Editor's Note

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

Member, ACPA Advisory Board

Member, ACPA Government Affairs Committee 

Editor, ACPA Update

There are over 5,500 hospitals in the country. The membership of ACPA represents at most 20% or those facilities per my totally non-scientific guess. That means there are thousands of hospitals that do not have “peer” support for the many complexities of utilization review, amongst the many other areas the physician advisor supports.  

And from some of those hospitals I hear stories. “Our orthopedic surgeons still admit all Medicare total joint patients as inpatient.” “We don’t do stress tests on Sunday so Saturday patients with chest pain get admitted as inpatient since they will be hospitalized for two midnights and won’t be audited.” “Almost all chest pain patients get seen by GI and have an EGD if their cardiac workup is negative.”  

Why do I bring this up? Well, while many of us have horror stories dealing with the commercial and Medicare Advantage payers and wish they would stop, the way ACPA members ensure compliance and quality care at their facilities can, in some ways, be viewed as an outlier. The insurers see cases from all hospitals, not just those where there are ACPA members ensuring compliance. What is happening on those 4,000+ hospitals that the insurers see every day that forces them to adopt such draconian measures? I don’t know but I suspect some of it is not pretty.  

I certainly hope that ACPA will continue to grow and continue to educate a growing number of physicians from hospitals where the C-suite has the insight to see the great value in the role of the physician advisor, bridging the gap between the medical staff and the administration, translating the often incomprehensible regulations and policies from CMS and the payers, and offloading some of those non-patient care duties, like talking to insurance company medical directors, that add no value to the physician’s goal of providing excellent care to every patient. Perhaps when that time comes, insurers will trust every doctor in every hospital to always do what is right and will be able to sunset prior authorizations and denials. 

Moving on, last month the newsletter included the case submitted by Dr. Bernard Emkes of a patient with dementia who presented with A fib with a rapid ventricular response and then refused a cardiac evaluation after converting to sinus rhythm. I received several wonderfully descriptive responses with Dr. Tamara Kile and Dr. Jack Sublett chosen to receive Amazon gift cards for taking the time to describe their thought process. I thank everyone that submitted comments. 

But as we often see with the cases published by the ACPA Observation Committee, there was no unanimity in the responses. Some favored billing inpatient with an AMA discharge, others advocated billing inpatient with a faster than expected recovery and some felt self-denial was appropriate. As a few pointed out, patients presenting with A fib with RVR in 2022 usually convert to sinus with a few hours of iv diltiazem and then get started on oral anticoagulants that become effective immediately, obviating the need for bridging heparin or enoxaparin. Once they are in sinus, does the average paroxysmal A Fib patient need to stay in the hospital? 

Does that mean these patients have an expectation of under two midnights and should start as Observation? If most go home in one day, which would fit into the CMS case-by-case exception for inpatient admission with a one midnight expectation because of high risk? Should high risk be limited to a select population of “higher risk” patients? Does that require hypotension? Does cardioverting the patient emergently make them high risk and “inpatient worthy”? Last month I noted the recent literature about same day discharge colectomy. Medicine in 2022 is not medicine in 2010 or perhaps even 2019 pre-COVID. If you think that a Medicare contractor or insurance company medical director is going to consider what happens in a small community hospital where the local physicians care for their own patients and haven’t quite kept up with the advances in medicine, think again. 

And then there is the question of the patient’s decision-making capacity. She lives in a locked chronic dementia unit so was she competent to refuse further evaluation? As was pointed out, a psychiatrist is not needed to determine competency; the hospitalist can determine if the patient understands the treatment being offered along with the risks, benefits, and alternatives. While they may not like to make that determination, they are fully qualified to do it.  

Answers to such cases are never easy. Which brings me to my last words- are you on your hospital’s Ethics Committee? If not, you should be. Cases presented at the Committee usually have long lengths of stay, high costs, and disagreements. What better place for the physician advisor? 

Don’t forget to read this month’s articles. We have two great submissions from the CDI Committee, a great article on the new terminology for heart attacks, and the always important President’s Corner.  

Finally remember when you promised to write an article for an upcoming issue of the ACPA newsletter? Yes, you really did. Please send it to [email protected]. Any length, any topic. Am I begging? Yep. I am not too proud to beg. You know why? Because all of you have something to share!  

Acute MI – Another Evolution in Terminology

Russell Firman MD, FACEP, CHCQM, PHYS-ADV 

Member, ACPA Observation Committee 

The American College of Cardiology released a new consensus statement, “Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. (1) The most important content for Physician Advisors is the incorporation of the new “STEMI equivalents” for emergent revascularization. These EKG findings that do not include elevation of the ST segment of the EKG include De Winter T Waves, Hyperacute T waves, Posterior MI, and LBBB with Smith – modified Sgarbossa Criteria. The old STEMI paradigm alone does not capture all acute MI’s that are occluding or severely compromising flow to the coronary vessel. (2) The term acute “occlusive myocardial infarction” includes both “STEMI” and “STEMI equivalent” EKG findings for emergent revascularization.  

The guidelines state: “In the absences of ischemic ST – elevation, the EKG should be examined for other changes that have been associated with coronary artery occlusion.; when present, these should prompt evaluation for emergency coronary angiography.” The consensus statement recommends STEMI and STEMI equivalents be managed per the 2013 ACCF/ AHA STEMI guidelines.  

More patients (STEMI equivalents) will be eligible for emergent cardiac catheterization. What is in this for the Physician Advisor you might wonder? It is amazing how quickly these patients go home, sometimes before a midnight, or even after only one is crossed. An inpatient only procedure (IPOL) is an exclusion for a Medicare part A short stay. Most Medicare Advantage (MA) plans allow an IPOL procedure to be an exception in their short stay or observation policies. So, let’s review the two inpatient only codes associated with the coronary revascularization.   

Inpatient only codes description: 

CPT 92941 - Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel 

HCPCS code C9606 - Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel (This code is a facility code, not to be used by physicians. For facility coding, 92941 is used if there is a non-drug eluting stent used and C9606 used for a drug-eluting stent. Although both of these are inpatient only for Medicare and would be denied on an outpatient claim, they may be needed for other payers and there are equivalent pairs for stenting in the non-MI setting which is often performed and billed outpatient.) 

The new STEMI equivalent EKG findings may erroneously be called “NSTEMI” by people unfamiliar with the new guidelines. Our role should be to educate that the more appropriate terms are “STEMI equivalent EKG findings” or “(acute) occlusive MI.” Acute Occlusive MI includes all STEMI’s and all the new STEMI equivalent EKG findings and even better aligns with the CPT code definition. A true “NSTEMI” now should only include those EKG patterns that do not include a STEMI or any of the new STEMI equivalent EKG findings mentioned in the new guidelines. A true NSTEMI usually waits to undergo cardiac intervention after a delay for stabilization, usually the next day on an urgent basis. The CPT 92941 definition should not be used with a NSTEMI when the treatment of an acute occlusion does not require an immediate intervention. Do not miss the opportunity to capture the IPOL procedure for your patients who are undergoing emergent catheterization for the new STEMI equivalents. Make sure your coders and case managers have access to this information as well. An appropriate CPT code of 92941 without an Inpatient order is a lost opportunity and may not be reimbursed. On the other hand, an unknowing provider may call a “STEMI equivalent” a NSTEMI, thereby resulting in an erroneous code assignment and another lost opportunity for an IPOL procdure. 

Keep an eye out for a future Observation Committee Town Hall where we will review this case with a few twists, and some other great examples of short stay Inpatient Only Procedures and other topics made for you to add value to your team. 

1. http://hqmeded-ecg.blogspot.com/ 
2. https://doi.org/10.1016/j.jacc.2022.08.750 

Dr Firman is Lead Physician Advisor at St. Joseph’s Health in Syracuse, NY 

You’ll Catch Your Death of Cold?

Melinda Battaile, MD, FHM, MMCI    

Member, ACPA Clinical Documentation Integrity Committee

As the general public, insurance companies, even practicing physicians make their assessments on the relative worth, safety, and quality of care delivered at various institutions and where they will practice or refer a patient or loved one to obtain care, one might wonder where they get the basis for their assessments. How do insurance companies decide which hospitals and MDs to keep or release from their health plans? Where does CMS come up with star ratings? Or Healthgrades? 

The answer, of course, is from the documentation in the medical record. And more specifically, from the ICD 10 codes that are assigned by coders after a case is completed. As physicians, in training, we are taught the necessity of documenting our findings and treatment plans in the medical record. We know the components of an H&P and a progress note and that these documents are there to communicate with our colleagues and other staff and to establish a record of the patient’s health care. This is the primary purpose of our documentation. We also learn, while physicians in training, a myriad of terms that can apply to any one condition often substituting jargon for the concise clinical terms used in Morning Report,  Harrison’s and Cecil’s.  

As a member of our health system’s CDI physician advisor team, I was a part of our mortality review team.  This group focuses on reviewing cases where the observed to expected mortality suggests that a death was unexpected. Our team uses a widely available mortality model / data system used by many other tertiary care centers across the country. The models have, for individual DRG groups, variables that effect the expected mortality. The variables are groups of diagnoses. For example, there is a variable titled electrolyte abnormalities that includes, among others, hypo- and hypercalcemia, -natremia, -kalemia as well as metabolic acidosis and alkalosis. We compare the coded diagnoses and, on review of the chart, look for possible diagnoses that were present but not captured in coding that could impact this metric. If the attending MD agrees, through a compliant query process, that a diagnosis was appropriate to the encounter the capture can more accurately portray the patient’s expected mortality. One case that I reviewed for mortality purposes nicely illustrates the necessity of accurate, succinct documentation of each diagnosis in clinical terminology that the treating physician monitors, treats etc., in order to accurately portray the patient’s condition and, in this instance, accurately capture in codeable terms the expected mortality. 

The H&P in this case was very brief. Any physician who would subsequently review the documentation would have a vivid picture of the patient’s acuity at presentation. 

Elderly man sent in by ambulance from NH. He has been treated for flu the last several days. He is febrile, unresponsive and not arousable, guppy breathing, hypotensive on pressors. We  attempted to obtain code status and could not. 

ABG: 6.90/90/120 on 100%, now intubated 

Plan: Continue Mech vent, to ICU on Levophed, broad-spectrum antibiotics and bolusing fluids.  

Despite aggressive, goal directed care this patient passed away shortly after admission. 

When approaching a mortality review, I look first at the coding summary. This is the report that comes at the end of the stay that includes the final ICD-10 codes associated with the encounter, whether the diagnoses were present on admission, whether they are potential CC or MCCs, any procedures performed and finally the DRG assigned. In this particular case, I scrolled down to the bottom of the page and much to my surprise I found that the assigned DRG was Otitis Media and URI without MCC.   

The next thing that I did was check that I had the correct coding summary for the patient whose H&P I had just read.  After confirming that this summary applied to the patient the investigation into the “disconnect” between the coded summary, and hence the expected mortality, and the clinical picture presented in the H&P was commenced.  

We could start this by going back and looking at the codes for some of the terms and phrases that are documented and that catch our eye as trained physicians; guppy breathing, hypotension requiring pressors, not arousable, pH 6.90. If one takes these clinically evocative terms and applies the corresponding ICD 10 codes they will quickly discover that there are no codes associated with any of them. These oft used clinical terms had no impact on the patient’s coded summary. It is as if these conditions did not exist and they were not coded.   

Recall that coders are not (usually) clinically trained. They receive training in the incredibly complex coding rules, regulations, and guidelines. The clinical education consists mostly of vignettes on what to consider when they see certain documentation, e.g. orthopnea, peripheral edema, Lasix, tachypnea. Is there an opportunity to compliantly query the MD for heart failure? They get really good at spotting these combinations of signs and symptoms and know the rules that specify when they can ask the treating  MD if a specific condition was present. The coder in this case did query the attending MD on the patient’s respiratory status at presentation. The attending was asked if the patient’s presentation was consistent with respiratory distress, respiratory failure, ‘other’, none of the above.  The attending chose respiratory distress. And this is how the PDX landed as influenza because the flu was documented. Since there was no further specification as to manifestations of the influenza, such as pneumonia, the default was the unspecified ICD-10 code of “with other respiratory manifestations.” This lack of specificity for the principal diagnosis (PDX) landed the case in the DRG as URI. Respiratory distress is a symptom and if the underlying cause is known, that must be the PDX. The coder was reluctant to pose more queries for other potentially appropriate diagnoses represented in the documentation, given the response of many MDs to any query much less to multiple queries.  

As coded, the patient’s expected mortality was essentially nil.  

As a DRG trained physician advisor working under the exacting tutelage of my colleague and boss, Vaughn Matacale, who is a contributor to the latest version of AHIMA’s Guidelines for Achieving a Compliant Query Process, I wrote several compliant queries supported by the documentation in the chart.  The patient’s final coding summary more closely matched his clinical presentation.  

I have used this case to illustrate to my clinical colleagues the necessity of using precise clinical terms for documenting diagnoses in order to accurately portray each patient’s clinical presentation, risk, comorbidities, and treatment course.  I have also used this case to educate our CDI staff on the opportunity for additional queries when appropriate and compliant and supported them when they sometimes receive complaints from the clinical staff. When appropriate, more than one query might be necessary to make sure that the patient’s clinical picture is captured in the coded language. The use of clinical terms instead of jargon decreases the need for the coder to clarify. In the end the expected mortality, which is a reflection of the documentation, more closely matches the observed mortality. 

Dr. Melinda Battaile is Medical Director Utilization Review Physician Advisors at ECU Health, Greenville NC 

An Introduction to Physician Advisors to the Industry Standard for Compliant Query Composition 

Erica E. Remer, MD, CCDS,

Member, ACPA Advisory Board

Chair, ACPA Clinical Documentation Integrity Committee

As physician advisors (especially if you work in the CDI realm, but even if you don’t!), you need to be familiar with the Guidelines for Achieving a Compliant Query Practice (2022) Update which came out on October 10. It is a joint publication between the Association of Clinical Documentation Integrity Specialists (ACDIS) and the American Hospital Information Management Association (AHIMA). The first reason is because the physician advisor should be able to recognize and counsel against non-compliant query construction in the clinical documentation integrity (CDI) sphere. 

The second reason relates to the fact that in 2001, Centers for Medicare and Medicaid Services (CMS) established the position of widespread support for “guidelines” from either CMS or industry representatives (such as American Hospital Association Coding Clinic and/or AHIMA) to govern query form content and processes, identifying AHIMA’s original practice brief as a source (CMS Policy Clarification on Coding Compliance – Use of Physician Query Forms). This is the basis for the current iteration to declare that all stakeholders including, for example, quality, care management, and physician groups and external reviewers such as the Office of Inspector General (OIG), government contractors, and payer review agencies, are expected to follow the compliant query practices set forth. Physician advisors are included in the grouping of individuals who are expected to follow these guidelines while working to clarify healthcare documentation. 

Many of the guidelines are unchanged from the previous versions, but I am going to highlight certain points, changes, or nuances in this article. 

Multiple choice options 

• Only clinically relevant options should be included. They must be supported by the clinical indicators (e.g., don’t give the choice of “acute hypoxic respiratory failure” if the oxygen level is normal). 
• When using a template, options which are not clinically credible or relevant should be deleted 
• There is no mandatory minimum or maximum number of choices necessary to constitute a compliant query composition 
• If a choice presents a diagnosis not previously offered and it is supported by the clinical indicators, it is compliant and not considered “introducing new information”  
• There is no specific order mandated (e.g., the maximally risk-adjusting diagnosis may appear at any level in the list of choices) 
• The customizable choice of “other” must be offered. “Other” is not the same as “unable to determine,” which is one of my pet bugaboos. If a provider is being asked a query because the coder needs information to assign a code, “unable to determine” may not get them any closer to a codable diagnosis.  

Other query guidelines 

• Reimbursement, quality metrics, or other reportable data are never to be included 
• I refer you to the very extensive list of reasons why queries are generated. One of the new stipulations is that a mere signature on an ancillary note may not suffice for coding as is. The provider needs to address the diagnosis in their documentation establishing a valid secondary diagnosis. Malnutrition is the poster child for this guideline. 
• Queries should not be leading, defined as a request for clarification that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure (this definition was found in previous iterations of the Compliant Query Guidelines). 
• Titles of queries and query templates should not be leading. For instance, if inquiring about hypoxemia, using a query entitled, “Acute respiratory failure,” would be considered non-compliant. 
• This guideline dissuades from using uncertain diagnosis words (e.g., possible, probable, suspected, likely, rule out) unless the provider used one of those terms of uncertainty. The previous guideline allowed for this practice if the query was generated at or post- discharge. 

Other  

• This practice brief addresses how organizations must develop policies and procedures regarding problem list management. Problem list diagnoses (and I would go even further and say all diagnoses in the medical record such as in the impression list) should not present financial or quality implications (e.g., comorbid condition or complication (CC/MCC) designation, hierarchical condition categories (HCC) designation, hospital acquired conditions (HACs), patient safety indicators (PSIs), etc.). 
• Provider education may use real cases with queries, but they should not be identifiable, and reimbursement/quality impact can only be presented post-bill. No changes to the documentation or the billing should be performed as a result of education. I used to lose a battle to win the war – I would let a query get closed out unanswered or answered unsatisfactorily, and then point out how much money had been left on the table, after the fact. It was often very illustrative and impactful. 
• Only providers delivering clinical care to a patient may be queried. The practice brief explicitly mentions that physician advisors may not answer queries. 
• Some organizations include queries in the medicolegal record; some do not. If they are not included and only part of the business record, they are still discoverable. The advantage is that it takes work for the government or other auditor to view the institution’s dirty laundry rather than it being aired out in the electronic medical record. 
• The practice brief sets out an outline of how to develop query policies and procedures. There are many opportunities for the interested physician advisor to be involved. 
• Regardless of the methodology, all queries must adhere to compliant standards. Technological alerts, triggers, flags, etc. are all considered queries. Artificial intelligence needs to be intelligent enough to give appropriate, compliant choices. 

I am going to inject some of my own advice here. I caution physician advisors against querying on their own. I believe it is best practice for PAs to concentrate on educating and leave issuing queries to the CDI team or coders. If your institution permits PAs to query, then do it compliantly. Don’t give in to pleas of, “Just tell me what to write!” That would be considered leading. 

This practice brief is considered the industry standard. Read and digest it. We must all abide by compliant query best practice or risk the consequences. 

Dr. Erica Remer is the founder and president of Erica Remer, MD, Inc., a consulting firm putting MENTATION back into Documentation, Beachwood, OH. She can be contacted at [email protected]

November 2022

A comic strip has been displayed on my fridge for at least nine years, now.  It’s from Patrick McDonnell’s “Mutts,” and features frame after frame of a cat moving through life and reacting with purrs as he watches the sun rise from a window, receives a bowl of food from his human companion, is serenaded by a bird on a branch, runs through gold and bronze leaves with his feline and canine buddies, and then admires the moon and stars before heading into his house for the night.  The last frame shows him cuddled up in bed on a pillow, sighing, “We have a lot to purr about.” 

In an incredibly short span of time, I have had the privilege of witnessing the evolution of many rising leaders and content experts within our physician advisor community.  Folks I met briefly at a National Physician Advisor Conference (NPAC) years ago, colleagues I’ve exchanged a few e-mails with over time, and individuals I’d never heard or read from before who suddenly were front-and-center sharing their big ideas.  This experience was bookended and on full display the other week during our board of directors’ retreat and our first ever Essentials & Fundamentals event.   

You may not fully appreciate it yet, but our College’s leadership team is filled with some terrific minds. These people not only know their stuff but are also unconditionally committed to the ACPA’s goals involving education of our membership.  Likewise, the enthusiasm and fire I saw in the attendees at Essentials & Fundamentals outside Chicago last month has me incredibly excited about the future of our organization because there are SO many smart folks we’ll get to know in the coming years. 

Along with participating in the efforts of our four committees (Government Affairs, Clinical Documentation Integrity, Observation, and Pediatric) and penning an article for this newsletter, another prime opportunity to get involved in our community and make your mark recently opened up!  Applications to speak at the 2023 National Physician Advisor Conference taking place April 17 – 19 at the Loews Portofino Bay Hotel at Universal Studios in Orlando, Florida are being accepted through November 11th at https://acpadvisors.org/content.aspx?page_id=22&club_id=90610&module_id=541461 so don’t delay.  It doesn’t matter if you’ve been doing this job for decades or just a year or two – if you have information or valuable insights to share, please apply!  All are welcome, even if you aren’t a physician but instead, work in other aspects of leadership within case/utilization management, Clinical Documentation Integrity, revenue cycle, or quality.  We’re looking forward to learning from you! 

I am so grateful for everyone who has taught me so much and provided such friendship and collegiality in the last number of years during my involvement with the American College of Physician Advisors.  I have strived to be effective in delivering a message during my presidency that ALL are welcome, you all have such important perspectives to disseminate, and I am just so incredibly, incredibly proud of all who have taken it upon themselves to step up, make a mark, and make a difference.  We have a lot to purr about, indeed. 

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV

(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