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B illing E ducation T ransition I nto P ractice. Presenter: Gord McInnes, MD, FRCPC EM Supported by:. Case #1.
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Billing Education Transition Into Practice Presenter: Gord McInnes, MD, FRCPC EM Supported by:
Case #1 • At 0758 on Tuesday morning you see a 12 year old with fever x 7 days. Parents say she doesn’t seem her self today “like she is confused”. Vitals 130-28-105/60 – 38.7 Minimal oral intake x 5 days. She looks sick. Nurses place an IV and you order a bolus of 20 ml/kg. She is clinically dry on your exam. Blood work is drawn. You do an LP then start antibiotics and Peds is called for admission. You periodically reassess her in between seeing other patients until Peds arrives and takes over.
What do you need to document? Document: • Chief Complaint • Hx of past and present illness • Relevant personal, family and social hx • Physical exam with special attention to local examination relevant to presenting complaint • Initiation of therapy provided • Includes observation and/or reassessment of patients within 3 hours,
Same Case but… • You recognize how sick she is, move her to the trauma room if not already there or an “appropriate resuscitation area”. Start 2 iv’s fluid boluses, monitors and then from 0820-0835 hrs you do the LP. Following this you reassess her, start IV Abx and while continuing to monitor her you document your resuscitation and monitoring. You leave to see other patients @ 0852 hrs. You do brief reassessments @ 0920, 0940 and hand over care to Peds at 1000 hrs.
Billing? * NR: Level 3 care continued until 1000hrs and Pediatrics assumed responsibility for patient
What do you need to document? • Same thing PLUS: • “but does not meet criteria of EM Resuscitation fee and hence does not require constant care by the EP”. • Why this met the EM Resuscitation Fee code? • “This was an extremely ill child with potentially life threatening infection requiring me to remain at the bedside to actively resuscitate her and monitor the effects of my resuscitation until….”
Same Case but… • You see the patient, you tell the nurses to move her to a more appropriate area, you order 2 iv’s plus start bolus, order the blood work & cultures and then call Peds. You ask Peds “do you want to see her first or should I start Abx now? “ They say we’ll be right down. You document your assessment and management and how sick the child is and you bill what? • 01833 $163.63 • 03333 $0.00
EM Consultation Questions Q. Is the paper chart adequate documentation for an EM Consultation? A. No Q. Is the electronic chart adequate documentation for an EM consultation? • Yes, If the requesting physician has access to this record. Q. The NP working in Cardiology sees a patient and send them to the ED because they have CP, can you bill a consult? • Yes, the NP has a MSP billing number and may be billed a consult. Q. You are working as the TTL and your Colleague calls you in for a Trauma, can you bill them a consult? A. Yes and if they require active resuscitation it does not need to be the first 30 minute of care, just thirty minutes at some time.
More EM Consultation questions • Q. A patient goes to a WIC or GP’s office and says “I have CP” they are sent to the ED by the MOA, Consult? • A. No, the referring patient must have seen and examined the patient. • Q. A patient goes to a WIC or GP’s office and is seen and examined by the GP for their sore ankle and sent to the ED. Is this a consult? • A. Depends. If it is a twisted ankle and you get an X-Ray and provide standard care then no – this is not “complex, obscure or serious” • Yes, if the mechanism does not fit and you work the patient up for other causes i.e. septic joint, crystal arthropathy and fulfill the documentation needed to bill a consult.
Q. What if the patient was seen 2 days ago and told to come to the ED if things worsened? • Yes with reasonable documentation • “Thank-you Dr Smith for encouraging Patient X to come to the ED for her worsening condition since you saw her on Date in the office. At that time I understand her findings were …. And now she has progressed and ….”
What can you do when GP’s don’t see their patients and send them in for care? • Dictate a note back anyways. • State: “I understand this patient came to your office for care and was directed to the ED by your office staff. In the future our department would prefer if you could have a quick look at patients like this prior to sending them to ensure they are triaged appropriately and you are happy with the means of transport given the medical situation. Documentation of your concerns and any other documentation that may you believe may be helpful would also be useful. Regarding this specific patient I found that she…” • If it continues to happen, consider…
Transfer of Care Questions • Q. Your colleague is wrapping up their evening shift and they say: “Hey, I’m just waiting for the CT on Mrs. Smith, if it comes back negative can you just send her home, if it is positive just treat her. Go ahead and bill another visit fee or a consult after midnight.” Should you do this?
A. No to Visit Fee and No to Consult Q. What do you do? • “How about you just put them on auto-pilot and the nurses can discharge them if the scan is negative. If it’s positive, what were your plans, a DOAC? If so, you could write up the prescription as per their renal function and the nurses could give them that. If anything turns sour or there are questions, I am happy to be a resource and get involved. Thanks.” • Remember: “What comes around, goes around”.
Visits and Procedures I gave you 8 scenarios 1. Syncope and cleaned and stapled 3.5 cm scalp laceration 2. Cut arm while moving furniture, 22 cm forearm laceration, cleaned, anesthetized and explored if needed. 3. Fell and has soft tissue injury to thumb and superficial laceration that you repair with glue after cleaning and updating Td. 4. Deep laceration to leg from Chainsaw requiring deep and multiple layered suture repair, edges were ragged and required debridement after cleaning and anesthetizing. 5. Falls off bike and breaks clavicle + suture repair 3 cm laceration above right eye brow. 6. Sideswiped by dog while running, minimally displace distal lateral malleolus # and superficial wound on thenar eminence, cleaned and steri-striped +/- Dermabond. 7. 13 year old slips on dock and falls barefoot, 4 cm piece of wood lodged deep in foot, ketamine provided, foot incised, FB removed, wound repaired. 8. 82-year-old man trips and falls down two steps, he has a 2cm laceration to his right brow and a wrist fracture. There is no one to help with the sedation so you call the RT and give the Propofol yourself, the sedation takes 17 minutes. While he is asleep you reduce his fracture and put on a short arm cast and you fix the laceration without any local. And you were to pick from the following fee items
8. 82-year-old man trips and falls down two steps, he has a 2cm laceration to his right brow and a wrist fracture. There is no one to help with the sedation so you call the RT and give the Propofol yourself. While he is asleep you reduce his fracture and cast him and you fix the laceration without any local. 54702 $296.55 Level 1 or 2 (documentation & care dependent) 13611 1172 x 2 01165 51016 You are now the one providing the sedation
Telephone codes • Templates provided • Doctors call you for advice • Patients Bypass you but you organize all the care • Microbiology & Radiology Call backs
