HEALTH FOR ALL

Home » Archives for Oktober 2013

Top 10 Most Commonly Used E/M Codes By Volume and Charges.

What are the top 10 most commonly used E/M service codes based on the number of visits and charges? There's a file for that! Evaluation and Management (E/M) CPT® codes are used by clinicians to bill Medicare and other insurance organizations. According to the Evaluation and Management Services Guide (page 6), E/M services refer to "visits and consultations" furnished by physicians and other qualified non-physician practitioners (NPP). The Office of Inspector General (OIG) published a May 2012 report titled Coding Trends of Medicare Evaluation and Management Services. Between 2001 and 2010, the OIG says E/M charges increased 48% from 22.7 billion to 33.5 billion dollars a year. The number of E/M services billed increased 13% from 346 million to 392 million encounters in 2010. The average Medicare payment per E/M service increased from $65 to $85. They also found physicians billed higher levels of service across all types of E/M services.

Why is this important? Because the assumption of physician fraud is alive and well. One of the report's stated objectives was to "to identify and describe physicians who consistently billed higher level E/M codes in 2010". The Centers for Medicare & Medicaid Services (CMS) has started sending letters to physicians with outlying billing patterns defined by computer algorithms. If you are a physician who consistently bills at a higher level than your colleagues, you may get correspondence from the Centers for Medicare & Medicaid Services detailing these concerns. The complex rules of E/M medicine are not routinely taught with urgency to training or practicing physicians. This leaves untrained physicians guessing how to choose the correct E/M code. The best defense a physician can mount is to accurately submit E/M charges based on what their medically necessary documentation supports. I have provided many of these coding rules in detail on my bedside cheat sheet pocket card previewed below.

If you want to know which E/M codes the Recovery Audit Contractors (RAC) are likely reviewing, I think it's important to know which E/M codes are most commonly being used. This CMS website provides access to yearly updated Excel files containing Medicare Part B National Summary File data. Each of these yearly titled zip folders contain a file with information on allowed services, allowed charges and payments for all E/M CPT® codes. As of this publication, the most recent E/M information is provided in the Y2011_99201.xls file embedded within this 2011 file folder. I think this data gives a good idea of the most often used E/M codes by clinicians. While these files don't include E/M data by physicians billing to non-Medicare insurance companies, I think it's safe to assume this CMS data provides a large enough sample size to make assumptions on the top 10 most frequently used E/M codes. I have reviewed the file data and created these tables below for reference.

TOP 10 E/M CODES BASED ON ALLOWED SERVICES (dollar amounts rounded up)

2011	CPT® code	Allowed services	Allowed charges ($)	Payments ($)
1	99213	100,268,652	6.8 billion	4.7 billion
2	99214	81,310,974	8.2 billion	5.7 billion
3	99232	50,949,134	3.6 billion	2.8 billion
4	99233	22,285,570	2.3 billion	1.8 billion
5	99212	18,501,855	745 million	530 million
6	99231	12,406,607	480 million	380 million
7	99223	11,771,925	2.3 billion	1.8 billion
8	99285	9,879,784	1.7 billion	1.3 billion
9	99215	9,694,388	1.3 billion	940 million
10	99308	9,636,112	620 million	460 million

Based on Medicare Part B data, the most popular E/M code in 2011 was the mid level established office visit (99213) at just over 100 million allowed encounters. This code was paid for nearly 25% more often than CPT® 99214, the second most popular E/M code based on the number of allowed services. This top ten list includes all three hospital follow up codes (99231-99233), four of the five established outpatient clinic visit codes (99212-99215), the level 3 inpatient hospital admission code (99223), the highest ER code (99285) and a nursing home code (99308). Some billing codes pay more than others. What are the top 10 Medicare Part B E/M codes based on allowed charges and payments instead of allowed number of services?

TOP 10 E/M CODES BASED ON ALLOWED CHARGES AND PAYMENTS (dollar amounts rounded up)

2011	CPT® code	Allowed charges ($)	Payments($)	Allowed Services
1	99214	8.18 billion	5.71 billion	81,310,974
2	99213	6.79 billion	4.71 billion	100,268,652
3	99232	3.57 billion	2.84 billion	50,949,134
4	99223	2.31 billion	1.81 billion	11,771,925
5	99233	2.25 billion	1.79 billion	22,285,570
6	99285	1.67 billion	1.30 billion	9,879,784
7	99204	1.34 billion	962 million	8,570,728
8	99215	1.32 billion	935 million	9,694,388
9	99291	1.12 billion	884 million	5,045,749
10	99222	1.00 billion	784 million	7,506,127

Based on allowed charges and payment, the most expensive E/M service is the level 4 established patient clinic code (99214). Three new codes make the top ten list based on allowed charges and payments. They are the initial critical care code (99291), the level four new patient clinic code (99204) and the level 2 initial inpatient hospital evaluation code (99222). When based on allowed charges, three of the most common E/M codes based on frequency of allowed services fall off the list. They are the level two established patient office visit (99212), the level one inpatient hospital subsequent care code (99231) and nursing home code 99308.

The Happy Hospitalist provides a great resource for learning many of these most frequently billed E/M codes as well as guidance on many frequently encountered clinical scenarios that involve coding confusion. You can find the entire collection of E/M coding information in the evaluation and management resource area. In addition, the E/M pocket reference card detailed below provides guidance on how to approach E/M decision making at the bedside. You can also find a wealth of other information in the hospitalist resource area as well..

LINK TO E/M POCKET CARD POST

Click image for high definition view

Young Invincibles in Illinois

From Visualizing Health Reform,
Illinois Health Matters

Two months ago, Young Invincibles launched our Midwest Regional office here in Chicago. One of the main reasons why we chose to come to Illinois is that it has one of the highest numbers of uninsured young adults. In Cook County alone, over 158,000 19-35 year olds could be eligible for Medicaid and another 190,000 could be eligible for tax credits to make health insurance more affordable. Across the state, 286,000 19-35 year olds could receive Medicaid. Another 345,000 young adults in Illinois could receive tax credits.

Young Invincibles was founded around providing a voice for young adults in the Affordable Care Act (ACA) debate. Since then, we’ve worked hard to educate our generation about the benefits of the ACA, even as we expanded to work on other economic issues that affect young adults. As of October 1st, the launch of the health care marketplaces, we’ve been hard at work with Illinois Health Matters and many other organizations here in Illinois to spread information about the ACA to many uninsured young adults.

To help with that effort, we’re dispelling a few myths about young adults and health insurance that we’ve heard a lot.

Myth #1: Young adults choose not to get health care because they think they’re young and invincible.
This misconception is actually how Young Invincibles got its name! For the most part, our generation does not believe we are invincible, but instead have been shut out of buying insurance because it traditionally had been too expensive for many people. In fact, over 70% of young adults say that health insurance is very important to them. But, many young adults are just beginning their careers and may be working part-time jobs where they aren’t offered health coverage by their employer and can’t afford it on their own. With the ACA, that will change a lot. Now, a majority of uninsured young adults will be eligible for Medicaid or new tax credits to help reduce the cost of health insurance.

Myth #2: Young adults are young and healthy and won’t get sick or injured.
With more accessible health care, we will be able to take care of ourselves. While injuries can come at any time, like a broken finger playing softball or partially collapsed lung from falling on a speaker (both of which are true stories), it’s harder to predict when you’ll get hurt or sick. Coverage offers protections against those catastrophes. Moreover, many preventive services are now covered under the ACA, such as blood pressure tests, cholesterol screenings, HIV screenings, and many common immunizations. By taking advantage of these new, free benefits, you can prevent and treat diseases and conditions before they become a major issue, saving you money and improving your health.

Myth #3: Obamacare and the ACA are two different things. Obamacare is a type of insurance to be purchased.
Many people are still confused by the use of different names for the Affordable Care Act, such as Obamacare and the ACA. The Affordable Care Act, ACA, and Obamacare all refer to the same law.

There is also no government insurance takeover of private insurance. The only government insurance are programs like Medicare and Medicaid. If you buy a plan on the Health Insurance Marketplace, you will be purchasing private insurance, but with new protections and preventive care to ensure that you are buying a comprehensive plan that truly does cover your health care needs.

While these are just some of the common myths and misconceptions out there about the ACA, we still have a lot of work to do to get more information out to the people who need it. Check us out at health.younginvincibles.org to see what resources and information we have available. You can also vote in our video contest! Don’t forget to check us out on Twitter and Facebook, too!

Brian Burrell
Midwest Regional Manager
Young Invincibles

(Posted originally on the YI Blog)

99203 CPT® Code Description, Progress Notes, RVU, Distribution.

This 99203 CPT® lecture reviews the procedure code definition, progress note examples, RVU values, national distribution data and explains when this code should be used in the clinic and hospital setting. CPT stands for Current Procedural Terminology. This code is part of a family of medical billing codes described by the numbers 99201-99205. CPT® 99203 represents the mid (level 3) office or other outpatient new patient visit and is part of the Healthcare Common Procedure Coding System (HCPCS). Make sure to also review the lecture on the level 4 new clinic visit as well. A patient is considered outpatient until inpatient admission to a healthcare facility occurs. This procedure code lecture for new office patient visits is part of a complete series of CPT® lectures written by myself, a board certified internal medicine physician with over ten years of clinical hospitalist experience in a large community hospitalist program. I have written my collection of evaluation and management (E/M) lectures over the years to help physicians and non-physician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex criteria required to stay compliant with the Centers for Medicare & Medicaid Services (CMS) and other third party insurance companies.

You can find my entire collection of billing and coding CPT® lectures together in one place on my Pinterest site (CPT® lectures here and other associated E/M lectures here). You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you master these E/M procedure codes, remember, you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.

99203 MEDICAL CODE DESCRIPTION

My interpretations discussed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion. I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding. I have provided access through Amazon to the 2015 CPT® standard edition pictured below and to the right. CPT® 99203 is an office or other outpatient procedure code and can be used by any qualified healthcare practitioner to get paid for their office or other outpatient new patient services. The American Medical Association (AMA) describes the 99203 CPT® procedure code as follows:

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

A new patient is defined as a patient who has not received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years. The definition of a new patient was updated in 2012.

This medical billing code can be used for time based billing when certain requirements are met. However, documentation of time is not required to remain compliant with CMS regulations. If billed without time as a consideration, CPT® 99203 documentation should comply with the rules established by the 1995 or 1997 guidelines referenced above. The three important coding components for an new patient office or other outpatient visit are the:

History
Physical Exam
Medical Decision Making Complexity (MDM)

For all new patient office or other outpatient visit codes (99201-99205), the highest documented three out of three above components determines the correct level of service code. Compare this with the requirement for the highest documented two out of three above components for established patient office or other outpatient visit encounters (99211-99215). Stated another way, the lowest level of documentation for history, physical and medical decision making complexity will determine the overall appropriate level of E/M service in this code group. In order to appropriately code a level 3 (99203) new patient office visit, all three components (history, physical and MDM complexity) must achieve level 3 status. What are the minimum requirements for this level 3 visit? These requirements are discussed below. In addition, as with all E/M encounters, a face-to-face encounter is always required. However, in the case of outpatient clinic codes, Medicare does allow incident to billing, where the the service is provided by someone other than the physician. If certain requirements are met, the physician may collect 100% of allowable charges in these situations. Services billed incident to are billed under the physician's provider number.

Detailed history: Requires four or more elements of the history of present illness (HPI) OR documentation of the status of three chronic medical conditions. One element from the past medical history or social history or family history is also required. The review of systems should inquire about the system directly related to the HPI and at least 2-9 additional systems.
Detailed examination: 1997 guidelines require documentation of at least 12 elements identified by a bullet in two or more organ systems(s) or body area(s). Alternatively, documentation of six organ systems or body areas with at least 2 bullet elements each is allowed as well. 1995 guidelines require an extended examination of the affected body area(s) and other symptomatic or related organ system(s). The CMS E&M guide on pages 31 and 32 describes the acceptable body areas and organ systems on physical exam.
Medical decision making of low complexity (MDM): This is split into three components. The two out of three highest levels in MDM are used to determine the overall level of MDM. The level is determined by a complex system of points and risk. What are the three components of MDM and what are the minimum required number of points and risk level as defined by the Marshfield Clinic audit tool?

Diagnosis (2 points)
Data (2 points)
Risk (low); The risk table can be found on page 37.

The medical decision making point system is highly complex. I have referenced it in detail on my E/M pocket cards described below. These cards help me understand what level of service my documentation supports. I carry these cheat sheet cards with me at all times and reference them all day long. As a hospitalist who performs E/M services almost exclusively, these cards have prevented me from under and over billing thousands of times over the last decade.

CLINICAL EXAMPLES OF CPT® 99203

What are some progress note documentation examples for a CPT® 99203, the level 3 new patient visit in an office or other outpatient setting? Many doctors use the subject, objective, assessment and plan (SOAP) note format for their documentation, although this is not a required format. A CPT® 99203 note could look like this:

Subjective: Abdominal pain. RLQ. Started yesterday. Constant. 2/10. (at least 4 HPI). No nausea, chest pain, dizziness, shortness of breath (at least 2 additional ROS). Nonsmoker (at least one element from past history, social history and family history).
Objective: 120/80 80 Tmax 98.9 (three vital signs = one bullet) abdomen no masses, positive bowel tones, RLQ tender with guarding; lungs clear; heart no murmur, RRR; legs no edema; skin no rash, eyes, no icterus, no JVD, alert, mild distress. (at least 12 total bullets in 2 areas)
Assessment: 1) Abdominal Pain NOS 2) HTN-controlled (2 points for diagnosis)
Plan: Trial of Tylenol for pain (OTC medications are considered low risk for management options on risk table)

In this example, the history (subjective), physical (objective) and MDM (assessment and plan) components all meet the minimum requirements to get paid for a 99203 new patient outpatient clinic visit based on the definition of this CPT® code detailed above. Remember, the code group (99201-99205) requires all three elements (history, physical, MDM) to meet the minimum level of service as opposed to the outpatient established code group (99211-99215) which has the two out of three requirement. Stated another way, the lowest level of documentation from history, physical and MDM will determine the overall appropriate level of service for new clinic patient evaluations. If the MDM and physical meet criteria for 99203 but the history only meets the criteria for a 99202 visit, then 99202 is the correct code to choose for the visit. Taken to the extreme, if the MDM and the physical exam both meet criteria for 99205 but the history only meets the criteria for a 99201 evaluation, then the correct code to choose is 99201. Here is another example of an appropriately coded 99203 new patient office visit:

History: Cough resolved; No SOB; No CP (2-9 ROS). Stopped taking lisinopril due to cough (one element from past medical history)
Physical Exam: 140/80 80 Tmax 98.9 (three vital signs = one bullet) alert, NAD, no icterus, no JVD, abdomen no masses; no palpable organomegally; lungs clear, normal chest wall motion; heart no murmur, regular rhythm; legs no edema, symmetric size; skin no rash or cyanosis, fingernails normal (at least 12 total bullets from two or more areas)
Assessment: HTN-worse, see med changes.
DM-stable, no changes planned.
COPD-stable, no changes planned. (the status of three chronic medical conditions in place of HPI) (3 points for diagnosis under MDM)
Plan: Start ARB for HTN. (prescription management is moderate risk on the risk table)

As you know, documenting the status of three chronic medical conditions can substitute for the HPI. Add in at least 2 additional review of systems and one element from past medical family and social history and this is the minimum history documentation required for CPT® 99203. With at least 12 bullets documented in the physical exam and a minimum of low complexity for MDM (this visit actually meets criteria for moderate complexity), this note is complete and accurate and meets documentation requirements to get paid for a new patient level three office visit (99203). All physical exam components offer value to the encounter to exclude potential complications of therapy or to search for evidence of decompensation of disease.

The MDM is of moderate complexity. This MDM documentation gets four diagnosis points for discussing two stable problems (two points total for DM and COPD) with an established problem that's worsening and no more work up planned (two points for HTN). In addition, zero points are earned for the data component, but risk is moderate based on prescription drug management. Prescription drug management is considered moderate risk, as is detailed on my bedside E/M reference card shown below. That means, the highest two out of three components for MDM is moderate. While the MDM is of moderate complexity, the overall correct level of service is limited by history and physical documentation that only supports a level 3 service. And remember, for new patient outpatient visits, the correct code is supported by the lowest level of documentation for history, physical and MDM.Below is another example of a new patient 99203 office visit:

S: HA present 4/10, global pain for 3 days and constant. No ringing in the ears (at least 4 HPI). No nausea/vomiting. No chest pain or SOB. (at least 2 additional ROS) No FH brain cancer. (one element from family history)
O: 120/80 80 Tmax 98.9 (three vital signs = one bullet) alert, head atraumatic, NAD, no icterus, no JVD, abdomen no masses; no palpable organomegally; lungs clear, normal chest wall motion; heart no murmur, regular rhythm; legs no edema, symmetric size; skin no rash or cyanosis, fingernails normal. (at least 12 total bullets from two or more areas)
A: Acute HA, NOS. Stable. (one new problem with more work up planned and of uncertain prognosis is 4 points on MDM for diagnosis and also moderate risk too)
P: Check CBC/BMP.

This new patient outpatient evaluation is appropriate for CPT® 99203 as the history, physical and MDM all contain necessary the necessary documentation based on the Marshfield Clinic audit tool. Medical decision making is moderate because the diagnosis element is high complexity (4 points for new diagnosis with more work-up planned), the data element is low complexity (only one point for ordering lab), and the risk table is moderate for dealing with an undiagnosed new problem with uncertain prognosis. Therefore, the highest two out of three elements in MDM is moderate. Here is another progress note example of a level 3 new patient office visit:

S: 48 year old male here to establish care. No CP/SOB/N/V/HA. No polyuria, polydypsia. (at least 2 additional ROS) Nonsmoker. (one element from social history)
O: 120/80 80 Tmax 98.9 (three vital signs = one bullet) alert, head atraumatic, NAD, no icterus, no JVD, abdomen no masses; no palpable organomegally; lungs clear, normal chest wall motion; heart no murmur, regular rhythm; legs no edema, symmetric size; skin no rash or cyanosis, fingernails normal. (at least 12 total bullets from two or more areas)
A: 1) HTN, controlled 2) DM II, controlled 3) CAD, controlled (three points on MDM for diagnosis and substituting three chronic medical conditions for HPI)
P: Increase Metformin from daily to BID dosing. (moderate risk for prescription drug management)

Both the history and physical meet minimum criteria for CPT® 99203. Medical decision making is moderate based on a moderate risk table assessment and three points in the diagnosis section, which is one point more than is necessary to bill a 99203 new patient office visit.

Notice in my progress note examples above that each element from history and physical and MDM must meet the minimal element requirements based on the description of the code detailed above. If documentation in any of these three elements fail to meet the minimum requirements, the correct CPT® code is the code based on the element with the lowest level of documentation. In addition, some face-to-face encounters may contain elements whose documentation support a higher CPT® service code individually, but not as a whole, since history, physical AND MDM must all meet minimum thresholds.

USING NEW PATIENT CLINIC CODES IN THE HOSPITAL SETTING

The CPT® medical billing code group 99201-99205 should used by hospitalists and other physicians or non-physician practitioners in the hospital setting under certain circumstances. I have previously discussed all the possible initial encounter codes that could be used in the hospital setting. These new patient clinic and other outpatient visit codes are included as possibilities. I have provided a detailed discussion of that decision tree analysis at the link provided just above. However, I will discuss the pertinent portions of that analysis here.

For patients admitted observation status, the attending physician should choose from the observation group of medical codes 99218-99220 for the initial encounter, 99224-99226 for observation status follow-up codes, and 99217 for observation discharge. Under certain situations, same day admit and discharge billing codes 99234-99236 or critical care procedure codes may also apply too. This is not the case for consultants taking care of observation status patients. What codes should a consultant use in an observation status situation? This is where the correct code decision can get very complicated. Medicare no longer recognizes consult procedure codes. Consultants should pick the appropriate level of service from the new outpatient clinic code group 99201-99205 as their initial encounter, but only IF the patient has NOT been seen previously by the physician or a physician partner of theirs in the same group and exact same specialty and subspecialty within the previous three years. Alternatively, critical care codes can be used instead if documentation supports their use.

If the patient HAS been seen in the last three years by the same physician or partner physician in the same group and exact same specialty and subspecialty, the consultant should use the established patient clinic code group 99211-99215 on their initial date of service and continue to use that code group for all subsequent observation services, including the day of discharge. Remember, all hospital observation CPT® code groups are reserved only for the attending physician. If a patient qualifies as a new patient but clinician documentation does not support any code from the code group 99201-99205 (usually because of the three out of three documentation requirement), then it is appropriate to instead choose a code from the established patient code group (99211-99215) that meets documentation requirements. This guidance has previously been confirmed by Medicare carriers.

The above discussion relates to Medicare because Medicare does not accept consult codes. Other insurances may still accept consultation codes. In those cases, the consultant should chose a level of service from medical code group 99241-99245 (outpatient consult codes) as the initial encounter and then pick a billing code from the established patient clinic codes 99211-99215 for all subsequent care visits, including the day of discharge, while the patient is hospitalized for observation services. If the patient is formally admitted inpatient, the consultant should use the inpatient subsequent care codes 99231-99233 for all subsequent face-to-face encounters.

DISTRIBUTION OF NEW PATIENT OFFICE OR OTHER OUTPATIENT VISIT CODES (99201-99205)

What is the distribution of CPT® code 99203 relative to other levels of service in this medical code group? The chart below was published in May, 2012 by the OIG in a report titled Coding Trends of Medicare Evaluation and Management Services on page 21. As you can see, between 2001 and 2010, the distribution of new patient office visits 99204 and 99205 has shifted higher (an increase of 12% and 4% respectively) while the proportion of level three 99203 has remained constant with no change from 2001-2010. On an absolute basis, of all codes in the group 99201-99205, CPT® code 99203 represented 37% of all services from code group 99201-99205.

CPT 99201-99205 services distribution chart 2001-2010

Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99203 encounters were billed and the dollar value of their services for Part B Medicare. As you can see in the image below, E/M code 99203 was billed 9,479,315 times in 2011 with allowed charges of $955,752,231.12 and payments of $663,786,846.85.

2011 National Part B Summary File 99201-99205 CMS 2011

RVU VALUE

How much money does a CPT® 99203 pay in 2016? That depends on what part of the country you live in and what insurance company you are billing. E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs). This complex RVU discussion has been had elsewhere on The Happy Hospitalist. For raw RVU values, a CPT® 99203 is worth 2.17 total RVUs for facility services and 3.04 total RVUs for non-facility. The work RVU for 99203 is valued at 1.42. A complete list of RVU values on common hospitalist E/M codes is provided at the linked URL. What is the Medicare reimbursement for CPT® code 99203? In my state, a CPT® 99203 pays just over $72 (facility) and just over $100 (non-facility) in 2016. The dollar conversion factor for one RVU in 2016 is $35.8043.

My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through on the provided link. If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.

LINK TO E/M REFERENCE CARD POST

Click image for high definition view

Be Covered Illinois Care Fair a Huge Success

On Sunday, October 6th, Be Covered Illinois hosted a Care Fair with many of its partners on Chicago’s southwest side. It was a sight to see! The doors opened at 11:00am, but by 9:45, a line of people stretched outside the building waiting to get in. By the time the event ended at 5:00pm, 5,227 visitors had attended the event. Fifty-two registered In-Person Counselors representing 15 community organizations staffed the enrollment area, the largest gathering of certified navigators yet to be seen in the nation. A big ‘thank you’ and a shout-out to the following agencies for supporting the event with navigators:

• AIDS Foundation of Chicago
• Chicago Childcare Society
• Children’s Home and Aid
• Chinese American Service League
• El Hogar del Nino
• Health Leads USA
• Illinois African American Coalition for Prevention
• Instituto del Progreso Latino
• Lawndale Christian Development Corporation
• Metropolitan Family Services
• Pilsen Wellness Center
• Puerto Rican Cultural Center and Prime Care
• Sinai Community Institute
• The Resurrection Project
• United Way of Metropolitan Chicago

Despite the fact that the federal site – healthcare.gov – was still having difficulties, the resourceful navigators were able to engage attendees in conversations about the law and make hundreds of follow-up appointments with those seeking to enroll in health coverage on the Illinois Health Insurance Marketplace.

In addition to navigators, there were six groups serving as subject matter experts to help answer questions about the new health care law, and 36 organizations that provided information on the resources they provide for communities. The event was supported by almost 200 volunteers, as well as dedicated medical professionals that provided seven different medical screenings, including 527 flu and TDAP vaccines. As a thank you for attending the event, each family left with a bag of healthy groceries, 2,000 bags in all.

The day’s events were a testament to the fact that there is both interest in and the need to secure access to health insurance, and more importantly, health care services for the many people who until now had few healthcare options. With ACA, they will now have many more opportunities to secure access to coordinated, high quality healthcare when they need it.

The Be Covered Illinois Care Fair provided an important opportunity for community organizations to educate attendees about health reform and the health insurance marketplace and how the law can benefit them. People who came were genuinely hungry for knowledge. Knowledge is power, and that Sunday we empowered 5,227 people to have the information they need to gain new access to health care – care that they told us in no uncertain terms – was not only wanted, but desperately needed. As the day wound down, their personal stories and the smiles on their faces were all I needed to confirm that this Be Covered Illinois Care Fair was truly a success.

Words, however, cannot do justice to the positive spirit and collaboration that infused the Care Fair. To get a better sense of that, please take a look at the story that Sarah Schulte of ABC-7 News did on the news that evening.

If you wish to join us as a Be Covered partner organization, request resources or learn more about what we’re doing, please visit: www.becoveredillinois.org

Donna Gerber

Chair, Be Covered Illinois Campaign
Vice President, Community Investments
Blue Cross and Blue Shield of Illinois

How the Affordable Care Act Helps Immigrants

There are at least 40 million immigrants in the United States, accounting for about 13% of our country’s total population. The Affordable Care Act (ACA, also known as ObamaCare) helps immigrants by providing new and strengthening current health insurance coverage opportunities. Below are six important points about the ACA that all immigrants need to understand.

Lawfully present immigrants are eligible to purchase private health insurance plans in the health insurance marketplaces. Every state has made available to its residents access to a state or federal online marketplace where applicants will be provided a range of affordable private qualified health plans for them to enroll in. Essential health benefits, pre-existing conditions, and preventive care will all be covered under these qualified health plans. Open enrollment in these plans is from October 1, 2013, until March 31, 2014. Applicants must have enrolled in and purchased coverage by December 15, 2013, for coverage to start on its earliest date: January 1, 2014.

Lawfully present immigrants may qualify for federal financial help to lower the cost of their monthly premiums and cost-sharing (e.g., co-payments, deductible, co-insurance) to help them afford a private insurance plan through the Marketplaces. Lawfully present immigrants with household income between 100% and 400% of the federal poverty level (FPL) ($45,960 for an individual or $94,200 for a family of four) are eligible for premium tax credits and between 100% and 250% of the FPL ($28,725 for an individual and $58,875 for a family of four) are eligible for the cost-sharing reduction subsidies. The tax credit alone is estimated to provide $2,700 per family that purchases coverage on the Marketplace, reducing premium cost by an average of 32%. To qualify for this federal financial help, applicants cannot be offered affordable health insurance through their job or be eligible for Medicaid.

Most lawfully present immigrants who meet Medicaid program requirements, such as income and state residency, can enroll in Medicaid after they have been in the United States for 5 years or more. Some groups of lawfully present immigrants do not have to wait five years before they may enroll in Medicaid, including refugees, asylees, and pregnant women and children in some states. Immigrants will benefit greatly in states that choose to add the ACA’S new Medicaid eligibility category, which will expand that program to all adults under age 65 with household income of less than 138% of the FPL (about $15,800 for an individual and $32,500 for a family of four). In fact,more than half (52%) of uninsured Hispanics with incomes below this limit reside in states adding the new Medicaid eligibility category. Use of Medicaid does not affect one’s immigration status (public charge decision) unless the Medicaid use is for long-term care such as nursing home care.

Lawfully present immigrants with household incomes of less than 100% of the federal poverty level are also eligible for the private Marketplace coverage and can get help paying premiums and cost sharing if they are ineligible for Medicaid (either because they are not LPRs or because they are LPRs with less than five years of residency).

Undocumented immigrants may not buy health insurance through the Marketplaces, even at full cost. However, until this is remedied, undocumented immigrants need to know that
community health centers, strengthened by ACA funding, will still accept patients regardless of immigration status, emergency rooms will continue to treat undocumented immigrants for free or at very low cost, many hospitals have charity care obligations that essentially provide free care to low-income patients, regardless of immigration status, undocumented immigrants may purchase health coverage through an employer or a spouse’s employer, undocumented immigrants may purchase private health insurance off of the Marketplace, and some state-funded Medicaid programs are open to them regardless of immigration status.

Undocumented immigrants also need to understand that, if they have family members who are U.S. citizens or lawfully present, these family members are required to have health insurance under the law starting in 2014, or face a penalty at tax time, unless they qualify for some exemption. This means that undocumented parents who have lawfully present or U.S. citizen children must ensure that their children have health insurance (through a child-only private Marketplace plan or through Medicaid, for instance). It’s important to remember that only those individuals in a family who are applying for health insurance are required to provide citizenship and immigration status. So undocumented parents applying through the Marketplace for private or Medicaid coverage for their eligible family members will not be asked for a Social Security Number for themselves (only for the applicants).

There is no charge to individuals who receive in-person help in enrolling in Medicaid or Marketplace coverage. The ACA provides federal funding to train and certify in-person consumer assisters to walk individuals through all of their health insurance coverage options. You can find an in-person assister by going to your Marketplace’s website. These assisters cannot and will not charge individuals for this enrollment assistance, including answering questions post-enrollment. Lastly, enrollment information is not shared with immigration agencies for the purpose of enforcement.

Andrea Kovach
Sargent Shriver National Center on Poverty Law

(Reblog from the Shriver Brief)

Worst Smells In The Hospital? There's a List For That!

I recently asked my thousands of Facebook readers to describe the worst smell in the hospital in their own words. They did not disappoint. The hospital setting provides the perfect opportunity to experience a crisis of unimaginable olfactory proportions. Some people thought the smell of rotting flesh was the most intolerable smell in the hospital. Other folks said the unmistakeable smell of melena was the worst. Walking off an elevator onto a floor or unit and experiencing the smells of nasal suicide is a sure fire way to create interesting conversation. Simply ask anyone who's job is stuck in the DEFCON 4 zone what is the smell and where is it coming from and you'll be sure to get your unprofessional comments tank filled for the day. It's not their fault though. Their speech filters are contaminated with nasty.

What are different solutions to getting rid of these terrible odors? Is it medical grade air freshener? Is it expensive air filtration systems? Is it for doctors and nurses to wear a mask or munch on peppermint? As we say in medicine, treat the underlying cause. The underlying cause isn't the rotting flesh or the melena. It's that the patient is on the same floor at the same time as you are. Stop wasting time covering up the smell with expensive gimmicks. The quickest and easiest way to make the worst smell in the hospital go away on your shift is to transfer the patient to another floor, unit, hospital or to Heaven as quick as possible. Whatever it takes, just make it happen if you want to maintain your sanity for the next 12 hours.

Here is the definitive internet resource of the most awful smells in the hospital, provided by my thousands of Facebook readers. If you haven't joined the conversation yet, you are missing out on a never ending parade of sarcasm, comedy and insight. Join Happy and his crusades today and never miss the opportunity to hear others describe nasty vaginal yeast infections again. In the famous words of a nationally known and highly respected ER doctor, be prepared for post traumatic pelvic exam disorder (PTPED) when retained tampons show up at 3 am with a chief complaint of 'my Virginia hurts'.

Burn victim.
Frumunda cheese. You know, the white gooey stuff "from under" the panus, the breast and scrotum.
GI bleed poop. This was the most popular worst smell in the hospital.
We suggested at work the other night that Febreeze should do a nursing/hospital commercial. Like a blindfolded nurse saying "Hmm smells like a summer meadow" and then zooming out to show a drunk homeless man with a rotting leg and a GI bleed. I would buy THAT product!
Scrambled eggs coming out of the GI fistula in my patient's dressing after he refused to stay NPO.
Abdominal fold yeast. Never do an abdominal exam blindly or without gloves. It takes days to go away.
Old Jevity in a feed bag is pretty rank too.
I'm needing some Zofran all of a sudden!
The air freshener used to hide the smells is WORSE than the smells! It always makes my eyes water and I start sneezing. To me, that is the worst thing ever in a work environment. It makes me miserable and it lingers forever!
The smell of the stretcher from a woman who had a tampon in place for everlasting days and continued to have sex. Pity the ER doc who retrieved it (see PTPED above). The linens were tossed in the garbage.
C diff poop. This was the second most popular worst smell in the hospital.
The smell in the med room after someone sneaks one out and leaves.
The underside of any female quarter ton plus patient with weeping edema, pressure ulcers, diarrhea etc. Smells like opening the lid of a two week old dumpster in August.
Patient with C Diff AND a colostomy bag that burst everywhere. I am sure that I have devolved PTSD from that incident.
Incontinent hobo with melena AND trench foot.
Cdiff, necrotic tissue, and rocephin smells like cat piss.
Old poop. It has a certain smell when someone's been backed up for days. Also, trachs that reek. REALLY reek. Ugh.
Feet of a homeless drunk men rank at the top!
Dead gut.
The worst smell is a GI bleed from a patient with a necrotic bowel. He had a history of a Low Anterior Resection with a colostomy.
G.I. bleed is even nastier than C-diff.
A stillborn that had crowned days before the mom came in complaining of constipation. She "didn't know" she was pregnant. Rumor has it an OR nurse passed out and the OR had to be fumigated.
The stench of a pseudomonas infection of a patient's trach makes me want to hurl.
I'm going say gastric lavage contents.
First incision into an abdomen with necrotic bowel.
Cdiff, GI bleed poo, vomit.
Wound debridement.
C diff is the only thing that can make me gag. Pseudomonas is close however.
My mom has this gem to contribute: a vaginal vault full of retained tampons.
Gangrene. It somehow finds a place in your sinuses and takes up residence.

Forgot about that one. The first time I ever saw/smelled that, I was an aide, and the nurse that I was helping to change the dressing didn't warn me ahead of time. I almost passed out from the smell!

Rotten crotch. That stench always seems to stick to the walls and in your nose for too long afterwards.
A patient on a vent with a beard who drools, that even the best oral care can't fix.
Cdiff vs GIB.
Our ER constantly smells like a mixture of mouth wash (the bums drink it to get drunk), B.O., stale urine & swamp feet.
Near the pathology lab. Ewwww! I never know what THAT smell is!
My friend had a patient that had just had sex. She complained of cramping and smelled horrible while doing the vaginal ultrasound. Then a green gooey blob came out of her vagina. No wonder she was cramping and smelled!
GI bleed poop hands down!
GI bleeds. Makes the entire floor stink. And yeast in skin folds.
I hate the smell of eggs on the morning breakfast today's mixed with all of the various smells coming out of patient rooms. Disgusting.

I wonder why that is? Our eggs are weird also, when you open the cart and that smell hits your face.

Colostomies always get me. I nearly start heaving just thinking about it.
Yea, someone would come to the ER like that and literally permeate the whole place for hours. Made my eyes water.
Abdominal fold cheese that's been brewing for a long long time, added to crotch rott and swamp butt. All wrapped up in soiled clothing permeated with it all.

Your's is the best description of all..LOL. Forgot about crotch rott and swamp butt crack.

Tunneling gas gangrene will definitely leave in impression. Stands out for me in a 40 year.career!
Lower GI bleeds sometimes get me; Anaerobic abscesses are always fun; Trichomonad and bacterial vaginosis together make my eyes water.
Unwashed bodies with a hint of ass.
Tarry stools.
Colostomy. Hands down the worst.
I have asked many times "Why doesn't Yankee Candle make a 'GI bleed' scent?"
The urine of a patient in ESRD!! Ewwww.
GI bleed, c-diff and pressure ulcers.
Patients that have been in ICU for awhile and come to surgery. I don't know what the smell is, but it always smells the same.
I'm going with C-diff and infected draining wounds.
UTI urine.
Colostomy bags.
Sputum smells pretty rank to after sucking it out of a trach.
Dickfarts.
I was just saying the other day that our elevator had the most horrible, strange smell.
Gangrene.
Theres no smell like a fresh 90% burn hot out of the mercy flight.
Made me wish we had a spa tank in the decon room. Dunk them in and Calgon take me away.
I had to step away from the computer. I CAN'T start my day this way. I've smelled all of them too.
Either gangrene or burnt flesh. The smells that you can't get out of your nose.
I really hate the smell of people after a MVA or motorcycle accident who've been thrown from the vehicle. Its that smell of sweat, blood, dirt and gravel. It is very distinct! Usually old drunk stench and urine go with it!
Ileostomy.
Pee pee smell, stell smell!
Plus the stench from a colostomy.
A retained tampon!
Colostomy bag and sepsis. I had to wear three masks.
Other than some bad cafeteria food, I say infected wound/gangrene and weight 400+ pounds can't wash backside smell.
Homeless feet in the summertime.
We once had a guy who worked in another department who left behind the strongest stench of BO behind. He would be nowhere around, but you knew by the smell he was the last one on the elevator.
Uterine cancer patient with old rancid clots expressed per vagina.
When a patients leg is so necrotic there are maggots coming out of it.
Bloody leg bag urine. Gets me everytime.
Lower GI Bleed. Smells like death.
Additionally, drunks and/or crackheads who have been locked in seclusion all night. When you open that door, you had better stand back!
Any kind of poop.
A colon that has burst.
Deficated infarcted bowel. The patient died 5 min after. Only time I ever vomited in the laundry bag.
How about when you go to pick up a patient in the ER and the nurse hands you a cup with a cotton ball soaked in essence of peppermint oil (You know the stuff-one drop will make the entire floor smell like peppermint!) and tells you, "Put this in your truck; you'll need it." Eyes very wide, "Why????" "You'll see." OMG! I could smell the woman from 4 rooms down as I approached! She was about 500 pounds and had not bathed in WEEKS. I had to take her back to her apartment and somehow get her up 15 steps. In a wheelchair. With oxygen. Thank goodness for firemen lift assist!!
GI bleed smell. In the back of the ambulance. With no ventilation! ACK!
Been in this 10 yrs. The one I can't stand worse than C Diff, GI bleed or a pressure ulcer. I had a patient come in that was ESRD and had not bathed in who knows how long. So nasty funk hoohah! Needless to say she got a bath by 3 of us on admit!! It was horrible.
Oozing necrotic wounds.
Wow graphic!!! Now I remember why I didn't accept that orderly job when I got out of high school . When they mentioned the pathology lab I excused myself and went back to sniffing gasoline and exhaust fumes at the gas station!

If you have your own worst smell experiences in the hospital, make sure to leave a comment below to help other doctors, patients and nurses gain insight into the dangers of working in a hospital. Now, please enjoy these original Happy Hospitalist ecards.

"You know you're a nurse if you can name that smell in two whiffs!"

Name that smell in two whiffs nurse ecard humor photo

"I worked an entire shift in the ER without smelling something nasty. Said no ER nurse ever."

Worked an entire shift in the ER without smelling something nasty nurse ecard humor photo

"I asked Santa for a melena free Christmas day shift." Let's see if the fat ass can pull through."

To view this ecard product selection, turn off the “content filter” function on the left hand side of the Zazzle store linked above.

This post contains humor that may only be understood be some healthcare professionals. Read at your own risk.

Getting Ready for The Affordable Care Act

Small Organizations in the Wake of the Affordable Care Act 144

Understanding the ways in which the Affordable Care Act (ACA) will affect small organizations and change the shape of the health care market isn't easy, especially with the large amount of misinformation that has been spread about the law. To help make the picture clearer, Donors Forum’s Chicago Grantmakers for Effective Organizations hosted a session on Small Organizations in the Wake of the Affordable Care Act.

Stephanie Altman, Health and Disabilities Advocates, Kathy Chan, EverThrive Illinois, and Judith Haasis, Community Health, provided detailed information about what organizations can expect in the new environment and how the coming changes will affect them as individuals and employers.

Two key things nonprofit employers need to know about the ACA:

Organizations with fewer than 50 full-time equivalent employees are not required by the law to provide insurance for their employees
ACA provides an increased range of options for insuring employees.

The Small Business Health Options Program, or SHOP, can be accessed through healthcare.gov, and it can connect businesses with fewer than 50 employees to insurance options that might work for them.

Smaller nonprofits can also benefit from available tax credits. Organizations with fewer than 25 employees and annual average wages of less than $50,000 that pay more than 50 percent of the cost of health insurance premiums for their employees, may be eligible for a tax credit equal to 35 percent of their expenses. Organizations must obtain insurance through the SHOP marketplace to get the credit.

The many variables affecting an organization's health insurance decisions are best served by working with an expert. Navigators or assistors have been trained to work with small businesses and individuals to help them connect to benefits for which they might be eligible.

Businesses and individuals can also work with brokers, who can tailor recommendations to them in ways navigators cannot. Brokers are paid by insurance companies, so they will not add to an organization's expenses, and they can help businesses find plans that work for them.

It is important to note that navigators and brokers are prohibited from charging for their services.

The Individual Market

Along with providing possible subsidies for small businesses, the ACA makes significant changes to the insurance market for individuals. Changes from the ACA can be generally grouped into two areas:

Changes that affect the quality of insurance policies
Changes that provide more access to health insurance

Some of the provisions in the former category have already taken effect, like the provision stating dependents can remain on an insurance policy until they are 26 and the removal of lifetime limits on benefit amounts. Many major provisions, including the health insurance marketplace, are now starting up, with the marketplace accepting applications in anticipation of a launch in January 2014.

Other provisions will take effect at the beginning of 2014. They will describe a basic level of health insurance that all people should be able to access. There will be far fewer variables insurers can use to adjust premiums. Factors that were used in the past, such as gender or pre-existing health factors, cannot be taken into consideration. The only factors that will affect individual prices are age, geography, and tobacco use.

On the quantity side, the ACA expands Medicaid eligibility in states that opt in to the expansion, including Illinois, while also providing subsidized insurance options through the marketplace for individuals. This presents several possible challenges for organizations.

First, there is already a shortage of Medicaid specialty care providers, and having more individuals using Medicaid could make this shortage more pronounced. For primary care, Medicaid reimbursement rates are being raised to Medicare levels, which should help shortages in that area. Building specialty care capacity will be a challenge.

Another challenge is that as many as 1.5 million state residents will have insurance they didn't have before, and many of them are not familiar with the best ways to make use of access to preventative care. Helping people use their new resources to best improve their health will be important.

While ACA implementation is expected to significantly lower the numbers of uninsured in Illinois, undocumented immigrants are not covered by the ACA.Organizations committed to providing health care to uninsured, low-income individuals will still be needed. They must figure out how to adapt, including whether they should introduce new revenue streams by doing things such as taking in Medicaid patients.

The new environment presented by the ACA will be challenging, but it also presents opportunities for organizations and funders to enhance the health of people throughout the region as they work together.

Resources for individuals and organizations:
Illinois Health Marketplace (www.getcoveredillinois.gov)
How will the ACA impact nonprofit employers?
Employer Responsibility Under the ACA

~ Jason Hardy, Member Services Associate, Donors Forum