SOGH September 2017 Newsletter 

PRESIDENT'S MESSAGE

The lead news item for this month is the announcement of agreement by Consultare Partners to continue providing management services for SOGH.  This means that Toni Capra as Executive Director will carry through her duties at the Annual Clinical Meeting.  She also will support the initiation of our strategic plan which is being led by Tanner Colegrove, our President Elect. With the support of Janet Burkard, membership operations will flow seamlessly into 2018.

Now for a somewhat bothersome but true anecdote:

Recently a hospitalist was awakened from a deep post-call sleep at home by the unexpected ringing of the front doorbell. On the porch was a patient who had located the doctor’s residential address through an internet search. The patient had come to ask about her hospital experience. The encounter was resolved with the patient being given information on how to obtain her medical records from the hospital.

• Accurate contact information for follow up should be made available to the patient at the time of discharge. 

• Outpatient follow-up resources from inpatient encounters would ideally include a communication mechanism between the two providers. 

• Hospitalists should consider possible mechanisms for participation in post-hospital care after notification by the follow-up provider. 

• Recognizing that mental reaction to a totally unexpected challenge is different from ordinary thought, one might react to such situations by use of a familiar checklist; as would be done in a car accident. 

• Provider safety is important even outside the hospital. Effective precautions for safeguarding providers’ personal contact information are best made before experiencing an adverse event.

Continuing on the subject of an individual hospitalist’s wellbeing, one must realistically acknowledge variations in sleep patterns and the stress that accompany a hospitalist’s professional life. When accommodations are made incrementally over a period of time, manifestations of prolonged stress might not be readily perceived. To help in recognition, one could use the self-assessment form here. Excessive and/or rapidly increasing stress might indicate need for assistance. Hospital and medical society physicians’ health committees could be among appropriate choices for help. Of relevance is a session, “Managing Stress, Building Resilience: The Imperative of Self-Care for Health Professionals" at our ACM on Tuesday, September 26^th, 2017.

Two links for self-help are: 

Medical Student Stress & Burn Out

10 Tips for Conquering Stress

Ending my last President’s Message, I would like to thank all of the individual members of SOGH for allowing me the opportunity to serve.

With Gratitude and Best Regards,

 IN THE NEWS

SOGH Featured in US News & World Report  

  "Hospitals Ramping Up Round-the-Clock Staffing for Pregnancy Emergencies"

“CODE THIS!” (Case of the Month)

Multiple Co-Morbidities in Pregnancy in an Established Patient in the Third Trimester

by Lori-Lynne A. Webb, CPC and Renee Allen, MD, MHSc., FACOG

Case Excerpt (summary and narrative of actual case):

31 yo G4P1112 at 34 3/7 weeks EGA (by 8 week ultrasound) presented to L&D with complaints of decreased fetal movement and abdominal pain . On this day she hasn't felt the baby move and came in to OB Triage for evaluation.  After arriving she reported that she felt the baby move three times in the first twenty minutes of being monitored. 

The patient complained of 24 hours of intermittent abdominal pain.  When she arrived she was contracting every five minutes; which corresponded to her intermittent abdominal pain.  She denied vaginal bleeding or loss of fluid.  She reported some recent vaginal discharge evaluated by her private OBGYN and found to be normal (negative wet prep, negative gonorrhea and chlamydia testing). She last had sex 8 weeks ago and her last pelvic exam 2 days ago.

Her pregnancy was complicated by cholestasis, and she has been performing regular fetal kick counts.  The cholestasis of pregnancy was diagnosed several weeks before this triage visit.  She had been on oral ursodiol therapy.  The pregnancy was also complicated by morbid obesity, with a BMI 54, macrosomia, and polyhydramnios ( AFI 26 and EFW >90^th  percentile).. 

Her first delivery in 2010, was by cesarean section at 41 5/7 weeks for arrest of descent.  The operative report was available in her chart.  A low transverse incision was documented.  Her second delivery was a successful VBAC induced at 36 2/7 weeks. Details of the delivery are documented in the EHR . 

Triage course:  The patient was evaluated for preterm labor with serial cervical exams and a fetal fibronectin (FFN), which was negative.  Her initial cervical exam was 2cm and a repeat cervical exam two hours later was unchanged.   Antenatal corticosteroids were considered. The patient was coincidentally fasting for previously planned gestational diabetes screening and an order was placed for a fasting glucose and metabolic panel.  Her fasting glucose was elevated to 112 mg/dl.  A 50gram glucose challenge test was ordered and was also elevated to 189 mg/dl.  Given the potential diagnostic confounding effect of corticosteroids, a diagnosis of gestational diabetes was made without further glucose testing. 

Her systolic blood pressure was elevated intermittently during her evaluation.  She denied headache or visual changes.  She denied right upper quadrant (RUQ) pain.  Her abdominal pain was determined to be contractions. A preeclampsia evaluation was done. HerCMP was normal.  Her protein:creatinine ratio was indeterminate at 0.2 and a 24 hour urine collection was started.

Results Review

The final diagnosis and assessment provided by the OBGYN Hospitalist was: 

1. Preterm contractions: Preterm contractions with preterm cervical dilation to 2/50/-2.  Cervical exam remained unchanged over 2 hours and 2 examinations and the FFN was negative.  Given no cervical change and negative FFN, the OB Hospitalist did not proceed with antenatal corticosteroids (ANCS) secondary to new diagnosis of GDM.  The patient was counseled that antenatal steroids may be recommended later for fetal lung maturity given anticipated delivery at 36-37 weeks due to cholestasis of pregnancy.
2. Decreased fetal movement, resolved shortly after arrival. Patient had a reactive non-stress test (NST) with category I fetal heart tracing.
3. Gestational Diabetes (GDM), diagnosed during this triage visit based on fasting glucose 112mg/dl and 1hr GTT 189 mg/dl.  Plans were made for the patient to receive diabetes education. The patient was instructed to begin blood glucose monitoring and to return to OB Triage immediately if her blood sugars are >200mg/dl.  The basics of a diabetic diet was discussed with the patient with the caveat that more formal and extensive education would be provided from the diabetes education center.
4. Intermittently elevated blood pressures with indeterminate protein:creatinine ratio.  A 24-hour urine protein test was ordered as an outpatient and the collection kit and instructions provided.  Preeclampsia precautions were reviewed.
5. Cholestasis of pregnancy.  Normal LFTs today via CMP.  Delivery plan is for delivery at 36-37 weeks per MFM.  The patient had questions regarding her mode of delivery.  Given that she previously had a successful VBAC and now has a favorable cervix, the patient was encouraged to consider attempting another VBAC and to discuss it with her MFM.

Follow up with her own private OBGYN is scheduled for 3 days after this triage visit.  

As the OB hospitalist, how would your services be coded?

ANSWER:

ICD 10 Diagnosis Coding considerations include:

ICD10-CM     O24.419  Gestational Diabetes

ICD10-CM      O13.3     Elevated blood pressure affecting pregnancy in third trimester, antepartum

ICD10-CM      O47.03    Preterm uterine contractions in third trimester, antepartum

ICD10-CM      O26.613  Cholestasis of Pregnancy  (Liver and biliary tract disorders in pregnancy  third trimester )

Z3A.34           34 weeks gestation of pregnancy

Evaluation and Management Codes (E&M)

99214-25 

CPT codes

59025-26 The Fetal NST CPT code is 59025 with modifier 26 (professional component) – reading and interpretation by physician only.

Coding Brief

The OB/GYN hospitalist in this case correctly assigned, based on the patient’s presenting history, signs, symptoms and clinical examination, diagnoses of gestational diabetes, preterm uterine contractions, elevated blood pressure affecting pregnancy in third trimester and cholestasis of pregnancy.

Under ICD-10, any pregnancy complication diagnosis code must be accompanied by a code in the Z3A family, specifying gestational age. Also per the ICD-10 guidelines, if the trimester is known, it is to be coded, in addition to the weeks of gestation.  In this case Z3A.34 denotes 34 weeks gestation.

An established patient is defined as an individual who has received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years.  Providers must use procedure codes 99211, 99212, 99213, 99214, and 99215 when billing for established patient services provided in the office or an outpatient (OB Triage) or other ambulatory facility.  In the case of OB triage, if this patient was seen by any member of the OBGYN Hospitalist team on a previous date within the last 3 years, these codes would be applicable.

Usually the presenting problems that support CPT code 99214 are of moderate to high severity office or other outpatient established patient visit. Counseling and or coordination of care with other providers or agencies are provided as well. .  In addition, as with all E&M encounters, a face-to-face encounter is always required.

The American Medical Association (AMA) describes the 99214 CPT procedure code as follows:

“Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components:  A detailed history; A detailed examination; Medical decision making of moderate complexity.  Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.  Usually, the presenting problem(s) are of moderate to high severity.  Physicians typically spend 25-45 minutes face-to-face with the patient and/or family.”

The 99214 CPT code can be used for time based billingwhen certain requirements are met. However, documentation of time is not required to remain compliant with CMS regulations. If billed without time as a consideration, CPT 99214 documentation should comply with the rules established by the guidelines referenced above. The three important coding components for an established outpatient clinic note are the:

1. History
2. Physical Exam
3. Medical Decision Making Complexity

Appropriate documentation for this type of encounter requires TWO out of THREE of the following :

1. Comprehensive History
2. Comprehensive Exam
3. Moderate Complexity Medical Decision-Making

For all established office patient billing codes (99211-99215), the highest documented two out of three above components determines the correct level of service code. Compare this with the requirement for the highest documented three out of three above components for new office patient care encounters (99201-99205).  Again, only the highest two out of three components are needed to determine the correct level of care for CPT 99214.

Modifier 25 may be used to identify a significant, separately identifiable E&M service performed by the same physician on the same day as another procedure or service. Specifically, the American Medical Association (AMA) Current Procedural Terminology (CPT) book defines Modifier 25 as a Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E&M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. This modifier is not used to report an E&M service that resulted in a decision to perform surgery. In this case, the NST interpretation also occurred on the same days as the evaluation for abdominal pain and decreased fetal movement.  Documentation that supports the provision of a significant, separately identifiable E&M service must be maintained in the client’s medical record.  And as always, the OB Hospitalist’s documentation has to support the claim that is billed to the insurance carrier. 

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 CM/PCS Ambassador/Trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at [email protected] or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/. 

Dr. Renée Allen served as co-author of this column.  She is Chair of the SOGH Coding Committee and is the SOGH Liaison to the ACOG Committee on Health Economics and Coding.  She currently works as an OB/GYN Hospitalist with Mednax/Obstetrix at Eastside Medical Center in Snellville, Georgia. 

Questions regarding this case? Contact us at:

 [email protected]

Sim Corner

Fire in the OR

Case summary:

Length 10-15 minutes

Cesarean delivery

Target group: Obstetricians, Anesthesia, Nurses

Team members for the Scenario:

Obstetrician

Anesthesia

Scrub RN

Circulating RN

Patient

Family Member

General Learning Objectives

• Communicate effectively with team using crisis resource management skills
• Communicate an adverse event with a patient and her family

Scenario specific Goals:

1. Complete appropriate documentation of fire risk assessment
2. Recognize and activate the emergency response system to fire in the OR suite
3. Locate the OR suite fire alarms and fire extinguishers
4. Demonstrate how to safely extinguish a fire in proximity to a surgical site
5. Demonstrate appropriate technique in evacuating an intraoperative patient from the affected surgical suite
6. Implement infant security plan
7. Employ the SBARR technique to inform and prepare incoming team members for action

Debriefing overview:

• Review sequence of events
• Review learning objectives
• Review communication and team work skills
• What went well?
• What would you do differently next time?
• Share key assessments and learning points with those present and not present.

Additional Information:

• Allergies: NKDA
• Medications: PNV
• Ht 5’6
• Weight 170lbs
• EFW 3000g
• PSH Neg
• OB History:   Previous C-section x1
• VS HR 85; RR 20; BP 118/70; Temp 37.4
• FHT’s category 2      
• GBS unknown
• 1 hour Glucola:110
• Social history negative

Set up: Patient (staff or mannequin) in OR bed with Cesarean delivery drapes placed.   Large bright orange flames made out of orange/red felt or construction paper with adhesive tape applied.  This is attached to area where flames erupt (Above waist vs below waist)

Equipment:

• OR table
• Cesarean section drapes
• Flames (Bright orange felt or construction paper in shape of flames with adhesive tape)
• Cesarean instruments
• Baby
• Warmer
• Fire Extinguisher

Sequence of Events: 

  Sequence of Events:

1. Responder #1 (Scrub RN)—Identifies emergency and reports fire
2. Responder #1/ 2— Calls for removal of drapes
3. Responder #2 (OB) Asks for extinguisher to extinguish fire
4. Responder #3 (Circulation RN)— retrieval of  extinguisher and activation of emergency system
5. Responder #4 (Anesthesia) Preparation of patient for removal from OR
6. Responder #4 (Charge)—  Removal of baby and all other personnel.

1) Drapes to be removed right away if possible

2) Discuss the RACE mnemonic ( Rescue –Alarm- Contain-Extinguish)

4) Discuss the PASS mnemonic ( Pull-Aim-Squeeze-Sweep)

5) Knowledge of activation of fire emergency

6) Knowledge of local fire alarms and extinguishers

7) Examine patient for burns

8) Maintain communication with patient and family

Debrief: 

• Implement infant security back up plan (stationing staff at unlocked exit doors)
• What can be used to decrease Fire safety risk
• When does Fire safety risk end
• (Establish psychological safety during introduction to scenario and revisit here)
• Emotions --> Ask “How did that feel?”
• Focus on the performance, not the performer
• Ask “What went well?” and “What would you do differently?”
• Move to practice --> “How could this happen to you?”

Calibrate --> Identify and correct misconceptions

Reference:  "Resources and Tools for Preventing Surgical Fires, US, FDA"

 

 

 

ACM 2016 Poster Contest Winner

SOGH will present the 2nd Annual Poster Contest at the upcoming Annual Clinical Meeting in New Orleans.  Details of contest participants and the winning poster submission will be announced in the next newsletter.