Category Archives: General Health

Coding Correctly in 2023

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The following information was provided by our coding advisor, Mary Suhr.

Key points:

  1. Time codes (when used) for inpatient visits have changed (see below). In 2023, when you share a service with an APP, you may bill on patient medical decision making or time spent.  You can add the time together and whoever spends more total time on that date of service (including face to face and non-face to-face) gets to be the service provider for that charge. 
  2. Extra time code: 99418 for every 15 minutes increments above average inpatient code.
  3. Observation codes are obsolete.
  4. Specific requirements for documentation of History and Physical exam are NOT needed for coding. Good documentation is still important part of medical practice and for liability; patient still needs to be examined.
  5. ALL outpatient and inpatient E/M visits will be leveled using the same methodology.
  6. Coding is based on medical decision making or time code (whichever has higher complexity). When selecting a level of service for Medical Decision Making, there is still the concept of having three components/tables and the requirement that two of the three components are met.  Tables 1, 2, and 3 outline the requirements.
  7. CPT 99251 (Straightforward Inpatient Consult) and CPT 99241 (Straightforward Outpatient Consult) are going away because the history and exam requirements for consults no longer apply and history/exam was the only difference between level 1 and level 2 consultation codes.
  8. For consultations, you still need a requesting provider, a reason for the consult and a report back to the provider.  CMS was explicit this year that assuming care of the problem is not considered a consult.
  9. Consultations cannot be shared between two providers (e.g. physicians and APPs).  If a consultation is shared between an APP and a MD, our advisor recommends the use admission codes for those.  This is true for inpatient consultations as well as office-based consultations.

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Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Why Are Immunization Levels Falling? It is not just due to COVID-19 and Anti-Vax Attitudes

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EJ Emmanual, M Guido. NY Times (12/28/22): Covid Isn’t the Only Reason Children’s Vaccination Rates Are Falling

Why does Mississippi have the best childhood immunization rates (99%)? This is due to state policies. This article reviews the small but significant drops in childhood immunizations which is opening the door for highly contagious diseases like measles.

Some excerpts:

U.S. routine childhood vaccination rates have historically been among the world’s best. But within the first year of the pandemic, the nation’s children missed nine million vaccine doses for diseases like polio and measles. Rates for the three major childhood immunizations — for measles, mumps and rubella; chickenpox; and diphtheria, tetanus and pertussis — fell by an average of 1.3 percentage points, with the rates in seven states and many cities falling under 90 percent…

Measles should not be taken lightly. The virus is highly contagious; according to the C.D.C., if one person has it, up to 90 percent of the people close to that person who are not immune will also become infected. It can live up to two hours in the air. One to three of every 1,000 children who contract measles die of respiratory and neurological complications…

Covid vaccine acceptance and anti-vax attitudes do not fully explain differences among states. Neither do red-blue partisan affiliations or the strength of a state’s public health system. Instead, the decline is rooted in longstanding policies among some states that allow, for instance, for nonmedical exemptions, failures to rigorously enforce vaccination requirements and inadequate public health campaigns…

Vaccines are one of the few true cost savers in medicine. The routine immunizations of children born from 1994 to 2018 are projected to prevent nearly one million early deaths and save nearly $1.9 trillion in economic costs — more than $5,700 for each American, according to the C.D.C. For measles, a state might spend more than $2 million responding to a single outbreak, with each case costing nearly $50,000 on average, according to an analysis of a recent outbreak in Washington State.

To avoid dangerous and costly outbreaks, states should introduce enforceable solutions that give their children and communities the best protections against vaccine-preventable infectious diseases.

Related blog posts:

Unrelated issue -improving numbers of physcians being trained in psychiatry:

U.S. News & World Report’s Flawed Rankings Plus One

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HJ Humphrey, D Levinson. Stat. 11/22/22. Deans: Dump that USNWR ‘best medical school’ survey Thanks to John Barnard’s twitter feed for this article.

This article recommends medical schools stop participating in U.S. News & World Report’s (USNWR) ‘best medical school’ survey. I would advocate for eliminating USNWR’s reports more broadly including their ranking of hospitals and medical specialties.

The medical school rankings rely on the following:

  • Federal research dollars
  • Reputation – “assessed by a survey (with an abysmal response rate) of medical school deans, department chairs, and residency program directors”
  • Ratio of full-time faculty to students
  • Students’ median scores on the Medical College Admission Test and their undergraduate grade-point averages
  • Acceptance rate 

Some excerpts:

  • “Yale and Harvard Law Schools recently announced they would no longer participate in U.S. News & World Report’s (USNWR) flawed ranking system, followed closely by additional schools. The nation’s medical schools need to follow their lead. Why? The USNWR ranking system is in direct opposition to medical schools’ goal of educating a well-trained, diverse, and culturally competent medical workforce..”
  • “It is hardly a secret among medical school deans that the USNWR rankings are based on data not directly related to educational process, quality, and outcomes. Nor can they trust the veracity of the data that are provided, given the recent scandals reported in other professional schools and colleges that manipulate the formula to their own advantage.”
  • “Comprehensive analyses of USNWR rankings have long demonstrated that the methodology is ill-conceived, that the response rate of those completing the questionnaires that feed into the ranking formula would not meet the standards of a peer-reviewed publication, and that the most important aspects of educational quality are largely ignored.”
  • “There is peer pressure to stay within the system and to compete for the top prize because it feels good to see your school on top, no matter how flawed the measuring stick.”

My take: It is difficult to measure quality. I do not trust USNWR’s rankings with regard to “best” medical school, “best” hospital or “best” subspecialty. I think medical care would be better off without these reports. Another option would be to focus on reporting hard data, rather than the current aggregate format. This data could include federal research dollars and reputational surveys; the latter would need to be transparent with regard to methodology.

From The Washington Post, 11/23/22. Opinion  Americans are choosing to be alone. Here’s why we should reverse that. “Spending less time with friends is not a best practice by most standards, and it might contribute to other troubling social trends — isolation, worsening mental health (particularly among adolescents), rising aggressive behavior and violent crime. “

Most Popular 2022 Posts

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The list of the most viewed gutsandgrowth blog posts in 2022.

Links to Posts:

Have you tried out ChatGPT?

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There has been a lot written about ChatGPT (see some NY Times links below). Earlier this week, one of my sons placed the following prompt:

“Write me a funny poem about a doctor from Atlanta who deals with diarrhea all day long”

This is the ChatGPT response:

There once was a doctor from Atlanta
Whose patients all suffered from diarrhea
They came in by the dozens
Leaving behind a stench that was quite humbling
But this doctor was quite unflappable

He had a cure for every case
And a smile on his face
As he worked tirelessly
To help each patient feel less queasy

His office was filled with the sounds of relief
As patients left feeling much less grief
They praised his skill and his bedside manner
And promised to spread the word about this Atlanta diarrhea-banner

So if you’re in Atlanta and feeling quite ill
And your stomach is acting quite shrill
Don’t hesitate, don’t be shy
Just make your way to this doctor’s side
And say goodbye to that diarrhea for good!

NY Times Articles:

“It can extrapolate and take ideas from different contexts and merge them together.” The new chatbots do this with what seems like complete confidence. But they do not always tell the truth. Sometimes, they even fail at simple arithmetic. They blend fact with fiction. And as they continue to improve, people could use them to generate and spread untruths.

An example cited in this article:

My take: ChatGPT (& similar programs) is a huge technological advance. In educational settings, it could help explain complicated topics. Of course, there is a concern that it could undermine education if students do not go through the process of doing their own work. In healthcare, it is possible that these programs could advance patient education and help in the diagnostic process.

Another example (on 12/16/22) -this took less than 30 seconds:

Lower Generic Drug Costs

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Related blog post: Why I No Longer Need to Be A Billionaire

Mark Cuban’s online generic pharmacy has added a number of new medications. Here are some of the added GI medications:

  • Aprepitant (generic Emend) 40 mg capsules #30 Cost $522 (Retail cost $2692)
  • Budesonide respules (generic Pulmicort) 0.5 mg/2 mL #30 Cost $18 (Retail cost $160)
  • Budesonide capsules (generic Entocort EC) 3 mg #30 Cost $16 (Retail cost $385)
  • Dicyclomine (generic Bentyl) 10 mg #30 Cost $5 (Retail cost $13)
  • Mesalamine (generic Lialda) 1.2 gm #30 Cost $37 (Retail cost $264)
  • Mupirocin 2% Ointment (generic Bactroban) 22 gm Cost $5 (Retail cost $52)

My take: While the prices are very good, I know some have had trouble working with the online pharmacy to get their prescriptions filled in a timely manner.

Camellia Flower

What is the Difference Between Burnout and Depression?

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S Sen. NEJM 2022; 387: 1629-1630. Is It Burnout or Depression? Expanding Efforts to Improve Physician Well-Being

Key points:

  • “This growing attention has helped to reduce the stigma associated with burnout, highlighting the health care system, rather than the individual, as the primary driver of the problem.”
  • What is burnout? “One review identified 142 different definitions of physician burnout in 182 studies.3 …the most commonly used is the Maslach Burnout Inventory, which assesses continuous scores for three domains: emotional exhaustion, depersonalization, and reduced sense of personal accomplishment.”
  • There is a lot of overlap with depression especially with emotional exhaustion. However, depression is still stigmatized as due to individual weakness. “Work-related stress is the primary driver of depression among physicians. A stark illustration of this dynamic is the fact that the prevalence of depression among training physicians before they enter residency is similar to that among young adults in the general population, but depression rates quintuple immediately after residency begins.”
  • “Whether burnout is meaningfully distinguishable from depression, the argument that depression and burnout are caused by fundamentally different precipitants is unsupported by the evidence to date”

My take (borrowed from the author): “Crucially, identification and treatment of depression can help reduce the risk of suicide among physicians. Unfortunately, when we encourage clinicians to consider themselves burned out rather than depressed, they tend not to seek or receive the individual-level interventions that can improve well-being.”

Related NPR Story (11/11/22): Study: Mindfulness-based stress reduction works as well as a popular anxiety drug. This report is based on the following reference:

The Harms from the Supreme Court’s Bruen Decision

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MR Ulcrich. NEJM 2022; 387: 1245-1247. Public Carry versus Public Health — The Harms to Come from the Supreme Court’s Decision in Bruen

Some excerpts:

“The majority opinion in Bruen, written by Justice Clarence Thomas, will have a devastating impact on efforts to mitigate gun violence and address racial disparities, but the reasoning used in the decision could cause even more havoc moving forward.”

“Allowing more guns in public does nothing to address the real drivers of criminal behavior, which include social determinants such as poverty, neighborhood violence, poor education, and substandard housing.2 Instead, an increased presence of firearms in public is likely to escalate confrontations, with data suggesting either that people who act aggressively are more likely to arm themselves or that people who are armed are more likely to act aggressively — or perhaps both.1“

“No right is absolute, and the government is able — if not obligated — to prevent harm to the broader public even in the exercise of constitutional rights. Such authority holds for the speech and religious practices covered by the First Amendment, and the Second Amendment should be no different. But the Court’s new theory of the Second Amendment compels lower courts to ignore public health research, empirical evidence, the current gun-violence epidemic, and other rights and liberties of the broader public.”

E Tobin-Tyler. NEJM 2022; 387: 1247-1249. A Grim New Reality — Intimate-Partner Violence after Dobbs and Bruen

“Pregnancy is associated with both the initiation of IPV [intimate partner violence] and an increase in IPV severity, making it a particularly dangerous time.3 Homicide is the leading cause of pregnancy-associated death in the United States; pregnant and postpartum women are more than twice as likely to die from homicide as from either hemorrhage or hypertensive disorders.3 …Studies show that abortion access plays an important role in reducing IPV.4 “

“In his dissent in Bruen, Justice Stephen Breyer noted that U.S. women are five times as likely to be killed by an intimate partner if the partner has access to a gun…In expanding the right to carry firearms, the Bruen decision exacerbates safety concerns for people actively trying to escape abusive relationships.”

NEJM Interactive: Gun Violence in the United States (last updated 6/30/22)

2022: 240 Mass Shootings in U.S as of 6/3022
Gun Deaths have been increasing with more than 45,00 in 2020.
Per capita deaths in 2020 -Wyoming and Mississippi have mortality rates

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