By Walter L. Green, MD, FACEP
UTSW, Dallas, Texas
Dr. Smith sees a 23-year-old male with a right hand injury. The patient was at a bar last night and hit another patron in the mouth. He has pain at the right 5th metacarpal phalangeal (MCP) joint and a small laceration. History is otherwise negative. Physical exam reveals a 1 cm laceration over the right 5th MCP, no surrounding redness or discharge, but the joint is tender with passive range of motion. Tetanus is updated and IV antibiotics given. X-ray shows a boxer’s fracture with displacement and no foreign body. Orthopedics is consulted.
Dr. Smith records a diagnosis of “fight bite.” Orthopedics decides to take the patient to the operating room for irrigation of the wound and repair of the open fracture.
The transition to ICD-10 will occur on 10-1-15. ICD-10 requires a higher degree of specificity to correctly code orthopedic and hand injures. In this example, it would be important to document where and how the injury occurred and whether alcohol was a contributing factor. The precise location of the fracture, including which hand, which finger, and which phalange are all needed for accurate coding of the encounter.
In this example, it would be better for the ED physician to diagnose “open, displaced fracture of right 5th metacarpal bone.”
The ED coder would assign the following ICD-10 diagnosis codes:
S62.336B (Displaced fracture of the neck of fifth metacarpal bone, right hand, initial visit for open fracture)
S61.451A (Open bite of right hand, initial encounter) to describe the mechanism of injury.
For the Evaluation & Management service, the coder would also assign a CPT code such as 99284.
For additional information on ICD-10 coding for emergency medicine, visit the ACEP Reimbursement page at http://www.acep.org/content.aspx?id=28754.
With passage of the Medicare Access and CHIP Reauthorization Act of 2015 it is official that ICD-10 CM will become a reality October 1st 2015. This is a huge deal for your billing company, hospital, payer contracts and you.
ICD-10 CM is an updated and expanded diagnosis coding system that will replace ICD-9.
At the very least, every clinician working in the ED will need to know how to document in an ICD-10 CM friendly manner. ICD-10 CM requires more specificity and details than ICD-9. Trauma and injuries make up a significant percentage of the new ICD-10 CM codes with laterality (left right upper and lower) now essential elements of the chart.
ICD-10 CM is ultimately tied to hospital and professional reimbursement; hence you also may be at risk for increased denials, charts deemed incomplete and an unhappy hospital CEO.
Here is a list of things you need to do now:
Identify your current systems and work processes that use ICD-9.
Diagnosis ICD coding is not just used for the final diagnoses, but is also used to justify ED testing such as CT scans, EKGs and lab tests. How does your current documentation system assign codes to diagnostics that you ordered? Although ED docs rarely order outpatient testing, be sure that your order form includes ICD-10 codes.
ED Professional Billing
Who is doing your professional billing? How are they going to implement ICD-10 CM? How are they conducting their internal and external validation testing?
Get to know your coder
Coder feedback will be critical. Try to develop a professional rapport with your coding staff such that they feel uninhibited to ask clarifying questions. Now might be a good time to buy the coding staff a large box of cookies.
ED Nurse documentation
Can you make your nurse triage note and nursing documentation more ICD-10 friendly? Consider prompts for external cause of injury, geographic location of injury and mechanism of injury. Documentation of laterality, left right and upper and lower now needs to be clearly documented.
Yes, once again physician productivity may go down. Perhaps your group is on the tipping point for the employment of scribes or extenders. ICD-10 may make such a decision more clear cut.
Randomly select 10-20 charts and ask your coders to code the charts via ICD-10 CM. This should provide a baseline to allow for individual provider education.
To help Emergency Physicians prepare for this change to ICD10, ACEP will be providing ICD-10 documentation tips and insights for the busy ED physician. You can find these resources in several locations, including:
ACEP’s monthly magazine, The Official Voice of Emergency Medicine, is planning articles in the months leading up to October 2015. Written by physicians, for physicians, news about ICD-10 will be specific to EM practice.
ACEP’s home page will include the latest updates, and an ongoing list of resources will be added to the Reimbursement section of the site. Currently, you can find clinical examples, an information paper and an ICD-10-CM manual.
EM Today Newsletter
ACEP partners with Bulletin Health Care to bring the latest health care news each morning from Monday through Friday. Included within EM Today is news and events specific to ACEP. Updates and links to the latest articles on ICD-10 will be included in this newsletter.
Each Saturday, a roundup of the week is delivered with ACEP partner, Multi-View. Also sprinkled throughout the newsletter are briefs specific to ACEP and emergency medicine. ICD-10 news will be included here.
ACEP has an active following on social media. Here are the outlets for information about ICD-10 to be disseminated through ACEP’s membership.
First of all, I’d like to thank ACEP members for allowing me to serve as your President since October. It has been a joy to do my part in advancing the specialty and continuing our efforts to improve your lives and the care of our patients. Each quarter, we’re going to offer a report about what we’ve been working on lately and some of the events that shaped emergency medicine. As you will read below, we have done a lot already in 2015, but a lot of important work is still to come over the next few months, particularly with legislation that directly impacts us and with our Clinical Emergency Data Registry. I look forward to visiting with many of you in Washington, D.C. in May.
SGR Repeal, EMTALA Legislation Top Advocacy List in Early 2015
Two major pieces of legislation kicked off the first quarter of 2015, beginning with the EMTALA Services Medical Liability Reform Bill in early February and continuing with an attempt to repeal the Sustainable Growth Rate in late March.
On Feb. 10, ACEP leaders joined Representative Charlie Dent (R-PA) at a news conference in Washington, D.C., to announce the introduction of the Health Care Safety Net Enhancement Act of 2015 — to improve emergency care for patients. H.R. 836 will encourage physicians and on-call specialists to continue their lifesaving work and ensure emergency medical care will be available for your constituents when and where it is needed. Specifically, the legislation addresses the growing crisis in access to emergency care by providing emergency and on-call physicians who provide EMTALA-related services with temporary protections under the Federal Tort Claims Act.
The Bill was referred to the House Energy and Commerce Committee. As of today, it has 32 co-sponsors, but we can use your help growing that number. Please click here to learn more, and please contact your Member of Congress and ask for support.
On March 26, the House approved a bill that proposed significant changes to the Medicare system’s reimbursement model. It signals what could repeal the Sustainable Growth Rate Formula. The New York Times called it the “most significant bipartisan policy legislation to pass through that chamber since the Republicans regained a majority in 2011.” If successfully passed, the bill would put an end to the recurring threat of payment cuts to physicians. The measure would also increase premiums for some higher income Medicare beneficiaries and extend the Children’s Health Insurance Program for two years.
Unfortunately, the Senate failed to consider the legislation on March 27 before adjourning for two weeks. Senate Democrats wanted a chance to consider several amendments to the House-approved bill, but Majority Leader Mitch McConnell (R-KY) did not agree to that request, instead stating he would work with Minority Leader Harry Reid (D-NV) during the recess to settle on a pathway forward as soon as the Senate returns on April 13, 2015. The Centers for Medicare & Medicaid Services has indicated that it will hold claims through April 14 to give Congress time to act.
We are disappointed the Senate failed to act before leaving town. We remain optimistic that, after fighting this battle for more than 12 years, we will finally rid ourselves of the flawed SGR permanently. We are calling for the Senate to act expeditiously as soon as they return and seize this opportunity to enact real, meaningful change in the Medicare program. Visit the ACEP Grassroots Advocacy Center to send a message to your Senators today.
Supreme Court Rules on Medicaid Rate Challenges
On March 31, 2015 the Supreme Court of the United States issued a ruling on the case of Armstrong vs. Exceptional Child Center. At issue was whether medical providers could sue over low Medicaid rates as a way to enforce federal payment requirements to assure that payments are consistent with efficiency, economy and quality of care sufficient enough to enlist providers so as to maintain adequate provider networks.
The opposing view was that such a ruling would result in endless litigation for higher pay and that Congress had not authorized such suits. The court was divided 5 to 4, ruling that providers do not have a federal cause of action to challenge low Medicaid rates. Instead providers with complaints must appeal to the federal government for enforcement.
ACEP has successfully used legal action in various states such as Louisiana, New York and Washington when the Medicaid plan offered unreasonably low payment, limited the number of ED visits for Medicaid patients, or restricted the approved diagnosis list so as to be unreasonable. Going forward, we will have to look to Congress or HHS regulatory staff to enforce Medicaid provisions, making strong relationships with your elected leaders important.
The ACEP Reimbursement Committee is considering whether a “white paper” should be developed to guide ACEP members and stakeholders regarding whether the Armstrong case could be distinguishable for emergency medicine. The issue is whether the “prudent layperson” provisions of the Balanced Budget Act of 1997 that apply to Medicaid HMOs and the ACA provisions barring prior authorization provide legal rights and/or remedies to emergency medicine that are unique and different from the legal basis presented by the plaintiffs in the Armstrong case.
American Hospital Association (AHA)
Publication Promotes Value of Emergency Care
In late March, the AHA issued a publication that highlighted emergency care’s value and role in the health care system. The report “explores the standby role and its critical importance to our nation’s health care system. It outlines the pressures hospitals face and frames critical economic and policy questions that must be addressed to ensure future hospital standby capacity can meet the growing health and public safety challenges.”
ACEP and the AHA worked together to issue a joint letter about the report, which was entitled “Always There, Ready to Care.” It was made available to all members. We encouraged ACEP members to share this report with key leaders and policy makers in your community and state and promote through social media. If you haven’t received a copy, click here.
ACEP Responds to Measles Crisis
On the heels of the Ebola crisis last fall, ACEP leaders and staff responded quickly to another epidemic when the United States experienced a record number of measles cases in early 2015.
This virus represents a challenge to Emergency Medicine because it is highly infectious and has been rarely seen in emergency departments in the recent past. ACEP developed a Fact Sheet about this disease for a review of its presentation, clinical course and implications for the ED. Emergency physicians and other health care professionals can visit acep.org/measles for more information and for new resources, which will be added as needed.
- Comment Period on tPA Clinical Policy Closed March 13: Early in 2015, ACEP opened a 60-day comment period on the draft clinical guideline: “Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department.” The next step is for the Clinical Policy Committee to review comments and draft a revision as appropriate to submit for ACEP Board approval.
- Mental Health, Substance Abuse Patient Care Resources Added to ACEP’s Website: In early January, ACEP combined numerous mental health and substance abuse resources at www.acep.org, anchored by the Emergency Medicine Practice Committee’s information paper on “Care of the Psychiatric Patient in the ED: A Review of the Literature.” Included on this new resource page was also information about sobering centers, ACEP Policy Statements, Patient Resources and more. See these resources here.
- ACEP Releases New Publication, Cardiovascular Emergencies: More than 6 million people present to EDs each year with chest pain and forms of cardiac disease—arrhythmias, infections and cardiovascular complications from other conditions. ACEP’s newest publication, Cardiovascular Emergencies, provides information to help you deliver efficient and cutting-edge care to patients who present with acute cardiovascular conditions. Learn more.
- EMRA Launches Updated PressorDex App: Newly revised and updated for 2015, PressorDex is a comprehensive therapeutic guide to the myriad of pressors, vasoactive drugs, continuous infusions, and other medications needed to treat the critically ill patient. Written by emergency medicine physicians for emergency medicine physicians, this app gives you concise tools for choosing the right medication and dosing regimen every time, even during the busiest of shifts. Find it and other useful EMRA apps here.
- Qualified Clinical Data Registry Work Continues: ACEP announced last year that it would begin work on a Qualified Clinical Data Registry (QCDR). This is a very complex project, but it will position emergency medicine to develop quality measures that will resonate with members and, we believe, improve quality. We can develop measures that apply to patients beyond the Medicare population. As Executive Director Dean Wilkerson, JD, MBA, CAE, wrote in the December issue of ACEP Now, “If we have our own QCDR, we can control the playing field and develop measures we believe are appropriate without having to submit them to the National Quality Forum for other groups to approve. Rather than having measures imposed on us, we will drive the measures ourselves.” Quality measure reporting and quality improvements are of increasing importance for physician reimbursement. ACEP’s QCDR will allow our members to avoid cuts to their reimbursement and obtain incentive payments. The initial testing and QCDR approval phase began in February 2015 with the participation of five emergency departments. The pilot phase is expected to begin in May of 2015. Through the aggregation and organization of data on clinical effectiveness, patient safety, care coordination, patient experience, efficiency and system effectiveness, ACEP’s Clinical Emergency Data Registry will provide clinicians with a definitive resource for informing and advancing the highest quality of emergency care. ACEP expects final approval of its Quality Measures and our QCDR later this month. Learn more about CEDR.
- End of Life/Advance Care Planning: A task force led by Vidor Friedman, MD, FACEP, Mark Rosenberg, DO, MBA, FACEP, FACOEP-D, and Sandy Schneider, MD, FACEP, has been assembled to prepare a white paper within the next few months to make recommendations to the Board on our next steps to promote a national discussion on EOL/AC issues.
- Psychiatric Emergency Care Initiative: We have already had our first summit of stakeholder organizations and have created COPE – “Coalition on Psychiatric Emergencies.” ACEP is a leader on the Steering Committee, and subcommittees have been created to: address education of the public and caregivers, study the latest advances in diagnosis and treatment, develop a research agenda, and configure an advocacy approach for true parity of care for psychiatric emergencies. In addition, we are working on a public relations release in the next few weeks announcing our mission and the stakeholders. Sandy Schneider, MD, FACEP, along with Barbara Tomar and Cynthia Singh of our staff are leading this effort.
- Sepsis Task Force: We have a task force led by Board Member John Rogers, MD, FACEP, Task Force Chair Don Yearly, MD, and Sandy Schneider, MD, FACEP, to review all of the current literature and summarize it for our members to use. We will also have an educational campaign for our members and other organizations highlighting our role in diagnosing and initiating treatment of sepsis to a point that we, Emergency Medicine, will “own sepsis.” We want to simplify sepsis management and also develop quality measures to be used by EP’s.
Join us in Washington, D.C. this May
The Legislative Advocacy Conference and Leadership Summit is coming up May 3-6 in Washington, D.C., and has been revamped for 2015. Don’t worry. The same excellent education will be available, but the schedule has been changed slightly to emphasize the unique opportunities available at this event. Sunday’s Leadership Essentials, presented by EMRA and the Young Physicians Section, is particularly appealing to those just getting started in advocacy and developing leadership skills. Monday is packed with the latest information about policy, payment models, innovation and much more.
Tuesday is Capitol Hill Day, when more than 500 emergency physicians head to the House and Senate office buildings to advocate for pending legislation and the need for reforms to strengthen emergency medicine and improve access to better patient care. Wednesday is a full day of leadership training and includes valuable CME courses. Please don’t miss this conference. I love our annual meeting in the fall, but this conference offers a chance to spend some time with people in a much more intimate setting while doing some excellent and crucial work for our specialty.
I’ll see you in Washington. Click here for more information.
Dr. Steven Stack to Take Over as AMA President
By the time our next quarterly update comes around, Steven Stack, MD, FACEP, will be the AMA’s 170th President. Dr. Stack takes over in June at the AMA annual meeting. He is the first emergency physician to ever hold that position, and when he assumes office, he will be the youngest president in the past century.
Dr. Stack currently practices in Lexington and surrounding central Kentucky. He has served as medical director of multiple emergency departments, including St. Joseph East (Lexington), St. Joseph Mt. Sterling (rural eastern Kentucky) and Baptist Memorial Hospital (Memphis, Tenn.). Born and raised in Cleveland, Dr. Stack graduated magna cum laude from the College of the Holy Cross in Worcester, Mass., where he was a Henry Bean Scholar for classical studies. He then returned to Ohio, where he completed his medical school and emergency medicine residency training at the Ohio State University before moving to Memphis to begin his clinical practice.
An expert in health information technology, Dr. Stack speaks on behalf of ACEP and emergency medicine at numerous events and conferences throughout the year and delivered the Rorrie Lecture last year at our annual conference.
We appreciate his efforts and congratulate Dr. Stack for his important new position.
New Headquarters Groundbreaking Set for April 16
I’m excited to announce that we will break ground on a new headquarters on April 16 on a six-acre tract of land near the Dallas-Fort Worth International Airport.
The new building will be three stories with approximately 57,000 square feet. This building will have all the things we do not have in our current building, including many member amenities, work areas, top-notch A/V capabilities and video conferencing, a small media room for filming and interviews, history recognition throughout the building and celebration of our specialty.
We have outgrown our space and comparison studies of other professional societies underscored what we expected – our outstanding staff is working under less than desirable conditions, especially as we grow in membership and management responsibilities (SEMPA, EMRA, CORD, EMF). A new building is also symbolic or our coming of age as a recognized and MAJOR specialty. We need advances in our headquarters for our staff and volunteers to serve our members and our patients.
This new building’s location is also nestled between two major hotels, allowing us to offer better service to our chapters and groups that use the national office for meetings and training, such as the Emergency Medicine Basic Research Skills (EMBRS) courses and the Emergency Medicine Foundation grant projects. The Texas chapter also uses our building for meetings, and this will assist in their efforts. There are other educational meetings ACEP may hold in this new building.
We have been in our current building for more than 30 years, and it has served us well. Our specialty is much different now, and this new headquarters is necessary for future growth.
Thanks for allowing me to update you on recent projects and offer a little about what’s coming around the corner. If you need anything, please don’t hesitate to contact me.
Dr. Michael Gerardi
ACEP is pleased to provide our members with a recent publication from the American Hospital Association (AHA) “Always There, Ready to Care,” promoting the extraordinary value of emergency medicine. The AHA is promoting this report by sharing it with policymakers, media and the public.
This publication describes the invaluable role of emergency physicians who must be prepared to respond to a wide range of medical conditions and are now experiencing capacity constraints in the face of rising demands.
It also describes the challenges of psychiatric patients in emergency departments, the complex issues of rural America and the nation’s increasingly heavy reliance on 24-hour access to care. In addition, it demonstrates the crucial role of emergency medicine in responding to disasters, featuring last year’s Ebola emergency and the outstanding response of emergency physicians following the explosions during the Boston Marathon.
The report concludes with a description of the funding challenges to maintaining the emergency department’s 24/7 role in an environment of declining financial support, asking the following policy questions:
- How will financing mechanisms need to be designed in order to support the 24/7 role in the future?
- How can the standby role be financed in an increasingly competitive health care marketplace where payers want to pay the lowest price?
- What is the appropriate role of government in supporting hospital-based disaster preparedness and relief?
- Should all health care facilities be required to support the community’s standby capacity and care needs?
- What steps can be taken to promote greater access to and utilization of primary care among low-income vulnerable populations to improve their health status and reduce the need for ED care?
Please share this report with key leaders and policymakers in your community and state and promote through social media.
|Michael J. Gerardi, MD, FAAP, FACEP
AHA President and Chief Executive Officer
By Nell Harrison
Scott Weingart labeled smacc the “Best conference ever” but is it really worthy of all the hype?
In the past two decades we have seen the Information, Technology and Communication revolution. In 2015 we can access the internet almost anywhere on our smart phones and tablets to connect with each other. The way we communicate and share information is changing. Social media platforms like “YouTube” and “Twitter” enhance the dissemination of learning material but more importantly they provide the opportunity for a two conversation between the teacher and student. We should ask ourselves then how can this new era of communication facilitate learning, particularly at critical care and emergency medicine conferences?
Smacc (Social media and Critical Care) so named because it is powered by a collaboration of FOAM (Free Open Access Meducation) websites from around the world, is truly different. It is a high power critical care conference but more importantly it is inspirational, informative and innovative. The collective experience gained growing these websites has guided the program formation.
There is energy at smacc that not only augments the learning atmosphere but it recharges our commitment to critical care. In the words of one delegate from #smaccGOLD 2014: “This was the first conference where I not only learnt plenty, but I came away proud to be a professional in critical care. I feel excited about taking all this back to work!”
Here are 10 reasons you should consider smacc Chicago in June 23-26 2015.
1: Speakers – The speakers are hand picked from both the FOAM world and the conventional conference circuit because they are inspirational leaders in their fields. http://www.smacc.net.au/speakers/
2: Topics – The sessions are delicately pieced together to cover issues from hard core medical science and research to education and end of life care, but more critically they embrace controversy. http://www.smacc.net.au/program/
3: Format – The style has an informal open feel that encourages a two-way conversation, which is further enhanced by the integration of social media into the sessions.
4: Community – smacc brings together all the critical care community together from Pre-Hospital/Emergency/Critical Care and Anaesthesia.
5: Excitement – The energy at smacc powers a vibrant atmosphere
6: Networking – All breaks and lunches are catered free to provide a relaxed atmosphere for delegates to come together
7: Social – All social functions are included in the registration to bring all delegates together as part of one critical care community
8: Workshops – Over 30 pre-conference workshops cater for every need from communication and debriefing to Airway and Ultrasound http://www.smacc.net.au/program/workshops/
9: Post-conference – All sessions at smacc are podcast and released FREE in a serial fashion over 6 months post conference as part of FOAM http://www.smacc.net.au/the-talks/
10: Not for Profit – smacc is administered by a charitable trust and no individual benefits financially
The theme for smacc Chicago is smaccFEST, because it is more than a conference, it is a festival. Smacc is a celebration of medical science, knowledge, education, ideas, community and innovation united by a love of practicing critical care. There are already over 1,300 delegates and many pre-conference workshops have sold out. Get more information here.
This month’s Annals is loaded with useful clinical info:
-Pediatric c-spines in blunt trauma
-Intranasal ketamine v fentanyl: grudge match
-Can depilatories dissolve more than hair?
-Ultrasound for pediatric forearm fracture reduction
-Presyncope in the ED: first high quality data set
-Tourniquet use and mortality in military settings: surprise?
-Beta-blockers in MI: again??
And much more…
Email any time, let us know what you think!
Apologies for lateness, but this one is juicy. Check it out here.
– After an ED visit for A fib, who should be anticoagulated——and who gets the adverse event?
– Clinical Policy: aortic dissection in the ED
– GAME CHANGER — Ketamine and ICP, a systematic review
– NEW SERIES — Expert Management: Managing propofol-induced hypoventilation
– Plain x-rays for pelvis fractures: they sometimes miss
– Geriatrics: Malnutrition in older ED patients
And much much more,
Reach out any time at firstname.lastname@example.org,
The Clinical Policies Committee of ACEP has completed a draft clinical guideline: “Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department.” Since the 2012 clinical policy on IV tPA, there have been changes to the clinical policies development process, the grading forms used to rate published research have continued to evolve, and some newer research articles have been published.
The draft is now open for comments until March 13, 2015.
To view the draft policy and comment form, Click Below:
Clinical Policy Comment Form – Intravenous-tPA
For questions, please contact Rhonda Whitson at email@example.com.
The December (ie holiday) issue of the podcast is up and running, so check it out. Highlights include:
-Diagnosing diagnosis: a video based study of how EPs make diagnoses
-Flexible bed usage in the ED, finding the sweet spot
-Patient satisfaction and operational characteristics in an ED: IMPORTANT associations
-RCT of antidote for latrodectism (widow spider bite poisoning)
And much much more!
Happy holidays to all and email any time,
Annals November podcast is posted for all to hear! Keep the feedback coming, and THANK YOU.
This month look out for:
-LEAN process for reducing ED LOS
-Case law on EMTALA and psych emergencies
-Press Gainey scores and ED analgesics: not what they thought
-Randomized trial of anti-emetics: no better than placebo???
and much much more!
Email any time, firstname.lastname@example.org,