in bulk. Printing and form costs, too, are often greatly reduced as the number of copies you order increases.

2. Pay invoices promptly. Some suppliers offer a small discount to customers who pay their account balances within a certain (short) timeframe. Take advantage of this savings opportunity when you see it on invoices, and don’t be shy about asking vendors about price breaks in exchange for paying quickly.

3. Do you belong to professional associations or your local Chamber of Commerce? If so, check the member benefits section on the organization website to see if you are eligible for discounts on services, supplies, or equipment purchases.

4. Say no to overtime. Salaries are one of the largest expenses in the practice budget. Keep payroll costs down by staggering staff hours if your office is open more than eight hours a day, hiring additional employees (perhaps part-time) if the workload is routinely too much for the full-time team to handle, and watching for “overtime creep” (15 minutes here, 30 minutes there). Note: If overtime is incurred despite your best efforts, remember that you’re required to pay it.

5. Make good use of your office space. If there are days that exam rooms sit idle because one or more doctors are off or in surgery, consider subletting space to a visiting specialist. Let your hospital administrator know if you have space available one day a week, or even two days a month. If they happen to be in the process of trying to woo a doctor from a nearby city to practice in the area, you may find yourself with a part-time tenant. Otherwise, spread the word around the medical community that you have space to sublet, or advertise in your county medical society newsletter. Ask other doctors who have done this for tips on how to make it work well for everyone involved.

And here’s a bonus tip involving bonuses: Challenge your staff to come up with quantifiable ways to cut expenses and reward them with cash bonuses or a percentage of the savings for a quarter or a year.

There are approximately 129 new valid diagnosis codes that will become effective on October 1, 2010. Many of these new additions are found in Chapter 14 among the codes for congenital anomalies of female genital organs, in Chapter 16 under symptoms involving the respiratory and digestive systems, and in Chapter 17 for injuries and poisoning. Significant changes were made to the supplementary classification chapter. Fifty-five of the new diagnosis codes effective on October 1st are new V codes.

Expanded Avian and H1N1 Codes

Both avian and H1N1 influenza have been expanded into three codes each. They now include codes with pneumonia, with other respiratory manifestations, and with other manifestations.

New Congenital Anomaly Codes

The new codes for congenital anomalies of female genital organs center on unique codes for Müllerian anomalies, which encompass all congenital anomalies of the uterus, cervix, and vagina since they stem from the same embryonic origin. The American Society of Reproductive Medicine recognizes seven types of uterine anomalies. Only two of the seven recognized types currently have specified codes in ICD-9-CM, but it is important to be able to differentiate between the anomalies because of the different gynecologic and obstetric implications they cause. The creation of new codes for these anomalies is meant to enhance communication about these conditions, and thereby improve patient care and management for conception and pregnancy issues.

New Signs and Symptoms Codes

New subcategory additions for symptoms involving the respiratory system expand hemoptysis, which has previously been used to code both an unspecified pulmonary hemorrhage and coughing up blood or bloody sputum. The new codes will now supply separate codes for unspecified hemoptysis (pulmonary hemorrhage NOS) and other hemoptysis (coughing up blood) as well as identify the rare case of acute idiopathic pulmonary hemorrhage in an infant over 28 days old.

Codes for symptoms of the digestive system expand fecal incontinence to distinguish between its different presenting symptoms, particularly incomplete defecation. A new code for fecal impaction was also created in the digestive system chapter, and tabular instructions distinguish between different presenting symptoms of incontinence and the other codes for impaction and constipation, which are not the same.

Also within Chapter 16, a new subcategory was created for signs and symptoms involving cognition that would allow the coding of cognitive symptoms related to other neurologic conditions or traumatic brain injury as supplementary codes that can present a clinical picture when there is no other more specific diagnosis available. These codes include cognitive symptoms such as attention or concentration deficit, visuospatial or psychomotor deficit, and frontal lobe and executive function deficit.

New Injury and Poisoning Codes

Very important changes within the injuries and poisoning chapter include the addition of a code specifically for poisoning by cocaine, or crack, 970.81, since this is a major central nervous system drug responsible for drug abuse and overdose that has not been specifically referenced in ICD-9-CM.

Category 999 Complications of medical care, not elsewhere classified has significant new diagnosis codes added for several conditions specifically related to the transfusion of blood or blood components, such as hemolytic transfusion reaction or HTR, for which no code currently exists in the classification system. Many of these transfusion disorders or reactions are currently under-recognized and under-reported, even though some can become debilitating or cause transfusion-related deaths. It is critical that these conditions are reported when they occur.

HTR is a blood transfusion reaction that causes an increased destruction of red blood cells due to some kind of incompatibility between the donor blood and the recipient. There is currently no provision in the classification system for distinguishing blood group ABO from non-ABO type hemolytic transfusion reactions, nor acute from delayed reactions, so unique codes have been created to help raise increased awareness of the prevalence of these conditions among recipients of blood transfusions and allow tracking for effectiveness of treatment.

New V Codes

V codes were created to report many new personal history conditions, such as a personal history of vaginal and vulvar dysplasia, personal history of combat and operational stress reaction, and personal history of corrected congenital malformations. The codes for insertion, routine checking, removal, and subsequent
reinsertion of IUDs have been modified into more specific codes in order to report these encounters more accurately, specifically, the ability to code removal with immediate reinsertion of IUD.

Body mass index (BMI) codes have also been expanded for reporting adult BMI measurements over 40 to distinguish specific ranges of BMI between 40 and 69.9, and 70 and over. This was necessary to track the population of morbid obesity as Americans are becoming more and more obese.

Two entirely new sections of V codes have been created—V90 Retained Foreign Body and V91 Multiple Gestation Placenta Status. The new category for retained foreign bodies reports cases of fragments or splinters embedded in an injured person that cannot be removed. Because of the potential health risks and hazards of embedded foreign bodies, the Department of Defense requested new codes to report an embedded fragment status that would identify the type of material, such as different types of metal, plastic, or organic matter. Although these codes are useful mainly for military purposes in cases of injuries from explosive devices, they are also applicable to any injury resulting in embedded fragments. The codes for multiple gestation placenta status were instituted to distinguish the number of placentae and amniotic sacs in cases of twin, triplet, quadruplet or other specified multiple gestation pregnancies.

“I was sitting in a dentist’s office when suddenly a patient storms out of an exam room and confronts the dentist in the hallway,” says Kristin Baird a practice consultant at Baird Consulting in Wisconsin and The Beryl Institute. “He said, ‘I’m sick of hearing your staffers talk about who’s dating whom, or who got drunk as a skunk last weekend. I won’t be back!’”

Indiscriminate tongue wagging — even seemingly harmless statements — can affect everything from staff morale to patient care. If you think your office is gossip-proof, you might be surprised. And if you don’t get a handle on the broad range of misstatements that could affect your practice, you could face serious consequences. Here’s how to recognize and fight gossip, rumors, and simply unwise remarks.

“Harmless” staff exchanges

Gossip is almost natural, especially in close environments. “We have six offices as of July 1 with over 75 employees, so it’s impossible to totally squelch office gossip,” admits Hilda Agajanian, director of the offices of The Oncology Institute in California. “People are always talking about the latest affair someone’s having, financial problems, who did/didn’t get a raise … there are all sorts of things that people bring up.”

In medical practices, there’s an added danger not found in other business offices: comments about the patients. “It doesn’t even have to be a word. It could be a sigh of relief, making it clear to colleagues how glad you are to see this pain-in-the-neck leave,” says Sue Jacques, aka “The Civility CEO,” who created the STAT (Stop Talking About Trash) program in Calgary, Canada. “Trust me, that gets your patients in the waiting room wondering, ‘What are they saying about me when I’m not here?’ That’s not a good image for a medical practice to build.”

Violating patient’s privacy

Consider this scenario: A nurse drops a folder by the front desk and says to the receptionist (in full earshot of the waiting room), “Stacy, please call the lab and see if we can speed up Mrs. Stevenson’s mammogram results.”

Then the receptionist, concerned about how Mrs. S is doing, asks her status. The nurse shakes her head and simply says, “It doesn’t look good.”

Starts getting trickier to define “gossip,” doesn’t it? Checking for or discussing a patient’s tests results so vocally can lead to rumors. “Brooklyn isn’t a small town, but the area in which we work is a relatively tight neighborhood. You never know when that patient is the cousin, best friend, or sister, for example, of one of your other staffers or someone in the waiting room,” says Russell Greenseid, DC, of Healthquest, a chiropractic/pain management practice in Brooklyn, N.Y.

It’s amazing how many ways there are to subtly create potential gossip problems. “Consider the light boxes in the hall. If your patients’ names are clearly labeled on the readings, your other patients can discover John Jackson’s had his hand X-rayed as they pass through,” says Baird.

At the very least, you’ve let others know John has been in for care for a broken hand, which is bad enough. Consider the patient who is seeking psychiatric care. “If Jane Doe has to leave her name displayed on a sign-in sheet at a psychiatrist’s office, think of the potential privacy issues,” says Shari McCartney, a lawyer specializing in healthcare compliance at Tripp Scott in Ft. Lauderdale, Fla.

Understanding consequences

HIPAA rules are a major reason more practices are now fighting gossip. “You’re discussing that colonoscopy in full earshot of the waiting room and the next thing you know, you’ve broken confidentiality,” says Mary Piece Brosmer, who provides practice cultural transformation through Consulting for a Change in Cincinnati, Ohio.

“Gossip at a physician’s office can rise to the level of a crime,” says McCartney. “Mr. Jackson can’t sue you, but he can report your office to DHHS or your state’s attorney general. I don’t know any doctor who wants the government to start investigating them.”

Besides, even office gossip isn’t good business — or good medicine. “The environment becomes negative, people can become paranoid,” says Jennifer Dominow, administrator of nursing services at Advocate South Suburban Hospital in Hazel Crest, Ill. When gossip is rampant, she says, “it’s hard [for staff] to deliver their best care — and that’s not what already vulnerable patients need from a health team.”

Methods of control

How do you stem these problems? “All our supervisors are trained in a warning system I established. It usually takes only one or two reprimands for our standards on gossip/privacy to become clear,” says Agajanian. “There are also numerous rules for insuring patient privacy. Example: All patients go by numbers, so someone calling from the front desk might ask, ‘Did we get the tests for M4562?’ instead of for Mrs. Stevenson.”

Baird heard the earlier dentist’s story while acting as a practice’s mystery shopper, one of her practice evaluation services to help identify potential privacy issues. Some of her other recommendations include: “Don’t have the doctor speak to the family in the waiting room, even if it’s good news. Make appointments in an area separated from the waiting room and use today’s technology to make follow-up appointments from the exam room.”

Jacques, a retired RN, teaches various control methods. “One technique is visual: Gossip starts with GO…so when you hear something you don’t approve of, get up and go. Don’t make a big scene, just leave,” she says.

HIPAA training, regular staff meetings (including those specific to the doctors themselves) and role playing are among the endeavors that keep Healthquest as close to a “gossip-free” zone as possible. So does addressing changes straightforwardly. “We brought the whole staff together and acknowledged it when there were going to be layoffs,” says Greenseid. “It still hurt, but it also squelched speculation and it let people look for new positions before they were let go.”

Brosmer actually encourages gossip, to a point. “I taught one office to incorporate a brief time during morning reviews for staff to discuss personal concerns. Saying it and leaving it, instead of banning it, worked well here,” she says.

Ultimately, experts agree, no method will work if the doctors don’t lead the way. They need to attend the training, be willing to listen to complaints — even about themselves — refrain from staff gossip, and catch themselves before saying anything about a patient outside a restricted environment like an exam room.

“Everything your patient comes in contact with should instill trust. We emphasize quality, but understand that your patients aren’t thinking quality as in clinical outcomes. They’re thinking more about the total experience,” concludes Baird. Wendy Meyeroff

Copyright 2010, Physicians Practice, UBM Medica. All rights reserved

One patient at MacArthur OB/GYN had a question about moving her ovulation. Others spoke freely about their experiences with an endometrial ablation procedure. Most just wanted to say “thanks” to the physicians and show off pictures of their newborns.

These medical questions and concerns — as well as helpful information on women’s health — are all online at the practice’s Facebook page.

“We are taking this giant world we live in, and we are turning it into this small town where people are interacting,” says Jeff Livingston, one of five OB/GYNs and one nurse practitioner at MacArthur OB/GYN in Irving, Texas.

MacArthur OB/GYN’s online community of about 600 people (and counting) provides a forum for questions and information shared between physicians and patients. Livingston monitors it daily, and encourages the discussions by posting links and questions.

Livingston is among a growing number of physicians joining social media networks as a way to share information with patients or connect with their colleagues. In fact, 60 percent of physicians reported using or being interested in using online communities, according to an early 2009 survey by Manhattan Research. And all signs point to this number continuing to rise.

But as the status updating, Tweeting, and blogging increases, questions about appropriate online content and patient privacy arise. Should a physician “friend” a patient online? Will patients put your practice at risk and raise privacy red flags by posting their personal health information on the public forum? What if the doc shares too much? Are you exposing your practice to a lawsuit risk by engaging online?

For Livingston and others, online networks have become a necessary venue for connecting — and many physicians are embracing so-called Web 2.0 without ill effects. With a few guidelines and a lot of common sense, social media can be a boon for your practice and your patients.

Where your patients are

If you’ve been reluctant to hop onto the social media bandwagon, it might be time to consider it. Patients are increasingly turning to the Internet for healthcare information. A recent Pew Research Center study found that 60 percent of adults look online for health information. Plus, 35 percent of adults used social media for health and medical purposes last year, Manhattan Research found.

If this is where patients are turning for health and provider information, perhaps it’s where you should be as well, to best educate them and reach new ones?

Livingston first realized his audience was online more than five years ago when he was conducting outreach education to teens about STDs and pregnancy prevention. He noticed his 15-year-old daughter interacting with her friends on the networking site MySpace, and as he put it, “A light bulb went off. Here I am trying to connect with young people in my community and I am not talking to them in the way they actually talk.”

His daughter helped him build his MySpace page, and he has since expanded to Facebook and Twitter, where he manages the messages for his practice. Now, the practice’s Facebook page is a thriving forum where Livingston shares relevant and credible healthcare information and his patients post photos and discussions.

But before signing up for an account, ask yourself why you’re entering the social media realm. Jim Tobin, president of Ignite Social Media, which worked with the Massachusetts Medical Society to promote their organization, says physicians should ask the question: What’s the point of it all?

And there can be several answers that garner benefits for your practice. Engaging online through social media can allow physicians to show — not just tell — that they are the experts. Your Web site might say you’re the best-trained or the most knowledgeable endocrinologist, but how about demonstrating that by offering helpful information and resources?

Social networks also can boost your search-engine rankings, notes Tobin, who is also the author of “Social Media Is a Cocktail Party.” Posts on Facebook and blogs, for example, are indexed and searched by Google and other engines, so fresh content will appear high on the list when a patient searches for a physician online.

Social media can be one tool of many to boost marketing and customer service, but businesses and organizations must first understand what they are getting into, Tobin says. “If you are completely booked up and you have met all your goals, maybe you don’t need to do this,” Tobin says. “But if there is an issue that needs to be solved, whatever the objectives are, [you should] set aside the plan to accomplish those.”

Same rules apply

Much discussion has revolved around what information should be shared and how to protect privacy online. But many experts say the same rules apply online as they do in real life.

“We make a big deal out of this, but it’s no different than anything else,” says Joel Diamond, a family physician in Pittsburgh who uses social media and blogs about health IT interoperability. “The technology offers other areas to get trapped with privacy, but it doesn’t add new privacy concerns. The basic issue is always what it has been.”

So even though you’re sitting behind a computer screen and engaging other people using Internet handles and avatars, you should treat it the same as, say, a cocktail party. What private information would you withhold there? Regardless of the setting, physicians should be cognizant of what information they are sharing, says Bruce Armon, a partner at Saul Ewing LLP in Philadelphia.

The only difference is that at a cocktail party, presumably you only have a small audience. “When it’s an online forum, you have a much larger and unknown audience that may be relying on the advice or the guidance the physician is providing,” Armon says.

Tobin puts it this way: “Picture the same behavior you would do in public, and picture it with a megaphone to your mouth and someone recording it forever.” That’s about right. Deleting something doesn’t necessarily mean it will be completely erased, so physicians must recognize the responsibility and liability of their online actions.

Of course, HIPAA is pretty clear — medical information is private and can only be released by the patient or by authorization of the patient. There’s no exception for social networks, so before you tweet, consider the privacy rules you know so well from the real world.

Look before leaping

Before logging on to a Twitter account, consider a few gems of advice from the experts:

Not all sites are the same. Social media has become a blanket phrase to refer to sites for connecting and sharing online. But physicians must understand that Facebook is different from Sermo is different from Twitter when it comes to audience and content. “What’s different is the detail of information or the depth of medical information shared,” said Jason Bhan, a family physician and cofounder of Ozmosis, a physicians-only network. At Ozmosis, cases are presented in the same way they would be in a hospital program setting, ensuring there is no identifying patient information divulged even though great clinical detail is shared. The physician-only forum makes that appropriate, Bhan says, adding that “a blog would be the wrong place.” A blog, for example, has a very different — and more public — audience than the doc-only sites like Sermo and Ozmosis, which provide a forum for physicians to share clinical and professional issues. Those conversations shouldn’t be shared with your patients or the general public. For the more public interactions, such as sharing health information and resources, look to sites like Facebook.

Consider boundaries when building an online presence. Armon suggests that physicians who have a personal profile online limit the connections to those outside of their professional life, and vice versa. If the page is for your practice, remember to keep it strictly business and make sure it fairly represents your practice, he says.

But what happens when a patient requests to be your personal friend on Facebook? Here, the expert opinions diverge. “I don’t do it,” says Bhan, adding that it’s probably not terrible, but could open you up to dealing with sensitive information should a patient contact you online.

David Harlow, founder of healthcare law and consulting firm The Harlow Group and author of a popular healthcare and law blog HealthBlawg, also advises against it. He says physicians on Facebook should connect with patients through the practice’s page, of which patient’s can become “fans,” rather than through individual profiles.

That’s how Livingston connects with his patients. For the most part, patients understand that they should connect with him through the fan page for MacArthur OB/GYN. “Very few are asking to be my friend personally,” he says. “Patients are smart people, and they understand how it works and for the most part they are respectful of the boundaries.” What about those few? Sure, “friend” them, he says. Thanks to privacy controls and account settings, Livingston can choose how much of his personal information he cares to share — or keep private — with his patients. He has a group of his friends tagged “patients,” where he can limit the information. “I can use the technology Facebook has in place,” he says.

Take it offline (or to a secure messaging system). There will likely be times, however, when a patient does cross the line and post a personal question or clinical details. But that’s not reason to halt social media operations, says Harlow.

“You don’t need to shut down in response to inappropriate information,” he says, adding that there are ways of responding. If a patient posts personal health information on your Facebook fan page, for example, don’t respond directly to that person’s post, Harlow warns. For example, a patient could post, “I’m cancer free for one year! Thanks, doc!” Be careful not to respond, “Great news that Mrs. Jones is breast cancer free for an entire year!” Even though your patient posted first (and the comment seems innocuous), your response could land you in hot water.

Instead, opt for a far less personal response. Consider writing something generic, such as, “Thanks for sharing. Check out our updated Web site here.” The other option is to send the patient a private message, Harlow says.

Whatever you do, don’t offer any medical advice online, Armon says. Sure, these forums are ideal for addressing a health topic broadly, but if it gets too personal, suggest your patient make an appointment.

That’s what Livingston did when a patient posted a discussion about moving her ovulation time to better plan a pregnancy. MacArthur OB/GYN’s response — visible to all of the practice’s Facebook fans — was general for the benefit of other patients, but also recommended a visit: “There are some ways with birth control pills for a patient to change when they ovulate. Since this is kind of a personal topic schedule to come in and you and your doctor can discuss the options. Anyone considering pregnancy should also be taking a prenatal vitamin ahead of time to get the folic acid into your system. This can prevent certain birth defects.”

Livingston’s practice recognized the demand for online communications with his patients — and the need to implement the “next step,” he says. “If you are going to be out there, you are teaching your patients to be online and be engaged, so you have to have a system in place to allow them to do that.” That system? A patient portal, a secure way to communicate that ensures patient privacy but allows them to access their information and send questions to their physicians. “You can imagine the efficiency has gone up, and patient satisfaction has gone up,” he says.

Be ready to respond. Whether with comments about personal medical information, praise for your practice, or even negative feedback, social media platforms open you up for communication — and you have to be ready to respond. Diamond once received a comment on his blog from a patient who had lost touch with him and wanted to schedule an appointment. Not a big deal, Diamond says, just a little awkward. And Diamond recognizes that a patient’s post could have also been something negative, rather than just an appointment request. “I think this is a brave new world we are in,” Diamond says. “I think we just have to confront that reality.”

You could always take down the negative post on your blog or Facebook page, but that seems to defeat the purpose of social media, right? “The whole attraction of Web 2.0 is the transparency and responsiveness,” says Harlow, who advises against deleting the negative messages. Instead, be ready with a response, and know in advance how you plan to confront such interactions.

Harlow says it’s a good idea to have clear policies and procedures in place that address this issue, which of course requires you to first determine why you’re getting into social media in the first place. These policies should be posted on your fan page or Web site, and reviewed at least annually to keep pace with the dynamic nature of the Web, he says. This will be particularly helpful if you have staff posting on behalf of your practice. You might also consider having someone tasked with monitoring the pages, deleting or responding to inappropriate posts.

Think before you post. The final point might seem obvious, but warrants a reminder. The Internet makes it almost too easy to type away and hit send before reviewing what you’ve written. But don’t make that mistake.

“Consider everything on the Internet permanent,” says Bhan. “There is no erase button or delete button. Anything you put out there — it’s out there and permanent.”

Several years ago, when Twitter and blogs were just catching on, there was a small wave of inappropriate postings by healthcare professionals, Bhan says.

There’s also no such thing as anonymity online. Remember the case of Dr. Flea? In 2007, a Boston-area pediatrician using that pseudonym had been blogging about his malpractice trial. He was exposed on the witness stand, and the case was settled.

Similarly, sharing too much about a patient online for the sake of venting about a case or attracting readers with juicy details can land you in hot water. You risk losing patients, or worse, facing a lawsuit.

But for the most part, physicians who are engaging online understand the platforms and the rules of engagement, Bhan says. Plus, healthcare professionals have been trained extensively on privacy protections. (And the same rules apply, remember?)

The permanence of online communiqué can be troublesome for physicians who naturally want to be helpful and engaged, but who might not take the time to double-check what they are sharing, says Armon. Although most tend to err on the side of caution, remember not to share any information that could come back to haunt you. What may seem harmless to you could be taken the wrong way by someone else, he says. “The risk is sometimes all of us type quicker than our mind can think and we might not be as accurate as we like,” he says. “Once a physician hits the send button the message can take on a life of its own.”

Copyright 2010, Physicians Practice, UBM Medica. All rights reserved

1. Use lists. This tried and true time management technique really does work. Each Monday, make a list of all the important tasks and goals you intend to accomplish during the week. First thing each morning, make a separate list (using your weekly list as a guide) that includes what you will do that day. Prioritize the list by giving each item a 1-2-3 or A-B-C ranking, and consider the value of doing the most challenging or least pleasant item on the list first. A daily list is a wonderful tool to reference when you slip into “overwhelm mode” (you know . . . that feeling of “I have so much to do, I don’t even know what to tackle next”).

2. Keep a “quickie” basket. This is where you toss anything that needs to be done that can be taken care of in less than five minutes – phone calls to return, something to look up online, an order to place, a brochure to skim, or a few pieces of mail to sort through. Grab something from the quickie basket any time you have a couple of spare minutes. Over the course of the day, you’ll be happily surprised to discover how many little things you can get out of the way between larger tasks.

3. Maintain a tidy work area. Take five minutes each morning to organize your workspace, and repeat the process around mid-day. This simple act will help you avoid wasting valuable minutes looking for your daily list, charts, forms, and supplies needed to do your job.

4. Bounce back from interruptions. Being pulled away from what you’re focused on to answer questions, take phone calls, and assist colleagues is all part of a normal work day. The goal is not to avoid interruptions, but to bounce back and regain focus quickly when the intervening task is complete. No magic bullet here – just observe yourself and practice mastering the quick transition until it becomes a habit.

5. Socialize strategically. A medical practice is a professional environment where a great deal is accomplished each day. And, like any workplace, it’s also a social environment. If you couldn’t enjoy a little friendly banter with co-workers off and on throughout the day, going to the office would be drudgery. That said, too much socializing can become a time drain. Make a pact with everyone in the office that it’s okay to say (and not hurtful to hear), “I’d love to visit, but I have to get this done right now.”

Hospitalist admit billing

Q A patient presents at the emergency room with a hip fracture. The orthopedic surgeon is called and he states that he cannot be there for two hours, and he then asks the hospitalist to admit the patient. The hospitalist does so. Here’s my question: Can the hospitalist perform and bill for the admission if the patient has no other medical reason to be admitted to the hospital other than the hip fracture? Also considering that the orthopedic surgeon will be billing a global CPT code for the hip repair?

A There are a lot of variables here. First, there is no definitive answer because every payer interprets these things differently. Do you want the Medicare answer? If so, what carrier? That’s probably what you want to know.

The patient is going to get admitted anyway. In the normal course of events the orthopedic surgeon would have done an ED consult, billed it with a -57, and let the admit go as part of the global, assuming surgery was done. He later would have likely turfed medical management of the patient’s problems to the hospitalist anyway, which would have been a subsequent visit on that same day.

In this delayed scenario, if the orthopedic surgeon thinks the patient needs to be admitted and stabilized by the hospitalist, then that should be enough. The orthopedic surgeon will then show up and do the surgery — and bill globally.

Don’t try to make a science of this; you have to deal with these events as they unfold, rather than define or pigeonhole the coding for every configuration of events.

Coding for pre-op exam

Q We are a primary care and endocrinology/diabetes group who is asked by various surgical offices to do preoperation exams and surgical clearances for our patients. The pre-op usually includes EKG with interpretation, lab work, and plan of care assessment pre- and post-op. After attending a recent coding seminar we realized we were not coding these correctly and should be asking, at the time of making the appointment with the surgical office, for the surgical code(s) and adding a -56 modifier on our billings, then as a courtesy reminding the surgical office to also add a modifier to their billing. Most offices seem aware of this and are happy to comply, and we have indeed received our portion of the fee from various insurance companies. We have run into some resistance with one group in particular, which leads us to some doubt and need for verification from an expert coder. Are we in fact coding/billing surgical clearances correctly now, or do we go back to billing E&M codes?

A I don’t know where you got this guidance, but I don’t think it’s the best. There is no single source of direct authoritative guidance I know of that says don’t do this, but there’s plenty of anecdotal direction.

The pre-op component of a surgical procedure is intended to be the preoperative services normally associated with that procedure, and performed by the provider performing the surgery. That is why it is part of the global package — it is part of those pre-op services normally included in the package. Most Medicare carriers also do not recognize modifier -56, if that says anything.

The services provided by a primary-care provider to clear a patient for surgery are services to assess the other problems the patient may have, any problems or conditions that may impact risk or contraindicate surgery, or those that simply need to be cleared. It is a separate assessment, or potentially different problems not related to the reason for the surgery, performed by a separate provider. It has long been recognized as best represented by a consult code in terms of code type.

Selecting high vs. moderate risk

Q I have kind of a technical question for you. Under the Diagnostic Procedure(s) Ordered column on the Table of Risk you have:

• Moderate — Cardiovascular imaging studies with contrast and no identified risk factors, e.g. arteriogram, cardiac catheterization
• High — Cardiovascular imaging studies with contrast with identified risk factors

A cardiologist orders a Myoview stress test, a nuclear study on a patient with an abnormal EKG to rule out coronary artery disease. The patient also has diabetes mellitus, hypertension, hypercholesterolemia, which are all stable at the time. Are these additional risks adequate to select a high risk?

Endoscopy has the same distinction relative to risk factors — moderate versus high risk. I never really know what to do about this. I have asked this question of several coders and no definitive answer has been given.

A There’s a reason that coders have likely been unsure here, and it’s because they probably don’t have a good sense of the risk that any given comorbid condition creates.

The middle column of the Table of Risk is tricky for two reasons: First, it contains examples of things that may represent a given level of risk (like the entries in the other columns), rather than a definitive measurement; and second, it depends on a given provider’s opinion relative to what risk is entailed with a given procedure, and may more importantly depend on the ability of a nonclinician auditor to recognize it.

Simply ordering a given test, and mentioning comorbid problems likely does not resonate with all reviewers, or resonate the same with all other clinicians. In my opinion what you need to do is to make a clear statement that the patient is at a given level of risk, use the words “moderate” or “high,” relative to a specific differential, diagnosis, or procedure.

In a Medicare document outlining medical necessity requirements we find the following statement: “Demonstrate clearly how physician work (expressed in terms of mental effort, physical effort, time spent, and risk to the patient) was affected by comorbidities or chronic problems listed.”

Copyright 2010, Physicians Practice, UBM Medica. All rights reserved