Editor's Note

Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI

Member, ACPA Advisory Board

Member, ACPA Government Affairs Committee 

Editor, ACPA Update

Happy holiday season to all. We are publishing a short edition this month as many of us are busy with work, the tripledemic of COVID, flu and RSV, and of course trying to find time for family. 

Thank you to all who donated to HealthCareWorkersvsHunger #HCWvsHunger. The Physician Advisor team came in 8th place. That is absolutely amazing. We may be few compared to the winning pediatrician team but we are generous.

The rest of this issue is all Observation. First we present the results of the case presented a few months ago about the elderly gentleman with dementia. The case and responses are provided for your review. 

We then shift gears to the other end of the spectrum with two new pediatric cases. Even if you are an adult physician advisor, be sure to read these cases and submit your answers. The link to enter your responses is found in the article. 

Once again, thanks for all you do for your institutions. This is not glamorous work, and we are unlikely to see an ad in an airline magazine for the nation’s top physician advisors, but our work is crucial. Be proud. 

PEDIATRIC Observation Committee Cases 

Provided by the members of the ACPA Observation Committee

To answer questions, go to https://www.surveymonkey.com/r/K9FMVKX

Case 1 

9-year-old female with no previous medical issues presents to the emergency department with vomiting and myalgias. Symptoms initially started 4 days earlier with ear pain, a low-grade fever, and sore throat. The patient saw the PCP and was started on an oral antibiotic for pharyngitis. In the interim she developed abdominal pain (usually around the time of receiving the antibiotic) and 2 bouts of non-bilious non-bloody emesis. The patient has also had increased thirst, headache, occasional blurry vision, and myalgias. 

Pertinent labs in the ED 

- US Appy: Negative  

- UA: Spec grav > 1.03, pH 6.0  

- VBG: 7.36/pCO2 44.6/HCO3 26  

- BMP: 124 Na, Chloride 90, Bicarb 15.9, Glucose 189  

- CMP: Albumin 2.8, AST 63  

- CBC: WBC 14.6, HgB 21.0, HcT 60.5, Plt 428  

- Urine Na < 20, UOsm 847 

Found to be positive for influenza A. 

Serial sodium measurements were obtained approximately every 4 hours as follows: 

126-128-129-128-130-131-132-134-135 

Due to the hyponatremia out of proportion to the degree of vomiting along with hypochloremia and metabolic acidosis, the team focused on a gastrointestinal process but remained cognizant of other potential diagnoses including several endocrinopathies. 

Patient was here for 2 days, approximately 60 hours. 

1. When the patient was first admitted what was the appropriate status? Please include rationale in comments.  

• Place in observation  
• Admit to Inpatient  

2. When repeated sodium measures showed persistent hyponatremia, what was the proper status? 

• Remain in observation  
• Remain in observation  
• Admit to inpatient  

3. Would your status be influenced if the payer were commercial vs Medicaid replacement? 

• Yes 
• No 

Case 2 

A 5-week-old female presented with 4 days of cough and congestion, with worsening work of breathing on the day of presentation. The PCP was consulted by phone and instructions were given to seek care for increased work of breathing. In the interim the parents had tried suctioning the nose with little success. Oral intake was fair, and the baby had normal wet diapers and stooling. There are several sick contacts in the household. 

Upon presentation to the emergency department a desaturation to 86% with sleep was noted. Supplemental oxygen was started, and the patient admitted for further supportive care. 

Birth history was unremarkable.  

Physical examination revealed a crying but consolable infant.  

VS HR 144, Temp 36.9 rectal, RR 60, BP 103/62. 

Respiratory exam revealed a tachypneic baby with tracheal tugging and coarse breath sounds in all fields. 

Viral panel was positive for RSV. 

Hospital course: 

On HD #1 (approximately 16 hours after arrival to the floor) a trial of room air failed, with desaturation to 84% with sleep, so oxygen was reinstated. A second trial of room air was attempted about 14 hours later. After about 10 hours of monitoring the child was discharged. 

1. What is the most appropriate initial status?  

• Place in observation  
• Admit to Inpatient  

2. If initially observation, would you change to inpatient when the trial of room air failed? 

• Yes 
• No 
• N/A – I would admit to Inpatient from ED.  

3. With high patient volumes and the need to free up beds, how long would you monitor after the second trial of room air? 

• < 6 hours 
• 6-12 hours 
• 12- 24 hours 
• > 24 hours 

4. Are there other ways to support this patient in your system? 

• ED boarder 
• Peds Observation unit 
• Conversion of surgical recovery areas to short stay units 
• Other 

To answer questions, go to https://www.surveymonkey.com/r/K9FMVKX

Observation Committee Case Analysis  

Provided by the members of the ACPA Observation Committee

Case Presentation 

A 74-year-old Medicare fee for service beneficiary with history of hypertension, hyperlipidemia, schizophrenia, type II diabetes mellitus, noninsulin requiring, with A1c of 4.5 presented to ED with complaints of generalized weakness for the past 1 to 2 weeks. Patient had been hospitalized 9 days prior w/ similar complaints and was discharged home with home health services, however patient continues to have weakness and recurrent falls at home. BP 175/62, O2 Sat RA 96%, Pulse109.Glucose: 105, BUN 21, creatinine 0.8 Calcium 11, sodium 146, Potassium 3.6, Bicarb 28, albumin 4, Total protein 7.8, ALT 34, AST 16, ALP 100, Bilirubin 0.7, CK 122, Phosphorus 3.1, magnesium 1.9, TSH 1.5, free thyroxine 1.16, Trop I 48.5, WBC 8.14, hemoglobin 13.2, MCV 83, platelet count 226.The patient was placed outpatient with observation for evaluation of rehab placement evaluation since failed outpatient, hypercalcemia, and diabetes medication adjustment. PT evaluated and recommended SNF placement, but because of patient’s hx of schizophrenia, patient required Level II PASRR (Preadmission Screening and Resident Review). Evaluation from state, for Level II PASRR evaluation, stated it would take 7-10 days to evaluate patient for placement. The patient was then transferred to a sister hospital while awaiting placement as acute medical issues had now been resolved and he continued in observation status. Main hospital was not in a surge capacity issue at the time, however due to waiting period was worried that they may have a bed issue and wanted to move the patient just in case. Patient sat at the sister hospital in observation for 10 days awaiting placement approval from the state for transfer. What is the proper level of care for the first hospitalization?  

Committee Analysis of Responses 

Thank you for your responses. We received a total of 38 responses. The results from those that responded marked 60% in favor of Outpatient services with Observation services (OBS), 24% custodial care, and 16% for inpatient level of care. A review of comments demonstrated a split perspective on hypercalcemia and whether this meets medical necessity to require inpatient level of care or could this be managed in an outpatient setting. Although the patients’ calcium levels were elevated, the concern is whether this is a chronic incidental finding in the patient and if it requires more than IV fluids and better diabetic management to correct.  Both services could be completed under OBS.   

In this case there was an additional question which asked if the status changed when the patient was admitted to the second hospital.  87% of the respondents said no, the remainder said yes.  However, the comments for those that stated yes, questioned some of the concerns that always relates to these case reviews which is, ‘needing some more information’ to see if the patient did have any acute issues related to his schizophrenia, which is why there was a presumption of needing a Level II evaluation from the state for post-acute placement.  In this case what we see is a patient with mild justification for admission due primarily to his social risk factors and inability to independently manage his health in an outpatient setting, compounded by a history of mental illness.  The move to the other hospital does not meet medical necessity, other than unloading beds from the main hospital while the patient awaits placement. The number of days this patient waited for placement is telling that the medical team felt that no other option was available for a ‘safe discharge’ other than SNF or the medical team was apathetic to this patient once transferred and pushing for a more expedient discharge plan. In this case, the patient likely resolved his observation services and was strictly custodial at the other facility while awaiting approval for a post- acute bed.   

Now, what can be done in this case?  Outside the PHE waiver, since the patient had a prior hospitalization that spanned greater than 3 midnights under inpatient status, if this was within 30 days the patient could transfer directly to skilled care from the prior hospitalization. Under the PHE, the 3-midnight ruling does not apply, unless the SNF refuses to accept.  Case management should be aware of this rule so they can quickly evaluate the patient for placement.  Since the patient was determined by therapy to require SNF and there is a clear ‘skilled need’ the patient, despite his schizophrenia, he should not remain hospitalized while awaiting Level II PASRR clearance unless the patient is anticipated to need SNF for greater than 30 days or is discharging from the hospital directly into custodial care.  There was no evidence that the patient was presenting with acute psychiatric symptoms.  Additionally, social work/ case management should identify in the patient’s history if he was classified with Serious Mental Illness (SMI); knowing this would impact the Level I PASRR evaluation and if negative, plus the need for only requiring short-term skilled from the hospital would have generated a negative screen for Level II evaluation.  This would have avoided the unnecessary length of stay and transfer to the sister hospital.  Once the patient is placed in SNF, it is up to the SNF to file an updated screening and Level II PASRR if that patient is planning to exceed their stay beyond 30 days and/or move into custodial care.    

3-Day SNF Rule:  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/SNF3DayRule-MLN9730256.pdf

PASRR: https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review/index.html

December 2022

This is the last President’s Corner in the last ACPA Update of 2022 and the end of my second year as ACPA’s president.  After spending the last 24 months sharing my thoughts, hopes, and moments of pride about the American College of Physician Advisors and the membership we serve, I wanted to step back and allow others on our Board of Directors to chime in. 

Starting with one of our newest BOD members, Elizabeth “Liz” Quinn is in a new position as National Physician Advisor Conference (NPAC) Chair.  The evolution over time of adding two BOD roles associated with NPAC’s planning, performance, and success is a testament to how very impactful and meaningful the conference is for our membership and others within the case/utilization management, CDI, and hospital rev cycle, and even payor worlds.  Liz remarked, “I really enjoyed the Bat Cruise during NPAC 2022.  The bats were cool, but my enjoyment really stemmed from being outside, drinking Corona, dancing to music, and socializing with the people I just spent the last two days with.  As physicians, we tend to always be ‘on.’  But, there is a lot to be said for just "hanging out" with new friends.” 

Physician Advisor Survey Champion, Dr. Alvin “Al” Gore, also believes a huge accomplishment in 2022 relates to NPAC being back in-person but also, that we hosted a second in-person educational event – Essentials & Fundamentals – for the very first time.  In his opinion, second only to this feat is, “Dr. Hirsch’s hairstyle which has persisted since the pandemic.  I know I can’t replicate it!” he laughed. 

On a more serious note, Vice President of Operations, Dr. Ahmed Abuabdou, is proud of ACPA’s creation of Vision 2032, our 10-year strategic planning project.  “This was a disciplined exercise carried out by ACPA leadership demonstrating commitment to the physician advisor community in becoming the professional home for physician advisors.  ACPA is coming along strong!” 

As some of the most accessible ways members can participate in ACPA’s educational efforts, our committees continue to shine.  Dr. Erica Remer, Chair of the Clinical Documentation Integrity (CDI) Committee, is excited about new and active members joining the ranks.  “The ACPA CDI Committee has expanded and gelled to become very active and productive with new leadership under vice chair Dr. Waldo Herrera-Novey and an infusion of new, engaged members.  We look forward to contributing to our fellow physician advisors’ education by collaborating on more town halls, sharing our expertise at NPAC, and creating more CDI resource materials.”  Government Affairs Committee Chair, Dr. Carolyn Dutton, adds, “our committee doubled in size since NPAC 2022 and we continue with a monthly meeting cadence.  We’ve effectively produced town halls to disseminate important regulatory updates to the ACPA membership including one coming up next February about how to obtain inpatient prior authorizations from Medicare Advantage plans on non-inpatient only procedures.” 

Finally, Dr. Clarissa Barnes, Vice President of Member Engagement, is most excited about members stepping out of the shadows into the spotlight.  “This year has been a year of growth,” she said.  “I am so excited to see so many emerging physician advisor leaders presenting at the National Physician Advisor Conference, joining our board of directors, and joining our committees.  I have also been thrilled to see so many colleagues become new physician advisors.  I cannot wait to see what 2023 has in store!”   

From all of us at ACPA, we wish you a fun, relaxing, and safe holiday season.  Here’s to 2023! 

Juliet B. Ugarte Hopkins, MD

(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