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Everything posted by coloradopa

  1. Incident to is relatively simple. The physician must see the patient and form the plan for each new problem. If a patient is new, then the physician must see the patient. If the patient develops a new problem then the physician must see the patient. The AAPC has a good article on this: https://www.aapc.com/blog/44912-seven-incident-to-billing-requirements/
  2. We had a bunch of APPs get theirs tonight. They are recommending not working the next day. I signed up and then asked to be unblinded from the Moderna study. Found out I received the Moderna vaccine in September. My N = 1 minimal side effects.
  3. I'm in the Moderna trial. The PIs are pushing to get the volunteers who got placebo vaccine first. Supposedly they will unblind when the first vaccine is released, so probably by December.
  4. I'll repeat what our ID folks said. You are at higher risk getting COVID in the community than you are in the hospital.
  5. it doesn't really have anything to do with taxes. It was aimed at the gig economy such as Uber. Physicians were exempted for locums purposes. The California nurses were pretty adamant that nurses not be exempted (probably makes strike breaking harder) so PAs and NPs got swept up in the mess.
  6. Its actually pretty normal for private insurance. PAs and NPs are generally not credentialed by most private insurance companies. This is slowly changing in some parts of the country. Generally the instruction from the insurance company is to bill under the supervising/collaborating physician. If you want to be sure, call the insurance company and ask; how do I bill for PA services? The answer will almost certainly be to bill under the supervising/collaborating physician.
  7. We basically staff 1 APP per 5-6 bed during the day and 1 app per 10-12 beds during the night. We work 13.3 hour shifts (basically pay 1.3 hours for sign out and catching up). Full time is 3 shifts per week. We don't allow 24 hour shifts unless in an emergency. We have a few evening shifts for surgical ICUs that get a lot of admissions between 3 and 11.
  8. 1. Then do critical care. I work in a academic transplant ICU. I run my patient list with a ton of autonomy. I do as many procedures as I want to do. I pick up as much extra work as I want. On the other hand OR? One patient, maybe get to do lines. Are you ACT or not? How much autonomy? Big sick cases probably not going to do. Pushing Propofol in endoscopy is not my idea of high intensity. 2. Are you sure? Most CRNAs and Anesthesiologists get along pretty well but there is a lot of bad blood in some places. Now they have a "nurse anesthesiologist" in Florida. 3. Depends. Here, we have lots of CRNAs and AAs not many critical care PAs and ACNPs. Pay is within striking distance of each other and I make more than a lot with a some extra shifts. Now if you want to live in the middle of nowhere I'm sure that's different but as others have said the opportunity cost is tremendous.
  9. First the disclaimer, you are responsible for your coding nothing here constitutes legal advice. There are two issues. One is do you need an office visit for the injection and the other is what is the appropriate code. For issue one it depends on medical necessity. The various medicare guidelines recommend testing testosterone levels then reassessing every 3-6 months as well as testing HCT every 3-6 months. Testosterone has a number of significant side effects and complications. If the treatment plan requires assessing the patient for side effects and complications prior to each injection then you probably have medical necessity. If you are just seeing the patient to increase the billing then you are not. The key is are you mitigating risk/adding value. For issue two it looks like 99213 would be appropriate. The HPI is unnecessary and not required for a 99213. For 99213 you need 2 of 3 of History, Exam and Medical decision making. For history you need and expanded problem focused history which is 1-3 HPI elements and one ROS. For exam you needs six bullets for one or more organ systems. For MDM you need 2 of 3 off problem points, data points or risk. Generally most coders believe that you can't get a higher level unless MDM supports that level (higher levels of History and exam don't trump lower levels of MDM). So if you ignore history you need six exam bullets (VS, appearance, CV, Pulm. Abdomen and extremities for example). Then you need MDM. If you have the chronic problem you are dealing with (low testosterone) and one other chronic problem you are good. Two data points (such as labs or xrays would be rare). For MDM prescription drug mangement is actually medium risk and would qualify for a level four. However given the lack of problems level 3 (99213) is appropriate. Hope this helps.
  10. Here is the medscape article. Interesting and entirely predictable. https://www.medscape.com/viewarticle/903840
  11. This is an article that it pays to look at the comments: Dr. Jonathan Anagnostou| AnesthesiologyDec 2, 2016 What about clinical practices or health systems which employ certified coders? carolyn buppert| Nurse Practitioner (NP)Dec 9, 2016 @Dr. Jonathan Anagnostou Yes, certified coders who are employed to code or to audit clinicians' coding would be in a position to code or to change a code prior to submitting for payment. This is similar to what happens in our institution. The organization is also at risk for billing submitted. CMS requires an organization to have an effective compliance program. So you can't say we told them not to. Most programs of any size audit notes and bills to make sure they are documented according to standards. On the other hand the organization should communicate if they are submitting bills that are different than what the provider submitted. Flag
  12. We don't have Procalcitonin so my experience with this is limited. However, 40% of sepsis is culture negative. The negative lactate is a bit of a puzzle but I have seen this in hypothermic patients. Once you resuscitate them and get them warmed up the lactate will probably go up. In our shop the patient would get 7 days of broad spectrum antibiotics unless they have something we could target. By the time the cultures come back negative the patient is either dead or getting better and nobody wants to stop abx.
  13. This is septic shock until proven otherwise. It smells of GNR sepsis. This is a relatively common presentation for someone with untreated sepsis for a while. Especially when found down. would be willing to bet that the urine comes back dirty. A couple of things. When you have a pH like that and found down I would check a CK. You could have a superimposed rhabdo. It really wouldn't change management much except to go to dialysis early. On the subject of lack of tachycardia. Two answers either temp or the patient is on a beta blocker (fairly common depending on age). For that matter a certain subset of patients don't mount a tachycardic response no matter what. It probably has to do with the hyperdynamic nature of the heart in most sepsis. The way that I put this together is patient gets a UTI. Develops septic encephalopathy and shock. Goes down. Lays there an unknown amount of time and the goes into renal failure as well. The reason that the pressure didn't come up is you haven't filled up the tank yet. The CVP of 2 (while not generally used as a measurement any more) indicates the patient is profoundly intravascularly dry. It sometimes takes 5-6 liters until the patient is tanked up although this is controversial:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5209309/ I generally give 30 ccs per kilo then put them on pressors. I also agree with dropping a probe to look at the IVC. That's a good way to guide further resuscitation. Also the Hgb is likely falsely high since the patient is probably hemoconcentrated. The patients BP is also probably artificially high due to temp. When you warm her up it will drop even more. I also disagree that you need SIRS plus a source to treat. In the new guidelines you have a QSOFA score of 2 which is enough to treat. Outside of known heart failure volume, pressors and early antibiotics are what improves survival. Overall it sounds like you did the right things. I would have gone to pressors earlier to get the pressure up while resuscitating but thats probably a style thing.
  14. I don't know if we have any PAs that split between ED and CCM but some of the CCM PAs moonlight in the ED. For us we work 3 days a week so there is time work elsewhere. We also staffed up critical care beds in the ED. Critical care in the ED is more difficult just due to the nurse staffing in our institution. On the other hand we do have PAs splitting jobs between departments. One of my coworkers is 1/2 time CCM and 1/2 time with our ID department doing sim training in Serious communicable disease (Ebola). She works six shifts a month then spends the rest of the month flying around the country doing training so the opportunity exists.
  15. I have a pretty simple way to address this problem. This is a nursing problem and nursing has to deal with it. I have variable relationship with the nurses but I have a very good relationship with the charge nurses who have a very dim view of nurses not doing their job. So if I have a problem with an order or timely work I simply point out the issue to the charge nurse who addresses it. Problem solved.
  16. Doesn't matter as far as shared billing is concerned. The person billing for a procedure must perform the critical portion of the procedure. The injection should be billed under your NPI.
  17. Here is a pretty good article. Look at question #3. http://www.medicaleconomics.com/modern-medicine-feature-articles/incident-billing-clearing-confusion Here is another: http://www.mdmag.com/physicians-money-digest/practice-management/non-adherence-to-incident-to-billing-can-prove-costly Here is CMS guidance: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf
  18. Two different issues: 1. For Medicare/Medicaid the first encounter must be by the physician and must document the plan of care. The APP can then see the patient for the same problem under incident to as long as the physician is in the suite of offices. This is called incident to. If this does not happen then it should be billed under the APPs NPI at 85%. It doesn't matter if the chart is co signed. Any patient that the APP sees for the first encounter or sees without the physician present is billed under the APP NPI. 2. For other insurance they are usually billed under the physician NPI at 100% unless the practice contract says different. With Medicare you are talking about fraud. I will also guarantee the ABIM does not say this is the way to bill. It seems you are working in a multispecialty center. I would talk to you practice manager or whomever is doing the billing let them know they may also be liable for fraud.
  19. It depends on how the physician contract is structured. Essentially both the PA and the surgeon need to be paid by the same entity. If the hospital is paying the physicians a salary and then billing for them they can bill for your services since both are employed by the same entity. Alternatively if they are given a stipend but then billing for their services then the hospital cannot bill for your services. In addition your assistance in managing their patients may be considered a Stark violation. In this case the surgeons can pay the portion of your salary dedicated to their patients and then bill for your services. Don't forget for Trauma you can also bill critical care if indicated. Contrary to whats posted above you should not be included in the hospitals cost report. Prior to 1998 PAs were included in the cost report but after 1998 with the ability to bill for our services Medicare rules state the hospital must bill for your services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1168CP.pdf
  20. What ARC-PA told you is true. There is a new accreditation process coming online through CAAHEP probably some time next year.
  21. Critical from EM or IM is 2 years. So if you do 4 year med school 3 year residency and 2 years CC then its 9 years. If you are in a 4 year EM residency its 10. LECOM would take 1 year off that.
  22. Actually there are now multiple options for EM/Critical care. We have two attendings that are double boarded.
  23. ARC-PA isn't going to look at this until at least November. However there is a new PA residency accrediting organization forming under CAHEP.
  24. You can have licenses in more than one state. A lot of practice in border areas have offices in 2-3 states. Generally to have an active license you a practice relationship with a physician. If you move and think you might come back you can usually put your license in suspension (lower cost to renew). Otherwise you can suspend/let the license lapse once you get your new license. Also if you work on a military installation or for VA you don't have to be licensed in the state you are in. You simply have to be licensed somewhere in the US.
  25. We cover our ICU 24/7. We have night shift and day shift. Basically we do 3 13.33 hour shifts per week (0600-1930 or reverse). You have to work 6 shifts per 2 week pay period. We get PTO instead of vacation/sick time. 8 hours per pay period (400 hours per year). We also get $2000 and 40 hours for CME. We have differentials for nights and weekends. If you are not weekend option you get $125 per weekend day or if you cover a night you get the same (if you are not on night differential). For extra shifts (beyond 6 per pay period) we have have a system that is specifically not called overtime. Since we are salaried and exempt we don't get overtime. Instead we get extra duty pay (for hours beyond normal duty). It essentially works out to $75/hour for days and $100/hour for nights. You have to do it in four hour blocks. Our group looked at weekends and essentially from a quality of life issue doesn't want to do more than 1/4. We have a weekend night and weekend day position that carries a differential. Basically 10 FTEs give you 2 providers 24/7 with extra for vacations.
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