Today was my first day in practice

[ventana]

I used to think my days were atypical until I started comparing notes (and gripes) with PA and MD/DO colleagues and this seems to be "normal." You have to figure for a GOOD SOLID 99214 you need 4+ HPI/ROS/PFSH, 5-7 system exam, at least 3 DX with moderate complexity and 25 minutes minimum of time with the patient. For a 99213 you need 1-3HPI/ROS/PFSH, 2-4 system exam, up to 2 Low complexity DX, and 15 minute visits. My patient population consists of minorities in inner city Oakland with T2DM, HTN, Hyperlipidemia as a MINIMUM and then tack on HIV, HCV, Cirrhosis, CKD, Polyneuropathy, OA, etc. etc... you kinda get the picture I hope. This is typically what I go through everyday so I get several 99214s and a few 99213s-which I count as blessings even though the reimbursement is not as much, but at least i know I can knock out the Chart note in less than 10 minutes or so. Having said all that....I still L O V E my job!!!!:love:

 

 

few billing pointers

 

1) ">25 minutes spent with patient with >50% of this time in counseling on ___________ and coordination of care" is an AUTOMATIC level 4 (99214) visit - don't have to worry about what else you document

2) ">15min........" is a level 3 visit

3) simply taking and commenting on BP is considered a "stable problem" and takes most level two visist to a level four - new problem and one stable problem is likely a level 4 visit - doucment that you eval their BP or the DM or thirr BMI (gotta love EMR BMI auto calculators) or their smoking, or there stable depression or any other the other stable issues.....

 

THIS IS HUGE for all us IM/FP PA's - look at chronic conditions and document that you looked at them

 

 

Here is a sample for a simple URI patient

 

CC: Here for 7 days of a cold

(then go on about the S/S of the cold and get some pert. negative)

 

ROS: make sure to touch on at least 4 systems

IE HEENT, neuro( no head ache), Resp - cough and describe, C/V no cp or palp, then throw in GI No N/V/C/D, and even GU for women - no UTI s/s

 

PMH: (the kicker)

DMII

HTN

Smoker

 

PE:

vitals including pulse, resp, bp, TEMP and FOX if URI s/s

 

A/P

1) URI - blah blah blah

2) DMII - last AIC 3 months ago, pt reports fasting sugars in AM at 100-110, will check AIC in next 3 months

3) HTN - stable on toprol, goodcontrol at 130/85 - will follow

4) Smoker - counseled on risk and benefit of smoking, patient un interested in quiting.

 

 

 

TADA - that is a 10 min visit, 3 min to document on a good EMR and you have a level 4

 

 

 

or as a different A/P (on a young healthy patient with URI and smoker)

A/P

1) URI - blah blah blah

2) smoker - strongly adivsed to quit - d/w patinet COPD, emphysema, pneumonia and the slow death associated with suffication from lung tissue destruction - > 25 min visist and >50% in counseling on this subject

 

TADA level four that is bullet proof with the auditor as you have documented the time based (as long as you really are doing it)

 

 

 

 

a large part of getting paid is figuring out that what seems stupid, simple and nothing to evn mention in a note for an experienced IM/FP provider is actually a big deal that a specialist would not feel comfortable on - ie have you even seen an othro comment on BP or A1C - our speciality is the intellectual world not the procedural world - hence when you look over a typical patients chart and talk to them you are likely already at a level 4 as they are complex and you are assessing many different things at once - our speciality is thought based and you need to be able to capature these brief thoughts and realize they are important (and not that hard to document)

[physasst]

Congratulations on the position! How have the patients reacted to being seen by you? Have you worked out a brief "what a PA is" blurb for them yet? There is always talk on here of patients in the US not knowing anything about PAs, and it seems like that would be even more of a challenge in Canada.

 

To speak to this, and for the OP. You should check out the latest issue (August, 2012) of Canadian Family Physician. Interestingly, it appears that Canadians are MORE willing (as were the Australians) to see PA's for emergency care than Americans........Crazy...

 

From the Abstract:

 

Objective To determine the willingness of Canadians to accept treatment from physician assistants (PAs).

 

Design Respondents were asked to be surrogate patients or parents under 1 of 3 conditions selected at random. Two scenarios involved injury to themselves, with the third involving injury to their children. The wait time for a physician was assumed to be 4 hours, whereas to explore the sensitivity of patients’ preferences for a range of times, PA wait times were 30 minutes, 1 hour, and 2 hours.

 

Setting Vancouver, BC.

 

Participants Two hundred twenty-nine mothers attending a hospital with their children.

 

Main outcome measures The main outcome measure was the proportion of individuals in each scenario who were willing to be treated by PAs for at least one of the time trade-off options offered. A secondary outcome was the proportion of individuals who changed their answers when the waiting time to see the PA varied.

 

Results Regardless of the scenarios, 99% of participants opted for PAs under the personal circumstances; 96% opted for PAs when the issue involved their children. The choice favouring the PA persisted, albeit at slightly lower proportions, as the difference in wait time between PAs and physicians decreased (85% and 67% for a difference in PA and physician wait time of 3 and 2 hours, respectively).

 

Conclusion These findings suggest that British Columbians are willing to be treated by PAs under most circumstances, whether this includes themselves or their children. The high level of willingness to be treated by PAs demonstrates public confidence in PA care, and suggests that the use of PAs in Canadian emergency departments or clinics is a viable policy response to decreasing primary care capacity.

 

 

 



[PAstudentCanada]

Congratulations on the position! How have the patients reacted to being seen by you? Have you worked out a brief "what a PA is" blurb for them yet? There is always talk on here of patients in the US not knowing anything about PAs, and it seems like that would be even more of a challenge in Canada.

 

Thanks. Patients have reacted well. The shortest blurb I give is "I'm a PA which means I practice medicine under physician supervision" but I am on the clinic web-site with an explanation and we have handouts in the waiting room and I am on a big screen in the waiting room.

[PAstudentCanada]

Yes, we can bill for that. The patients you are describing would be rare for me to see, I can think of maybe only 2-3 like that from my entire clerkship.

People come in that regularly? Does Canadian single-payer cover that?

 

The way I anticipate I'll have to do Family Medicine down here (I'm a recent grad looking for a job, so basing this on my rotations, which includes a potential job site), is address the DM, HTN, hyperlipidemia, obesity, smoking, WHILE ALSO trying to address the cc, which is usually a back strain or something musculoskeletal. The reason I can't focus on their chief complaint is because they haven't been in in over six months (maybe a year?), their sugar is totally out of wack, and their BP is 160/90. Also, they may or may not be taking their meds. And if they are taking it, maybe they are taking it wrong, not keeping track of their sugar etc. So all that has to be explained again. And they haven't had any preventive medicine in a long time. They are overdue on a pap, mammogram, colonoscopy etc. There's no way I could have them come back for any of this education or tinkering with meds, or scheduling, because they won't. Not only that, they only care about their back pain in that moment, and they are really hoping to walk away with a scrip for the pain. Returning again (and every week, wow!) is a bit of a hardship; they usually have co-pays, lost work etc.

This describes maybe 1/2 to 2/3 of the patients I saw at my potential future employer. And we are scheduled every 15 minutes, which the fairly newly minted doc & my potential future SP struggles to accomplish this (fortunately, many people don't show up, so his packed schedule is a bit more manageable). But there is NO way I'll see that many patients or even near it. In fact, I'll probably work with him more like I did in my rotations at least initially. And the EHR is a total nightmare--not intuitive at all...my potential future SP spends 2 hours after his 9 hours in clinic charting.

 

Canadian medicine sounds like a dream. Maybe I need to relocate!!

[physasst]

Thanks. Patients have reacted well. The shortest blurb I give is "I'm a PA which means I practice medicine under physician supervision" but I am on the clinic web-site with an explanation and we have handouts in the waiting room and I am on a big screen in the waiting room.

 

I bet they have. In addition to the article I just posted above, there was an article in 2011 in CFP as well discussing general Canadian physician workforce trends....

[MrBob]

Seems surreal. I'm in FM. Very supportive SP. saw 10 patients in 4 hours which I thought was good given it was all so new and the room is not set-up yet and the clinic is not completely familiar. I think I should be able to see 15-20 in that time in a couple of weeks. So weird to go from student to actual PA. Excited and numb at once! haha

 

Congratulations, Canada. I am going to assume you are practicing in Canada. Where? This is my 31st year...Darn that makes me feel old. I still remember my first day in an ER...overwhelmed. good luck and welcome to our profession. It is terrific having pioneers with us.

[Joelseff]

@ventana: thanks Jeff for the tips! I do put on the total time blurb for 99214s. My prob is I am using practice fusion which is slow when it comes to charting b/c I have to free hand type a lot of stuff like current meds and labs which doesn't auto populated in the note. We are switching to Allscripts in October. Hopefully that will cut my charting time some. Thanks again.

 

Joe

 

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[PAstudentCanada]

Thanks :) Near Toronto.

Congratulations, Canada. I am going to assume you are practicing in Canada. Where? This is my 31st year...Darn that makes me feel old. I still remember my first day in an ER...overwhelmed. good luck and welcome to our profession. It is terrific having pioneers with us.

[physasst]

Thanks :) Near Toronto.

 

Ever been to Ottawa???

 

I have a meeting there soon for an international research collaborative, and not sure what to expect. I've been to Toronto, never to Ottawa.

 

Mike

[MrBob]

Then you must have attended the meeting this summer. Toronto is a beautifully clean city. You are lucky to live there.

[PAstudentCanada]

Ottawa is nice. Go to Montreal while you are there.

Ever been to Ottawa???

 

I have a meeting there soon for an international research collaborative, and not sure what to expect. I've been to Toronto, never to Ottawa.

 

Mike

[PAstudentCanada]

I didn't. I couldn't afford it.

Then you must have attended the meeting this summer. Toronto is a beautifully clean city. You are lucky to live there.

[Beorp]

Maybe I've missed this, but how is it working in terms of which patients you see? Are you building your own patient load or will you just be seeing your SP's patients? Assuming you don't have your own patient load, are the patients specifically making an appointment to see you or is the option of seeing you being presented on the day of their appointment?

[x98peterson]

I don't know how you have time to see 4 an hour AND discuss every patient and have your doc see them as well..... Unless you are seeing all colds and stuff. I feel sorry for your patients that they have to come in weekly.... (people in USA wouldn't pay for that). You must have an awesome support staff and great system down! Are you in a government run clinic/community health center? I can whip out well child visits, colds, and HTN f/u's pretty quickly. I am sure you don't have much paperwork to deal with yet like refills, disability stuff, etc. After a year, you start getting all of that stuff, that would take me up to two hrs a day to complete.

[Walkoffshot]

As an aside PAstudentCAN, and sorry for hijacking the thread, but thought you may be interested. Here is an article from the Star Phoenix in Saskatoon, SK (where I am from) about incorporating PA's in Sask.

 

http://www.thestarphoenix.com/health/Physician+assistants+promoted+option+rural+health/7114889/story.html

 

People are most definitely taking notice.

[PAstudentCanada]

I am seeing both existing patients and new patients and when they book they are booking specifically to see me.

Maybe I've missed this, but how is it working in terms of which patients you see? Are you building your own patient load or will you just be seeing your SP's patients? Assuming you don't have your own patient load, are the patients specifically making an appointment to see you or is the option of seeing you being presented on the day of their appointment?

[d2305]

I've only been to Canada a couple of times, but Lake Louise is the place to see.

[PAstudentCanada]

I've only been to Canada a couple of times, but Lake Louise is the place to see.

There is a lot more to Canada than Lake Louise. Canada is the 2nd largest country in the world and 4th by land mass alone.

[mackjacks]

I've only been to Canada a couple of times, but Lake Louise is the place to see.

 

The Bruce Peninsula and niagara escarpment is my must see. Great backpacking. PAstudentCanada I am glad to hear it sounds like you have a situation that will work well for you!

[PAstudentCanada]

The Bruce Peninsula and niagara escarpment is my must see. Great backpacking. PAstudentCanada I am glad to hear it sounds like you have a situation that will work well for you!

 

Thanks :-)

[PAstudentCanada]

I need some advice. The way my SP and I are working is that once I see a patient I come get him (he is usually with another patient) and tell him I am ready to review. Then I wait and he comes into my exam room with me and the patient and I tell him about the patient. The problem is the patient often interupts to speak directly to him and he often starts taking hx or doing px on the patient.

 

Is this appropriate? I feel like it seems a bit off but maybe I am wrong?

[ventana]

I need some advice. The way my SP and I are working is that once I see a patient I come get him (he is usually with another patient) and tell him I am ready to review. Then I wait and he comes into my exam room with me and the patient and I tell him about the patient. The problem is the patient often interupts to speak directly to him and he often starts taking hx or doing px on the patient.

 

Is this appropriate? I feel like it seems a bit off but maybe I am wrong?

 

 

this is a great way as a student, but not really appropriate as a practicing PA - you are the provider - why have anotherprvider in the exam room at any time unless you want his PE skills......

 

besides that it is a good idea to have him review every case with you before the patients leaves for the first few weeks to months. Moreso to allow the doc to become comfortable with your skill set then anything else. Certainly if there is an urgent issue you should invovle him - ie BP 210/110 with urgent need for meds or something very time sensitive that the patient could be harmed by going home with out treatment at that time (but realistically that is almost never an issue in primary care)

 

The goal is to have you functioning as an efficient productive PCP in about a years time. With this in mind I would say as soon as he will let you (no more then 1-2 months) you should be seeing the patients alone with out him being involved unless you need him. Still go over every patient but might be at the end of the day. Then work towards having a more loose supervision where unless you have a question you don't get him.

 

In the long run you want to be running your own schedule, seeing all your own patients and grabbing your SP for questions - either as the patient is in the room if you have a true dx or txt question - but otherwise running your own show

[True Anomaly]

I need some advice. The way my SP and I are working is that once I see a patient I come get him (he is usually with another patient) and tell him I am ready to review. Then I wait and he comes into my exam room with me and the patient and I tell him about the patient. The problem is the patient often interupts to speak directly to him and he often starts taking hx or doing px on the patient.

 

Is this appropriate? I feel like it seems a bit off but maybe I am wrong?

 

Ever heard the term "historical alternans"?

 

I don't see anything hugely inappropriate about that. As a new PA, you're still getting your feet wet and every patient is a new learning experience, and by having the doctor in the room with you upon presenting he can then get a gauge as to the history you take and the physical you perform, and then discuss the plan outside the room. I will yield to Ventana as to the time frame as to when you should be seeing the patients on your own without him in the room doing presentations because the primary care setting is different than my own experience.

 

One way that your SP can make it a bit more comfortable for you and the patient is the tactic that was used when I was in residency, and was required to present all my patients to an attending or senior physician resident. This residency insisted on bedside presentation, and when the senior resident/attending would go to the bedside with me, they'd say to the patient, "Hello, I'm Dr. ****, I'm going to allow TA to present your case, but if at any time you feel you need to say anything please feel free to do so". Most of the time, the patient was fine with that and honestly didn't have anything to add. When they did, it often was an entirely new part of the history that I either didn't touch on or that they didn't volunteer despite me asking the same question- the anomaly of the "historical alternans" :D

[PAstudentCanada]

Thanks Tue anaomaly and PA Kellogg.

 

I think it might just be the way my SP is that makes me feel a bit uncomfortable. He is from Russia (med school in Russia) then residency in Israel, then was an Israeli army doc, then had a family practice in Israel then came to Canada and did another family medicine residency in Toronto and has been in practice here for 3 years. There are some cultural differences and I guess the way he goes about things just seems off to me.

 

In terms of plan, everything is done and discussed in front of the patient in the room.

[MrBob]

Perhaps this is a good time to begin marketing yourself (looking for something more suitable for you, maybe another job) As I understand it you have been doing this for a few years. Alternatively it might be a good time to have a frank discussion with your SP about how you can be a better and more cost effective "partner" in the office. Maybe he thinks this is how you like it.

 

Bob