Practice Management

The Centers for Medicare & Medicaid Services' (CMS) recently announced final rule [PDF] on Stage 2 compliance for "meaningful use" of electronic health records (EHR) has been met with mixed reactions among most providers and trade groups, including SHM which voiced its concerns back in July.

"It's the classic government mixed bag," says Brenda Pawlak, director of Manatt Health Solutions, a division of New York City law firm Manatt, Phelps & Phillips.

Physician groups, including SHM and the Medical Group Management Association (MGMA), have lauded CMS for pushing back the implementation of Stage 2 meaningful-use requirements to 2014 from 2013. They also praised the agency for halving to 5% the percentage of a practice's patients who interact with an online portal. But for some providers, even the 5% threshold will be difficult to meet. And because physicians have to meet all requirements to qualify for incentive bonuses, the issue could loom large for specific groups.

"I don't think the 10% to 5% is a substantive change," Pawlak says.

Although most hospitalists are not directly subject to "meaningful use" requirements, many are heavily involved with assisting their institutions with implementation. SHM, which voiced its concerns in a July letter to CMS, is following this topic closely.

Some physician groups also lamented that the deadline for Stage 1 compliance remains unchanged at 2015. As physicians and provider groups attempt to comply with myriad rules, Pawlak says, meeting the 5% threshold will emerge as more burdensome as the deadline approaches. Still, CMS and federal officials say, the final rule will help nudge the healthcare system further into the digital age.

"The big message here is the push on standards-based interoperability of information," says Farzad Mostashari, MD, ScM, of the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology. "We are staying on course with the road map that we set in Stage 1."

The Centers for Medicare & Medicaid Services' (CMS) recently announced final rule [PDF] on Stage 2 compliance for "meaningful use" of electronic health records (EHR) has been met with mixed reactions among most providers and trade groups, including SHM which voiced its concerns back in July.

"It's the classic government mixed bag," says Brenda Pawlak, director of Manatt Health Solutions, a division of New York City law firm Manatt, Phelps & Phillips.

Physician groups, including SHM and the Medical Group Management Association (MGMA), have lauded CMS for pushing back the implementation of Stage 2 meaningful-use requirements to 2014 from 2013. They also praised the agency for halving to 5% the percentage of a practice's patients who interact with an online portal. But for some providers, even the 5% threshold will be difficult to meet. And because physicians have to meet all requirements to qualify for incentive bonuses, the issue could loom large for specific groups.

"I don't think the 10% to 5% is a substantive change," Pawlak says.

Although most hospitalists are not directly subject to "meaningful use" requirements, many are heavily involved with assisting their institutions with implementation. SHM, which voiced its concerns in a July letter to CMS, is following this topic closely.

Some physician groups also lamented that the deadline for Stage 1 compliance remains unchanged at 2015. As physicians and provider groups attempt to comply with myriad rules, Pawlak says, meeting the 5% threshold will emerge as more burdensome as the deadline approaches. Still, CMS and federal officials say, the final rule will help nudge the healthcare system further into the digital age.

"The big message here is the push on standards-based interoperability of information," says Farzad Mostashari, MD, ScM, of the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology. "We are staying on course with the road map that we set in Stage 1."

The Centers for Medicare & Medicaid Services' (CMS) recently announced final rule [PDF] on Stage 2 compliance for "meaningful use" of electronic health records (EHR) has been met with mixed reactions among most providers and trade groups, including SHM which voiced its concerns back in July.

"It's the classic government mixed bag," says Brenda Pawlak, director of Manatt Health Solutions, a division of New York City law firm Manatt, Phelps & Phillips.

Physician groups, including SHM and the Medical Group Management Association (MGMA), have lauded CMS for pushing back the implementation of Stage 2 meaningful-use requirements to 2014 from 2013. They also praised the agency for halving to 5% the percentage of a practice's patients who interact with an online portal. But for some providers, even the 5% threshold will be difficult to meet. And because physicians have to meet all requirements to qualify for incentive bonuses, the issue could loom large for specific groups.

"I don't think the 10% to 5% is a substantive change," Pawlak says.

Although most hospitalists are not directly subject to "meaningful use" requirements, many are heavily involved with assisting their institutions with implementation. SHM, which voiced its concerns in a July letter to CMS, is following this topic closely.

Some physician groups also lamented that the deadline for Stage 1 compliance remains unchanged at 2015. As physicians and provider groups attempt to comply with myriad rules, Pawlak says, meeting the 5% threshold will emerge as more burdensome as the deadline approaches. Still, CMS and federal officials say, the final rule will help nudge the healthcare system further into the digital age.

"The big message here is the push on standards-based interoperability of information," says Farzad Mostashari, MD, ScM, of the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology. "We are staying on course with the road map that we set in Stage 1."

Kerry Weiner, MD, acknowledges gaps in the continuity of care for many hospitalized patients, with the critical time being the first few days, or even hours, after leaving the hospital. The only provider who "really understands" what needs to happen next for the patient "is the hospitalist,” says Dr. Weiner, chief clinical officer for IPC The Hospitalist Co.

For the past decade, IPC has staffed a care-transitions call center at its corporate headquarters in North Hollywood, Calif. Twenty nurses, case managers, and patient representatives attempt to contact all patients discharged to home by IPC hospitalists within 48 to 72 hours.

According to data presented last December at an Institute for Healthcare Improvement national quality forum, IPC call centers reached out to nearly 350,000 patients discharged between October 2010 and September 2011. The calls were successful 30% of the time, and a fifth of the contacted patients needed an intervention. IPC calculates that those interventions prevented 1,782 avoidable readmissions.

According to Dr. Weiner, call center staff follow discharge instructions from the hospitalists using brief, customized, technology-driven reports. They focus on key points that could become health issues in the first few days after discharge.

IPC hopes to expand its care-transitions continuum, in part by prioritizing those patients who need to be called and reaching more of them, he adds.

Kerry Weiner, MD, acknowledges gaps in the continuity of care for many hospitalized patients, with the critical time being the first few days, or even hours, after leaving the hospital. The only provider who "really understands" what needs to happen next for the patient "is the hospitalist,” says Dr. Weiner, chief clinical officer for IPC The Hospitalist Co.

For the past decade, IPC has staffed a care-transitions call center at its corporate headquarters in North Hollywood, Calif. Twenty nurses, case managers, and patient representatives attempt to contact all patients discharged to home by IPC hospitalists within 48 to 72 hours.

According to data presented last December at an Institute for Healthcare Improvement national quality forum, IPC call centers reached out to nearly 350,000 patients discharged between October 2010 and September 2011. The calls were successful 30% of the time, and a fifth of the contacted patients needed an intervention. IPC calculates that those interventions prevented 1,782 avoidable readmissions.

According to Dr. Weiner, call center staff follow discharge instructions from the hospitalists using brief, customized, technology-driven reports. They focus on key points that could become health issues in the first few days after discharge.

IPC hopes to expand its care-transitions continuum, in part by prioritizing those patients who need to be called and reaching more of them, he adds.

Kerry Weiner, MD, acknowledges gaps in the continuity of care for many hospitalized patients, with the critical time being the first few days, or even hours, after leaving the hospital. The only provider who "really understands" what needs to happen next for the patient "is the hospitalist,” says Dr. Weiner, chief clinical officer for IPC The Hospitalist Co.

For the past decade, IPC has staffed a care-transitions call center at its corporate headquarters in North Hollywood, Calif. Twenty nurses, case managers, and patient representatives attempt to contact all patients discharged to home by IPC hospitalists within 48 to 72 hours.

According to data presented last December at an Institute for Healthcare Improvement national quality forum, IPC call centers reached out to nearly 350,000 patients discharged between October 2010 and September 2011. The calls were successful 30% of the time, and a fifth of the contacted patients needed an intervention. IPC calculates that those interventions prevented 1,782 avoidable readmissions.

According to Dr. Weiner, call center staff follow discharge instructions from the hospitalists using brief, customized, technology-driven reports. They focus on key points that could become health issues in the first few days after discharge.

IPC hopes to expand its care-transitions continuum, in part by prioritizing those patients who need to be called and reaching more of them, he adds.

An author of new research that shows physicians are more likely to be burned out by work than other professions says the findings underscore the need for hospitalists to find a balance between their professional and personal lives.

The Archives of Internal Medicine report, "Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General U.S. Population," found that physicians were more likely than "working U.S. adults" to exhibit at least one symptom of burnout (37.9% vs. 27.8%, P<0.01). Physicians also were more likely to be dissatisfied with their work-life balance (40.2% vs. 23.2%, P<0.01), according to the data.

"It's a balancing act," says Colin West, MD, PhD, FACP, of the Departments of Internal Medicine and Health Sciences Research at Mayo Clinic in Rochester, Minn. "Every physician is a little bit different. Every person is a little bit different. If everyone is able to exert some control … and do what's meaningful to them, that gives them the best shot to balance."

Of specific importance for hospitalists, the research found that "front-line specialties" (including internal medicine, general medicine, and emergency medicine) exhibited the highest risk factor for burnout. Dr. West says more research would be required to determine how at risk hospitalists are, but given their position in the healthcare spectrum, he suspects they are among those at highest risk. He believes that the healthcare system as a whole needs to address the burnout issue, as repercussions can include problematic alcohol use, broken relationships, and suicidal ideation.

"The best group is that which strikes a balance," Dr. West says. "It's probably because [those physicians are not] feeling like they're dropping a ball. If you pick work over home, or home over work, then, basically, one is left behind."

An author of new research that shows physicians are more likely to be burned out by work than other professions says the findings underscore the need for hospitalists to find a balance between their professional and personal lives.

The Archives of Internal Medicine report, "Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General U.S. Population," found that physicians were more likely than "working U.S. adults" to exhibit at least one symptom of burnout (37.9% vs. 27.8%, P<0.01). Physicians also were more likely to be dissatisfied with their work-life balance (40.2% vs. 23.2%, P<0.01), according to the data.

"It's a balancing act," says Colin West, MD, PhD, FACP, of the Departments of Internal Medicine and Health Sciences Research at Mayo Clinic in Rochester, Minn. "Every physician is a little bit different. Every person is a little bit different. If everyone is able to exert some control … and do what's meaningful to them, that gives them the best shot to balance."

Of specific importance for hospitalists, the research found that "front-line specialties" (including internal medicine, general medicine, and emergency medicine) exhibited the highest risk factor for burnout. Dr. West says more research would be required to determine how at risk hospitalists are, but given their position in the healthcare spectrum, he suspects they are among those at highest risk. He believes that the healthcare system as a whole needs to address the burnout issue, as repercussions can include problematic alcohol use, broken relationships, and suicidal ideation.

"The best group is that which strikes a balance," Dr. West says. "It's probably because [those physicians are not] feeling like they're dropping a ball. If you pick work over home, or home over work, then, basically, one is left behind."

An author of new research that shows physicians are more likely to be burned out by work than other professions says the findings underscore the need for hospitalists to find a balance between their professional and personal lives.

The Archives of Internal Medicine report, "Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General U.S. Population," found that physicians were more likely than "working U.S. adults" to exhibit at least one symptom of burnout (37.9% vs. 27.8%, P<0.01). Physicians also were more likely to be dissatisfied with their work-life balance (40.2% vs. 23.2%, P<0.01), according to the data.

"It's a balancing act," says Colin West, MD, PhD, FACP, of the Departments of Internal Medicine and Health Sciences Research at Mayo Clinic in Rochester, Minn. "Every physician is a little bit different. Every person is a little bit different. If everyone is able to exert some control … and do what's meaningful to them, that gives them the best shot to balance."

Of specific importance for hospitalists, the research found that "front-line specialties" (including internal medicine, general medicine, and emergency medicine) exhibited the highest risk factor for burnout. Dr. West says more research would be required to determine how at risk hospitalists are, but given their position in the healthcare spectrum, he suspects they are among those at highest risk. He believes that the healthcare system as a whole needs to address the burnout issue, as repercussions can include problematic alcohol use, broken relationships, and suicidal ideation.

"The best group is that which strikes a balance," Dr. West says. "It's probably because [those physicians are not] feeling like they're dropping a ball. If you pick work over home, or home over work, then, basically, one is left behind."

The OB/GYN hospitalist field is growing, with at least 164 identified programs and 1,500 to 2,500 practitioners who spend all or part of their workweek in hospital labor and delivery departments. SHM and the American College of Obstetricians and Gynecologists helped birth the 90-member Society of OB/GYN Hospitalists in 2011, but it is now independent, says founding president Rob Olson, MD, an OB/GYN hospitalist practicing in Bellingham, Wash. The fledgling society is planning its second annual conference, Sept. 27-29 in Denver, with obstetric emergency simulation training, clinical lectures, and pearls from the experience of general hospitalist practice by HM pioneer John Nelson, MD, MHM.

Also known as laborists, these board-certified OB/GYN docs’ dedicated presence affords rapid on-site response to changes in patients’ conditions, Dr. Olson says. Laborists might cover nights and weekends, pick up unassigned patients, or cover for private obstetricians who are fully engaged. Laborists do not supplant the private practitioner’s role in delivering babies in the hospital, Dr. Olson says, “unless the private physician asks them to,” which, he adds, is happening more often.

Laborists typically are limited to labor and delivery services, although some also address gynecological cases in the ED. Most of the programs provide coverage 24/7, and invariably they are in facilities with medical hospitalists who might consult on medical complications for expectant mothers. One to two new programs open every month, Dr. Olson says, and his website lists 120 job openings. For information, visit www.ObGynHospitalist.com.

The OB/GYN hospitalist field is growing, with at least 164 identified programs and 1,500 to 2,500 practitioners who spend all or part of their workweek in hospital labor and delivery departments. SHM and the American College of Obstetricians and Gynecologists helped birth the 90-member Society of OB/GYN Hospitalists in 2011, but it is now independent, says founding president Rob Olson, MD, an OB/GYN hospitalist practicing in Bellingham, Wash. The fledgling society is planning its second annual conference, Sept. 27-29 in Denver, with obstetric emergency simulation training, clinical lectures, and pearls from the experience of general hospitalist practice by HM pioneer John Nelson, MD, MHM.

Also known as laborists, these board-certified OB/GYN docs’ dedicated presence affords rapid on-site response to changes in patients’ conditions, Dr. Olson says. Laborists might cover nights and weekends, pick up unassigned patients, or cover for private obstetricians who are fully engaged. Laborists do not supplant the private practitioner’s role in delivering babies in the hospital, Dr. Olson says, “unless the private physician asks them to,” which, he adds, is happening more often.

Laborists typically are limited to labor and delivery services, although some also address gynecological cases in the ED. Most of the programs provide coverage 24/7, and invariably they are in facilities with medical hospitalists who might consult on medical complications for expectant mothers. One to two new programs open every month, Dr. Olson says, and his website lists 120 job openings. For information, visit www.ObGynHospitalist.com.

The OB/GYN hospitalist field is growing, with at least 164 identified programs and 1,500 to 2,500 practitioners who spend all or part of their workweek in hospital labor and delivery departments. SHM and the American College of Obstetricians and Gynecologists helped birth the 90-member Society of OB/GYN Hospitalists in 2011, but it is now independent, says founding president Rob Olson, MD, an OB/GYN hospitalist practicing in Bellingham, Wash. The fledgling society is planning its second annual conference, Sept. 27-29 in Denver, with obstetric emergency simulation training, clinical lectures, and pearls from the experience of general hospitalist practice by HM pioneer John Nelson, MD, MHM.

Also known as laborists, these board-certified OB/GYN docs’ dedicated presence affords rapid on-site response to changes in patients’ conditions, Dr. Olson says. Laborists might cover nights and weekends, pick up unassigned patients, or cover for private obstetricians who are fully engaged. Laborists do not supplant the private practitioner’s role in delivering babies in the hospital, Dr. Olson says, “unless the private physician asks them to,” which, he adds, is happening more often.

Laborists typically are limited to labor and delivery services, although some also address gynecological cases in the ED. Most of the programs provide coverage 24/7, and invariably they are in facilities with medical hospitalists who might consult on medical complications for expectant mothers. One to two new programs open every month, Dr. Olson says, and his website lists 120 job openings. For information, visit www.ObGynHospitalist.com.

A new hospital patient-safety ranking system was released in July by Consumers Union (CU), an independent consumer advocacy organization in Yonkers, N.Y., and published in the August issue of its magazine Consumer Reports.¹ CU rated 1,155 hospitals in six categories, including hospital-acquired infections, readmissions, and the quality of communication by physicians and nurses to patients. The highest-scoring hospital: Billings Clinic in Montana, which received a 72 on CU’s 100-point safety score.

“The new Consumer Reports hospital safety ratings add to a growing list of publicly reported performance rating schemes,” says SHM president Shaun Frost, MD, SFHM, FACP, associate medical director for care-delivery systems at HealthPartners in Minneapolis. Hospitalists should be aware of these ratings and review them “with an eye toward identifying improvement opportunities that are within their scope of influence....Hospitalists must embrace these issues as theirs to own and improve upon, as the ability to demonstrably improve the safety and care quality in the hospitals in which we practice is dependent on us.”

Reference

1. Consumer Reports. How safe is your hospital? Our new ratings find that some are riskier than others. Consumer Reports website. Available at: www.consumerreports.org/cro/magazine/2012/08/how-safe-is-your-hospital/index.htm. Accessed July 31, 2012.

A new hospital patient-safety ranking system was released in July by Consumers Union (CU), an independent consumer advocacy organization in Yonkers, N.Y., and published in the August issue of its magazine Consumer Reports.¹ CU rated 1,155 hospitals in six categories, including hospital-acquired infections, readmissions, and the quality of communication by physicians and nurses to patients. The highest-scoring hospital: Billings Clinic in Montana, which received a 72 on CU’s 100-point safety score.

“The new Consumer Reports hospital safety ratings add to a growing list of publicly reported performance rating schemes,” says SHM president Shaun Frost, MD, SFHM, FACP, associate medical director for care-delivery systems at HealthPartners in Minneapolis. Hospitalists should be aware of these ratings and review them “with an eye toward identifying improvement opportunities that are within their scope of influence....Hospitalists must embrace these issues as theirs to own and improve upon, as the ability to demonstrably improve the safety and care quality in the hospitals in which we practice is dependent on us.”

Reference

1. Consumer Reports. How safe is your hospital? Our new ratings find that some are riskier than others. Consumer Reports website. Available at: www.consumerreports.org/cro/magazine/2012/08/how-safe-is-your-hospital/index.htm. Accessed July 31, 2012.

A new hospital patient-safety ranking system was released in July by Consumers Union (CU), an independent consumer advocacy organization in Yonkers, N.Y., and published in the August issue of its magazine Consumer Reports.¹ CU rated 1,155 hospitals in six categories, including hospital-acquired infections, readmissions, and the quality of communication by physicians and nurses to patients. The highest-scoring hospital: Billings Clinic in Montana, which received a 72 on CU’s 100-point safety score.

“The new Consumer Reports hospital safety ratings add to a growing list of publicly reported performance rating schemes,” says SHM president Shaun Frost, MD, SFHM, FACP, associate medical director for care-delivery systems at HealthPartners in Minneapolis. Hospitalists should be aware of these ratings and review them “with an eye toward identifying improvement opportunities that are within their scope of influence....Hospitalists must embrace these issues as theirs to own and improve upon, as the ability to demonstrably improve the safety and care quality in the hospitals in which we practice is dependent on us.”

Reference

1. Consumer Reports. How safe is your hospital? Our new ratings find that some are riskier than others. Consumer Reports website. Available at: www.consumerreports.org/cro/magazine/2012/08/how-safe-is-your-hospital/index.htm. Accessed July 31, 2012.

John Nelson, MD, MHM

There are lots of places to learn methods to improve patient satisfaction, including my thoughts from the January 2009 issue. Run an Internet search on “improve patient satisfaction” to get a huge number of articles, many of which have useful information and inspiration.

If you’re in a high-functioning hospitalist group, you’ve already read a lot on the topic, listened to presentations by someone at your hospital and elsewhere, and reliably reported and analyzed satisfaction survey results including HCAHPS questions and others. Maybe you’ve even engaged a consultant to help.

You might already have in place a number of strategies, such as reliably providing a business card with your photo, always sitting down in the patient’s room, asking “Is there anything else I can do?” before ending your time with a patient, etc. You’re doing all these things and more, but perhaps you’ve barely moved the needle on your satisfaction scores.

Despite your efforts, I bet your hospitalist group’s aggregate score is among the lowest of any physician group at your hospital.

You’re not alone.

What can you do about this?

High-Value Strategy: Phoning Patients after Discharge

I’m lucky enough to practice with some of the smartest, most professional, and most personable hospitalists you could ever meet. Yet our satisfaction scores are among the lowest for physicians at our hospital. Despite all of the improvement strategies we put in place over the last few years, our scores have barely budged. But that all changed once we instituted a formal program of phoning patients after discharge. That produced the largest uptick in our scores we’ve ever seen.

I can’t guarantee that our results are generalizable. But I have all the anecdotal information I need to be willing to invest the resources to make the calls. They improve scores. Likely more than any other single strategy. And they seem to have a positive effect on all survey questions, from how well the doctor explained things (nearly always the lowest of the HCAHPS scores for hospitalists) to the patient’s opinion of the hospital food.

Though initially resistant to expending the time and energy to make the calls, most in our group have said that they regularly feel really gratified by the response they get from patients or families. I think it is much better if a hospitalist who cared for the patient makes the calls, and I suspect (I have no proof) that calls made by a nurse or clerk are much less effective at improving patient satisfaction. And the call can serve as a valuable clinical encounter to briefly troubleshoot a problem or review a test result that was pending at discharge.

Simple Strategies

• More than 80% of these calls should last less than three minutes. Most patients or family members will report things are going OK and thank you profusely for the call. “No doctor has ever called before,” many will say. “Can we get you the next time Mom is hospitalized?”
• You could reduce the number of calls needed if you limit them to patients eligible for a survey; this typically is only about half of a hospitalist’s patient census. For example, patients on observation status and those discharged somewhere other than to home (e.g. to a skilled-nursing facility) are not eligible for a survey.
• It’s usually best not to tell a patient or family to expect the call. Surprising them makes them more delighted when you do call, and a patient told to expect a call but doesn’t get one will be less satisfied than if never told to expect it. Best if no one at the hospital knows you’re making the calls, because someone might brag about you and tell the patient to expect the call.
• For patients seen by several hospitalists, decide ahead of time which doctor makes the call. The doctor who discharged the patient is probably the simplest protocol.
• Develop a system to track patients who have been discharged. Every morning, we get a printout of all patients discharged the prior day. We try to call all patients the day after discharge to ensure that we reach them before they’ve had a chance to complete a satisfaction survey and before the discharging doctor rotates off.
• Develop a protocol to document the calls. Calls that lead to any new advice or therapies (e.g. see your primary-care physician sooner than planned) must be documented in the medical record, e.g., by dictating an addendum to the discharge summary. Don’t let the system get too complicated or keep you from making the calls.
• Use your judgment about whether to call the patient or just call a family member directly; it’s often better to do the latter.
• If you reach a voicemail (about 50% of the calls I make), leave a message and don’t keep calling back to reach a person.

Sample Scripts

Here are some simple scripts to use for post-discharge calls. If you reach the patient or family member:

• “This is Dr. X from Superior Hospital. I was just thinking about you/your mother/your father and wanted to know how things have gone since you/she/he left the hospital.”
• Ask about something related to the reason for their stay. “How is your appetite?” or “You haven’t had any more fever, have you?” or “Have you made your appointment with Dr. PCP yet?”
• “I hope things go really well for you, but if you ever need the hospital again, we’d be happy to care for you at Superior Hospital.”

If you get a voicemail:

• “This is Dr. X from Superior Hospital. I’ve been thinking about you/your mother/father since you/she/he left the hospital, and I am calling just to check on how things are going.” (For HIPPA reasons, don’t use the patient’s name when leaving a voicemail.)
• Mention some medical concern specific to the patient, e.g., “Your culture test turned out OK and I hope you’ve been able to get the antibiotic I prescribed.”
• “You don’t need to call me back, but if you have questions or want to provide an update, I can be reached at 555-123-4567.” (It’s very important to include this last sentence and a number where you can be reached. If omitted, many patients/families will think you must have called to convey something really important and will be distressed until able to reach you.)

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course.

John Nelson, MD, MHM

There are lots of places to learn methods to improve patient satisfaction, including my thoughts from the January 2009 issue. Run an Internet search on “improve patient satisfaction” to get a huge number of articles, many of which have useful information and inspiration.

If you’re in a high-functioning hospitalist group, you’ve already read a lot on the topic, listened to presentations by someone at your hospital and elsewhere, and reliably reported and analyzed satisfaction survey results including HCAHPS questions and others. Maybe you’ve even engaged a consultant to help.

You might already have in place a number of strategies, such as reliably providing a business card with your photo, always sitting down in the patient’s room, asking “Is there anything else I can do?” before ending your time with a patient, etc. You’re doing all these things and more, but perhaps you’ve barely moved the needle on your satisfaction scores.

Despite your efforts, I bet your hospitalist group’s aggregate score is among the lowest of any physician group at your hospital.

You’re not alone.

What can you do about this?

High-Value Strategy: Phoning Patients after Discharge

I’m lucky enough to practice with some of the smartest, most professional, and most personable hospitalists you could ever meet. Yet our satisfaction scores are among the lowest for physicians at our hospital. Despite all of the improvement strategies we put in place over the last few years, our scores have barely budged. But that all changed once we instituted a formal program of phoning patients after discharge. That produced the largest uptick in our scores we’ve ever seen.

I can’t guarantee that our results are generalizable. But I have all the anecdotal information I need to be willing to invest the resources to make the calls. They improve scores. Likely more than any other single strategy. And they seem to have a positive effect on all survey questions, from how well the doctor explained things (nearly always the lowest of the HCAHPS scores for hospitalists) to the patient’s opinion of the hospital food.

Though initially resistant to expending the time and energy to make the calls, most in our group have said that they regularly feel really gratified by the response they get from patients or families. I think it is much better if a hospitalist who cared for the patient makes the calls, and I suspect (I have no proof) that calls made by a nurse or clerk are much less effective at improving patient satisfaction. And the call can serve as a valuable clinical encounter to briefly troubleshoot a problem or review a test result that was pending at discharge.

Simple Strategies

• More than 80% of these calls should last less than three minutes. Most patients or family members will report things are going OK and thank you profusely for the call. “No doctor has ever called before,” many will say. “Can we get you the next time Mom is hospitalized?”
• You could reduce the number of calls needed if you limit them to patients eligible for a survey; this typically is only about half of a hospitalist’s patient census. For example, patients on observation status and those discharged somewhere other than to home (e.g. to a skilled-nursing facility) are not eligible for a survey.
• It’s usually best not to tell a patient or family to expect the call. Surprising them makes them more delighted when you do call, and a patient told to expect a call but doesn’t get one will be less satisfied than if never told to expect it. Best if no one at the hospital knows you’re making the calls, because someone might brag about you and tell the patient to expect the call.
• For patients seen by several hospitalists, decide ahead of time which doctor makes the call. The doctor who discharged the patient is probably the simplest protocol.
• Develop a system to track patients who have been discharged. Every morning, we get a printout of all patients discharged the prior day. We try to call all patients the day after discharge to ensure that we reach them before they’ve had a chance to complete a satisfaction survey and before the discharging doctor rotates off.
• Develop a protocol to document the calls. Calls that lead to any new advice or therapies (e.g. see your primary-care physician sooner than planned) must be documented in the medical record, e.g., by dictating an addendum to the discharge summary. Don’t let the system get too complicated or keep you from making the calls.
• Use your judgment about whether to call the patient or just call a family member directly; it’s often better to do the latter.
• If you reach a voicemail (about 50% of the calls I make), leave a message and don’t keep calling back to reach a person.

Sample Scripts

Here are some simple scripts to use for post-discharge calls. If you reach the patient or family member:

• “This is Dr. X from Superior Hospital. I was just thinking about you/your mother/your father and wanted to know how things have gone since you/she/he left the hospital.”
• Ask about something related to the reason for their stay. “How is your appetite?” or “You haven’t had any more fever, have you?” or “Have you made your appointment with Dr. PCP yet?”
• “I hope things go really well for you, but if you ever need the hospital again, we’d be happy to care for you at Superior Hospital.”

If you get a voicemail:

• “This is Dr. X from Superior Hospital. I’ve been thinking about you/your mother/father since you/she/he left the hospital, and I am calling just to check on how things are going.” (For HIPPA reasons, don’t use the patient’s name when leaving a voicemail.)
• Mention some medical concern specific to the patient, e.g., “Your culture test turned out OK and I hope you’ve been able to get the antibiotic I prescribed.”
• “You don’t need to call me back, but if you have questions or want to provide an update, I can be reached at 555-123-4567.” (It’s very important to include this last sentence and a number where you can be reached. If omitted, many patients/families will think you must have called to convey something really important and will be distressed until able to reach you.)

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course.

John Nelson, MD, MHM

There are lots of places to learn methods to improve patient satisfaction, including my thoughts from the January 2009 issue. Run an Internet search on “improve patient satisfaction” to get a huge number of articles, many of which have useful information and inspiration.

If you’re in a high-functioning hospitalist group, you’ve already read a lot on the topic, listened to presentations by someone at your hospital and elsewhere, and reliably reported and analyzed satisfaction survey results including HCAHPS questions and others. Maybe you’ve even engaged a consultant to help.

You might already have in place a number of strategies, such as reliably providing a business card with your photo, always sitting down in the patient’s room, asking “Is there anything else I can do?” before ending your time with a patient, etc. You’re doing all these things and more, but perhaps you’ve barely moved the needle on your satisfaction scores.

Despite your efforts, I bet your hospitalist group’s aggregate score is among the lowest of any physician group at your hospital.

You’re not alone.

What can you do about this?

High-Value Strategy: Phoning Patients after Discharge

I’m lucky enough to practice with some of the smartest, most professional, and most personable hospitalists you could ever meet. Yet our satisfaction scores are among the lowest for physicians at our hospital. Despite all of the improvement strategies we put in place over the last few years, our scores have barely budged. But that all changed once we instituted a formal program of phoning patients after discharge. That produced the largest uptick in our scores we’ve ever seen.

I can’t guarantee that our results are generalizable. But I have all the anecdotal information I need to be willing to invest the resources to make the calls. They improve scores. Likely more than any other single strategy. And they seem to have a positive effect on all survey questions, from how well the doctor explained things (nearly always the lowest of the HCAHPS scores for hospitalists) to the patient’s opinion of the hospital food.

Though initially resistant to expending the time and energy to make the calls, most in our group have said that they regularly feel really gratified by the response they get from patients or families. I think it is much better if a hospitalist who cared for the patient makes the calls, and I suspect (I have no proof) that calls made by a nurse or clerk are much less effective at improving patient satisfaction. And the call can serve as a valuable clinical encounter to briefly troubleshoot a problem or review a test result that was pending at discharge.

Simple Strategies

• More than 80% of these calls should last less than three minutes. Most patients or family members will report things are going OK and thank you profusely for the call. “No doctor has ever called before,” many will say. “Can we get you the next time Mom is hospitalized?”
• You could reduce the number of calls needed if you limit them to patients eligible for a survey; this typically is only about half of a hospitalist’s patient census. For example, patients on observation status and those discharged somewhere other than to home (e.g. to a skilled-nursing facility) are not eligible for a survey.
• It’s usually best not to tell a patient or family to expect the call. Surprising them makes them more delighted when you do call, and a patient told to expect a call but doesn’t get one will be less satisfied than if never told to expect it. Best if no one at the hospital knows you’re making the calls, because someone might brag about you and tell the patient to expect the call.
• For patients seen by several hospitalists, decide ahead of time which doctor makes the call. The doctor who discharged the patient is probably the simplest protocol.
• Develop a system to track patients who have been discharged. Every morning, we get a printout of all patients discharged the prior day. We try to call all patients the day after discharge to ensure that we reach them before they’ve had a chance to complete a satisfaction survey and before the discharging doctor rotates off.
• Develop a protocol to document the calls. Calls that lead to any new advice or therapies (e.g. see your primary-care physician sooner than planned) must be documented in the medical record, e.g., by dictating an addendum to the discharge summary. Don’t let the system get too complicated or keep you from making the calls.
• Use your judgment about whether to call the patient or just call a family member directly; it’s often better to do the latter.
• If you reach a voicemail (about 50% of the calls I make), leave a message and don’t keep calling back to reach a person.

Sample Scripts

Here are some simple scripts to use for post-discharge calls. If you reach the patient or family member:

• “This is Dr. X from Superior Hospital. I was just thinking about you/your mother/your father and wanted to know how things have gone since you/she/he left the hospital.”
• Ask about something related to the reason for their stay. “How is your appetite?” or “You haven’t had any more fever, have you?” or “Have you made your appointment with Dr. PCP yet?”
• “I hope things go really well for you, but if you ever need the hospital again, we’d be happy to care for you at Superior Hospital.”

If you get a voicemail:

• “This is Dr. X from Superior Hospital. I’ve been thinking about you/your mother/father since you/she/he left the hospital, and I am calling just to check on how things are going.” (For HIPPA reasons, don’t use the patient’s name when leaving a voicemail.)
• Mention some medical concern specific to the patient, e.g., “Your culture test turned out OK and I hope you’ve been able to get the antibiotic I prescribed.”
• “You don’t need to call me back, but if you have questions or want to provide an update, I can be reached at 555-123-4567.” (It’s very important to include this last sentence and a number where you can be reached. If omitted, many patients/families will think you must have called to convey something really important and will be distressed until able to reach you.)

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
• Medicine does the admission and medication reconciliation (“med rec”) at discharge;
• There is shared discussion on the need for transfusion; and
• There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
• Medicine does the admission and medication reconciliation (“med rec”) at discharge;
• There is shared discussion on the need for transfusion; and
• There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Dr. Hospitalist

One of our providers wants to use adult hospitalists for coverage of inpatient orthopedic surgery patients. Is this acceptable practice? Are there qualifiers?

—Libby Gardner

Dr. Hospitalist responds:

Let’s see how far we can tackle this open-ended question. There has been lots of discussion on the topic of comanagement in the past by people eminently more qualified than I am. Still, it never hurts to take a fresh look at things.

For one, on the subject of admissions, I am a firm believer that hospitalists should admit all adult hip fractures. The overwhelming majority of the time, these patients are elderly with comorbid conditions. Sure, they are going to get their hip fixed, because the alternative usually is unacceptable, but some thought needs to go into the process.

The orthopedic surgeon sees a hip that needs fixing and not much else. When such issues as renal failure, afib, congestive heart failure, prior DVT, dementia, and all the other common conditions are present, we as adult hospitalists should take charge of the case. That is the best way to ensure that the patient receives optimal medical care and the documentation that goes along with it. I love our orthopedic surgeons, but I don’t want them primarily admitting, managing, and discharging my elderly patients. Let the surgeon do what they do best—operate—and leave the rest to us as hospitalists.

On the subject of orthopedic trauma, I take the exact opposite approach—this is not something where we have daily expertise. A young, healthy patient with trauma should be admitted by the orthopedic service; that patient population’s complications are much more likely to be directly related to their trauma.

When it comes to elective surgery when the admitting surgeon (orthopedic or otherwise) wants the help of a hospitalist, then I think it is of paramount importance to establish clear “rules of engagement” (see “The Comanagement Conundrum,” April 2011, p. 1). I think with good expectations, you can have a fantastic relationship with your surgeons. Without them, it becomes a nightmare. As a real-life example, here are my HM group’s rules for elective orthopedic surgery:

• Orthopedics handles all pain medications and VTE prophylaxis, including discharge prescriptions;
• Medicine does the admission and medication reconciliation (“med rec”) at discharge;
• There is shared discussion on the need for transfusion; and
• There is shared discussion on the need for VTE prophylaxis when a patient already is on chronic anticoagulation.

We do not vary from this protocol. I never adjust a patient’s pain medications—even the floor nurses know this. Because I’m doing the admit and med rec, it also means that the patient doesn’t have their HCTZ continued after 600cc of EBL and spinal anesthesia. It works because the rules are clear and the communication is consistent.

This does not mean that we cover the orthopedic service at night; they are equally responsible for their patients under the items outlined above. In my view—and this might sound simplistic—the surgeon caused the post-op pain, so they should be responsible for managing it. With regard to VTE prophylaxis, I might take a more nuanced view, but for our surgeons, they own the wound and the post-op follow-up, so they get the choice on what agent to use.

Would I accept an arrangement in which I covered all the orthopedic issues out of regular hours? Nope—not when they have primary responsibility for the case; they should always be directly available to the nurse. I think that anything else would be a system ripe for abuse.

Our exact rules will not work for every situation, but I would strongly encourage the two basic tenets from above: No. 1, the hospitalist should primarily admit and manage elderly hip fractures, and No. 2, there should be clear rules of engagement with your orthopedic or surgery group. It’s a discussion worth having during daylight hours, because trying to figure out the rules at 3 in the morning rarely ends well.

Dr. Pinson:

Thank you for your inquiry to my June column, which outlined physician reporting of ICD-9-CM diagnoses. Confusion arises because there are two mechanisms for reporting facility-based claims: the professional (physician) bill and the facility bill. ICD-9-CM has been adopted under HIPAA for all healthcare settings. Several components of the ICD-9-CM manual offer instructions on its use. “How to Use the ICD-9-CM for Physicians (Volumes 1&2)” identifies “10 Steps to Correct Coding.”^2,3 Step 1 explicitly denotes the inability to use “rule out,” “suspected,” “probable,” or “questionable” diagnoses, and applies to all professional claims submitted on CMS1500 or electronic equivalent.³

The “ICD-9-CM Official Guidelines for Coding and Reporting” are a set of rules developed to accompany and complement the official conventions and instructions provided within ICD-9-CM and approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare & Medicaid Services (CMS), and NCHS. These guidelines are included on the official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.³

While Section I of these guidelines applies to all locations, Sections II and III refer to the selection of the principal diagnosis (the condition established after study to be chiefly responsible for the admission) reported by facilities for DRG payment on CMS1450 or its electronic equivalent.² Since DRG payment is based on the average resources used to treat inpatients, it is allowable to code a properly documented, “uncertain” condition as if it existed or was established. It does not apply to the outpatient setting. Outpatient, facility-based (Section IV) claims follow the same standards as professional claims, which should not list any diagnosis documented as “probable,” “suspected,” “questionable,” “rule out” or “working diagnosis,” or other similar terms indicating uncertainty.

Carol Pohlig, BSN, RN, CPC, ACS, is a contributing writer to The Hospitalist.

References

1. Hart AC, Stegman MS, Ford B, eds. ICD-9-CM for Physicians Volumes 1 & 2 2012 Expert Edition. OptimumInsight; 2011. Page vi.
2. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. Chapter 23, Section 10A. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf. Accessed July 24, 2012.
3. Hart AC, Stegman MS, Ford B. ICD-9-CM for Physicians Volumes 1 & 2 2012 Expert Edition. OptimumInsight; 2011. Page 1.

Dr. Pinson:

Thank you for your inquiry to my June column, which outlined physician reporting of ICD-9-CM diagnoses. Confusion arises because there are two mechanisms for reporting facility-based claims: the professional (physician) bill and the facility bill. ICD-9-CM has been adopted under HIPAA for all healthcare settings. Several components of the ICD-9-CM manual offer instructions on its use. “How to Use the ICD-9-CM for Physicians (Volumes 1&2)” identifies “10 Steps to Correct Coding.”^2,3 Step 1 explicitly denotes the inability to use “rule out,” “suspected,” “probable,” or “questionable” diagnoses, and applies to all professional claims submitted on CMS1500 or electronic equivalent.³

The “ICD-9-CM Official Guidelines for Coding and Reporting” are a set of rules developed to accompany and complement the official conventions and instructions provided within ICD-9-CM and approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare & Medicaid Services (CMS), and NCHS. These guidelines are included on the official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.³

While Section I of these guidelines applies to all locations, Sections II and III refer to the selection of the principal diagnosis (the condition established after study to be chiefly responsible for the admission) reported by facilities for DRG payment on CMS1450 or its electronic equivalent.² Since DRG payment is based on the average resources used to treat inpatients, it is allowable to code a properly documented, “uncertain” condition as if it existed or was established. It does not apply to the outpatient setting. Outpatient, facility-based (Section IV) claims follow the same standards as professional claims, which should not list any diagnosis documented as “probable,” “suspected,” “questionable,” “rule out” or “working diagnosis,” or other similar terms indicating uncertainty.

Carol Pohlig, BSN, RN, CPC, ACS, is a contributing writer to The Hospitalist.

References

1. Hart AC, Stegman MS, Ford B, eds. ICD-9-CM for Physicians Volumes 1 & 2 2012 Expert Edition. OptimumInsight; 2011. Page vi.
2. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. Chapter 23, Section 10A. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf. Accessed July 24, 2012.
3. Hart AC, Stegman MS, Ford B. ICD-9-CM for Physicians Volumes 1 & 2 2012 Expert Edition. OptimumInsight; 2011. Page 1.

Dr. Pinson:

Thank you for your inquiry to my June column, which outlined physician reporting of ICD-9-CM diagnoses. Confusion arises because there are two mechanisms for reporting facility-based claims: the professional (physician) bill and the facility bill. ICD-9-CM has been adopted under HIPAA for all healthcare settings. Several components of the ICD-9-CM manual offer instructions on its use. “How to Use the ICD-9-CM for Physicians (Volumes 1&2)” identifies “10 Steps to Correct Coding.”^2,3 Step 1 explicitly denotes the inability to use “rule out,” “suspected,” “probable,” or “questionable” diagnoses, and applies to all professional claims submitted on CMS1500 or electronic equivalent.³

The “ICD-9-CM Official Guidelines for Coding and Reporting” are a set of rules developed to accompany and complement the official conventions and instructions provided within ICD-9-CM and approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare & Medicaid Services (CMS), and NCHS. These guidelines are included on the official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.³

While Section I of these guidelines applies to all locations, Sections II and III refer to the selection of the principal diagnosis (the condition established after study to be chiefly responsible for the admission) reported by facilities for DRG payment on CMS1450 or its electronic equivalent.² Since DRG payment is based on the average resources used to treat inpatients, it is allowable to code a properly documented, “uncertain” condition as if it existed or was established. It does not apply to the outpatient setting. Outpatient, facility-based (Section IV) claims follow the same standards as professional claims, which should not list any diagnosis documented as “probable,” “suspected,” “questionable,” “rule out” or “working diagnosis,” or other similar terms indicating uncertainty.

Carol Pohlig, BSN, RN, CPC, ACS, is a contributing writer to The Hospitalist.

References

1. Hart AC, Stegman MS, Ford B, eds. ICD-9-CM for Physicians Volumes 1 & 2 2012 Expert Edition. OptimumInsight; 2011. Page vi.
2. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. Chapter 23, Section 10A. Centers for Medicare and Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c23.pdf. Accessed July 24, 2012.
3. Hart AC, Stegman MS, Ford B. ICD-9-CM for Physicians Volumes 1 & 2 2012 Expert Edition. OptimumInsight; 2011. Page 1.

Six out of 7 respondents to an unscientific survey at the-hospitalist.org correctly answered the question "Which patient being discharged DOES NOT require VTE prophylaxis?" while 14% of respondents answered incorrectly, according to veteran hospitalists who reviewed survey results.

Nearly 200 people responded to the survey, which provided the following answers:

• Hip/knee replacement patients;

• Hip-fracture surgery patients;

• Patients with advanced solid tumors;

• Patients with congestive heart failure; and

• Immobile or bed-bound patients.

The survey ran from June 29 to July 27 and was not limited to physicians. Sixty-six percent of respondents chose "patients with congestive heart failure" as their answer; 20% of respondents chose "patients with advanced solid tumors." Both types of discharged patients do not require VTE prophylaxis, according to the new American College of Chest Physicians (ACCP) guidelines, says Joseph Ming Wah Li, MD, SFHM, FACP, past president of SHM, associate professor of medicine at Harvard Medical School, and hospitalist at Beth Israel Deaconess Medical Center in Boston.

"Hospitalists are familiar with the fact that patients with advanced solid tumors without additional risk factors do not need extended prophylaxis, as per the guidelines put out by ACCP," Dr. Li says. "And patients with congestive heart failure being discharged from the hospital do not need extended thromboprophylaxis, either."

As for the 14% of respondents who chose incorrectly, Gregory Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, says extended prophylaxis "may not be on their radar."

"Hospitalists are still struggling to get a consistent approach to inpatient VTE prophylaxis, especially since the ACCP 9 guidelines changed methodologies and provided weaker support for prophylaxis," says Dr. Maynard, senior vice president of SHM's Center for Hospital Innovation and Improvement.

For more information, check out our "Key Clinical Question" outlining VTE prophylaxis guidelines.

Six out of 7 respondents to an unscientific survey at the-hospitalist.org correctly answered the question "Which patient being discharged DOES NOT require VTE prophylaxis?" while 14% of respondents answered incorrectly, according to veteran hospitalists who reviewed survey results.

Nearly 200 people responded to the survey, which provided the following answers:

• Hip/knee replacement patients;

• Hip-fracture surgery patients;

• Patients with advanced solid tumors;

• Patients with congestive heart failure; and

• Immobile or bed-bound patients.

The survey ran from June 29 to July 27 and was not limited to physicians. Sixty-six percent of respondents chose "patients with congestive heart failure" as their answer; 20% of respondents chose "patients with advanced solid tumors." Both types of discharged patients do not require VTE prophylaxis, according to the new American College of Chest Physicians (ACCP) guidelines, says Joseph Ming Wah Li, MD, SFHM, FACP, past president of SHM, associate professor of medicine at Harvard Medical School, and hospitalist at Beth Israel Deaconess Medical Center in Boston.

"Hospitalists are familiar with the fact that patients with advanced solid tumors without additional risk factors do not need extended prophylaxis, as per the guidelines put out by ACCP," Dr. Li says. "And patients with congestive heart failure being discharged from the hospital do not need extended thromboprophylaxis, either."

As for the 14% of respondents who chose incorrectly, Gregory Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, says extended prophylaxis "may not be on their radar."

"Hospitalists are still struggling to get a consistent approach to inpatient VTE prophylaxis, especially since the ACCP 9 guidelines changed methodologies and provided weaker support for prophylaxis," says Dr. Maynard, senior vice president of SHM's Center for Hospital Innovation and Improvement.

For more information, check out our "Key Clinical Question" outlining VTE prophylaxis guidelines.

Six out of 7 respondents to an unscientific survey at the-hospitalist.org correctly answered the question "Which patient being discharged DOES NOT require VTE prophylaxis?" while 14% of respondents answered incorrectly, according to veteran hospitalists who reviewed survey results.

Nearly 200 people responded to the survey, which provided the following answers:

• Hip/knee replacement patients;

• Hip-fracture surgery patients;

• Patients with advanced solid tumors;

• Patients with congestive heart failure; and

• Immobile or bed-bound patients.

The survey ran from June 29 to July 27 and was not limited to physicians. Sixty-six percent of respondents chose "patients with congestive heart failure" as their answer; 20% of respondents chose "patients with advanced solid tumors." Both types of discharged patients do not require VTE prophylaxis, according to the new American College of Chest Physicians (ACCP) guidelines, says Joseph Ming Wah Li, MD, SFHM, FACP, past president of SHM, associate professor of medicine at Harvard Medical School, and hospitalist at Beth Israel Deaconess Medical Center in Boston.

"Hospitalists are familiar with the fact that patients with advanced solid tumors without additional risk factors do not need extended prophylaxis, as per the guidelines put out by ACCP," Dr. Li says. "And patients with congestive heart failure being discharged from the hospital do not need extended thromboprophylaxis, either."

As for the 14% of respondents who chose incorrectly, Gregory Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, says extended prophylaxis "may not be on their radar."

"Hospitalists are still struggling to get a consistent approach to inpatient VTE prophylaxis, especially since the ACCP 9 guidelines changed methodologies and provided weaker support for prophylaxis," says Dr. Maynard, senior vice president of SHM's Center for Hospital Innovation and Improvement.

For more information, check out our "Key Clinical Question" outlining VTE prophylaxis guidelines.

Although a recently released study of Medicare data uncovers little progress in reducing hospital readmissions, and the Oct. 1 deadline to implement CMS’ Hospital Readmissions Reduction Program looms, Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), says she's not worried about the ability of America’s hospitalists to rise to the occasion and get a handle on the problem.

Dr. Clancy recently wrote a commentary outlining the government's approach to controlling readmissions, stating that taking aim at readmissions is 1) an integral component of its value-based purchasing program and 2) is an opportunity for improving hospital quality and patient safety.

"Hospitalists are often on the receiving end of hospitalizations resulting from poor coordination of care. I think it would be very exciting to be part of the solution," Dr. Clancy says. She says she observed firsthand during a recent hospital stay how hospitalists helped her to think about how she should care for herself after returning home. But her father suffered a needless rehospitalization when important information (how much Coumadin to take) was miscommunicated in a post-discharge follow-up phone call, causing him to start bleeding.

"Hospitalists who want to embrace the challenge will find a phenomenal amount of information on Innovations Exchange, where people from all over America are sharing their clinical innovations."

Dr. Clancy says she hopes AHRQ-supported tools and studies "will make it easier for hospitals to do the right thing."

Although a recently released study of Medicare data uncovers little progress in reducing hospital readmissions, and the Oct. 1 deadline to implement CMS’ Hospital Readmissions Reduction Program looms, Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), says she's not worried about the ability of America’s hospitalists to rise to the occasion and get a handle on the problem.

Dr. Clancy recently wrote a commentary outlining the government's approach to controlling readmissions, stating that taking aim at readmissions is 1) an integral component of its value-based purchasing program and 2) is an opportunity for improving hospital quality and patient safety.

"Hospitalists are often on the receiving end of hospitalizations resulting from poor coordination of care. I think it would be very exciting to be part of the solution," Dr. Clancy says. She says she observed firsthand during a recent hospital stay how hospitalists helped her to think about how she should care for herself after returning home. But her father suffered a needless rehospitalization when important information (how much Coumadin to take) was miscommunicated in a post-discharge follow-up phone call, causing him to start bleeding.

"Hospitalists who want to embrace the challenge will find a phenomenal amount of information on Innovations Exchange, where people from all over America are sharing their clinical innovations."

Dr. Clancy says she hopes AHRQ-supported tools and studies "will make it easier for hospitals to do the right thing."

Although a recently released study of Medicare data uncovers little progress in reducing hospital readmissions, and the Oct. 1 deadline to implement CMS’ Hospital Readmissions Reduction Program looms, Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), says she's not worried about the ability of America’s hospitalists to rise to the occasion and get a handle on the problem.

Dr. Clancy recently wrote a commentary outlining the government's approach to controlling readmissions, stating that taking aim at readmissions is 1) an integral component of its value-based purchasing program and 2) is an opportunity for improving hospital quality and patient safety.

"Hospitalists are often on the receiving end of hospitalizations resulting from poor coordination of care. I think it would be very exciting to be part of the solution," Dr. Clancy says. She says she observed firsthand during a recent hospital stay how hospitalists helped her to think about how she should care for herself after returning home. But her father suffered a needless rehospitalization when important information (how much Coumadin to take) was miscommunicated in a post-discharge follow-up phone call, causing him to start bleeding.

"Hospitalists who want to embrace the challenge will find a phenomenal amount of information on Innovations Exchange, where people from all over America are sharing their clinical innovations."

Dr. Clancy says she hopes AHRQ-supported tools and studies "will make it easier for hospitals to do the right thing."