In this Update:

Editor's Note

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

Member, ACPA Advisory Board

Member, ACPA Government Affairs Committee 

Editor, ACPA Update

My first talk to a case management audience was over 12 years ago and I still recall how nervous I was. Over the ensuing time, I have given talks before groups of all sizes and no longer get nervous. But it happened at this year’s ACPA National Physician Advisor Conference.  What an audience. Attendees from around the country including so many of the pioneers of the field and many, many new physician advisors eager to learn. I most feared Dr Paul Simmons from Mass General Brigham raising his hand and correcting me, as he did in a conference about 10 years ago. I’ll never forget that and he probably won’t either. And as always, I had so little to say and so much time. Wait, stop, reverse that. Man, I love what I do! I hope you all feel the same about your work. 

What we do it hard! First, you cannot become a physician advisor and give up on your medical learning, even if you are not practicing clinically. You need to continue to keep up with medical and surgical advances (and reversals). And you need to master the many regulatory nuances of hospital operations. And as we have often discussed, there is no single job description for a physician advisor. If you tried to perform all the duties that were discussed at NPAC at your institution, you’d surely do few of them well. 

But hopefully you gained as much from NPAC as I did and you plan to attend the 2024 NPAC in Coronado, California in April, 2024. Mark your calendar now. In the meantime, get on the Whova app and watch the sessions you missed and be sure to read the questions and answers on the app to continue your education and earn a few more CME credits.  

This month we have a great article on teaching clinical documentation by two ACPA members, Drs. Prasad and Briggs. Take a read and click on the embedded link to see the APCA CDI resources page. (A tip- if you are not signed into the ACPA site, you may have to log in then go back to the article and click the link again to get to that page.) 

We also have the results of the January ACPA Observation Committee cases and some new cases for you. As with most months, there was a difference of opinion on the cases. That’s to be expected but we can all learn from each other’s opinions. And remember, without the chart in front of you to be able to answer those “what about the EKG? What was the BP in the ambulance? How did they respond to the Lasix in the ED?” questions that pop up in your head, there are no right or wrong answers. But PLEASE do this month’s cases. You can find them right here: https://www.surveymonkey.com/r/May2023ACPA 

Finally, the Observation Committee wanted me to make members aware about the new FREE educational resource created by the ACPA Observation Committee for members. Currently this page has 4 modules that can serve as quick reference guide for Physician Advisors on various topics related to Observation care. They plan to add more modules throughout the year. You can find the Observation Resource Page here- Observation Resource Page - American College of Physician Advisors Inc. (acpadvisors.org) 

Remember, ACPA is here for you. Tell us what you want, what you need, and what you can contribute. You can always contact me at signaturedoc@gmail.com.  

Responses for January 2023 Newsletter cases

Provided by the members of the ACPA Observation Committee

Seventy-five-year-old female with a history of atrial fibrillation on blood thinner was brought to the emergency room by ambulance after falling at home. She also had a recent fall about a week ago. She said she hit her head but did not lose consciousness. She was placed in hospital bed to be closely observed, especially with blood thinner usage.

Physical therapy evaluation recommended a short-term skilled nursing facility to improve her mobility. The patient also tested positive for COVID with no active symptoms.

Based on freedom of choice, the patient selected two skilled nursing facilities close to her family and was willing to go to either. The social worker contacted both facilities and noted that the first facility required a negative COVID test before admission, and the second facility could not accommodate the patient for another three days due to staffing shortage. Noted, the hospital also has one floor closed due to staffing shortage as well; at the same time, the hospital has outside transfers lining up to be admitted urgently.

Since this patient highly likely will not be discharged for several days, what is her most appropriate status, outpatient/observation or inpatient?

Q1: The case facts may support one status or another. About 88% of the respondents recommended observation/outpatient status. Since this fall is fresh and was associated with a head injury for someone on blood thinner, observation is appropriate to do frequent examinations and neuro checks to ensure the patient did not have any intracranial bleeding or other occult injuries. In a different scenario, assuming the fall happened several days earlier, and the patient never had any symptoms or objective findings, admitting the patient to a hospital bed will become custodial as the goal is to arrange for a skilled nursing admission and not medical. Neither observation nor inpatient is appropriate under such circumstances.

The history did not give enough facts regarding what happened during the stay, which could determine the medical necessity that support an inpatient level of care. For instance, if the patient has a prolonged change in mental status, hypoxia requiring oxygenation and complete treatment for Covid, or extended monitoring, at that point, the medical necessity will be established for inpatient status, which should be strongly considered. Without these additional medical factors, the long stay becomes a discharge issue, not supporting an inpatient level of care.

With the need for hospital beds to accept urgent transfers, what is the best way to handle this discharge dilemma considering the patient's medical condition is stable to be discharged and can be managed in a skilled level of care?

Q2: In healthcare, we always face multiple priorities simultaneously. While we must protect patients' freedom of choice and the right to choose what facility they want to go to, at the same time, hospitals must provide care for other patients who might need a hospital bed. Although occasionally, circumstances could delay transfer to SNF, such as no bed available or very restrictive policies at the skilled nursing facility that require a negative Covid test before the transfer, in such cases, it’s not unreasonable to go back to the patient and ask for additional choices, for facilities of their choice, and have available beds or less restrictive policies. Thus, 75% of you felt the next best step in management of this patient would be to expand referrals. 

About 20% of the respondents favored the option of issuance advanced beneficiary notice. This is where discussion with patient/family about alternate options is extremely helpful. Some hospitals may also use this is an indicator to stop observation billing clock and delineate the rest of the care to be custodial in nature. Additionally, ABN and HINNs do not cover every scenario, as they have very specific requirements. 

There are many challenges imposed on healthcare due to the pandemic; what are your thoughts regarding how healthcare system should act differently, especially when facing staffing shortages?

Q3: This question created various answers, as no single solution can solve this dilemma. With the current staffing challenges, many hospitals had to close many floors and reduce their capacities. This pressured healthcare to save hospital beds for those who can only be treated in a hospital setting and increased the consideration of alternative options. Many responders to this question emphasized the need to optimize outpatient resources. Emergency rooms face difficulties sending some patients home when there’s no guarantee that someone will see them within a reasonable time. Hence, they end up admitting those patients for safety concerns. Increasing outpatient access and helping patients schedule their appointments will reduce the so-called soft admissions. Another area brought up is the need to revisit the current discharge to skilled nursing facility model, as it requires a cumbersome precertification process. Hospitals, skilled nursing facilities, and health plans should align and establish a seamless process. Programs such as ED to SNF or floor to SNF that require no front-end authorization reduce the unnecessary utilization of hospital beds waiting for a pre-cert to be approved, especially when a weekend is in the middle. Waiver programs seen during the pandemic should not be activated only when there is a crisis. Holding a patient at the hospital until a Covid test is negative is another issue that needs to be revisited, as SNFs might be able to accept these patients and isolate them instead of delaying their transfer. Finally, going home with family support and home care is a valid option. Like any other service, home care does not have unlimited resources, and careful selection to what cases will require home care will spare these resources for those who need it the most.

80-year-old male with past medical history of CVA, HTN, Atrial fibrillation on Xarelto who presents with brief episode of tingling in left arm. Initial CT head is negative for any acute process. By the time hospitalist comes down for evaluation, patient’s symptoms have resolved. Patient is placed in Observation status for TIA with expected LOS of 1 Midnight. Hospitalist orders the stroke order set which includes neurology consultation, neurological assessments, ECHO and MRI/MRA to rule out acute CVA. After 1 Midnight, the physician advisor reviews the case and notes patient has no recurrence of symptoms. Patient’s MRI/MRA is negative for acute process. However, given atrial fibrillation on anticoagulation, the attending does not want to discharge prior to ECHO being completed. Unfortunately, the ECHO team is backed up and may not be able to perform the ECHO until the next day.

Since the patient is expected to spend a 2nd midnight pending ECHO, what status do you recommend?

Q4: With a national shortage of ultrasound techs, many health care systems are likely seeing delay in routine testing like ECHO. Almost 85% of the respondents felt patient should be continued in observation status but out of that about 74% felt avoidable delays should be charted on ECHO department. A small subset of 6% of the respondents felt the 2nd midnight of pending ECHO is appropriate for Inpatient status as CMS allows for 24 hours to obtain tests. Best practice would be to chart avoidable delays and share date with UM committee to see where barriers exist in the system to improve LOS for these observation patients. 

After 2nd Midnight, ECHO is performed but it is 5pm and there is still no final read on the ECHO.

Q5: Again here about 85% continued to recommend observation with about 70% again recommending charting avoidable delay. 0% recommend inpatient order here due to new finding of ECHO performance while 8% continued to recommend inpatient as they did in the prior question. Many recommended more practical solutions like contacting the cardiology for a verbal read or discharging the patient with outpatient follow up of results. Comments also included adding modifier to the claim to remove any excess charges for the care provided while pending ECHO due to avoidable day. 

Would your status recommendation change if this patient was Medicare fee for service or Medicare Advantage?

Q6: Given the recent news about CMS release of CMS-4201-F, CMS codified the requirement that Medicare Advantage plans must follow the Two-Midnight Rule. If we were to re-survey, maybe the % of responses will change. However, since this survey was sent prior to the CMS news, about 26% said their recommendation would change if this was a Medicare Advantage payer. Reasons included that Medicare Advantage does not follow the Two-Midnight rule and if a denial was issued it would not be winnable on a peer to peer. However, 74% of the respondents said their response would not change based on payer. Based on the comments it seems majority of those respondents would not change recommendation as ECHO can be performed outpatient and there was an obvious delay in care.

Training the Trainees in the Art of Clinical Documentation - Making the Case for “Catching Them Young” 

Rupesh Prasad, MD, CPE, FACP, CHCQM-PHYADV, FABQUARP 

Member, ACPA CDI Committee 

Heather Briggs, MD, PHD, FACP, CHCHM-PHYADV, CCDS 

Member, ACPA CDI Committee 

Clinical documentation serves a key role in communication among the members of a multidisciplinary patient-care team. In addition to being a legal record of all the events, it plays a central role in handoffs and transitions across care settings. The information contained in documented medical records is also used to report outcomes and quality metrics for hospitals, health systems, frontline career providers, and for reimbursement and revenue cycle management. Lastly, it aids in research into disease processes, population health, and policy development. 

Trainees which include residents, advanced practice practitioners (some institutions have fellowships) and medical students are responsible for the majority of documentation in academic medical centers. Despite this, many programs do not offer any formal education on clinical documentation, and trainees also lack an understanding of its importance. A recent article on a quality improvement project on clinical documentation integrity (CDI) involving residents from the University of Kansas Health System revealed that residents perceived CDI and queries as a primary means for financial gain, benefitting the hospital and their faculty physicians (Rouse et al., 2022). A survey in ACGME-accredited programs on the perceptions of residents on clinical documentation and patient care revealed that most considered documentation obligations excessive, compromising time spent with patients, and negatively affecting patient care (Christino et al., 2013). Research into documentation of trainees reveals that the writing process plays a pivotal role in supporting thinking in patient care, rather than just a means for communication (Bowker et al., 2022). The physician advisor plays a key role in this education as demonstrated in an article that described a physician-led initiative that resulted in an increase in Case Mix Index (CMI) with improved documentation of major complications/comorbidities on inpatient vascular surgery patients (Aiello et al., 2018).  

There is a multitude of interventions that could be used to educate and guide trainees in clinical documentation as a skill set during training. Physician advisors and CDI specialists can partner with program faculty to plan interventions ranging from formal didactics, and presentations on topics, to elbow-rounds and case-based discussions. They could also include involvement in PDSAs (Plan-Do-Study-Act) and query response processes that could provide the trainees with additional exposure to quality improvement (QI) processes. 

In our health system, we have been successfully engaging our trainees including residents and their faculty. Explaining the need to focus on clinical documentation to capture the severity of illness, and its impact on patient safety and outcomes, while simultaneously being beneficial to the trainees in improving efficiency and reducing time spent in documentation has been successful in increasing engagement with the CDI team. We regularly partner with CDI specialists to present on high-yield topics identified through queries. In addition, residents get additional exposure to CDI during their elective focused on Care Management and Quality. The trainees can also participate in projects, sparking enthusiasm, and enabling them to assess the impact through measurable outcomes. 

Interventions geared towards teaching effective and accurate clinical documentation to trainees early in their careers, are likely to be hardwired and sustained in their future. 

The CDI Resource site provided by the ACPA through its CDI Education Committee serves as a great resource for tips on providing Clinical Documentation education to the trainees. Material on trainee education is to be uploaded imminently. 

What strategies and processes do you have at your institutions to impart clinical documentation education to your trainees? We would love to hear and learn from them. Please feel free to reach out to dr_rupesh01@yahoo.com or aggiemd00@gmail.com.

References: 

1. Rouse, M. W., Jones, M. D., Zogleman, B., May, R., Ekilah, T., & Gibson, C. A. (2022). Resident integration with inpatient clinical documentation improvement: a quality improvement project. BMJ Open Quality, 11(2), e001300. https://doi.org/10.1136/bmjoq-2020-001300 
2. Christino, M. A., Matson, A. P., Fischer, S. A., Reinert, S. E., DiGiovanni, C. W., & Fadale, P. D. (2013). Paperwork Versus Patient Care: A Nationwide Survey of Residents’ Perceptions of Clinical Documentation Requirements and Patient Care. Journal of Graduate Medical Education, 5(4), 600–604. https://doi.org/10.4300/jgme-d-12-00377.1 
3. Bowker, D., Torti, J., & Goldszmidt, M. (2022). Documentation as composing: how medical students and residents use writing to think and learn. Advances in Health Sciences Education. https://doi.org/10.1007/s10459-022-10167-x 
4. Aiello, F., Judelson, D. R., Durgin, J., Doucet, D. R., Simons, J. P., Durocher, D., Flahive, J. M., & Schanzer, A. (2018). A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin. Journal of Vascular Surgery, 68(5), 1524–1532. https://doi.org/10.1016/j.jvs.2018.02.038 

Rupesh Prasad is a Hospitalist, Informaticist and Medical Director Care Management with Advocate Health in Milwaukee, Wisconsin. 

Heather Briggs is a Hospitalist and CDI Learner Medical Director with University of Colorado School of Medicine and UCHealth at University of Colorado Anschutz Medical Campus in Aurora, Colorado.  

Observation Committee Newsletter Cases for May 2023

Provided by the members of the ACPA Observation Committee

Read the cases and submit answers here: https://www.surveymonkey.com/r/May2023ACPA

Case 1  

A 68-year-old male with CHF, ESRD, DM2, permanent AF, prior CVA with hemiparesis, and known nonadherence to meds including insulin and warfarin presented to the emergency room after missing last hemodialysis session. He was asymptomatic.  Blood pressure was 220/100; K was 6.3, INR 1.2, glucose 375, and INR 1.2. 

What’s the most appropriate status for this patient? 

1. ED Discharge  
2. Place in Observation Status 
3. Outpatient Status in Bed (Custodial Care) 
4. Admit to Inpatient Status 

Case 2  

A 75-year-old woman with DM and HTN presented at 2200 to a rural hospital with unilateral vision loss.  Head CT and remainder of exam was normal.  Creatinine was 2.5 from baseline of 1.3.  Hospitalist is called for admission who recommends transfer to urban hospital due to lack of neurologist at the current hospital. ED team is insisting on at least posting orders until there is acceptance for transfer from urban hospital.  

What status is appropriate?  

1. Place in Observation Status 
2. Admit to Inpatient Status 
3. ED to ED transfer  

The hospitalist starts the admission process. An admit to inpatient status order is placed and H&P is completed with plan of care to transfer to urban hospital when next bed is available. Patient is still boarding in the ED when a bed becomes available at the urban hospital. A few hours later around 0400 am, patient is transferred from the ED directly to the urban hospital without arriving on a floor unit at the rural hospital. The case is caught in your short stay self-audit process for a review if it is appropriate for an Inpatient claim.  

What status is appropriate? 

1. Admit to Inpatient status with transfer exception 
2. Self-denial with Condition Code W2  
3. ED Discharge  

May 2023

What an amazing event the 2023 National Physician Advisor Conference (NPAC 2023) was! With 343 individuals present in person and another 112 watching sessions virtually from their home or office, it was our largest and most comprehensive event, yet. The desire to interact, collaborate, and meet new connections among the attendees was palpable with every break and shared meal which makes me tremendously pleased about our decision to extend next year’s NPAC in Coronado, California to three-and-a-half days April 15 – 18, 2024. Sun, sand, and a gorgeous resort filled with physician advisors? Make sure to block off your calendars, now! 

Drs. Scott Ceule and Stephanie Van Zandt as NPAC 2023 Co-Chairs (see their AWESOME photo from the conference below!) and Dr. Liz Quinn as NPAC Chair welcomed dozens of speakers, many first-time presenters for our college, to the stage. Seeing so many new faces share their experiences and recommendations for excelling in the physician advisor role was really satisfying. On the other end of the spectrum, treasurer and past president Dr. Charles Locke and I were honored to present the 2023 Dr. Ronald Rejzer Distinguished Achievement Award to Dr. Lawrence Field, a founding member of ACPA and the College’s first treasurer from the start of the organization in 2014 into 2020.   

Larry was responsible for the development of the method to initially fund ACPA – monitoring and reconciling all financial aspects for cash, credit, merchant accounts, banking, and insurance relationships for the College. In addition, he compiled all financial reporting as required by law. Dr. Field was an integral decision-maker within the Executive Committee and Board of Directors and successfully guided the financial well-being of the organization from a start-up into an organization that has the financial resources and stability to support the physician advisor community at the highest level free from commercial bias. A photo of Charlie, Larry, and me can be found below and you can find ALL of the shots taken by our photographer at NPAC 2023 at https://galleries.jmphotochicago.com/Clients/ACPA-NPAC-2023/ (use password "moss"). Speaking of photos – thanks to all who shared theirs on the Whova app! I loved seeing the comradery on full display and can’t wait to enjoy more next year…beside the Pacific Ocean! 

Juliet B. Ugarte Hopkins, MD

(Pronouns: She/Her)

President, ACPA