Crash Cart: Why Spending on EDs has Sykrocketed; DNR Tattoo Taboo? Why Wood You Do That?

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This week: Facility coding and virtual monopoly blamed for extreme ED bills; Should docs trust tattooed medical instructions?; Popping zit with woodworking blade = bad idea. Join in as our editors discuss the week’s headlines.


In an analysis of over 70 million ED bills, the Health Care Cost Institute (HCCI) and Vox have determined that facility fees rose 89 percent between 2009 and 2015, which is twice as fast as the price of outpatient health care and four times as fast as overall health care spending

Moreover, overall ER spending increased by $3 billion despite a 2 percent decrease in the number of fees billed. Some experts say hospitals can boost prices because of their market power. Original Article by RevCycle Intelligence // Accompany Article by Vox.

Nicholas Genes, MD, PhD: ED use of higher-acuity billing codes increased substantially from 2009-2015, just as electronic health records were adopted in large numbers. Probably not a coincidence. I’ve long argued that EMR finally lets us document the care we were always giving – maybe now fewer charts are downcoded because our documentation is better (and so, we should have been collecting more prior to 2009). Or maybe the charts are full of garbage macros and unnecessary, cookbook orders and the charts should be downcoded. Maybe both are true, and it varies case-by-case, or ED by ED.

I just know that, in most shops, when a EP codes a chart as 99283 and the billing company later says it could have been a 99284, if only the documentation was better, the doctor will get dinged. Get enough dings in a month, or year, and the doctor starts to suffer professional consequences. It’s just what’s happening. Meanwhile there is essentially zero pressure from the billing companies (or administration) about charting less. If an EP takes extra time (or uses a macro) with an ankle sprain and codes it up to a 99285, no one says “hey, you’re being inefficient, and possibly fraudulent, so spend less time on charting for cases like this.” Maybe the billing company will downcode it; maybe they won’t. The doctor rarely even sees what ends up getting billed in his or her name. I’m not saying that doctors aren’t responsible for their notes, but we practice in a system where everything is geared toward charting more.

Ryan McKennon, DO: I agree with Nick, EMR had a lot to do with this and maybe it is just ERs getting paid what they were supposed to and catching up to the changes in CPT. The argument that “ER care” as a whole is monopoly a little ridiculous. Hospitals compete with each other all the time, and prices for a given CPT code are generally set by CMS or the insurer following suit, not the individual hospital. The exception is for those without insurance. ERs are also not “the only care setting open during off-hours.” Urgent care are usually available and many offices have late hours on certain days. Finally, there is no incentive to decrease resources which would result in lower CPT codes. Could that abdominal CT or head CT be done as an outpatient? Probably, but patients wants to know now. They have to pay their co-pay or deductible anyways, not much financial incentive not to. Docs don’t want to liability, especially if the patient doesn’t or can’t follow up in a timely manner. Not doing may also result in lower RVUs. All of this results in a level 4 or 5 visit which may otherwise be a 2 or 3.


The case of a 70-year-old Miami man without ID admitted to Jackson Memorial Hospital unconscious and high BAC with a “Do NOT Resuscitate” tattoo raised questions for doctors

The doctors later discovered he had a history of lung disease, heart problems, and diabetes. They consulted an ethics expert and honored the man’s wishes, but the case is underscoring the need for EOLC standards and people to take their life in their own hands via advance directives. Original Article by The New York Times.

E. Paul DeKoning, MD, MS: Probably fits into the category of measure twice, cut once. I’d probably talk to my risk management folks, too. How many times do we encounter families who disagree with a family members advance directive or a patient who doesn’t even recall ever completing a DNR? You would think that if he went through the effort to get the tattoo and this his seeing this in the mirror every day would mean he actually agreed with its message. Then again, it wasn’t tattooed as a mirror image so he could actually read it.

Nicholas Genes, MD, PhD: It’s great that an ethicist was available in this case, and he makes a good point: “You don’t go through that trouble, look at it every day in the mirror and actually not mean it.” But I could easily see an ethicist (or a lawyer) arguing the converse: end-of-life wishes can change faster than tattoos can be removed – would you bet this guy’s life that he hasn’t updated his goals of care? In the future, perhaps, we’ll have tattoos of the URL to our secure cloud storage, accessible by ED physicians, where we’ve uploaded a MOLST form that’s kept up-to-date with our wishes.

Ryan McKennon, DO: The article states the tattoo “produced more confusion than clarity.” Seems pretty clear to me. He had already filled out the requisite paperwork (though did not have it on him). If that tattoo had not been there, I have no doubt CPR would have occurred. More confusion? Maybe, but that confusion worked in his favor preventing procedures being performed against him that he explicitly did not want.


Advice: Don’t pop zits using a woodworking blade

Popping zits have been decried as bad practice for decades, but doing so with a woodworking blade could do more than spread bacteria and cause more zits—it could lead to a nasty fungus. Original Article by Gizmodo.

E. Paul DeKoning, MD, MS: Huh. Who knew?

Nicholas Genes, MD, PhD: There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy.

Ryan McKennon, DO: Well, there goes my idea for patenting a new dual use cutting device.


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