Lost in TranslatYIN – July 2024

Dear NES Providers,

           I hope you all are enjoying your summer.  Hopefully you are staying cool and beating this record heat we are having.  I wanted to thank you all for reading and applying the documentation pearls in these newsletters.  Your feedback is vital to the success of NES and I’ve gotten a tremendous amount of feedback from you all.  I can tell that you all are applying these documentation tips in your charting as I am seeing an increase in critical care and smoking cessation across the board.  Thank you all.  You all deserve to be commended. 

           July’s Documentation topic is all about Physician Observation and how to bill for it.  Truth be told, billing for Physician Observation was pretty rare prior 2020.  Then a little thing called COVID happened.  Suddenly, there were critically ill patients boarding in every Emergency Department.  I remember in Cleveland our hospital was completely full and our ED had 20 inpatient boarders every day.  Thus, we were trying to turn over 160 patients a day with 10 beds and 5 hallway beds.  It was a tough time.  CMS recognized how difficult these times were and made guidelines on how to bill for Physician Observation as a result of the pandemic.  

           Do you all remember how many RVU can be obtained for billing for critical care?  The answer is 6.31 RVU for the first 30 minutes to 74 minutes.  Billing for physician observation results in 6.18 RVU.   Anecdotally, prior to COVID, I almost never did a second troponin on a chest pain patient.  These days, doing an initial troponin and then a delta troponin in 2-3 hours is almost standard practice.  Chest pain patients that get a second troponin can all be counted as Physician Observation.  Isn’t it crazy to think that a chest pain patient that gets 2 troponins, generates almost as many RVU as the subarachnoid hemorrhage that you just flew out of the ED?  I am 100% positive that all of you are observing patients in your Emergency Department, so now it’s just a matter of correctly documenting it and getting credit for the incredible work that you are already doing.  

            Patients that qualify for Physician Observation are any patients in which you use TIME as a factor to determine if the patient is going to be admitted, discharged, or transferred.  The chest pain patient with a second troponin is a perfect example.  Another example is when a psychiatric patient that comes in manic.  You are unsure if that patient is bipolar manic, decompensated schizophrenic, or just happened to mix methamphetamines with alcohol.  Thus, you observe this patient in the ED and wait for labs, urinalysis, and a tox screen and potentially get a psychiatry consult.  Another prime example of Physician Observation is the COPD and asthma patient that you are keeping in the Emergency Department to get a couple extra breathing treatments and walking pulse ox.  For my Emergency Department in Ohio, we do not have inpatient psychiatry.  Thus, all patients with bipolar mania, decompensated schizophrenia, and major depression end up being transferred.  These psych patients are in my department for minimum 6 hours.  These patients are ideal for physician observation.  As well all know and have experienced, often these psych patients are in the Emergency Department and perfectly calm.  1 hour later, these patients get very aggressive and start yelling and require chemical and/or physical restraints.  Therefore, we are observing these psychiatric patients and monitoring their behavior.  Time is definitely a factor to see if their bipolar mania is escalating or to see if the patient is returning to baseline.  

             As I previously mentioned, in order to correctly document Physician Observation, time needs to be the main factor to determine the disposition of the patient.  CMS used to require a family history for these patients.  This is no longer true.  We also need to document the date and time that the observation started and the date and time that the observation ended.  Also needed, is what the patient was offered during their observation (ie, serial EKGs, serial troponins, multiple albuterol nebulizer treatments) and the disposition of the patient.  This seems complicated; however, I promise you it is not.  I have taken the liberty of making 7 physician observation templates for you all to use as examples.  These templates include the conditions that commonly qualify for Physician Observation.  These examples include chest pain, alcohol intoxication, depression, abdominal pain with nausea vomiting, and COPD/asthma.  In order to use these templates and correctly bill physician observation all you must do is copy and paste these templates into your MDM and fill out the date and time the observation started and the date and time the observation ended.  The brackets [ ] in red, are designed for you to insert the date and time the observation started and ended.  The last statement reflects the disposition of the patient.  If the patient is admitted, delete the [ discharged ] and [ transferred ] brackets.  If the patient is discharged, then delete the [ admitted ] and [ transferred ] brackets.  

               Please let me know if any of you have any questions.  As always, my door is always open.  Thank you all for everything that you do.  

OBSERVATION TEMPLATES

 

Chest Pain

Patient is being observed in the Emergency Department for chest pain. Observation time was started at [ ] on [ ]. Patient is currently stable and non-toxic appearing. Observation is being initiated in the Emergency Department to allow time to help differentiate if the patient’s chest pain is due to Stable Angina, Musculoskeletal Chest pain, Pleurisy, and Anxiety versus Unstable Angina, Non-ST elevation Myocardial infarction, and ST elevation Myocardial Infarction. The patient will receive serial troponins and repeat EKGs to help monitor for all aspects of Acute Coronary Syndrome. Observation for this patient ended at [ ] on [ ].  The patient was [discharged] [admitted] [transferred] from the Emergency Department after observation was completed.

Psychiatric Complaint

Patient is being observed in the Emergency Department for depression and anxiety. Observation time was started at [ ] on [ ]. The patient is currently stable and non-toxic appearing. Observation is being initiated in the Emergency Department to allow time to help differentiate if the patient’s depression and anxiety is due to Substance Induced Mood Disorder and Anxiety versus Major Depressive Disorder, Bipolar Mania, Bipolar Depression, and Schizophrenia. The patient will receive frequent psychiatric assessments from the provider as well as from nursing staff. The patient will also be monitored for the need of PRN agitation medications such as Haldol, Ativan, and Benadryl. Observation for this patient ended at                [ ] on [ ].  The patient was [discharged] [admitted] [transferred] from the Emergency Department after observation was completed.

Alcohol Intoxication/Overdose

Patient is being observed in the Emergency Department for encephalopathy. Observation time was started at [ ] on [ ]. The patient is currently stable and non-toxic appearing. Observation is being initiated in the Emergency Department to allow time to help differentiate if the patient’s encephalopathy and delirium is due to alcohol intoxication and polysubstance abuse versus stroke, transient ischemic attack, major depression, overdose of medication, arrhythmia, seizure, or closed head injury/concussion. The patient will receive frequent assessments from the provider as well as the nursing staff. The patient will be monitored for the need for diagnostic imaging such as a CT head, MRI brain, chest x-ray, and serial EKGs to evaluate for prolonged QTc intervals. The patient will also be monitored for the need of PRN agitation medications such as Haldol, Ativan, and Benadryl. Observation for this patient ended at               [ ] on [ ].  The patient was [discharged] [admitted] [transferred] from the Emergency Department after observation was completed.

New onset Seizure

Patient is being observed in the Emergency Department for new onset seizure, lactic acidosis. Observation time was started at [ ] on [ ]. The patient is currently stable and non-toxic appearing. Observation is being initiated in the Emergency Department to allow time to help differentiate if the patient’s seizure and lactic acidosis is due to new onset epilepsy vs alcohol withdrawal, status epilepticus, arrhythmia, polysubstance abuse, overdose of a psychiatric medication, or sepsis. The patient will receive frequent assessments from the provider as well as the nursing staff. The patient will be monitored for the need for diagnostic imaging such as a CT head, MRI brain, EEG, a repeat lactic acid, and serial EKGs to evaluate for prolonged QTc and QRS intervals. The patient will also be monitored for the need of PRN medications such as ativan, and valium. Observation for this patient ended at [ ] on [ ]. The patient was [discharged] [admitted] [transferred] from the Emergency Department after observation was completed.

Asthma Exacerbation

Patient is being observed in the Emergency Department for asthma. Observation time was started at [ ] on [ ]. Patient is currently stable and non-toxic appearing however still short of breath above their baseline. Observation is being initiated in the Emergency Department to allow time to help determine whether the patient will require inpatient admission for Asthma exacerbation vs if the patient is stable for outpatient management with prednisone and albuterol. The patient will be monitored on a continuous pulse oximeter and be given additional albuterol nebulizer treatments. Observation for this patient ended at [ ] on [ ]. The patient was [discharged] [admitted] [transferred] from the Emergency Department after observation was completed.

COPD exacerbation

Patient is being observed in the Emergency Department for COPD exacerbation. Observation time was started at [ ] on [ ]. Patient is currently stable and non-toxic appearing however still short of breath and not at their baseline. Observation is being initiated in the Emergency Department to allow time to help determine whether the patient will require inpatient admission for COPD exacerbation and acute on chronic respiratory failure vs if the patient is stable for outpatient management with prednisone, albuterol, and azithromycin. The patient will be monitored on a continuous pulse oximeter and be given additional albuterol nebulizer treatments and steroids. Observation for this patient ended at [ ] on [ ]. The patient was [discharged] [admitted] [transferred] from the Emergency Department after observation was completed.

Abdominal pain/Nausea and Vomiting

Patient is being observed in the Emergency Department for abdominal pain, nausea/vomiting. Observation time was started at [ ] on [ ]. Patient is currently stable and non-toxic appearing however still experiences abdominal pain and vomiting. Observation is being initiated in the Emergency Department to allow time to help determine whether the patient’s abdominal pain is due to gastritis/enteritis and cyclical vomiting syndrome vs early small bowel obstruction, early mesenteric ischemia, or abdominal viscous perforation. The patient will have serial abdominal exams, frequent reassessments and offered medications such as zofran, phenergan, reglan, haldol, and IV fluids. Observation for this patient ended at [ ] on [ ]. The patient was [discharged] [admitted] [transferred] from the Emergency Department after observation was completed.