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

Didn’t get around to doing the Observation Committee cases last month?  Well, I am in a good mood so I am not going to name names and single out the people who did not respond since you know who you are (and all responses are anonymous so I really have no idea who did or did not respond). But please do it. Your colleagues took the time and effort to write these questions. So stop reading and click this link to review the cases and answer: https://www.surveymonkey.com/r/32Z9RJN.   

Have you booked your hotel for NPAC? Don’t wait; get a room at the conference hotel so you can sleep as late as possible and just stumble down to the conference room after a fun night of socializing or chasing your kids around The Wizarding World of Harry Potter. Dr. VanZandt has some other compelling reasons to go so read her article and find a link to the registration page. 

The rest of this issue is full of great stuff. Drs. Raghavan and Fong write a compelling article justifying the use of a PA. Dr. Remer and Dr. Barnes have fantastic CDI articles on surgical complications and anemia respectively. As editor I have read their articles several times and each time I learn something new.  

You have probably seen the notification that the ACPA Board has chosen Dr. Clarissa Barnes to be the next ACPA president. Dr. Ugarte Hopkins has asked her to write this month’s President’s Corner so be sure to read that. 

Finally, if you have not yet submitted your comment to CMS on their proposed MA rule, read Dr. Dutton’s article on how ACPA has made it easier for you to help drive the MA plans to long-overdue accountability.  

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.  

Getting Your Surgeons to Document Complications Appropriately

Erica Remer, MD, CCDS

Member, ACPA Board of Directors

Chair ACPA CDI Committee 

When I was a physician advisor, one of my biggest challenges was getting in front of and motivating surgeons to document the patient encounter. One of their, and CDI’s, biggest concerns is triggering patient safety indicators (PSIs) and having their quality metrics look bad. If there is a righteous complication, the provider should own it, and the clinical documentation integrity specialist (CDIS) shouldn’t try to eliminate it from the record. If the documentation suggests a complication which didn’t really occur, then a query may be necessary to get the verbiage corrected to paint an accurate picture of the encounter. 

In my opinion, the only thing more annoying to a provider than receiving a query about whether there was a complication when there wasn’t one, is receiving a query when CLEARLY there was one. I saw a case where a pacemaker wire punctured a coronary artery resulting in an emergency bypass and the CDIS queried to see if this was “integral to” the procedure. C’mon, man!  

In October 2022, the ICD-10-CM Official Guidelines for Coding and Reporting were revised regarding Documentation of Complications of Care. In essence, they determined that the condition must be “clinically significant,” but the provider doesn’t have to explicitly label it as a “complication.” If the course of the surgery can be perceived to have been altered, then the guidelines state it is appropriate to report a complication code. If the documentation or the circumstances are not clear, then a query for clarification may be indicated. 

PSIs evolve, and the physician advisor should be aware of the current specifications which can be found at https://qualityindicators.ahrq.gov/measures/psi_resources. It is important to be aware of the inclusion and exclusion criteria. I think the surgeons need to know some basic information about the PSIs in question, but then I decided to distill the issue down to some basic questions. Here is the information sheet I have devised for PAs to share with their surgeons: 

Information for Surgeons regarding PSIs 15 and 9 

• An accidental puncture or laceration implies a surgical complication in coding; traumatic injuries like stab wounds do not qualify. Not all accidental punctures or lacerations trigger the Patient Safety Indicator (PSI) 15, Abdominopelvic Accidental Puncture or Laceration Rate (PSI 15 Accidental Puncture or Laceration specs). The key points are: 

• The patient must undergo a second abdominopelvic procedure one or more days after the index procedure (during which the accidental puncture or laceration was incurred) 
• The accidental puncture or laceration cannot be present on admission (POA-Y would indicate that you did not cause it on this encounter) 

• However, PSI 15 may not be the only quality reason why organizations scrutinize accidental punctures or lacerations. We want to ensure that accidental punctures and lacerations are identified when they occur to see if there is necessary remedial action to prevent future occurrences, and that accidental punctures and lacerations are not coded when they are not present, due to misconstrued verbiage. 
• The coder has specific guidelines regarding documentation of complications of care (ICD-10-CM Guidelines for Coding and Reporting, I.B.16.): 

• There must be cause-and-effect between the surgery and the resultant condition 
• The documentation must support that the condition is “clinically significant” 
• The provider does NOT need to explicitly call it a “complication” 
• If the condition alters the course of the surgery, it is appropriate to report a complication code 
• If the documentation is not clear as to whether there is a cause-and-effect relationship, whether it is clinically significant, or whether the course was altered, a query for clarification is indicated 
• N.B.: If you use the word, “postoperative” or “postprocedural,” the coder infers a causal relationship as opposed to a temporal reference. 

To decide whether an occurrence/event was, and should be documented as, an accidental puncture or laceration, the surgeon can ask themselves a key question with several follow-up questions: 

• Should I be considering and documenting an occurrence/event as an accidental puncture or laceration which will result in a specific ICD-10-CM code indicating a “complication?” 

• Was the occurrence/event/action integral to or inherent to the procedure? Was it intentional? (E.g., in order to resect that tumor, you have to incise the bowel. That is inherent to the procedure. Or an adhesion is so thick and tightly fixed that the ureter must be transected and anastamosed because the adhesion could not be peeled off)   

• Yes, it was à not accidental puncture or laceration. [Document something like: In order to resect the tumor, the right colon was transected in the usual fashion and a primary anastomosis was undertaken.] 
• No, it was not à potentially a complication. Go to next question to explore further. 

• How often does this type of occurrence/event occur? 

• This commonly or sometimes occurs in this type of surgery with this type of pathology even to a highly experienced surgeon, was unavoidable à may not be considered accidental puncture or laceration. Go to next question. [Document something like: In the course of freeing up the mass from the stomach to which it was strongly adherent, the tissue was noted to be friable. This was not unexpected and hemostasis was attained using the electrocautery.] 
• This rarely occurs during this type of surgery with this type of pathology and was not expected à consider this an accidental puncture or laceration.  [Be aware that words like “complication of, accidental, inadvertent, unintended, unexpected, we caused” could signal to the coder that you acknowledge that this was an accidental occurrence.] 

• Did you or would others think the occurrence/event was clinically significant? 

• No, it was a minor, trivial, inadvertent occurrence which did not require any significant attention or expenditure of resources; there was no change in course of surgery (e.g., superficial, small serosal tear which required a few simple sutures to oversew it) à not accidental puncture or laceration [Document something like: In the process of releasing the bowel from the adhesions, a small serosal tear due to adhesions occurred and was easily oversewn. There was no alteration of course of surgery and no adverse effects anticipated.] 
• Was there an occurrence/event which was not as a result of the surgery, per se, but due to the pathology being addressed or underlying conditions or comorbidities (e.g., a highly vascular tumor bleeding, more than typical bleeding due to coagulopathy from advanced liver disease)? à not accidental puncture or laceration 
• Was there an occurrence/event (which was attributable to the procedure as opposed to the pathology) which significantly concerned you, caused you to take unusual action, put the patient at greater risk for further complications, altered the course of the surgery, increased the length of the procedure, required additional/not routine resources, or changed the disposition/status of the patient (would have gone home but instead got admitted inpatient or placed into OBS) à accidental puncture or laceration  [For instance, a small enterotomy that is easily oversewn and poses no further risk may not necessitate diagnosis of an accidental puncture or laceration, whereas a larger one which spills bowel contents into the abdominal cavity and requires bowel resection, washout, unscheduled antibiotics, or placement into OBS or full admission would constitute an accidental puncture or laceration. Another example would be if there was an event which precluded the use of mesh, when that would have been the standard of care, for fear of contamination due to accidental spillage. That should also be documented and count as an accidental puncture or laceration.] 

• Words which might convey that the surgeon does not deem the occurrence/event accidental include: necessary, required, intentional, unavoidable, routinely expected, and as part of the pathology…  
• The most important thing is to tell the story of the encounter and TELL THE TRUTH. It is unreasonable to believe that a surgeon will never have a complication. The intent of PSIs is to identify individuals who have more than their share of complications and determine if a quality review or change in process is in order. 

To summarize decision points to determine accidental puncture or laceration: 

• Integral/inherent to, unavoidable? 
• Common occurrence or unexpected and rare? 
• Clinically significant? 
• Changed course of surgery or disposition? 

• While we have your attention, let’s talk about PSI 9, Postoperative Hemorrhage or Hematoma for a moment (https://qualityindicators.ahrq.gov/Downloads/Modules/PSI/V2022/TechSpecs/PSI_09_Postoperative_Hemorrhage_or_Hematoma_Rate.pdf). These are the two inclusion criteria which cause a patient to fall into PSI 9: 

1. There must be an ICD-10-CM code of postprocedural hemorrhage or hematoma, as opposed to an intraoperative issue (although the latter might result from an accidental puncture or laceration) AND 
2. A procedure to treat the hemorrhage or hematoma must ensue (e.g., evacuation/drainage, occlusion/restriction, repair/revision, resection/excision, control of bleeding) 

• In terms of the postprocedural hemorrhage or hematoma documentation and coding: 

• Is it clinically significant? For example, a small hematoma which requires no intervention and is not painful or impairing function, does not require imaging or other investigation, might be noted in the physical examination but need not be formally diagnosed in the impression list and coded if the clinician does not believe it rises to the level of being clinically significant. Clinical significance is somewhat subjective; a small hematoma of the parathyroid may be more significant than a similar sized hematoma of the abdominal wall. 
• Was action necessary? For instance, if a diagnostic ultrasound to rule out continuing bleeding is needed, if the blood loss is so significant that the patient needs transfusions, or if a procedure is undertaken to address the condition– these would be examples of actions which would support a secondary diagnosis of clinically significant postprocedural hemorrhage or hematoma. 
• If no procedure was necessary, a diagnosis of a postprocedural hemorrhage or hematoma may be appropriate but that alone will not trigger PSI 9. 

• Exclusion criteria for PSIs are important. 

• D68.32, Hemorrhagic disorder due to extrinsic circulating anticoagulants, D68.4, Acquired coagulation factor deficiency, and thrombocytopenias are exclusions for PSI 9.  [Since no one is going to use that precise terminology, there are guidelines allowing coders to pick up these diagnoses from other verbiage. To capture D68.32, the surgeon needs to document something like: Bleeding worsened (or “exacerbated by, complicated by, increased due to”) due to coagulopathy from anticoagulation (or specific anticoagulant like warfarin, enoxaparin, etc.). D68.4 can be coded from Coagulopathy due to liver disease. Link the coagulopathy to the cause.] 



• D62, Acute posthemorrhagic anemia or acute blood loss anemia (ABLA) may be seen with either PSI 9 or 15. This constitutes a comorbid condition or complication (CC) which indicates higher severity and complexity of the encounter. D62 is NOT an adverse quality indicator. If there is a drop of 2-3 g of hemoglobin due to bleeding, most providers would consider making the diagnosis. Surgeons should not avoid using the diagnosis, erroneously thinking they will be dinged for it.  A patient does not have to be transfused to diagnose D62, but best practice is to document what action is being taken (e.g., will recheck H/H q 6 hours and will transfuse if < 7 g/dL or symptomatic at < 10 g/dL; administering Venofer®). It is best practice to link with the cause (e.g., ABLA due to the ruptured mesenteric artery, as opposed to being inferred as being due to the surgery). ABLA due to a laceration during a procedure suggests “clinically significant.” Run through the other questions to determine if this occurrence/event should be considered an accidental (puncture or) laceration. 

Hopefully you can adapt this information to share with your surgeons. Good luck!  

Dr. Erica Remer is founder and president of Erica Remer, MD, Inc. 

Government Affairs Committee Comment on CMS 4201-P 

Carolyn Dutton, MD, FACP, FACEP 

Member, ACPA Board of Directors

Chair, ACPA Government Affairs Committee 

The American College of Physician Advisors (ACPA) Government Affairs Committee (GAC) has been hard at work developing a formal comment to the Centers for Medicare and Medicaid Services (CMS) on the recently published CMS 4201-P. This proposed rule details policy and technical changes affecting the Medicare Advantage (MA) Program as well as several other areas of focus. We extend a huge thank you to Drs. Ronald Hirsch and Edward Hu for their stellar work!  

A notice was recently sent out to ACPA members encouraging enlistment of physician advisor comments to CMS regarding their experiences with Medicare Advantage Organizations (MAO). In the template we created for anyone to use, we asked that CMS require MAOs to abide by the Two Midnight Rule and apply peer-reviewed journal and evidence-based consensus statements in lieu of commercial screening criteria to make status determinations. We discuss that inpatient stays of two midnights or more should not be the focus of inpatient utilization review. Regarding skilled nursing facility (SNF) care, we ask that CMS establish a minimum number of days of initial coverage, recommending seven, prior to delivery of a Notice of Medicare Non-Coverage. We commented that MA plans should adopt the same coverage criteria as Traditional Medicare regarding inpatient rehabilitation facility (IRF) stays and recommend that MA plan readmission policies be no more restrictive than those of Traditional Medicare.  

The proposed rule, as well as the GAC, also supports the creation of MA plan utilization management committees. Furthermore, we reinforce that the medical director for the plan must have direct access and responsibility to review the same source information as physician advisors for an organization when issuing a determination. We suggest that MA plans adjudicate a requested level of service based on Traditional Medicare criteria. In addition, we would like to explicitly include mental health conditions in the definition of emergency medical condition (EMC) and ask that medical necessity denials for hospital services rendered prior to stabilization of the EMC be prohibited.  

Hospitals frequently provide emergency services that MAOs are statutorily prohibited from requiring prior authorizations on yet are financially responsible for that care. Some MAOs then issue medical necessity denials retrospectively because there was no prior authorization. This also occurs when an MAO does not include a basic or supplemental service benefit on its prior authorization list and then upon retrospective review for medical necessity, issues a denial. This is not the intent of CMS. For care exempted or prohibited from prior authorization, we ask for protection from retrospective medical necessity denial. 

Here is the link to the proposed rule. At the top right of the page is a green button which allows you to “submit a formal comment” which is where you can paste your edited version of the comment template. Underneath the green button is the option to select and read previously submitted comments. Please note that as of January 26, only 78 comments have been submitted to CMS. The ACPA is now more than 1,000 members strong. We urge you to submit your comments to CMS before the February 13th 5:00 PM EST deadline including your own experience regarding MA plans. Here again is the link to the ACPA template which you may elect to use and alter for your own purposes. As a group as well as for the patients we represent, we must make our voices heard! 

Dr. Carolyn Dutton is the Director of Operations for Physician Advisor Services at Atrium Health in Charlotte, NC.

Acute Blood Loss Anemia (D62): In Denials, Not All Literature is Created Equal 

Clarissa Barnes, MD, FACP 

President-Elect, ACPA 

Anyone who works clinical validity denials knows that there are some diagnoses that seem to crop up over and over again. One of my favorite “habitual offenders” in the realm of frequently denied diagnoses is Acute Blood Loss Anemia (ABLA), also known as acute post hemorrhagic anemia. The reasons insurance companies and other payers cite to deny can be variable, but lately there has been a concerning trend of using scientific and medical literature inappropriately to deny valid ABLA diagnoses. It can be intimidating when you receive a denial with multiple citations explaining why this patient does not have anemia and therefore cannot have Acute Blood Loss Anemia. However, when validating a diagnosis, not all literature (no matter how great the source) should be equally weighed.   

What is considered to be “enough” blood loss to qualify for ABLA has sometimes been a debate. Personally, I subscribe to the very precise definition of “it depends on the clinical scenario.” In the right context, 1-2 g/dl is plenty, especially when the patient is already starting from a lower value. A 1g/dl change is often cited as not significant enough to be a true drop, but the patient acutely bleeding who just went from 8 g/dl to 7 g/dl (and therefore just lost 12.5% of his/her blood) would beg to differ.   

While there is room to discuss and debate how much blood loss is enough, what constitutes anemia has generally been accepted as standard. The World Health Organization’s definition of anemia is specific to gender and gravid status. Specifically the definition of anemia is:  

• Hemoglobin is less than 13 g/dl in males  
• Hemoglobin is less than 12 g/dl in females  
• Hemoglobin is less than 11 g/dl in pregnant females (or immediately post-partum).  

(If you’re looking for some great additional CDI resources on ABLA and other diagnoses, check out the Clinical Documentation Committee page on the ACPA website here.) 

ABLA is often the only CC on a chart and can look like an easy target for payer denial. After all, removing the only CC moves the DRG and decreases what they need to pay.   

Unfortunately, there appears to be an emerging trend to deny the diagnosis of ABLA citing sources with different criteria for anemia. After all, you cannot have ABLA without anemia, right? (If the lowest value does not reach a threshold for anemia, then you have R71.0, precipitous drop in hematocrit).   

The most egregious attempt to discredit ABLA by arguing the definition of anemia is by using the citation of the Common Terminology Criteria for Adverse Events (CTCAE) which indicates that anemia is defined as a hemoglobin of 10 or less. (1) Using the CTCAE to negate the diagnosis of ABLA is inappropriate since this definition of anemia is not meant to be applied to the general population. These criteria are to clarify what is considered an adverse event in patients using therapies for cancer. “These criteria are used for the management of chemotherapy administration and dosing, and in clinical trials to provide standardization and consistency in the definition of treatment-related toxicity.” (2) In other words, this definition is strictly to clarify and track possible adverse events related to chemotherapy and is not meant to be used to define anemia for patients with acute blood loss.   

The other, albeit less common, strategy is to try to use the more restrictive WHO definition with a hemoglobin level of less than 11 g/dl (meant for pregnant patients) in non-pregnant patients. This is obviously also not correct since there are separate definitions for non-pregnant people for a reason.     

Both of these strategies use literature that is scientifically accepted (whether it’s using the CTCAE or the WHO) but in an improper way. Do not get caught off-guard by the source of the citation but take the time to find out what the scope of evidence is. A winning appeal in this scenario explains not only why the WHO definition is correct, but also why the other definitions are wrong.    

Citations:  

1. Common Terminology Criteria for Adverse Events (CTCAE) Version 5.0 Published: November 27, 2017 by the U.S. Department of Health and Human Services. National Institutes of Health National Cancer Institute. https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/ctcae_v5_quick_reference_8.5x11.pdf  
2. Common Terminology Criteria for Adverse Events. UpToDate. https://www.uptodate.com/contents/common-terminology-criteria-for-adverse-events#:~:text=CTCAE%20stands%20for%20Common%20Terminology,cancer%3B%20causality%20is%20not%20required.  

Dr Barnes is system physician advisor for UR and CDI at Avera Health. 

NPAC is Coming! Will You Be There?

Stephanie Van Zandt, MD 

Vice-Chair, NPAC 2023 

It’s that time of the year, with the excitement of the holidays past us, to start revving up your engines to incite impactful change in your healthcare facilities; New action plans and initiatives to improve the patient transition of care through your hospitals. So, what does this have to do with NPAC 2023? Well, to paraphrase the lyrics from the song, Danger Zone: it’s time to spread your wings and jump into (PA) overdrive! The NPAC 2023 Planning Committee is super excited and hard at work to provide an exciting and transformative conference April 17th-19th for physician advisors, new and old! We have a full-throttle agenda with a wide-spectrum of topics to pique your interest, ranging from the seemingly drab regulatory update promised to be sprinkled with the spiciness of Dr Hirsch’s profound explanations to intriguing UM scenarios from a pediatrician to the rest of us adults medicine practitioners who have no idea what drives the TIKTOK generation. And as part of our mission, a TOP GUN expert will impart secrets of effective leadership in complex organizations. We are planning on giving you all the tools for success to establish yourselves as a tour de force at your healthcare facilities so that your C-Suite leadership can’t live without you! 

Physician Advisors are called upon to solve complex problems and bridge departmental silos to create processes and outcomes benefiting their facilities and health system. The focus of the 2023 National Physician Advisor Conference is Physician Advisors serving as mavericks of change transforming their roles to meet the needs of a multi-faceted, rapidly changing healthcare environment. Physician Advisors produce transformative value within all aspects of healthcare especially in the ability to adapt to new challenges, provide insight for health systems, and create collaborative efforts across the spectrum. As the Physician Advisor role transforms and leads change, this conference is a perfect fit for your professional engagement, discourse, and shared experiences.   

Ok, now why you should really attend NPAC 2023: the cool swag promised to be a hit due to the awesome logo and theme for NPAC 2023: Mavericks of Change – The Transformative Value of Physician Advisors (aviator sunglasses optional); the endless love of your family because you brought them the center of the fun-universe: Orlando Florida; experiencing the raucous OSV Quiz Bowl; making new and old connections at Dine with the Docs; or simply for the unsurpassed value of in-person networking with your peers. 

The agenda is set and our nationally recognized experts and first-time phenoms promise a thrilling, rapid paced conference to make you the TOP GUN at your healthcare facility. Please register on the ACPA website: NPAC 2023 | Welcome - American College of Physician Advisors Inc. (acpadvisors.org) 

Dr. Van Zandt, MD is Medical Director Physician Advisor Services and Utilization Management/Complex Managed Care Denials at BayCare Health System.

Enhancing the Revenue Cycle Through Streamlined Physician Advisor Programs 

Siddharth Raghavan, MD, FACP, CHCQM-PHYADV 



Ronald L. Fong, MD, MPH, MBA  

A surefire way to enhance your revenue cycle operations is through developing an internal physician advisor program. Doing so enhances an organization’s healthcare mission and clarifies financial stewardship. There are compelling cases for healthcare systems to invest in an internal physician advisor. For example, a previous study calculated physician advisor interactions approached $2 million in annual savings from audit reductions, decreased billing errors, and reimbursement loss in reviewing chronic obstructive pulmonary disease MS-DRGs for a 250-bed hospital.  Accurate capture of patient placement has also shown a 50% reduction of commercial insurance denials. 

Physician advisors can also reduce costs associated with compliance and regulations. In 2017, the AHA reported $39 billion per year cost for quality reporting requirements with an average-sized community hospital cost of $7.6 million per year to support compliance efforts with federal regulations. The physician advisor mediates the balance between revenue integrity and audit risk through patient placement reviews and analysis of quarterly CMS PEPPER findings to determine risk for improper payments based on practice patterns.    

The decision to hire a physician advisor yields benefits beyond financial ones. Outsourcing physician advisor work to external entities may limit the potential value of this integral role. In the care continuum, internal physician advisors work with clinicians, care coordinators, and social workers to achieve successful outcomes through the alignment of working relationships with the execution of vision. 

Departmental structure and role development  

Internal physician advisor structuring needs to align with organizational needs. The hiring of a physician advisor onto the medical or administrative staff is preferred for single hospital institutions for several reasons. First, the formal recognition of the physician advisor as a physician colleague and integral component of the care team is critical to their future success. Second, electing the physician advisor as a voting member of the utilization review committee promotes adherence to CMS’ Conditions of Participation. Finally, a direct line to the CMO will increase visibility and support the physician advisor as a valued physician leader in delivering patient centric, cost-effective care. 

Multi-hospital organizations seeking to centralize and standardize clinical operations may elect for an enterprise level physician advisor program. This can be accomplished by partnering with key stakeholders, including utilization management, CDI, and physician leadership to determine the appropriate model for implementation. Scope of the anticipated physician advisor role should also be clearly delineated to assure commensurate influence and authority, as opportunities abound for physician advisors to scale up valuable skills over time. A robust physician advisor training program and sound on-boarding process will yield returns beyond expected for the role. 

Creating a staffing model 

The staffing of an internal physician advisor program may depend on the existence of external vendors to perform daily physician advisor functions. Annual costs to outsource this work run into millions; most efficient internal physician advisor programs can operate at a fraction of this, based exclusively on cost savings per review performed. Without existing physician advisor resources, decision-makers should attend to budgetary constraints and opportunity costs as a basis for physician advisor staffing. There is no standard methodology to determine physician advisor staffing; however, commonly used methodologies include: FTEs per hospital bed, anticipated scope, or expected number of secondary reviews. 

While staffing based on hospital bed count is straightforward, defining physician advisor job duties that guide a balanced workload can be challenging prior to formal role development. If the latter is the preferred method of hiring, it is important to include a significant “non-productivity factor” (30%–50%) for the staffing of on-site physician advisor positions involved in physician education, complex care rounds, and patient throughput activities. In contrast, remote physician advisors generally require a lower “non-productivity factor” (10%), being heavily weighted toward review-based work. A hybrid team of on-site and remote physician advisors interspersed throughout all operating units will be well positioned to take on a host of revenue cycle responsibilities.  

Measuring effectiveness 

Upon establishing the basic tenets of an internal physician advisor program, standard workflows should be aligned around operational KPIs. This will facilitate physician advisor performance accountability and ensure proper patient placement status critical to hospital billing outcomes. Key elements to consider are: existing platform capabilities, ease of physician advisor interactions, extraction of data, and ability to interface with payers. Concurrent utilization review, peer-to-peer discussions, MS-DRG validation reviews, and clinical appeals workflows can be standardized with far-reaching impacts on hospital reimbursement even in year-one of implementation.  

Equally important is the objective value by which internal physician advisor programs are measured–revenue recovery and cost savings–to support an adequate ROI in relation to the cost to deploy or insource such a program. While there may be areas of uncertainty in quantifying this work, it is a crucial step in justifying the existence or expansion of an internal physician advisor service. Direct savings or hard revenue may be attributed to the physician advisor based on reduced labor expenses, inpatient authorization, Condition Code 44 claims, Medicare part A billing, and overturned payer denials. While difficult to measure, indirect savings or “soft revenue” may also be realized through CDI efforts, excess or avoidable day reduction, decreased observation hours, and efficient bed utilization. Altogether, the potential outcomes are improved incremental revenue capture, lower avoidable write-offs, and reduced dollars at-risk.   

Summary 

Well executed internal physician advisor programs can yield a significant ROI and offer a layer of regulatory oversight that is often overlooked by external vendors. The roadmap to implementation may vary yet it is vital to consider the potential physician advisor impact on multiple lines of business and revenue streams. Just as importantly, internal physician advisors can seamlessly integrate into existing cross-functional care teams by serving as an unbiased sounding board for physicians and case managers alike. Instilling this spirit of collaboration early in the inception of an internal physician advisor program will assist in breaking down departmental silos and magnify desired outcomes–appropriate resource utilization, revenue integrity, and recoupment of denied or at-risk dollars–in pursuit of effective, efficient patient care practices.   

Siddharth Raghavan, MD is System Director, Physician Advisor Service at Sutter Health.

Ronald L. Fong, MD is Physician Advisor at Mercy General Hospital, Dignity Health.

This article was reprinted from HealthLeaders Media with the author’s permission.

February 2023

If your hospitals are anything like mine, I am sure you continue to have struggles that test you. Personally, I am wrestling with getting our Observation Unit up and running and the Length of Stay issues commonplace lately. While it can be stressful, every challenge gives me an opportunity to learn something new. Not to be too cheesy about it, but one of my biggest takeaways from COVID is gratitude. And I am so grateful to be the President-Elect for the American College of Physician Advisors. A lot of people have spent a lot of time and effort creating and expanding the College. To be entrusted with the responsibility of carrying on this work is an enormous responsibility. I will do my best to be worthy of the faith the Board has placed in me.   

Speaking of the Board, as members of ACPA please know you are well-represented by some of the most amazing people I have had the pleasure to work with. They take their responsibilities to the College and our members very seriously and everything they do is with you all in mind. I am excited for 2023, so make sure you follow us on social media (Twitter @AmerCollPhyAdv LinkedIn https://www.linkedin.com/company/aihcd-org Facebook https://www.facebook.com/AmericanCollegeofPhysicianAdvisors ) or check your email for announcements as they come up.    

There does seem to be a trend in medicine lately to wonder if memberships in professional organizations and societies are worth it. I think it always makes sense to ask the question “is my money being well-spent” before writing a check (not that anyone writes checks anymore…). As for my membership in the ACPA, my answer is always a resounding YES. From a practical standpoint, membership gets me discounts on the National Physician Advisor Conference (don’t forget to register here) and our educational offerings like the TLC Modules. It is important for me to be part of my professional community and participate in groups like our committees and certainly ACPA has given me leadership opportunities I would not have had anywhere else. One often overlooked benefit is the strength of our voices when we speak collectively. The Government Affairs Committee put together a series of comments for CMS 4201-P recently and submitted it on behalf of the College (as well as put together a template if you want to submit your own comments). Being able to speak with a collective voice gives us the power to advocate to change things that make no sense and that can be very powerful.    

If you’re a member, you are already used to getting the Newsletter in your email (and available on the website) every month. This month we’re making the Newsletter publicly available. Consider it a Valentine’s Day gift and a good example of resources and updates you get with membership that you cannot get anywhere else. If you want to be a member, click here. If you aren’t sure and want to chat, I would love to talk to you.    

I started this President’s Corner with gratitude and would like to end it with some additional thank yous. First, a big thank you to Dr. David Balt for helping introduce me to the world of physician advisors and his continued mentorship. Thank you to the rest of the Avera system team including Stacy Reck and Christi Freeland as well as the McKennan team of Dr. Katie DeJong, Dr. Kwabena Kwakye, Dr. Magdalene Fiddler, Sheila Austin, Laurie Auch, Suzanne Pica, and Rhonda Roesler for indulging my ideas as we build a physician advisor program I am very proud of.   



I owe the biggest THANK YOU to Dr. Juliet Ugarte Hopkins. She has shown me a leadership ideal I cannot hope to replicate. She, Dr. Charles Locke, Dr. Edward Hu, and Dr. Ronald Rejzer have all made invaluable contributions to the College and the physician advisor field. I would be remiss to not also mention Dr. Ronald Hirsch who many know from social media fame and who continues to push our educational capital forward by editing this Newsletter. I am excited to see what challenges we will see over the next several years and how we as physician advisors can impact the healthcare landscape for the good of our patients. I am grateful for all of you and proud to call you my colleagues. 

Clarissa Barnes, MD, FACP 

President-Elect, ACPA 

Dr Barnes is system physician advisor for UR and CDI at Avera Health.