Grand Rounds Recap 5.1.19

Healthcare economics and how docs get paid: new physician reimbursement frontier WITH DR. wiler

Payment system prior to 1992

  1. Physicians would evaluate patients or perform procedures

  2. They would document the encounter

  3. A bill would be sent to the patient

  4. Payment would be received

Payment system today

  1. Physicians evaluate patients or perform procedures

  2. The encounter is documented

  3. The documentation is then translated into CPT codes

  4. A bill is then generated with charges from the practice’s fee schedule

  5. The bill is processed by insurance OR sent to the patient directly

  6. The bill can be paid OR modified/discounted OR denied

CPT Codes:

  • Current Procedural Terminology: describes healthcare services provided by physicians or other providers.

  • Developed by the American Medical Association CPT editorial panel and used to justify medical necessity.

  • The worth of a CPT code is determined by the associated Resource Based Relative Value Scale (RBRVS)

    • RBRVS is determined by the associated Relative Value Units (RVUs) of which there are three types:

      • Physician work RVUs: Value assigned to the actual work provided by the physician

      • Practice expense RVUs: Value assigned to anticipated use of supplies, billing collections, support staff etc

      • Professional liability RVUs: Value assigned to malpractice insurance premium associated with the work

  • Calculating the total RVU for a given CPT code:

    • Work RVU + Practice Expense RVU + Professional Liability Insurance RVU = Total RVU

    • The Total RVU is then multiplied by a geographic adjustment factor set by the Centers for Medicare & Medicaid Services to give the final total dollar amount assigned to a given CPT code.

Alternative Payment Models

  • A payment approach that gives added incentive payments to provide high quality and cost-efficient care. Alternative payment models can apply to a specific clinical condition, a care episode, or a population of patients.

How to increase generated income:

  1. See more patients leading to more generated billable CPT codes

  2. Improve documentation leading to the ability to capture more billable CPT codes

  3. Decrease cost/waste for the practice as the Practice expense RVU is set.

small group oral board cases WITH DR. betz and dr. curry

Three Patient Encounter - “The Triple”

Patient 1

A 26 year old male presents to the ED with acute right sided knee pain. He describes hearing a pop while playing soccer followed by severe pain and in ability to bear any weight on his right lower extremity. He has no significant past medical history, takes no daily medications, has no surgical history, and he does not smoke, drink alcohol, or use illicit drugs.

His vital signs show mild tachycardia but are otherwise within normal limits. His physical exam is significant for an obvious deformity of the right lower extremity with diffuse swelling about the right knee. He has 2+ distal pulses and distal sensation and motor function is intact. Xray of the right knee shows an anterior dislocation of the tibia over the femur.

Reduction under procedural sedation is performed and repeat pulses remain 2+; however, ABI’s show concern for arterial compromise in the right lower extremity. A CT angiogram of the right lower extremity shows abnormal filling of the popliteal artery with surrounding hematoma concerning for arterial injury with minimal distal reconstitution. Vascular surgery is consulted and the patient is taken emergently to the operating room.

Patient 2

A 62 year old male is brought to the ED by EMS for acute onset of chest pain. The patient describes onset of chest pain while mowing his lawn approximately 1 hour prior to arrival. The pain is located centrally with radiation to the left side of his chest and to his back. He has a past medical history significant for hypertension and diabetes. He takes metoprolol and metformin daily and states he is compliant with all medications. He smokes approximately 1/2 pack of cigarettes daily, drinks alcohol occasionally, and does not use illicit substances.

Vital signs are significant for tachycardia in the 110s and a blood pressure of 180/110. His physical exam is significant for 1+ left upper extremity radial pulse and 2+ right upper extremity pulse.

An EKG shows ST segment elevations in an inferior lead distribution. His Chest Xray shows concern for a widened mediastinum. A CT aortogram shows a type A dissection involving the right coronary artery and continuing through the abdominal aorta into the left common iliac artery.

The patient undergoes heart rate and blood pressure control with esmolol and nicardipine drips. Vascular surgery is consulted and the patient is taken emergently to the operating room.

Patient 3

A 35 year old male presents to the ED by private vehicle for cough. He describes a cough ongoing for one week. He has associated mild shortness of breath and subjective fevers. He has a past medical history significant for HIV without AIDS. He is currently compliant with his HAART medications. He smokes 1/2 pack of cigarettes per day, denies alcohol or illicit substance use.

His vital signs are significant for mild tachycardia and oxygen saturation of 92% on room air. After being placed on 2 liters oxygen by nasal cannula his oxygen saturation improves to 96%. His physical exam is notable for decreased breath sounds and rhonchi in the right lower lobe.

His Chest Xray shows a right lower lobe consolidation. The patient is started on broad spectrum antibiotics including vancomycin, cefepime, and azithromycin. He is admitted to hospital medicine.

Single Patient Encounter

A 31 year old female presents to the ED accompanied by her friend. They were shopping at a local mall when the patient had onset of a severe headache and blurred vision that worsened over two hours and is now at a 6 out of 10. She does not normally experience headaches.

Her initial vital signs are: HR 105, BP 179/98, RR 18, SpO2 on RA 99%, T 37.4 C

She describes her current headache as severe, worst behind her eyes, and not like any headache she has had in the past. She has no chronic medical conditions, takes no daily medications, does not smoke tobacco, drink alcohol, or use illicit substances. She has no significant family history or surgical history.

Additional history obtained from the patient shows that she just delivered a healthy baby ten days ago and has been doing otherwise well since discharge from the hospital.

Physical exam is notable for an obese female with no blurring of the optic discs on fundoscopy. She has some mild swelling of her hands and feet. The rest of her exam is normal including a neurologic exam.

A non-contrast head CT is normal. Her labs are notable for proteinuria but otherwise are unremarkable.

Shortly into the encounter the patient has a generalized seizure. She is provided 4 grams of magnesium IV and the seizure stops. Additionally, she is provided IV labetalol for control of her hypertension. OBGYN is consulted and she is admitted to the hospital for further management.

Simulation: In-Flight emergencies WITH DR. hill, Dr. Lafollette, and dr. lang

You are a physician on your way Las Vegas to attend the national emergency medicine conference.

Passenger 1

A passenger in first class starts to complain of anxiousness, and oral tingling. Flight crew ask if there is a doctor on the plan and you respond to assist this passenger. The passenger is a 30 year old male who states this is his first flight. He is very nervous to be flying. He is complaining of acute and worsening anxiety, oral tingling, and now difficulty breathing.

Further history shows that he had just eaten the free “snack mix” provided by the flight crew. He has a history of allergy to peanuts. The flight crew provide you with the medical emergency supplies. You administer 0.3mg of intramuscular epinephrine and inhaled albuterol. The passenger improves substantially following your interventions.

Passenger 2

During the flight another passenger begins to complain of severe nausea and falls down while trying to get up to use the restroom. You respond to this passenger and find he is sitting with this friend. You obtain additional information that they are both very excited to be going to Las Vegas and have been drinking “gin and tonics” for the past few hours. Assessment of the patient shows that he is still protecting his airway but is clearly very intoxicated. You provide him with an emesis basin and assign his friend to ensure that he does not aspirate on his emesis.

Passenger 3

After assisting the two passengers above you are called to assist a third passenger towards the back of the aircraft. Upon arriving to the passenger you find them having a generalized tonic-clonic seizure. You receive additional history from the passengers friend that they are diabetic. You empirically provide them with IV dextrose and diazepam which causes the seizure to stop.

In-Flight Emergencies

  • Each domestic flight has access to a ground medical control that can assist the flight crew in responding to medical emergencies. Additionally, the flight crew have access to very basic algorithms for managing emergencies that may occur. That being said, it is possible that during a flight a physician will be called upon to respond.

  • The Aviation Medical Assistance Act protects responding providers against liability except in cases of ‘‘gross negligence’’.

  • Each aircraft is required to carry a limited set of medical resources. This is mandated by the Federal Aviation Administration.

    • Assessment supplies

      • Blood pressure cuff

      • Stethoscope

    • Acute interventional equipment

      • Oropharyngeal airways

      • Bag-valve and cardiopulmonary resuscitation masks

      • IV administration set

      • Saline solution

      • Needles and Syringes

    • Medications

      • Acetaminophen

      • Albuterol, metered dose inhaler

      • Aspirin

      • Atropine

      • Dextrose 50%

      • Diphenhydramine

      • Epinephrine 1:1000 and 1:10,000

      • Lidocaine

      • Nitroglycerin tablets