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Clinic closeup: Dr. Jeffrey Susman, Dean ad interim of John Sealy School of Medicine, visits with Dr. Anthony Rogers and Dr. James Veselka at the Family Medicine Practice at the Dave Bleakney Building in Angleton. | | |
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Awareness, Education, Prevention Reduce Cervical Cancer Risk
January is Cervical Health Awareness Month, an important opportunity for patients to learn more about cervical cancer and what steps they can take to reduce their risk.
More than 14,000 women are diagnosed with invasive cervical cancer each year, according to the American Sexual Health Association (ASHA). ASHA shares that “cervical cancer is the fourth most common type of cancer for women worldwide, but because it develops over time, it is also one of the most preventable types of cancer. Deaths from cervical cancer in the United States continue to decline by approximately 2 percent a year.”
At UTMB, women’s health specialists like Karren Lewis, MD, MPH, strive to reduce that number even further by educating their patients, working collaboratively with primary care to reach more patients, and emphasizing the value of early detection and prevention.
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January is Stalking Awareness Month
By Maggy McGiffert, M.A., Lead Research Manager, Center for Violence Prevention, UTMB
January 2023 is National Stalking Awareness Month – the 19th annual call to recognize and respond to the dangerous and often misunderstood public health issue of stalking. As health care providers, it is important for UTMB faculty, staff, physicians, nurses, students, and affiliated community-based physicians to learn how to identify and intervene when we experience, see or suspect stalking.
What is Stalking? Stalking can involve physical acts such as following or approaching someone repeatedly in a threatening matter, sneaking into a person’s home or vehicle to scare them, or leaving strange or potentially threatening items. It can also involve actions through technology such as repeated unwanted phone calls, emails, texts, social media messages, tracking someone using spyware or accessing someone’s social media accounts without their consent.
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Student-led 5k Training Program Promotes Wellness for UTMB Community
It’s not uncommon to see more runners lacing up in January, the time of year when renewed health and fitness goals are fresh on everyone’s minds. While many abandon their goals shortly into the new year, fitness-minded individuals may be more likely to stick with a running routine if their training program includes a structured plan to build mileage and a goal run on the calendar.
It’s fitting that a 5k training program is among the first projects for UTMB’s Preventive Medicine Initiative (PMI), which focuses on preventive medicine education, student health and wellness, and health outreach in the Galveston community. Founded last year by John Sealy School of Medicine (JSSOM) students with Dr. Sarah Siddiqui as faculty advisor, PMI has launched “From Couch to Finish Line,” a seven-week program open to all UTMB students, faculty, staff, their families and friends, and community members. It is modeled after the well-known Couch to 5k program.
| The Preventive Medicine Initiative officers are, from left to right, back: Ethan Ha, Brian Liao, Jonathan Adams, Tony Phan, Jr.; and front: Jessica Ngo, Anaelle Lahitte-Crohare, Stephanie Kim, Kyle Sheth. |
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Front-Page News
UTMB Transplant Surgeon Featured in Houston Chronicle Cover Story
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UTMB transplant surgeon Trine Engebretsen, MD, was featured in a front-page story in the Houston Chronicle on Jan. 2.
The story focused on her experience as a liver transplant recipient and her marriage to fellow transplant recipient Ryan Labbe. They are believed to be the first pair of liver transplant recipients to have children together.
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RCO Coding Clip:
Does Your Documentation Justify the High Level of Service You Are Billing?
Referencing the age old saying of “if it wasn’t documented, it wasn’t done…” This holds true for any service performed. The documentation must demonstrate medical necessity and justify the CPT code billed. Remember, only the problem(s) addressed (defined by the AMA as those being evaluated or treated at the encounter) may be considered for leveling. Your documentation must be specific. Documentation for a LOS 5 OP visit, or LOS 3 IP initial or subsequent hospital or observation care requires the following:
Choosing LOS based on MDM requires:
High level of problem(s) addressed. Is there one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment? Is there one acute or chronic illness or injury that poses a threat to life or bodily function in the near term without treatment? If so, documentation is key.
Extensive level of data to be reviewed and analyzed. Two categories must be satisfied and clearly documented. Category 1 includes the ordering or reviewing of test/study results, obtaining history from someone other that the patient or reviewing old medical records. At least three of these items must be done in any combination of the bullets on the MDM table. Category 2 represents independent interpretation. This requires looking at an actual image or specimen and documenting your brief interpretation. Category 3 includes discussion of the management or test interpretation with another provider or appropriate source requires a summary of the conversation and who you spoke with.
High risk of morbidity or mortality of patient management. Examples provided by the AMA are drug therapy requiring intensive monitoring for toxicity. This includes drugs that require monitoring at least quarterly and are on the UTMB list of drugs for this purpose. Decision regarding elective major surgery with patient or procedure risks identified. Decision for emergency surgery or a decision to admit the patient, a decision not to resuscitate or de-escalate care due to a poor prognosis and finally, parenteral controlled substances were added this year.
It is important for your documentation to include at least two of the 3 elements that satisfy the LOS 5. In some cases, your cognitive thinking can be helpful. For instance, if you considered surgery but then decided against it due to other factors, document this. This will justify the decision for surgery area in Moderate or High level of risk depending on the surgery.
Total Time – this will include both face-to-face and non-face-to-face activities performed on the same calendar date as the evaluation and management service. You must at least reach the time requirement for the highest code in any given category of services mentioned above.
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Have coding questions or need additional training? We are here to help! We invite you to contact us to schedule large group, small group, or 1:1 training.
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RCO Coding Clip is a monthly feature in the FGP Newsletter, with educational and informational items for providers from our Revenue Cycle Operations Coding Team. | |
Recognizing Clinical Excellence in Pediatric Surgery | |
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As we enter a new year, we would like to continue to highlight APPs who were nominated for Awards of Excellence. Sarah Mims, FNP-C, was nominated for the APP Award of Excellence in Clinical Practice by Dr. Ravi Radhakrishnan. He wrote:
“Ms. Mims has been a model APN. She functions as an independent practitioner of pediatric surgery and is an invaluable member of the team. She consistently goes above and beyond in facilitating care for our patients and in support of the faculty and residents. She continues to make herself available to our fellows, residents, and students, teaching them and clarifying their questions on the service. Her work ethic and dedication to our patients are admirable.
"Our pediatric surgical patient population is quite diverse. As a result, our patients’ families have varying levels of resources to help care for their children. Ms. Mims will regularly contact and follow-up with patients to ensure that nothing falls through the cracks. She is in constant contact with our most chronically ill patients, many of whom have her personal cell number. Her efforts are one of the main reasons that the surgical care to UTMB’s most vulnerable population rivals that of many major children’s hospitals.
"Ms. Mims holds herself to the highest possible standards. She is always available to our patients and ensures that the patient is taken care of, no matter the effort involved. Ms. Mims’ ability to effectively communicate with our colleagues from other services, attention to detail, efficiency, and empathy for our patients have made her a vital member of the surgical team. She has served as an example of an excellent clinician to our surgical fellows, residents, and students many of whom turn to her for guidance in clinical care of our patients.”
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APP Corner is a monthly feature by, about, and for UTMB's Advanced Practice Professionals. | | |
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Do you know where on one of our UTMB campuses this photo was taken?
We feature sights across our UTMB campuses each month. If you think you know, email Robert with the location. We will share the location next month!
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December Winner
Congratulations to Jeffrey Farroni, PhD, JD, Associate Professor in Bioethics and Health Humanities. He was the first to identify this artwork in the hallway on the second floor of John Sealy Hospital, located between the skywalk and the main elevators.
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