ACPA Update February 2022

In this Update Editor's Note Observation Committee November Cases  Cancelled Surgery – Change the Status?  Medicare Advantage Star Ratings... What Are They? Why Should We Care? What Can We Do About Them?  NICU Baby Listed as “Self-Pay”: You’ve Got to Be Kidding!  APCA Observation Committee Cases of the Month  President's Corner ‌ ‌ ‌

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

I don’t know how many of you listen to the webcast/podcast “Monitor Monday,” but in mid-January there was a segment by health care attorney David Glaser that really boiled my blood. (Disclaimer- I also appear on that webcast, and you all should listen to it for great information, along with Talk Ten Tuesday.) He described denials he was defending for one of his clients from the UPIC. As with many government agencies, these audits are contracted out to a private company. These were inpatient admission denials for stays that were over two midnights, so the question was not whether they met the Two-Midnight Rule. I suspect that for many of you, your first thought was that the patient was kept for social or convenience and denial was therefore appropriate. But that was not the case. These patients clearly required hospital care. They were denied because, as he reported, “the patient did not require inpatient care and could have received care at an Observation level of care.”   WHAT??? Was he kidding? Nope, and these admissions were not from 2013, prior to the Two-Midnight Rule. That’s right, this Medicare contractor, who is paid millions of dollars to be experts in the rules and regulations, was using an admission standard that was over 8 years out of date. In fact, as I write this, the Rule is over 3,808 days old. (You can see the Two-Midnight Rule clock suggested by Dr Ugarte Hopkins on my webpage www.ronaldhirsch.com.) This is inexcusable. I know David Glaser is going to appeal these, and hopefully embarrass the contractor, but at what point should the government take action? If you see such denials, fight them and file a complaint.   In this issue we have some more great articles. Drs. Lau and Narasimhan write about pediatrics and a baby who was “self-pay” and received a large bill for the care. Dr. Libertin talks about Star ratings and the Medicare Advantage plans. Just as doctors worry about their Press-Ganey scores, MA plans really care about their Star rating, but for the MA plans the stars are worth millions of dollars.   The Observation Committee gives you a double treat- both the results of the last survey and two brand new cases. These are tricky. Read them closely and please add your comments. And finally, I submitted an article to this issue on billing cancelled surgery. It is an issue that arises on occasion and as physician advisor you should know the answers.  Finally, February brings Valentine’s Day. Want to make my February 14th special? Submit an article for the ACPA journal. Email me at signaturedoc@gmail.com for the submission guidelines.

Observation Committee November Cases  Provided by the Members of the ACPA Observation Committee

Below are the cases presented in November with responses and commentary from the ACPA Observation Committee members.  Case 1:  A 78yom with HTN, DM, CKD3 presented with syncope. Hospitalized overnight for observation; serial troponins negative, telemetry uneventful, TTE not consistent with CAD sequelae or concerning structural abnormalities. Discharge was planned. While undergoing an ambulatory oximetry study, the patient had cardiac arrest. Resuscitation was unsuccessful. Prior to claim submission, a member of the UM team suggests that an inpatient claim is appropriate, as unexpected death is an allowable exception to the 2-midnight policy and a defective IP order should not be sole grounds for a denial.   Q1 - Would you recommend billing part A inpatient?  Q2 - Would you ask the attending to write an inpatient order?    Discussion: 13 of 28 respondents would not bill Part A; 8 would. The majority of comments mention death as an allowable exception to the 2-midnight rule. After review I sent this through as an outpatient claim. In my opinion, it is important to consider that, except for acute intubation and IP-Only procedures, the exceptions to the two-midnight rule—death, AMA departure, transfer to another facility for ongoing care, new hospice election, and unexpected improvement—rely on a two-midnight expected stay shortened by one of those events. In this specific case, there was never a two-midnight expectation, the patient was appropriately in hospital outpatient status, and the unexpected cardiac arrest and death thus do not meet exception criteria, and I would not submit a Part A claim. 18 of 28 respondents would not have requested an IP order be placed after the patient’s death because one cannot enter valid orders after discharge/death. One commenter correctly noted that the absence of a typical “admit to inpatient” order is no longer grounds for sole Part A claim denial as long as intent for IP status can be gleaned from the documentation—though in this case the documentation did not support inpatient status in any way.  Case 2:  An 89yo nursing home resident with severe dementia was found unresponsive in bed and taken to a local ED, where she was found to be in shock from a ruptured AAA. Air transfer to a tertiary center was arranged; the patient coded in the local ED with subsequent ROSC, and coded again just before landing. The patient was taken to the OR while CPR was in progress; after assessment the accepting vascular surgeon discontinued resuscitation efforts. There was no admission order and documentation was limited.  Q3 - What would you advise the first hospital to bill?  Q4 - What would you advise the receiving hospital to bill?  Comment: 21 of 28 respondents answered question 3 with “Emergency Department visit”, 1 indicated “observation”, and 5 indicated “inpatient admission.” In this case, the patient only received ED services locally before transfer to a higher level of care; there was no local admission, and thus neither justification for a Part A claim nor an exception to the two-midnight rule as discussed above. As for the receiving hospital, 17 of 28 respondents recommended inpatient status, 4 recommended ED visit, and 6 recommended Observation services. The single comment noted “If incision was performed in the OR, inpatient. If surgery was not actually started, outpatient.” That was the decision I made; no surgery was initiated, and while the effort and resources expended were high, I had a hard time justifying an IP claim for this case. I still second-guess this one at times.    Case 3:  An elderly person with many comorbidities presented shortly after midnight with acute stroke symptoms; evaluation confirmed a large CVA. Immediate aggressive treatment was initiated in the ED, along with Neurology and Neurosurgery consultation. The patient required sedation, intubation, and ventilation. After several hours of aggressive care, the patient’s surrogates opted for a comfort-based approach. The patient was subsequently admitted to inpatient status and placed in the neuro ICU for end-of-life cares including terminal extubation, with death expected shortly after extubation. The patient died on hospital hour 17. Prior to an initial claim, you are asked to consider a self-denial/Part A to B rebill because, while the patient was emergently intubated and died, the stay was zero midnights and “only comfort cares were provided.”    Q5 - What do you advise?  Comment: For this case, 14 respondents would bill Part A, and 12 would self-deny and rebill to Part B (ie, make outpatient). The nuances of a case like this are challenging; as noted above, an exception to the two-midnight rule generally presupposes a two-midnight expectation. If someone is admitted and expected to die within a few hours, then it is challenging to argue a two-midnight expectation—especially if they do! On the other hand, in the case as presented, the patient was emergently intubated, the team spent several hours engaged in aggressive, life-prolonging care, and tried to prevent the patient’s death. The documentation was largely completed AFTER major decision points, and for a non-coroner’s case death is often sparse. In this case, since the initial cares were oriented towards life prolongation/cure and end-of-life care was choses after the failure of endovascular intervention, I opted for an inpatient claim. Had there been an immediate end-of-life approach without attempt at life prolongation, I probably would have self-denied and rebilled.

Cancelled Surgery – Change the Status?  Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI Member, ACPA Advisory Board  Editor, ACPA Update

The flip flop by CMS on the Inpatient Only List (IOL) has left many with their head spinning, and with good reason. First they remove 298 surgeries from the list, including many where patients always stay over two midnights, leading to education sessions and program redesigns to get status correct. Then CMS says “never mind” and puts most of them back. As a reminder, the IOL only applies to traditional Medicare and not Medicare Advantage plans. The MA plans can elect to follow it but are not required to use it. In fact an MA plan can allow an inpatient only surgery to be done at an Ambulatory Surgery Center. Nope, don’t try to rationalize that. It’s an indefensible decision by CMS but they make the rules.  But the question occasionally comes up about what to do about the status of the patient who is admitted for an inpatient surgery, either inpatient only or not, but then the surgery gets cancelled before being completed. If the inpatient only procedure was not done, should the status be switched to outpatient via condition code 44 or self-denial and rebill?  And as usual, the answer is “it depends.” Below I will use examples to describe the common scenarios, noting all are Medicare.  Scenario 1 Patient scheduled for planned revision total hip arthroplasty, HCPCS 27132. It is on the IOL. Patient stops at registration, is registered as inpatient. The surgeon has sent in their preop orders including an inpatient order and that is activated. The patient signs the paperwork, gets their Important Message from Medicare, goes into the pre-op area and puts on their gown. The RN starts their iv and gets vitals. The patient mentions “oh, by the way, my husband was diagnosed with COVID two days ago.” The RN informs the surgeon who cancels the surgery.     In this case, the patient has been formally admitted and the surgery is cancelled before being started. The fact the patient’s husband was ill could have been ascertained prior to the patient’s arrival so CMS would say this inpatient admission is inappropriate and you should not bill an inpatient admission. You can change the status to outpatient with the condition code 44 process which would allow billing any services as part B, or you may simply submit a no-pay inpatient 110 claim and get paid nothing. The same would apply if the patient in pre-op said they had a cold or sore throat or were pregnant, all findings that should have been discovered before formal admission.  Scenario 2 Patient scheduled for planned revision total hip arthroplasty, HCPCS 27132. It is on the IOL. Patient stops at registration, is registered as inpatient. The surgeon has sent in their preop orders including an inpatient order and that is activated. The patient signs the paperwork, gets their Important Message from Medicare, goes into the pre-op area and puts on their gown. The RN starts their iv and gets vitals. The patient is taken into the OR. The anesthesiologist induces anesthesia and as the surgeon is preparing the patient, the patient goes into ventricular tachycardia that resolves after 15 beats. The surgeon cancels the surgery and the patient is taken into the recovery room. Cardiology is called, an EKG and labs and an echocardiogram are done. The potassium is 2.9 and is replaced. Her hydrochlorothiazide is stopped. The cardiologist orders a telemetry bed to keep the patient overnight and get a stress test in the am. Testing is negative and the patient is discharged to reschedule their surgery.    In this case, the patient was formally admitted as inpatient but did not undergo the planned surgery. But surgery did start with induction of anesthesia. But the patient had no incisions and certainly did not get her hip replaced. This would be billed as an inpatient admission. The patient was admitted as inpatient for hip surgery and the surgery began. The principal diagnosis would be osteoarthritis of hip, with ventricular tachycardia and hypokalemia as secondary diagnoses, along with others. But the claim would not include the ICD-10-PCS code for the hip replacement surgery since it was not done. The coders would only code what was done- initiation of anesthesia, EKG, echocardiogram, one inpatient day on a telemetry unit, stress test, etc. The encoder would then assign the appropriate DRG.   Scenario 3 Patient scheduled for knee replacement, HCPCS 27447, not inpatient only. The surgeon scheduled the surgery as inpatient and a written order was provided. The preop documentation notes a healthy patient with a BMI of 28, non-smoker, and no medical issues. They are classed as ASA 2. The surgeon’s patients normally are discharged the day after surgery. The patient arrives, registers, is formally admitted and given the Important Message from Medicare. The surgery commences and anesthesia induced. The patient’s blood pressure starts fluctuating and despite the best efforts of the anesthesiologist, it is determined unsafe to proceed. The patient is awakened, the blood pressure normalizes and the patient is sent to the recovery room. Cardiology is consulted, EKG, echocardiogram, and labs are done. The patient is kept overnight and discharged home.      In this case, the patient was formally admitted as inpatient for a surgery that is not on the inpatient only list. The surgery was not performed and the patient was discharged the next day. Here, the deciding factor is whether the inpatient admission was appropriate. It appears that there was no documentation to support an inpatient admission for this patient with no documentation of elevated risk, surgical complexity, or the expectation of a two midnight stay. So in this case, inpatient admission was not appropriate. Since the patient has already been discharged, the admission requires review as specified in 42 CFR 482.30(d). In all likelihood, the inpatient admission will be determined to be not appropriate and as a result, a no pay 110 inpatient part A claim will be filed, indicating osteoarthritis as the principal diagnosis with one inpatient day and the other tests listed. The surgery will not be coded. Occurrence span code M1 will be placed on the claim. Once that processes, a 121 inpatient part B claim can be submitted and payment will be made for the payable services.   Scenario 4 A patient is scheduled for a laparoscopic colon resection HCPCS 44208 for a dysplastic polyp. This surgery is inpatient only so the patient is formally admitted. The patient goes into the operating room and surgery is commenced. The surgeon starts the surgery and notes diffuse peritoneal seeding. A frozen section is sent to pathology revealing ovarian cancer. The surgeon then closes the abdomen and the patient goes to recovery. The patient is monitored for 4 hours and discharged home.     Here the patient commenced surgery and the peritoneum was entered but the colon resection was not performed. An inpatient admission would be billed. The principal diagnosis would be dysplastic polyp of colon and ovarian cancer with peritoneal metastasis would be a secondary diagnosis. The claim would not include the colon resection but would include coding for the incision of the peritoneum and the biopsy. The patient did not spend a night in the hospital but since the intent was an inpatient only surgery, a room charge can be added to the claim per chapter 3, section 40.2.2.K of the Medicare Claims Processing Manual.  As can be seen, the determination of how to bill a surgery that is cancelled is not simple. One needs to consider the initial status order and the validity of that order, along with when the surgery was cancelled and why. Only then can the correct claim be submitted. It should also be noted that scenario 1 could have been avoided if the hospital had a policy that for scheduled inpatient admissions, the inpatient admission does not formally begin until the patient enters the operating room. In that case, the condition code 44 process would not be needed and an outpatient part B claim could be submitted for eligible services. This is outlined in a 2014 article found here.   Dr. Hirsch is Vice President of Regulations and Education at R1 RCM Inc.

Medicare Advantage Star Ratings... What Are They? Why Should We Care? What Can We Do About Them?  Nicholas Libertin III, MD, CHCQM Member, ACPA Government Affairs Committee

What are Medicare Advantage Star Ratings? The Centers for Medicare & Medicaid Services (CMS) created a Star Rating system to help beneficiaries and their families compare plan performance and quality for Medicare Advantage plans.  The plans are rated on a one-to-five scale, with one star representing “poor performance” and five stars representing “excellent performance”. Medicare Advantage Star Ratings are released annually and reflect the experiences and outcomes of patients enrolled in Medicare Advantage plans.  They utilize 40 different performance measures, including process indicators (e.g. screenings), outcome indicators (e.g. blood sugar level for diabetes), patient satisfaction (e.g. rating of health plan) and timeliness of appeal decisions.   Why should we (health systems and providers) care?  Insurance providers have a great deal “on the line” with their Medicare Advantage Star Rating. As a result of changes made in the Affordable Care Act (ACA), plans that receive at least 4 stars and those without ratings (due to low enrollment) receive additional quality bonus payments from Medicare. From 2015 to 2021, the total annual bonuses to Medicare Advantage plans have nearly quadrupled, rising from $3.0 billion to $11.6 billion (Figure 1). The rise in bonus payments is due to both an increase in the number of plans receiving bonuses, and an increase in the number of enrollees. For example, United Health Care’s bonus from their star rating was 3.4 billion dollars in 2021 (Figure 2). Not only does an increase rating generate revenue, it also generates more enrollees for the plan.  In 2021, 81% of Medicare Advantage enrollees were enrolled in a plan with 4/5 stars or above (Figure 3). Furthermore, a study done by Healthpocket.com (a website ranking health plans) showed that the average attrition rate for two-star plans was 22% and only 2% for five-star plans. Lastly, the increase in revenue generated from the bonus payment enables a plan to provide more services to their beneficiaries and thus increase chances of retaining their star rating and enrollees. A simple jump from 3 to 4-star improvement can generate 134% more value to its members in extra benefits and rebates.

Figure 1

Figure 2

Figure 3

What can we do about them?  Some variables that dictate the Medicare Advantage Star rating are predetermined (diabetes control, screenings etc.), however there are other performance measure that providers can give necessary feedback, both positive and negative, to the plan and CMS. Customer experience related metrics are projected to determine 57% of overall Star ratings by 2023 (an increase of approximately 25%). In the future, excellent customer experiences will be crucial for Medicare Advantage plans longevity and success. Of the 40 different CMS measures, the most relevant to provider feedback are: customer service, rating of healthcare quality, rating of health plan, complaints about the health plan and reviewing appeals decisions. Many of these are obtained from the Consumer Assessment of Healthcare Providers & Systems (CAHPS) that patient’s complete and have a simple scoring system from “0-10” (0 being the worst, 10 the best). Providers and health systems can also file separate positive comments and grievances with the plan and CMS. Quantity is as important as quality in this instance, as CMS cites that the frequency of both types of comments in these categories directly effects a Medicare Advantage plan’s Star rating.  Providers can also, with the patient’s permission, file a grievance to CMS with form 1696. This form allows the provider or health system to file a claim, appeal or grievance with CMS on a patient’s behalf. Whichever avenue is chosen, it is important to educate patients on the significance of their feedback. Another potential avenue would be at the contracting level, Medicare Advantage plans are incentivized to seek collaborative arrangements with providers to share the financial benefits of quality and efficiency improvements.  Providers should strive to work together with Medicare Advantage plans to ensure we are helping achieve their mission of providing patient centered services that can get them the highest recognition by CMS. As the number of Medicare Advantage plans and their enrollees continue to increase, it is vital that health systems and providers provide necessary feedback and ensure insurance companies actions are accurately depicted in their Medicare Advantage Star Rating.    References:  https://www.cms.gov/newsroom/press-releases/cms-releases-2022-medicare-advantage-and-part-d-star-ratings-help-medicare-beneficiaries-compare  https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2021-star-ratings-and-bonuses/   https://www.cms.gov/newsroom/fact-sheets/contract-year-2021-medicare-advantage-and-part-d-final-rule-cms-4190-f1-fact-sheet  https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2021-star-ratings-and-bonuses/  https://www.cms.gov/files/document/ma-pdp-cahps-qapts-v11-complete-manual.pdf  Dr. Libertin is enterprise physician advisor for Cleveland Clinic and member of the Avon Hospital Medical Executive Committee.

NICU Baby Listed as “Self-Pay”: You’ve Got to Be Kidding!  Sumana Narasimhan, MD, FAAP     Member, ACPA Pediatrics Committee   Rhiana Lau, MD, FAAP Member, ACPA Pediatrics Committee

Hello from the Pediatric committee of the ACPA! We are a small but mighty group who have been active in discussing the unique issues that affect the youngest patients we all care about. This month, we are writing about a unique issue that affects newborns, specifically the ill newborn who requires intensive care and spends days/weeks in hospital, receiving lifesaving care, only to be denied by the insurance company! Here is a case scenario to help illustrate this kind of situation:  JD is an 18 year-old primigravida with history of poor prenatal care. She found out she was pregnant at 20 weeks. The father is 19 years old and works at a fast-food chain. The mother has health insurance through the state Medicaid program and the father has health insurance provided by his employer. At 28 weeks, an infant baby boy was delivered at the community hospital by emergency cesarean section due to intrauterine growth retardation and fetal distress. The infant had poor Apgars and required transfer to Level 4 Neonatal Intensive Care Unit (NICU) on his first day of life. At the NICU, he had multiple problems of prematurity including respiratory distress, feeding intolerance, necrotizing enterocolitis and electrolyte imbalances, requiring multiple subspecialty consultations, central lines and at least one surgical procedure. He was discharged to mom’s care after a 3 month stay in the NICU.  A bill for $ 250,000 was denied by mom’s insurance with the reason, “baby not on insurance policy”. Baby JD is listed as “self-pay”.   The above case describes an all too familiar scenario for those of us in the pediatric world. The numerous factors that are at play in situations like these are:  Young age of mother  Infant born at one hospital and transferred to another hospital   Mother may not have knowledge of the insurance process and the importance of having the birth letter verifying the baby’s birth.  Which insurance to use: Mom’s or Dad’s?  Insurance may change over the course of a long NICU stay.  Parents of a sick newborn may be preoccupied and overwhelmed with the rollercoaster of having a critically ill newborn and learning about the care of their child, hence insurance is not ‘top priority’.  What are the consequences of not having insurance on a newborn? Insurance coverage for newborn stay has widespread implications beyond the obvious reimbursement issue for the hospital. Babies such as the one in our vignette, require multidisciplinary care after discharge, with close follow-up with multiple subspecialties, physical, occupational (speech) therapy and often leave the hospital with supplemental oxygen. Medications, feeds and specialized equipment for feeding, transportation and respiratory support are sometimes required and it is critical to have insurance coverage at time of discharge from the neonatal intensive care unit.  It is important for hospital systems to recognize and refine the processes around newborn registration and insurance coverage in order to mitigate the issue of infants having unclear insurance coverage at time of discharge. The processes in place may vary by hospital level and by region. The following summarizes some of the issues and areas of focus that hospital systems may identify as opportunities for improvement:  Outborn vs inborn babies – These require different processes since mom may not be readily available if the baby was transferred to or from another facility. Engaging with the parent in-person/virtually/via phone call in a timely fashion after transfer can help smooth out the process.  Short stay admission – The baby may be discharged well before he or she is added to the policy, which may make retro authorization complicated. This could be mitigated by timely notification to the payor once the infant is added to the insurance plan.  Long stay admission – For long-stay NICU babies, insurance may change over the course of the admission. Having the primary team be aware of and periodically update insurance coverage (eg. weekly), thereby designating a member of the team to be responsible for this function may be helpful (eg. NICU social worker/UM/Registration). Insurance could also be added as a ‘check off’ box during clinical rounds/discharge planning as a helpful reminder.  Is the baby on mom’s policy / dad’s policy? – The infant may start off on neither or on one of the policies and then be changed to the other parent’s policy. This is an area that could easily be overlooked and hence an opportunity to refine processes (see # 5 below).  Education of parent(s) and/or guiding the parent through the insurance process – Parents, such as the young mom in the vignette, are usually overwhelmed with all that is expected of them during the neonatal period. Providing educational materials, timelines for completion, and meeting a parent ‘where they are at’ with their understanding of insurance is essential for success. Some parents may need staff help in filling out forms, especially if there are language barriers. Thus, an individualized approach can optimize parent understanding of the complex processes surrounding insurance.  Pre-emptive planning – Some centers engage prenatal providers and Mother-baby units to introduce educational materials early on to help new parents add their baby to the insurance policy timely.   Verification of Birth letter – This is a key document that is required by insurance companies before they can add an infant to the insurance policy. This letter is issued by the hospital where the infant is born and is usually mailed to the parent. Access to the “Verification of Birth Letter” could be improved by making it part of mom’s EMR or downloadable through a patient portal (eg. MyChart), if possible.  In summary, the addition of a newborn to insurance policy is an essential step that should be simple, yet is quite complicated in the case of newborns who require prolonged hospitalization beyond the well-baby nursery. Adding one’s baby to the insurance policy is usually a routine task that is taken care of after the baby is home with the parent(s).  However, parents of a sick newborn are faced with overwhelming stress that could relegate this otherwise ‘routine’ task to being overlooked, resulting in the unfortunate situation as in the vignette where an infant needing specialized care is listed as “self-pay”. This situation could be mitigated by refining processes around infant registration, increasing awareness, and educating parents about the steps required to add their infant to the appropriate insurance policy in a timely manner. This is a great opportunity for clinical, registration, and billing staff to work together as a team to improve processes that surround the littlest patients with whose care we are entrusted.  Dr. Narasimhan is a Pediatric Endocrinologist, Enterprise Physician Advisor at Cleveland Clinic and Associate Professor at The Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH. Dr. Lau is a Pediatric Nephrologist, Division Chief of Pediatric Specialties, Physician Advisor and Chair of the Utilization Management Committee for Kapi’olani Medical Center for Women and Children in Honolulu, HI.

APCA Observation Committee Cases of the Month  Provided by the Members of the ACPA Observation Committee

Here are this month’s cases. You can read the case and respond at: https://www.surveymonkey.com/r/GKGYDFY  An 87-year-old Medicare beneficiary with CAD, HTN, DM2, and CKD3 undergoes a transcatheter aortic valve replacement. The patient was initially admitted as inpatient, but discharge is planned after one midnight; the provider changes the patient’s status to “extended surgical recovery”, and the case manager contacts you for further advice. What is the appropriate status?  Outpatient, extended surgical recovery (or your local equivalent)  Observation; stay less than two midnights  Inpatient because complex procedure in elderly patient  Inpatient because possible inpatient-only procedure  A Medicare beneficiary is undergoing a planned inpatient-only procedure; after induction of anesthesia, the elevation mechanism on the operating table fails and the procedure is aborted. What is the proper billing status?  Inpatient for inpatient-only procedure, even if aborted  Change to outpatient   Do not submit a claim  A Medicare beneficiary presents to the ED at 0130 with abdominal pain; evaluation reveals appendicitis with fecalith. Surgery is recommended; however, the patient takes a DOAC and the surgeon wants a 48-hour washout prior to surgery. Antibiotics are started in the meantime. What status would you recommend?  Surgical outpatient status  Observation status  Inpatient status  Mrs. Jones, a 62-year-old female with a controlled history of COPD was admitted for surgical replacement of her left hip, which had been injured in motor vehicle injury at the age of 34. Her payor had declined to authorize the admission for an inpatient level of care. During her anticipated short stay in the post-anesthesia care unit, she remained unacceptably somnolent, dropping her oxygen level to 89% during attempts to wean from oxygen over a 2.5-hour area period. There were no focal neurological deficits, and she had no specific cognitive deficits when aroused in the PACU. She had scattered rales and minimal diffuse wheezing with a respiratory rate of 20 to 22 breaths per minute. The patient was admitted to a hospital room, maintained on 3 liters of oxygen by nasal canula and every four-hour nebulizer treatments. The patient had no chest pain. A chest x-ray was negative. Her oxygen level the next morning was in the area of 92% on 2 liters of oxygen, but dropped to 89% with ambulation to the rest room. By afternoon she was seen by a pulmonary consultant who suspected no additional pathology and recommended chest percussion be added to continuation of bronchodilator nebulizer treatments and incentive spirometry. By late afternoon her oxygen levels had improved slightly but she still had not reported flatus. Bowel sounds were infrequently heard, and with sips of fluid became significantly nauseated. She vomited once. Repeated electrolytes showed a sodium of 134, a potassium of 3.2, a CO2 of 20, creatinine of 1.6 and a BUN of 28. She was continued on IV fluids and an inpatient order was entered in the chart. Tolerating fluids on the morning of the third day she was placed on a clear liquid diet. With a bowel movement at noon, the patient’s diet was advanced. Her oxygen levels remained at 93% or above with light ambulation. With continued improvement, the decision was made at three in the afternoon of the third day to discharge the patient.   Respond and comment at: https://www.surveymonkey.com/r/GKGYDFY

American College of Physician Advisors President's Corner

February 2022

February might be one of the most painful times of the year for those of us living in the Midwest or other areas where it’s been cold, grey, and COLD for the better part of four-ish months (and will be for at least another two). But, this year…there is a super bright spot on the horizon coming up in April. The National Physician Advisor Conference (NPAC) is back IN PERSON this year!  Oh, I am just so excited to welcome everyone back for the two-and-a-half-day event we’ve missed since 2020! Yes, we have all become proficient with Zoom, WebEx, Microsoft Teams, etc., and no, I for one am not disappointed about eliminating my commute by working remotely. But, there is nothing that can replace the organic sharing of information and ideas over the course of the conference with fellow attendees. Whether it’s someone you’ve never met but works in your area of the country, a fellow RAC Relief listserv member you’ve seen post from time-to-time, or someone you truly keep in touch with on a regular basis between NPACs, it's great to be together. Come meet the members of our Board of Directors and Advisory Board! Participate in one of many ACPA Committee break-out sessions! While the attendee list for NPAC grows larger every year, this is not an overwhelming, impersonal event where you’ll get lost in the shuffle. If you’ve never been to an NPAC before, come see what I mean! If you have, AREN’T YOU SO EXCITED???   This year, to celebrate our togetherness after a two-year hiatus, we’re really taking advantage of NPAC 2022’s unique location. Austin, Texas bills itself as the Live Music Capital of the World® with more than 250 live music venues featuring rock, country, indie and Tejano music. Love the outdoors? Along with enjoying Austin’s downtown sights, there’s also Lady Bird Lake Hike & Bike Trail. Speaking of Lady Bird Lake, spanning directly across from the NPAC 2022 venue is Congress Avenue Bridge, under which the largest urban bat colony in North America roosts. Yes – bats! We’ve reserved two cruise boats for what is sure to be an incredible adventure and event to remember enjoying dinner on the water with new and old friends and witnessing one of the most incredible wildlife spectacles in the world as 1.5 million adorable fluff balls of darkness put on a spectacular show of dynamic, aerial acrobatics. Space is limited, so make sure you take advantage of our early bird rate and reserve your Bat Cruise spot!  Speaking of registration, in our sincere desire to welcome as many physician advisors and other hospital leaders as possible to our conference, we not only are keeping the discounted early bird rate open through March 15, but we ALSO elected to set the fees to what we had back in 2020. Please check out all of the details here and don’t hesitate to reach out to our NPAC Champion, Dr. Emeric Palmer or NPAC 2022 Chair, Dr. Elizabeth Quinn by sending an e-mail to colleen@frontlineco.com. The event they are preparing will simply be fantastic and I hope to see many of you in Austin, Texas this April!

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV (Pronouns: She/Her) President, ACPA Dr. Juliet B. Ugarte Hopkins is Physician Advisor for Case Management, Utilization, and Clinical Documentation for ProHealth Care, Inc. in Waukesha, WI.

‌ ‌ ‌ The American College of Physician Advisors (ACPA) publishes and distributes materials created by our members and speakers for the benefit of all ACPA members. ACPA does not certify the accuracy or authority of these materials. These materials are distributed and presented as research information to be used by ACPA members, in conjunction with other research deemed necessary, in the exercise of ACPA members’ independent professional judgment. Original and fully-current sources of authority should be researched by ACPA members. ACPA disclaims all liability in relation to reliance on the content of these materials. The views expressed in the materials are the views of the material's authors and do not represent the views of ACPA. Any references are provided for informational purposes only and do not constitute endorsement of any sources.