ED Financial Structure and Business Flashcards
In 2018, what percent of ED visits were done by independent APPs?
23%
Roughly how many ED visits are there per year?
150 million
Roughly how many EM physicians are there in the US?
40,000
What are some proposed solutions to the oversupply of EM physicians?
- Increase residency length to 4 years to slow the rate of new docs
- Increase resident salaries to deter new programs starting for low-cost labor
- Outlaw for-profit residencies
- Decrease residents per program (voluntarily)
- Better delineate the scope of PAs to prevent midlevel creep
By 2030, what is the projected supply and demand mismatch of EM physicians?
- Projected demand: 40,000
- Projected supply: 50,000
What are some demand strategies to help ensure a vigorous EM workforce?
- Make an MD-led emergency certification program to reward EDs that have a high MD-to-APP ratio so that patients know where they can expect a high level of care (which would hopefully increase volume to EM doctors)
- Expand the role of EM physicians (obs units, POCUS, telemedicine, EMS, critical care, proceduralist services, correctional facilities, and psychiatric emergencies)
- Non-clinical roles: policy, research, advocacy, legal consulting
What do you need to bill level 5?
- HPI: at least 4 elements
- ROS: at least 10 items
- PE: at least 8 organ systems
- 2/3 of FMH, Social, or PMH (can be one item as long as it’s specific)
Note: if you document a limitation to the HPI then you can get an exemption, such as for intoxication.
Include the phrase “_____________” after your DDx in the MDM section.
among multiple other possible etiologies
This helps to clarify what you’re thinking and to leave the door open to other things.
Why do you need to mention when you personally reviewed an image?
You get two MDM points for your personal review
Why do you need to document that you reviewed old records?
You get two points for mentioning review of records.
Sand goes for mentioning obtaining corroborating info from family or EMS.
What things are required for critical care documentation?
- A life threatening illness with organ dysfunction
- Urgent intervention by the provider
- Minimum 30 minutes involvement but not necessarily at the bedside
If you’re documenting EKGs, you need at least _______________ elements.
Three
What three things determine laceration reimbursement?
Location, length, and complexity
Document whether you did __________ in an I&D.
whether you packed or probed
These make it a complex procedure.
True or false: patients cannot refuse to have trainees participate in their care.
False
All trainee involvement must be disclosed as part of informed consent. Patients always have the right to refuse trainee involvement.
Review HIV disclosure laws.
All new HIV cases are required to be disclosed to the department of public health. There are anonymous reporting systems to notify exposed people. Some states have laws that mandate reporting to exposed people and criminalize the withholding of HIV status to exposed people.
The average ambulatory note in the United States is _______ times longer than notes in the rest of the world.
four
Make your MDM focused on this: _______.
why you think the patient has X and why you think they don’t have Y
What are E/M codes?
Evaluation and management codes
All ED visits are billed from 1 (least complex) to 5 (most complex). Nationally, 50% of ED visits are level 5 and the rest are mostly 3 or 4.
What does it mean to get downcoded?
When a visit should have been a higher level visit (based on the chief complaint) but failed to meet the necessary documentation criteria and gets billed as a lower tier.
What is needed to bill as a level 5 visit?
- Chief complaint
- HPI 4 elements (LOPQRSTAA)
- Two of the following: PMH, FMH, or SH
- ROS 10 items
- Physical exam 8 items
Every level of ED visit needs a _____________.
chief complaint
What is occurrence coverage?
It is malpractice coverage that covers you while you are at your job and after you leave.
Claims coverage must also be paired with ______________.
tail coverage
Claims coverage works only for claims filed while you remain at your job.
For looking at academic jobs, always ask what the likelihood of ________ is.
promotion (and how long this takes)
Ask what happened to the last 3 people who got the position.
For all jobs, ask what happened to the last __________.
people who took the job (like did they stay, how long it took to get partner, etc)
Review the requirements for the four levels of trauma centers.
I:
- Surgical residency and/or research program
- Full range of surgical specialists 24 hours a day
II:
- No surgical residency or research required
- Some surgical specialists 24 hours a day
III:
- No 24-hour surgeon requirement but some surgical capability
- ICU and emergency care capabilities
IV:
- No surgical requirements
- Must have a trauma-trained nurse and some form of 24-hour physician available but not ED doc
What percent of ED collections are from L1-L5 charts, CC, and procedures?
Charts: 80%
Procedures: 10%
Critical care: 10%
There are three columns of things that coders see. What are they?
Note, your chart is scored by the highest 2 of the 3.
Complexity and number of problems addressed
- Must include DDx and comorbid conditions
Amount and complexity of data reviewed
- Includes those you did review and those you considered and the rationale for not ordered
- The coding buzz words for reviewing is “independent interpretation”
- Includes specific notes and what you gleaned
- Consultants
Consideration of escalation of care:
- Should only be documented if you meaningfully considered it. If not, delete it! Good examples are if a patient declined admission or if you performed studies/observation that obviated the need of admission.
- Mention factors that affect patient risk such as homelessness, food insecurity, drug abuse
Importantly, you only get credit for “independent interpretation” of __________.
one thing
Same thing for consults. You only get credit for documenting one conversation with a consultant.
For the WEPPA template, delete the “considered admission” if you never considered admission.
… Just notes
If you actually ordered a prescription medicine, then you do not need to note that you considered __________.
a prescription medicine
Include in my usual template:
“Independent interpretation” of at least one radiograph or EKG
Document conversations with consultants.
Considered tests
Disposition considered
Historians listed
Social factors
Review the ESI grading system (per the ABEM boards).
1: needs immediate life-saving care (e.g., intubation, Narcan, stroke, STEMI, trauma)
2: potential but so far unknown high-risk diagnosis; altered patients; concerning vital signs
3-5: all stable, vary depending on resources
3: stable but multiple diagnostic studies needed
4: stable, only one diagnostic study needed
5: stable, no diagnostic studies needed
Review what you need to do prior to transfer to avoid EMTALA violation.
- Stabilize the patient to the best of your facility’s ability
- Certify that the benefits of transfer outweigh the risks
- Have a physician at the receiving hospital accept the patient
- Provide copies of the patient’s medical records to the receiving hospital
- Patient consents to transfer
- Organize transportation
What are the two tiers of EMTALA violation fines?
Hospital with > 100 beds: $106,000
Hospital with < 100 beds: $53,000
At what distance from a hospital does EMTALA apply?
250 yards
