ACPA Update January 2022

In this Update Editor's Note Now Available – 2022 Medicare Inpatient Only Lists! What to Do in 2022? Academics and the Physician Advisor  ACPA 2021 Survey President's Corner ‌ ‌ ‌

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Editor's Note Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI Member, ACPA Advisory Board  Editor, ACPA Update

Well, it is 2022 and that means the new CMS Inpatient Only List goes into effect. You know, it is strange that the 2022 Inpatient Only List goes into effect in January 2022 and not October 1, 2021 when the 2022 Inpatient Rule and all its provisions are implemented. Why is this? First, the Inpatient Rule follows the federal government’s fiscal year calendar but the Outpatient Rule follows the traditional calendar. OK, so then wouldn’t the Inpatient Only List start October 1st with the inpatient rules? Well, no, the inpatient only list is actually part of the Outpatient Payment Rule, in that it specifies which CPT codes cannot be paid on an outpatient claim. Yep, it is confusing, but understanding the nuances of the regulations is all part of being a physician advisor.   But the real news is that once again Dr. Edward Hu has produced customized Inpatient Only lists for ACPA members, as introduced in his article in this issue. Those who have met Dr. Hu know he is soft spoken and modest, so let me say what he did not say; this was no small undertaking, and he does it all himself. I constantly share that the Inpatient Only List should really never be used since the short descriptors are misleading. But Dr. Hu has found a way to create lists that allow you to really figure out what is inpatient only and what is not. So read his article then log onto the ACPA site and look for the lists.   This issue also includes an excellent article from Dr. Denise Goodman on being a physician advisor in an academic setting. My 20+ years of practice were in the community setting so I never had to “publish or perish” as do those in academia. Her review provides a great overview on how to incorporate the academic world into a role as a physician advisor. And she is so right- every single day the work of a PA is loaded with information that is worthy of data collection and sharing. In fact, I was able to experience a bit of that in 2021 when Dr. Charles Locke asked me and Dr. Hu to co-author a publication for the Journal of the American Academy of Orthopedic Surgeons on the financial effects of the inpatient only list changes for common orthopedic and spine procedures. We made it through peer review and were published this month. You can read it here. Speaking of 2022, Dr. La Charite' has a great article on setting goals for yourself for 2022. I know I am tired of hearing about benchmarks for length of stay or case mix index or observation rate, so instead of having a Key Performance Indicator thrown at you, follow his advice and take the lead.   Finally, The ACPA member survey is out and the results are summarized in an article by Dr. Al Gore. Now before you go madly searching for the salary results, remember the results do not represent benchmarks for salary or duties, but only what your fellow PAs are doing and getting paid.    Finally, was your 2022 resolution to write an article for ACPA newsletter as a first step to a peer-reviewed article as Dr. Goodman describes? Email me at signaturedoc@gmail.com for the submission guidelines. It may not get you publication points for your career advancement but your mom will be proud of you.

Now Available – 2022 Medicare Inpatient Only Lists! Edward Hu, MD, CHCQM-PHYADV Member, ACPA Government Affairs Committee ACPA Past President, 2016 - 2018

The 2022 Medicare Inpatient Only (IPO) lists by specialty are now available for American College of Physician Advisors (ACPA) members! These contain both "inpatient only" procedures and "not inpatient only" procedures in different columns to assist you in identifying the right procedure. Similar to prior years, the lists are organized into 16 specialties that are further divided by organ system, anatomic location, or purpose (depending on what makes the most sense for that specialty). Minor procedures that are obviously not inpatient only are sometimes omitted (such as screening colonoscopy or transthoracic echocardiography). Anesthesia, laboratory, and drug codes are, as a rule, omitted from the lists, as well.  As many of you know, the Centers for Medicare and Medicaid Services (CMS) reversed its decision to abolish the IPO list over three years, after the first year of phaseouts in 2021. Of the almost 300 procedures removed on January 1, 2021, all but three of them have been placed back on the IPO list for 2022. These three include total shoulder arthroplasty, total ankle arthroplasty, and one type of anterior column lumbar fusion surgery. CMS also finalized the return of a two-year exemption on denials for level of care for each procedure removed from the IPO list. Since these three procedures were removed at the beginning of 2021, they are exempted until the beginning of 2023. We have highlighted them green in these lists. The almost 300 procedures placed back on the IPO list as of January 1, 2022, are highlighted in blue. The other highlighting you will see is yellow for new codes (whether inpatient only or not inpatient only). We generally also annually remove discontinued and non-payable codes for Medicare. The presence of the code on the list, however, does not mean Medicare automatically covers the service. Medicare coverage of CPT codes is typically administered at the MAC level.  Similar to prior years, there is a compilation file of all the specialty specific lists. This will be most useful when searching for a CPT code or a keyword - just use the CTRL-F function in your pdf browser.  Do not post any of these lists on the internet. Members may share them with staff at their institutions who can benefit from them, but encourage them to join ACPA for all the other educational and networking opportunities ACPA provides!  Once again, we emphasize that the official IPO list remains CMS OPPS Addendum E and that the CPT codeset is owned and maintained by the American Medical Association (AMA). The official references remain the "source of truth," and these lists cannot be relied upon as definitive information.  Dr. Edward Hu is System Executive Director of Physician Advisor Services of UNC Health

What to Do in 2022? Trey La Charité​, MD, FACP, SFHM, CCS, CCDS     Member, ACPA Clinical Documentation Integrity Committee

If your organization is anything like mine, you have just received the annual request for your individual and/or your program’s performance goals for 2022. Ugh.  Although I have received this request for the last 15 years, it still elicits the same visceral consternation as the first time I saw it. While the clinician side of us will always be perplexed by what we view as a superfluous endeavor, we must respond if we wish to continue our physician advisor agendas. Yes, like it or not, it’s another new year.  Now what?  To begin with, I certainly recommend you take a few moments to bask in the glow of the things you accomplished in 2021. However, while you are allowed a fist bump or two, don’t let that warm and fuzzy feeling lead to complacency.  The time to delineate your objectives for the current year is now. And rest assured, if you don’t have a clear direction as to where you want to focus your efforts, your C-suite already has a list of what they think you and your people can do for them.    So what challenges are you going to try to tackle this year?  Are you going to undertake an ED provider medical necessity education program because every elderly patient with a UTI does not need an acute care bed?  Are you going to join the contracting team because you are tired of a particular payor giving your organization and their beneficiaries the ‘denial of services rendered’ run-around? Do you want to get involved in denials management because you are fed-up with the post-discharge payor and recovery auditor thievery you consistently witness?  Are you going to aggressively push for more FTEs in your case management, utilization review, or clinical documentation integrity programs because you know there is so much more that could be accomplished with just a few more bodies?   The list is simply endless.  Knowing that there is no shortfall of things to do, it is easy to suddenly feel overwhelmed. As both a clinician and an administrator, you have a unique and broad perspective regarding hospital operations and management. However, there are more things that need your input than your mental and physical bandwidth will allow you to undertake.  Therefore, when setting goals, be reasonable and realistic. Remember that you are only human. Your list should be focused and doable. If you do not achieve what you said you could do, next year’s list of goals may be constructed without your input.  Once you have your list, my advice is to pick one thing on that list, go at it hard, and get it done. There is plenty of time to move to the next thing once that initial priority is hammered out.  My experience is that trying to tackle the entire list at one time divides your limited resources. As a result, nothing receives the due diligence it deserves increasing the chances for failure.  Be proscriptive and pragmatic.  In the hospital setting, you will never run out of issues that need your scrutiny. Trust me.  However, you simply cannot handle them all at the same time.  Lastly, never forget that being an effective physician advisor in one realm often leads to requests to take on more responsibility in other areas. Be very wary of mission creep. If you allow yourself to be spread too thinly, nothing gets done well. Learning when to say ‘no’ can be just as important as knowing when to say ‘yes’.  Not to mention that you probably have a family who would also like to see you on occasion this year. No pressure, right?  Now…Go Forth and Conquer!  Dr. La Charité is Medical Director for CDI and Coding at University of Tennessee Medical Center

Academics and the Physician Advisor  Denise Goodman, MD, MS, FCCM Member, ACPA Board of Directors Chair, ACPA Pediatric Physician Advisor Committee

Many of us practice in an academic environment, where advancement requires scholarly productivity. In addition, for those who may receive a mission-based incentive bonus, the research mission includes publication in peer-reviewed journals. At the same time, many of the critical activities we perform related to hospital operations and financial health, such as status determinations, peer-to-peer results, and provider education, do not neatly fall into academic categories of productivity or achievement. One solution is to consider where the two parts of our job intersect, and how we might leverage operational tasks into peer-reviewed papers.  How is a busy physician advisor going to do this? I think it breaks down into 3 steps:  What types of projects, programs, or initiatives lend themselves to publication?  What strategies might we use to find time in our schedules to do this and ensure success?  How will we disseminate our findings? Who is the audience, and how do we reach them?  First things first. Nearly any initiative one undertakes may lead to a publication, presentation, or scholarly product. For instance, nearly any quality improvement project with clinical implications (readmission reduction, creation of an intermediate care unit, or clinical pathways, etc.) might be amenable to publication in a clinical journal related to your specialty (internal medicine, pediatrics, hospital-based medicine, family medicine, and the like). There are specific guidelines for how to organize, structure, and report quality improvement work and the good news is that these guidelines are not just for organizing the paper at the end of the project. They form useful roadmaps for how to structure your intervention from the beginning, ensuring that you have not inadvertently forgotten important details and steps. The most common guideline for quality work is SQUIRE (Standards for QUality Improvement Reporting Excellence). This can be found at the Equator Network webpage or at the SQUIRE site.  If you need to gather baseline data or extensively review literature, for instance comparing the performance of 2 scoring systems or looking at trends over time (particularly if these reflect multiple sites), consider whether this could be expanded to original research. Depending on the question you are asking this sort of work might be appropriate for a clinical journal or for a hospital operations journal.  Perhaps the biggest hurdle is finding the time and means to turn one’s work into a manuscript. It can seem daunting, and finding time may be a challenge. In addition, writing manuscripts may not have been a principal focus of one’s career. There are a few ways to tackle this. One is to engage a partner. For instance, there may be a young physician looking to advance his or her academic career – let them take first crack at the manuscript. They will rightfully be first author, and you may be further down the author list, but if you have something important and useful to say to your peers then it deserves to be out there. If data analysis and visualization are a challenge, there may be resources from your hospital’s data team. Another approach is to volunteer to give Grand Rounds – just the effort to review the project, organize your thoughts, and compare to similar published initiatives goes a long way toward compiling the perspective and materials to inform a manuscript.  Not all work needs to be original research. I worked with a team on improving our discharge efficiency and in the course of that work we amassed a substantial library of approaches used at other institutions. One of the members of our team developed that into a review for Hospital Pediatrics entitled “The Perfect Discharge: A Framework for High-Quality Hospital Discharges” which uses the National Academy of Medicine quality domains to frame the attributes of an ideal discharge process.  So, now you’ve done the work and organized your thoughts, where can it go? The most important thing is to ask yourself who you wish to be the audience. This may be clinicians in the field, C-suite leaders, or others. We’ve identified common academic journals, and also the strategy of giving a Grand Rounds as a form of dissemination. Physicians may be less familiar with journals used by hospital administrators, so ask your leadership what they read. For instance the Journal of Healthcare Management is the official journal of the American College of Healthcare Executives. The Healthcare Financial Management Association publishes HFM. There are numerous quality journals, including the Joint Commission Journal on Quality and Patient Safety, BMJ Quality and Safety, and others. Similarly, there are a number of informatics journals if your solution centered on an electronic health record solution. If you were involved with provider or trainee education, education journals or online education portals may be most appropriate. So be inspired! We do important work and there are numerous opportunities to share the knowledge gained and, in so doing, to also contribute to the scholarly mission of our institutions.  Dr. Goodman is Medical Director, Case Management and Care Coordination (Physician Advisor) at Ann & Robert H. Lurie Children’s Hospital of Chicago

ACPA 2021 Survey Alvin Gore, MD Member, ACPA Board of Directors ACPA Physician Advisor Survey Champion

Shortly after Thanksgiving, the 2021 ACPA Physician Advisor survey became available to ACPA members. This year’s survey is a result of responses from 226 Physician Advisors from 42 states which makes it the most extensive survey to date.   The format of this survey was different as compared to prior versions. It consisted of 2 portions- the 1st (larger) part asked the respondents about their professional practice, while the 2nd (smaller) part was new and focused on the wellbeing and professional satisfaction of physician advisors. Dr. Clarissa Barnes, ACPA’s VP of Member Engagement, advocated for adding the wellbeing portion since at that point there had been little to no data about how physician advisors’ professional satisfaction related to their clinical peers.   While it is impossible to summarize all the numerous data points in a short article, a few points could be made. Here are some observations from a professional portion of the survey.   Every subsequent survey had more participants- likely related to the growth of both the physician advisor field and the ACPA as a professional organization. 89% of the respondents in the most current survey were ACPA members.  Many more physician advisors are holding a variety of additional certifications, which speaks for ever increasing spectrum of professional involvement.  The majority of our colleagues are relatively new to the field; however, we are developing a subset of industry “veterans” with 10+ years of experience.  There was a significant rise in remote work setting, certainly accelerated by the COVID-19 pandemic.  There is a consistent and increasing trend towards full-time Physician Advisors.  There seems to be an ongoing increase in the scope of work for Physician Advisors, encompassing not just the traditional activities, but also including new duties, such as contract work, clinical validation denials, population health initiatives and quality-related work.  ACPA continues to be a great resource providing numerous educational opportunities, such as The Learning Center (TLC), this newsletter and others.  Turning to the wellbeing portion of the survey, here are some of its observations:  Most of the respondents are satisfied with their current job.  There appears to be a relationship between work-related stress and job satisfaction.  Similarly, another correlation became obvious- when PA work autonomy is high, there is low likelihood of burnout. As autonomy is restricted, the burnout rates rise. It is notable that the system-based issues were primary contributors to the burnout feeling.  Physician advisors are gradually adopting the use of social platforms and currently LinkedIn is the most common.  To conclude, all of us at ACPA are very grateful to all the respondents making this survey possible. The survey (including all the financial info) is available to the ACPA members on the ACPA website. Dr. Alvin Gore is Physician Advisor and Director of Utilization Management at St. Joseph Health in Sonoma County, California

American College of Physician Advisors President's Corner

January 2022

President’s Note: Happy new year, everyone! I am so happy to introduce the ACPA’s newest Vice President of Operations, Dr. Ahmed Abuabdou, by featuring his thoughts about our College’s future in this month’s President’s Corner. Welcome, Ahmed!

–Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, FABQAURP

Happy New Year to the ACPA community! As I start my term as ACPA Vice President of Operations, I was asked by our president to share who I am and what I envision for the College this year. Without hesitation, I said, absolutely! As leaders who pursue success and inclusiveness, we are obligated to share our vision and future direction with our community.  My name is Ahmed Abuabdou and I serve as Associate Chief Medical Officer and Associate Professor of Medicine at the University of Arkansas for Medical Sciences, Little Rock, AR. I became an ACPA member in 2016 and in 2017 attended my first National Physician Advisor Conference (NPAC) in Greenville, SC. I was blown away by the richness of the content, the networking opportunities, and the collegial nature of the College’s leadership. I immediately realized that there was an enormous effort, energy, and element of time dedicated by all who worked to make ACPA a reality. At the end of the conference, I made a commitment to be involved and joined the ACPA CDI Committee. Six years later, I am humbled to serve this organization and its members as VP Operations.  So, what is coming down the pike?  In the last ACPA Board of Directors retreat which occurred in November of 2021, several great ideas were pitched which will bring high-value to ACPA members. It became apparent that we need a strategy in order to execute and deliver on these ideas and initiatives. The top priority project which we will achieve by the end of this year is the ACPA Strategic Plan (Vision 2032). This strategic plan will set the future direction of the ACPA in key domains such as physician advisor education and credentials, advocacy and inter-agency relationships, and member engagement. We will capitalize on our strengths, recognize our weaknesses and turn them into opportunities, and define our position in the landscape of physician advisory as the professional home of physician advisors. We will aim to be the organization which sets industry standards in the field of physician advisory.  Another priority project will be collaboration with my colleague, Dr. Clarissa Barnes, Vice President of Member Engagement, aiming to overhaul the ACPA technology platform where functionalities are maximized and the experience of visiting the ACPA website becomes unparalleled. While 2022 started with the blizzard storm of the Omicron variant, we believe that a ray of hope still exists and ACPA will continue to support the physician advisor community. Stay safe! And let’s be role models to everyone by doing what’s right – get your boosters, wear your mask, wash your hands, exercise social distancing, and be an awesome physician advisor!

Ahmed Abuabdou, MBBS, MBA Vice President – Operations, ACPA Dr. Ahmed Abuabdou is Associate Chief Medical Officer for UAMS Medical Center in Little Rock, Arkansas

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