abpmr pip form - cpmiohio.com · e/m codes 99213, 99214, the rest were billed as g codes instead of...
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ABPMRPIPFormCreated:01/09/2020•Lastupdated:02/23/2020
WhichABPMRPIPareyoucompleting?
Createmyownproject
Note:IfyoubeginoneoftheGuidedPIPprojectsandlaterwishtoswitchtoanothertopic,yourworkwillnotautomaticallytransferover.Inthatcase,werecommendcopyingallyourworktoaseparatefile(Wordorsimilar)beforeyou"Withdrawapplication"andstartover.
Pleasemakeaninitialselectionbelow.
CreatemyownPIP
1.)GeneralData
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Startdate: 08/01/2019
Enddate: 02/23/2020
A)Describe,indetail,yourroleintheproject.
VoluntaryPracticeImprovementProject(PIP):
ImpactofthefrequencyoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)onthepainreduction,functionalimprovementandcontinuityofcareofchronicpainpatients.
LeonMargolinMD,PhD/ComprehensivePainManagementInstitute,LLCsubmittedasarequiredformaintenanceofcertificationofAmericanBoardofPhysicalMedicineandRehabilitation
Background:OpioidepidemiccrisisaffectsthelivesofthousandsofAmericansonadailybasis.Since1999hundredsofthousandsofAmericansdiedfromoverdoses.OnanaveragedayintheUScloseto5,800peoplemisuseopioidsforthefirsttime,over1,000Americansonanaveragedaytreatedintheemergencydepartmentsforissuesrelatedtoopioidmisuse.Thesocietalandhealthcarecostofopioidepidemicisatleast55billiondollarseachyearanditcontinuestorise.Properscreeningofpainmanagementprogrampatients(includingSBIRTprotocol(Gcodes,POCUDSandNCV/EMG)fornarcoticmedicationsisextremelyimportantinpreventionofstreetdruguse.2018NationalDrugThreatAssessmentconductedbytheDrugEnforcementAdministration,showedthatprescriptiondrugssuchas“opioidswereresponsibleforthemostoverdosedeathsofanyillicitdrugssince2001”and“heroin-relateddeathsnearlydoubledfrom2013to2016”.Ohiooneofthestatemostlyaffectedbytheopioidcrisis.EfficientandethicalpainmanagementprogramthatusesappropriatetestingtodocumentorganicpathologyandscreenappropriatecandidatesforpainmedicationsandreferredotherpatientstoAddictionmedicineevaluationisextremelyimportantinthischallengingenvironmentoftheopioidepidemiccrisis.(basedHHS2017five-pointstrategy).Nationalandstateguidelinesrequireriskstratificationandclosemonitoringofpatientsonchronicopioidmedication.ThisstudyteststheimpactofthefrequencyoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)onthefunctionalimprovementandcontinuityofcareofchronicpainpatients.
B)Datesofyourproject:
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2.)Plan:Identifyanareainyourpracticethatneedsimprovement.
A)Whatistheproblemyouaretryingtosolve?
Whatdoyouwanttoimprove?Lookforinefficiencies,annoyances,orsafetyissues.Considercomplexissues,butfocusonsimplesolutions.
Nationalandstateguidelinesrequireriskstratificationandclosemonitoringofpatientsonchronicopioidmedication.ThisstudyteststheimpactofthefrequencyoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)functionalimprovementandcontinuityofcareofchronicpainpatients.ThissfrequencyoftheSBIRTprotocol(GcodessuchasG0397),POCUDS(80307,80304)andminimallyinvasiveprocedures(76942,64450,64418,20533andothersimilarcodesisbasedonthe“PainManagementBestPracticesInter-AgencyTaskForceReport”,MedicareMLNandLCDOHL36029,Medicareguidelinesforthepresumptiveanddefinitivetesting.
Dr.MargolinmaintainsactivecertificationbytheABPM&R;inPM&R;andPainMedicine.Ourpractice,ComprehensivePainManagementInstitute,LLCestablishedcredibleevidencebasedprotocolsbasedonthethe“PainManagementBestPracticesInter-AgencyTaskForceReport”,MedicareMLNandLCDOHL36029,Medicareguidelines.
Ourpracticeisatertiaryreferralpracticethatgetsreferralforhighriskpatients.ThisisthereasonforconductingthisstudythatteststheimpactofthefrequencyoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)functionalimprovementandcontinuityofcareofchronicpainpatientsforqualityofcaredocumentationandinformationforthethirdpartypayers.
MedicalNecessity:MostoftheComprehensivePainManagementInstitute,LLC(CPMI)patientsarecomplexhighormediumriskchronicpainpatientswithmultiplemedicalorpsychologicalcomorbidities(asreflectedintheNARXscoresheetenclosed).
After2011asaresultofregulatorychangesinthestateofOhio(includingHB93law),CPMIreceivedahighnumberofreferral/evaluationrequestsforhighriskchallengingpatientpopulation.ManyofthesechronicpainpatientsseenbytheCPMIsufferfromanxietyanddepression,and/ordrugseekingbehaviorandhadchallengesincompliancewiththeprimarycareprovidersprogram.Thestateandfederalguidelinesrequiredimplementationofthealternativetreatmentstoopioidmedicationsincludingminimallyinvasiveultrasoundguidedprocedures.
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MedicareMLNdefinestheSBIRTscreeningastimespentonthestructuredlassessmentreview;theMLNdoesnothavedefinitivefrequencyparametersforsuchscreening.OurpracticesettheSBIRTprotocolbasedontheLCDOHL36029.LCDOHL36029setsthefrequency1-3timesin3monthsforthehigh-riskpatients(thevastmajorityofthesamplepatientsfallinthisoftherangehigh-riskpatientsthatarethemajorityofourpatients–94%asabove).Theother6%haveotherfactorsandelementsdiscussedbelow.Thisfrequencyisalsoconsistentwiththeindependentbillingandcodingreviewsthatthepracticehasconducted.
CostEfficiencyoftheTesting:
Thecostofopioidepidemicismorethan55billiondollarsayearandkeepsrisingannually.PainManagementprogramslikeourpracticethatcarefullyscreenandtestpatienttoproperlydocumentorganicpathologyandutilizealternativetreatments,carefulmonitoringandSBIRTapproachnotonlypreventsignificantmorbidityandmortality,butsaveverysignificantcoststothehealthcaresystem.Insufficienttesting,monitoringandlackofalternativestoopoidmedicationscanpotentiallyresultineitherprescribingopioidmedicationstonotappropriatecandidatesthatcanpotentiallyoverdoseordivertmedicationstootherpeople,ornotprescribing5/9appropriatepainmedicationstopatientswhomaylookforalternatives“onthestreet”withsignificantrisksormorbidityandmortality.ThehostofhospitalizationincludingER,inpatientcare,ICU,detoxificationandmaintenanceprogramsisastronomicandcanbereducedbypatientscreeningtreatmentintheoutpatientprogramslikeourpractice(ComprehensivePainManagementInstitute).Thisapproachisalsosupportedbythe2017fivepointstrategybytheHHS.WhentheinsurancecarrierschallengethenecessityofSBIRTprotocol(Gcodes),itdeniescoverageforproceduresthatarerequiredbytheOhiostatelaw(pleasereviewMichaelStaplesattached)andcreatesa“catch22scenario”thatputsthepateintsandthestaffatrisk.Theseproceduresincludefacetofacetimespentbyphysicianandthenursepractitioners,morethat30minoftelecommunicationvideomaterial,structuredreviewofseveralassessmentsincludingpatient’shistoryandphysicalexamination(atleast20-25minaccordingtoMedicare),PADT(atleast15-20minasperASAM),COMM(atleast10-15min),FlowchartformbasedonSMBOAdministrativeRule4731-21-02(atleast10-15min),withdrawalassessmentform(atleast5-10min),pointofcareandconformationurineandsalivadrugscreenreviews(atleast10min),OARRSreviews(atleast10min),andseveraleducationalmaterials(atleast10min).Isummary,thedocumentedtimespentonSBIRT(Gcode)clearlysignificantlyexceedsthe30minuterequirementoftheGcodebilled.Inaddition,theinitialevaluationincludesadditionalassessmentssuchasSOAPP-RandORTandadditionaleducationalmaterials.DenialpaymentsfortheappropriatetestingandscreeningproceduresfordrugsandalcoholrequiredbythestateandnationalguidelineswouldnotonlysignificantlyimpactCPMI’sabilitytofunctionasabusiness,butwouldalsoputanextremelyvulnerablepatientpopulationatrisk.Ourpatientpopulationis
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uniqueascomparedtomanyofourpeers.Ourpatientsareextremelycomplex;wetakeprideincreatingindividualizedtreatmentplanswhichdorequireasignificantamountoftestingandtimeforscreeningforsubstanceandalcoholuse.However,thisallowsourpatientstoachieveanextraordinaryleveloffunctionrelativetomanagingtheirpainandpreventmorbidityandmortality.Thequalityofcareweprovideresultedinseveralclinicalawards(i.e.PatientChoiceAward,MostCompassionateDoctorawardsforseveralyears,2019“Top10”OhiophysicianawardinPainMedicine)andreferralswegetfrommajorhospitalssuchasOSUMedicalCenter,Riverside,Grant,MtCarmel,AdinaHealthandUniversityHospitalsinClevelandandevenotherpainmanagementpractices.Manyofourpatientsareopioid-dependent,iftheirmedicationsarenottimelyreviewed,thiscancausepatientmorbidityincidenttoabruptlystoppingtreatment.
Itisdifficultformanypatientstofindalternativeproviders.Ifleftuntreated,patientsmayturntoillicitmeansofobtainingsubstitutemedicationswhichdrasticallyincreasestheriskofoverdoseanddeath(overdosedeathrateinOhioisthehighestinthenationandisupmorethan800%since2013).Thecostoftheopioidepidemicisestimatedasmorethe600billionnationwide,werunalowcostprogramthatsavedhundredsofthousandsofdollarstoMedicarebyidentifyingandreferringforaddictiontreatmentshundredsofpatientsusingourSBIRTprotocol.Webilledmuchlowerratesthancomparablehospitalbasedprogramsandchoselowercostcodes(i.e.Gcodesvs.officevisitandtimecodes).
Insummary,denialpaymentsfortheappropriatetestingandscreeningproceduresfordrugsandalcoholputsindangeraboutseveralhundredhigh-riskpatients(justinDecemberof2019wehadacaseofassaultbyadischargeddrugseekingpatientandanattemptedassaultbyanotherpatientouroffice).
RiskStratificationforthepatientinthesample1(pleaseseeNARXtablebelow):
NARXScoreanalysisofthepatientsinthesample.Ourtreatmentprotocol,includingtheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)isbasedonpatientriskstratification,NARXriskstratification(validatedbytheCMS)LCDOHL36029andstateandnationalguidelines.
PleasefindtheNARXscoredetailedvalidationandanalysisattached(attachmentNARXManual,NARXclinicalapplication).TherenofrequencyguidelinesfortheGcode,howeverNARXscore(thatshowstheriskofoverdoseanddeath)seemstobethegoldenstandardacceptedbytheCMSandMedicare.TheclinicalrecommendationsbytheCMSandSMBOattached(attachmentNARXManual,NARXclinicalapplication).
Only6%ofthesample1patients(3/50pts)arelowrisk(NARXbelow100)
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Only16%arehighrisk(NARX100-189)Oddratioforoverdoseincreased10times(chapter12OverdoseRiskScorepage63attached).
Therestareveryhighrisk34%(NARXabove200)andextremelyhighrisk24%(NARXabove350).Oddsratiofordeathfromoverdoseis10-12timesaverage(seeclinicalapplicationoftheNARXscoreattachedpage67).Oddratioforoverdoseincreased10-12timesormore(chapter12OverdoseRiskScorepage63attached).
UndoubtedlythepatientwiththistypeofriskwouldrequirefrequentGcodescreeningandothertestingsuchasEMG.
Thevastmajorityofthe“sample1”patientswereonincreasedriskdoseoftheopioids(morethan20MME-increasedriskofdeathasperCDC2016guidelinesincreasedadjustedhazardratio(HR)foranyoverdoseanddeath)https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf,manypatientsobtainedoipidsfrommorethanoneprescriber,usedmultiplepharmaciesandmultipleclassesofopioidmedications,somealsousedsedativesorstimulatesthatgreatlyincreasedtheriskaccordingtheCDCguidelinesandNARXscoredatabase(pleasefindoriginalNRAXscorereportsforeachpatientattached).ThesetypeofriskypatientsclearlyrequirehighfrequencyofSBIRT(Gcodeuse)basedonthecriteriadiscussedabove.
Riskstratificationofthesample2(sentbyaseparateemail)demonstratedsimilarresults.
UseofSBIRTGcodevs.useoftheE/Mofficevisitcodes.ManyoftheCPMIpatienthavemultiplemedicalcomorbiditiesanddependantonthetransportation(canscheduleonlyalimitednumberofvisits).Thereforeonmanyoccasionswehavetoscheduleminimallyinvasiveprocedureandtheofficevisitformedicalmanagementatthesamedate.ThisstudyshowtheadvantagesofusingSBIRT/GcodesratherinsteadofE/Mlevel3or4codesintheseencounters.Thisapproachprovidescostsavingtothethirdpartyinsurancepayersandputsemphasisonthescreeningandbriefinterventionapproachwhichiscrucialinmanaginghighriskpatientsonopioidmedications.CostsavingsecondarytouseofGcodeusevsmoreexpensiveofficevisit(E/M)codes:
AccordingtothenationalstandardsforPainMedicine(https://www.aapc.com/resources/em_utilization.aspx),officevisitcodes99213and99214combinedconstitutealmost100%ofthetotalvisitbillings(48.8%for99213+44.9%99214).ThesecodesaremoreexpensivethanGcodesandcanalsobecombinedwithtimecodes.
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Ourbillingdataanalysisbelowshowsthatinourpracticethesemoreexpensiveofficevisitcodes(99213and99214)constituteonly16-30percentofthetotalannualvisits.
OurpracticestartedtheappropriateuseofGcodessinceitsinceptionin2014(whichexplainsthe91%percentincreaseincomparisonto2013).
TheuseofthesecodeswasbasedonthecertifiedbillerandcoderreviewbelowandsavedMedicaretensofthousandsofdollars(asprovenbythebillingandcodingdatabelow).
Youcanseeclearlythatonlybetween16-30%ofourfollowupvisitswerebilledasthemoreexpensiveE/Mcodes99213,99214,therestwerebilledasGcodesinsteadofmoreexpensiveofficevisitcodes.
InotherwordsthatneedtocomparemyGcodeandofficevisitcodesbilledthatwouldshowthatbilledgreatlybelowaverageformoreexpensiveE/Mcodesfortheofficevisits.Thatclearlyexplainsthe79timestheGcodewasbilled-itwasbilledfor79followupvisitsinsteadofmoreexpensiveofficevisitcode.
----------Forwardedmessage---------От:DAVIDDEPPENDate:пт,8нояб.2019г.в13:17Subject:FW:PracticeNumbersRequested-UpdatedTo:LeonMargin
Herearetheupdatednumbersforyou:
2014:OfficeVisits–2330GCodes–5104TotalVisits-8239
2015:OfficeVisits–2056GCodes–5622TotalVisits-8157
2016:
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OfficeVisits–1146GCodes–6621TotalVisits-7885
2017:OfficeVisits–1373GCodes–7294TotalVisits-8491
2018:OfficeVisits–1160GCodes–7907TotalVisits-8111
2019:OfficeVisits–2317GCodes–8838TotalVisits-9494
Thanks,DavidDeppenOfficeManagerPracticePro,LLCP:937-322-4911
Thisanalysisprovesasignificantcostsavingtothethird-partypayerofthisprotocolsince2014tillpresent.CrediblebillingandcodinganalysisandreviewfortheGcodeimplementation:
----------Forwardedmessage---------От:DavidDeppenDate:ср,12мар.2014г.в08:17Subject:RE:screeningGcodesTo:LeonMargolin,DavidGuido
HerearethecodesfromtheHCPCSbook:
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G0396Alcoholand/orsubstance(otherthantobacco)abusestructuredassessment(e.g.,audit,dast),andbriefintervention15to30minutesG0397Alcoholand/orsubstance(otherthantobacco)abusestructuredassessment(e.g.,audit,dast),andintervention,greaterthan30minutes
NothingspeakstoonlytimeforMDsotimespentbyotherassociatesonthisservicecouldbeincluded.Theonlyitemthatwesuggestisthatsomewhereinthechartnoteitisdocumentedthatmorethan30minuteswasspentcoveringthisissueseparatelyfromotherservices.
Thanks,DavidDeppenPractice-ProLLC937-322-4911ImplementationoftheLCDOHL36029:OurstudyalsoprovidesaclearproofthatfrequencyoftheSBIRT/GcodemonitoringshoulddependonthecompliancewiththeprescribedopioidmedicationsandNARXscoreriskstratification,ratherthanrelianceontheself-reportedriskfactorslikealcoholordruguseintheinitialevaluationbythestafforbyapainpsychologist.
LCDOHL36029setsfrequencyofmonitoringthatdependsonprescribedopioidmedicationsandotherelements(seeExhibit21)andnotonlyontheinitialpsychologicalevaluationthatused:
◦Patienthistory,physicalexamination,andpreviouslaboratoryfindings;
◦Currenttreatmentplan;
◦Prescribedmedication(s)
◦Riskassessmentplan
TherationalforsuchscreeningLCDOHL36029definesas:
a.Identifiesabsenceofprescribedmedicationandpotentialforabuse,misuse,anddiversion;
b.Identifiesundisclosedsubstances,suchasalcohol,unsanctionedprescriptionmedication,orillicitsubstances;
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c.Identifiessubstancesthatcontributetoadverseeventsordrug-druginteractions;
d.Providesobjectivitytothetreatmentplan;e.Reinforcestherapeuticcompliancewiththepatient;
f.Providesadditionaldocumentationdemonstratingcompliancewithpatientevaluationandmonitoring;g.Providediagnosticinformationtohelpassessindividualpatientresponsetomedications(e.g.,metabolism,sideeffects,drug-druginteraction,etc.)overtimeforongoingmanagementofprescribedmedications.
Alltheseelementsandfactorsareclearlydocumentedinourrecordsandevaluatedinourstudy.Wewouldliketoillustratetheimportanceofthisapproachusingtheexamplesbelow:
PatientexamplesthatshowanefficientSBIRTimplementationthatenablessuccessfulpatientparticipationintheprogramandtimelydetectionofaberrantdrug-seekingbehavior.Example#1:DS.Thispatient-reportedthelastdrink26yearsago,however,thispatientmeetscriteriaforahigh-riskpatientwithachronicpainsyndromesecondaryfailedbacksyndrome(s/p4backsurgeries).ThisisanexampleofSBIRTscreeningdirectedtowardscompliancewiththeprescribedopioidsubstancesandconfirmationofthelackofthenonprescribednarcoticsubstancesasperSMBO,OhioBoardofPharmacyandNARX,CDC,andLCDOHL36029WewillanalyzethenecessityandthefrequencyfotheSBIRTandGcodescreening(SBIRT/Gcode)codeatleast79SBIRT(Gcode)performedsince2015)andtheimpactonpatientcomplianceandparticipationintheprogram.CaseReview:Thisisapatients/p4backsurgeriesthatrequireschronicpainmanagement.HisenclosedBoardofPharmacyNARXscoredefineshimasahighriskpatient:NarcoticScore470SedativeScore170OverdoseRiskScore190(Oddsratioforoverdoseanddeathisabout10timeshigherthanaveragepleaserefertotheNARXscorereviewmaterialenclosed).Inaddition,heiscurrentlyon60MMEdaily(3timesthedangerousdosethresholdperCDCguidelines),hehasreceivedmorethan150prescriptionsfrom5differentprescriberusing2differentpharmaciesincludinghigh-risksubstanceslikeOxycodone,MorphineSulphateandFentanyl(thatisresponsibleforalargenumberofoverdosesanddeath).Sincethisisahigh-riskpatientonchronicopioidmedications,herequiresfrequentfollow-upvisitsandcompliancemonitoring.Ourpracticemonitoredthepatientcompliancewithatleast79screeningsandbriefinterventionsperformedoverthespanofthelast3-4years.ThisnumberisconservativeforthistypeofpatientandrequiredbytheSMBO,OhioBoardofPharmacyandNARX,CDC,andLCDOHL36029.Thescreeningsarerelatedtocontinuousexposuretodifferentnarcoticsubstancesandnottohispriordrinkinghistoryasdescribedabove.Ofnote,thischartwasreviewedbytheBoardofPharmacyin2015andfoundfullycompliantasdocumentedonthechart.Thisexampleshowshowefficientandcost-effectiveuseoftheSBIRTscreening(G0397code)usesaves
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enforcescomplianceforthehigh-riskpatientsandsavesfundsforthird-partypayers.Inaddition,thispatienthasbeencomingtoourpracticeforcloseto5years(despitemultiplecompetingprovidersjustafewmilesaway)andevenvolunteeredavideotestimonial(togetherwithcloseto70otherpatients).Example#2:LH,ontheinitialinterviewwiththepainpsychologist–thepatientdidnotreportanyhistoryofalcoholordrugabuse.HerenclosedBoardofPharmacyNARXscoredefineshimasaveryhigh-riskpatient:NarcoticScore451SedativeScore290OverdoseRiskScore370StimulantScore20(Oddsratioforoverdoseanddeathisaboutatleast12timeshigherthanaverageormorepleaserefertotheNARXscorereviewmaterialenclosed).Additionalriskfactormorethan100MMEwithaverage40MMEdaily(pleasefindtheoriginalNARXreportenclosed).Recentlypatientisgetting60MMEdaily.TheseareverydangerousdosesaccordingtotheNARXandCDCguidelinesattachedthatrequiresfrequentSBIRT(Gcodescreenings).
Thepatientreceivedmorethan82prescriptionsforseveraltypesofmedicationsincludingPercocet,Oxycodone,Morphine,Hydrocodone,Phentermine,Lyrica,andGabapentinfrom7prescribersand5pharmacies.44screeningsandbriefinterventions(SABIRT/Gcode)performedoverthespanofthelast3-4yearsforsuchriskpatientisareasonablerequirednumberasperSMBO,OhioBoardofPharmacyandNARX,CDC,andLCDOHL36029.Thescreeningsarerelatedtocontinuousexposuretodifferentnarcoticsubstances.Thisexampleshowshowefficientandcost-effectiveuseoftheSBIRTscreening(G0397code)usesavesenforcescompliancefortheveryhigh-riskpatientsonmultiplecontrolledsubstancesandsavesfundsforthethird-partypayers.
Example#3:LHCaseReview:Thisisapatientwithspinalstenosisrequireschronicpainmanagement.Inaddition,thepatientreportedbeingavictimofphysicaldomesticabuse(additionalriskfactor)andrequiredchronicbenzodiazepinetherapy(alprazolam).Pleasefindtheurinescreenreportenclosed.Thepatienthadmultipleprescriptionsofalprazolam(potentbenzodiazepine)combinedwithopioidswhichisahigh-riskregimenforovermedicationanddeathandrequiresSBIRTinterventionseachtimethecombinationsareprescribed,accordingtotheCDCguidelines(enclosed).Pleasefindthelistoftheprescriptionsenclosed.Infact,completelyignoredtheenclosedabnormalurinedrugscreen(dated11/22/2017enclosed)whichpositivefornonprescribedbenzodiazepine(whichaveryhigh-riskfactorasperenclosedCDCguidelines)andthefollowuppainpsychologyreport(January18)thatconditionedpatientclearanceforopioidswithclosedmonitoring(SBIRTprotocol/Gcodes).26screeningsandbriefinterventions(SBIRT/Gcodes)performedoveraprolongedperiodoftimeforsuchaveryhigh-riskpatientaremedicallynecessaryandrequiredbytheSMBO,OhioBoardofPharmacy
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andNARX,CDC,andLCDOHL36029.Thescreeningsarerelatedtocontinuousexposuretoacombinationofbenzodiazepinesnarcoticsubstancesandnottopatient’spriordrinkinghistory.Thisexampleshowshowefficientandcost-effectiveuseoftheSBIRTscreening(G0397code)usesavesenforcescomplianceforthehigh-riskpatientsonopioidsandbenzodiazepinesandsavesfundsforthethird-partypayers.Cases1-3showthatdespitetheinitialdenialofpriorriskfactors(i.edrinkinghistory)ontheinitialpsychologicalinterview,NARXscoreandstructuredassessmentanalysiscanhelptoimplementproperSBIRT/Gcodescreeningforsafetyandcompliance.
Example#4:JMPatientchartreviewshowsthatthepatientwasprescribedonOctober20,201630tabletsofOxyCodone5/APAP325for15days(pleaseseeBoardofPharmacydatabaselistofmedicationsenclosed).On11/2/16ourpracticeperformedarandomurinescreenthatwasNEGATIVEforprescribedOxyCodone(pleasefindtheurinescreenenclosed).TheurinescreenwasreviewedbyDoctorofPharmacologyconsultantanddiscussedwithpainpsychologist,bothofthemrequestedtightmonitoringbecauseofconcernformedicationdiversion(whichisconsideredafelonybythestateofOhioandfederallaw).Inaddition,thefollow-upnotedated11/02/16statesthatdidnotbringmedicationsbottleforpillcountandthepatientstatesshehasalotofPercocetathomethatsupportsthisconcern.Unfortunately,thepatientwasnotcompliantwiththereasonablemonitoringandselfdischargedherself.Ofnote,thispatienthasahighNARXscore(Narcoticscore371,Sedativescore150,Overdoseriskscore170),shereceivedopioidmedicationsfrom7prescribers,using4pharmaciesbasedontheBoardofPharmacydatabase.Insummary,ourmanagementofthecasewasappropriateandmandatedbythefederalandstatelaw,SMBO,OhioBoardofPharmacy,DEAandCDCregulations.Examplesofproperuseofinformedconsentandrespectforpatientautonomy.InthepreviouspartofthestudydedicatedtotheEMG/NCVprotocol,weintroducedtheuseofinformedconsentinourpractice.Thefollowingexamplesanalyzetheuseoftheinformedconsentbythepatients.
Example#5ST
Teresaisahigh-riskpatients(pleaseseetheenclosedBoardofPharmacyNARXscoredefinesherasahigh-riskpatient:NarcoticScore441SedativeScore200OverdoseRiskScore340(Oddsratioforoverdoseanddeathisabout10timeshigherthanaveragepleaserefertotheNARXscorereviewmaterialenclosed).TheBoardofPharmacyalsomentionedmorethan5opioidsorsedativeprovidersfrom4pharmacies.PropertestingsuchasNCV/EMGtestingisnecessaryforsuchapatientfordocumentationoforganicpathology.Thispatientalsohasbeencomingtoourpracticeforseveralyears(despitemultiplecompetingprovidersjustafewmilesaway)thattestifiesforthequalityofcareshehasreceived.
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Thispatient“firstrefusedtheneedleEMG,thenlefttheboxuncheckedandthenagreedtotheneedleEMGtest”.TeresarefusedtheneedleEMGin2014,laterwhenthepatientrequiredprolongedcarein2016andin2017sheagreedtotheneedletesting.In2016shegaveverbalconsent(notmarkingthecheckboxisirrelevantbasedontheAANEMethicalguidelinesenclosed)and2017shegavebothverbalandwrittenconsentwhichisalsoconsistentwiththeguidelines.PatientinformedconsentforandagainstthetestingwasrespectedeachtimeasperAANEMandMedicareconsentpolicy.The2014and2016testswerebothcarpaltunnelevaluationexemptbytheAANEMpolicyandprovidedcredibleinformationevenwithouttheneedletesting.Inaddition,incompliancewiththeOHLCDthisanalysisshowsthatinthisandothercasesweneverSOLELYontheNCSdatabutonthedetailedanalysiswedescribed.
Example#6MS…patienttestimonialdifferencebetweenEMGandprocedureMarkisahigh-riskpatient(pleaseseetheenclosedBoardofPharmacyNARXscoredefineshimasahigh-riskpatient:NarcoticScore381SedativeScore160OverdoseRiskScore210(Oddsratioforoverdoseanddeathisabout10timeshigherthanaveragepleaserefertotheNARXscorereviewmaterialenclosed).Infact,Markrecentlyhadaurinescreenpositiveforuseofillicitmarijuana(asperPharmacologydoctorattached).BoardofPharmacyalsomentionedmorethan4opioidsorsedativeprovidersfrom2pharmacies(totalmorethan50prescriptions).PropermonitoringtestingsuchasNCV/EMGtestingandalternativeproceduresarenecessaryforthispatient.Thispatientalsohasbeenseenatourpracticeforseveralyears(despitemultiplecompetingprovidersjustafewmilesaway)thattestifiesforthequalityofcareshehasreceivedClosefollowupthatincludedaninterviewbypainpsychologistandpsychologicalassessmentshelpedtoaddresspatientanxieties.ThispatientinitiallyrefusedtheneedleEMGtesting.Eventhoughthetestiscalled“needle”EMG,thetestisperformedusingarecordingprobe(andnotaneedle)inaconventionalsense(nothingisinjectedthroughtheEMG“needle”).Thereforeit’squitenaturalforapatienttorefusetheneedleEMGtestingthatdoesnotdirectlyreliefthepain(andalsoinvolves6-12probesticks).Atthesametimethepatientagreedtothenerveblockinjectionthatinvolvedonesmallneedlestickthatprovidesimmediatepainreliefthroughmedicationsinjectedthroughtheneedle.
PatientinformedconsentforandagainstthetestingwasrespectedeachtimeasperAANEMandMedicareconsentpolicy.The2014and2016testswerebothcarpaltunnelevaluationexemptbytheAANEMpolicyandprovidedcredibleinformationevenwithouttheneedletesting.
B)Whatdata(objectivemeasurements)doyouhavethatsupportsthisasaproblem?
Reviewyourrecordsorbegintrackinghowoftentheissueisoccurringandunderwhatconditions.
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Sample1andSample2:RigorouscategoricaldatabasedonPADT,FunctionalFlowchartforms,initialandfollowupevaluationforms,informedconsentandmedicalnecessityforms(examplesemailedtoKendall),OARRS(OhioPMR)etc.Studydesign:Retrospectivereviewof155charts(pleaseseethelistoftheselectedchartsenclosed)thatstudiestheimpactofthefrequencyoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)onthetreatmentdecisionmaking(suchaschoosingnonopioidadjuvantmedicationsandopioidmedications,painreductionandfunctionalimprovementasdocumentedbyPADTformsandperformanceofproperclinicalassessmentasallthecomplianceandparticipationintheprogram(lengsofparticipationinmonths).Pleaseseetheattachmentbelow.Whenpainreductionwas30%-50%wedefineditasa“moderate”,above50%a“significant”andmorethan70%averysignificantpainreduction.WhenfunctionalimprovementasdocumentedbyPADTincluded2parametersormore,wecalleditsignificant,ifonlyoneparameterwecalledit“moderate”functionalimprovement.If3orfunctionalparametersimprovedwecalledaverysignificantimprovement.POCUDStestingUseofthePOCUDStestingperformedincompliancewiththestateandfederalguidelinesaspartofthepatientmonitoringprogramusingtheriskstratificationscalediscussedabove.Datashowssignificantimpactofthetestingonthepatienttreatmentplanandcompliance.
Ultrasoundguidedprocedures.Ultrasoundguidedprocedures(peripheralnerveblocks,triggerpointinjectionsandothers).Theminimallyinvasiveproceduresarecosteffectivealternativestotheopioidmedicationsrequiredbytheguidelines.Allthepatientreceivedtheinformedconsentandthemedicalnecessityforms.Statisticalanalysisshowsastrongimpactoftheseproceduresonthepatienttreatmentplanandcompliance.Analysisofsample3–dischargedpatients:Wehavereviewedthechartsofpatientpositivelyscreenedfornoncompliancewiththepatientcontract(illicitsubstanceabuse,failedpillcounts,doctorshopping,urinescreensnegativeforprescribedmedicationsandotherissues)usingtheSBIRTprotocol(Gcodes)thatwediscussed.
Sample1andSample2:RigorouscategoricaldatabasedonPADT,FunctionalFlowchartforms,initialandfollowupevaluationforms,informedconsentandmedicalnecessityforms(examplesemailedtoKendall),OARRS(OhioPMR)etc.Studydesign:Retrospectivereviewof155charts(pleaseseethelistoftheselectedchartsenclosed)thatstudiestheimpactofthefrequencyoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533
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andothersimilarcodes)onthetreatmentdecisionmaking(suchaschoosingnonopioidadjuvantmedicationsandopioidmedications,painreductionandfunctionalimprovementasdocumentedbyPADTformsandperformanceofproperclinicalassessmentasallthecomplianceandparticipationintheprogram(lengsofparticipationinmonths).Pleaseseetheattachmentbelow.Whenpainreductionwas30%-50%wedefineditasa“moderate”,above50%a“significant”andmorethan70%averysignificantpainreduction.WhenfunctionalimprovementasdocumentedbyPADTincluded2parametersormore,wecalleditsignificant,ifonlyoneparameterwecalledit“moderate”functionalimprovement.If3orfunctionalparametersimprovedwecalledaverysignificantimprovement.POCUDStestingUseofthePOCUDStestingperformedincompliancewiththestateandfederalguidelinesaspartofthepatientmonitoringprogramusingtheriskstratificationscalediscussedabove.Datashowssignificantimpactofthetestingonthepatienttreatmentplanandcompliance.
Ultrasoundguidedprocedures.Ultrasoundguidedprocedures(peripheralnerveblocks,triggerpointinjectionsandothers).Theminimallyinvasiveproceduresarecosteffectivealternativestotheopioidmedicationsrequiredbytheguidelines.Allthepatientreceivedtheinformedconsentandthemedicalnecessityforms.Statisticalanalysisshowsastrongimpactoftheseproceduresonthepatienttreatmentplanandcompliance.Analysisofsample3–dischargedpatients:Wehavereviewedthechartsofpatientpositivelyscreenedfornoncompliancewiththepatientcontract(illicitsubstanceabuse,failedpillcounts,doctorshopping,urinescreensnegativeforprescribedmedicationsandotherissues)usingtheSBIRTprotocol(Gcodes)thatwediscussed.
Statisticalanalysis(dataintableformatsentbyaseparateemail):Sample1NARXScore(riskstratification)andSBIRTprotocolscreeningeffectivenessanalysisThetablebelowhowtheaverageNARXscoreschangeswithMonthsinProgram:Table1MonthsNARXAverage/Max/Pts
Short(1month)3084506Medium(>1month,<2years)27139013Long(2years)30977023
NARXScore(riskstratification)andSBIRTprotocolscreeningeffectivenessanalysisresults:
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Enforcingandmonitoringpatientcomplianceisamajorchallengeforpainmanagementprograms.TheaverageandthemaximumNARXscoresreflectthehighriskandtheveryhighriskprofileofourpatientpopulation.OurSBIRTprotocolandothertestsandtreatmentdescribedinthestudyiseffectiveinmonitoringandenforcingthehighriskpatientcomplianceforprolongedperiodsoftime(morethan23months).
FunctionalImprovementAnalysisThetablebelowcomparesMonthsinProgramvsFunctionalImprovement(basedonthePADTandothertools).Giventhelownumberofpatientsinthe‘lessthan2yeargroup,these3groupsarecombined.Table2ModerateSignificantVeryTotalLessthan2years1676292years5120262182655
Table3%ofRowTotalsforthetableaboveModerateSignificantVeryLessthan2years55.2%24.1%20.7%>2years19.2%3.8%76.9%
Forexample,ofthe26patientswith2yearsoftreatments(forwhomwealsohaddataonFunctionalImprovement),20ofthemor76.9%showedVerySignificantImprovement.Performingachi-squaretestonTable3(combiningthefirst2columnstoenhancethetest)showsthereisasignificantdifferencein‘monthsofTreatment.(p<.01)FunctionalImprovementAnalysisResults:Thereisasignificantrelation(at.05level)betweenMonthsinProgramandFunctionalImprovement.TheSBIRTprotocolandothertreatmentsinourprogramshowedastrongstatisticallysignificantimpactonthepatientfunctionalimprovement–whichisthemainoutcomemeasureofthepainmanagementprogram.
PainReductionanalysisTable5ModerateSignificantVeryTotalPtsLessthan2years2242282years175426Total399654
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Table6%ofRowTotalsforTableaboveModerateSignificantVeryLessthan2years78.6%14.3%7.1%>2years65.4%19.2%15.4%
Mostpatientshadonlymoderatepainreduction(72.2%).Ofthepatientsintheprogramfor2years,15%(4outof26)hadVerySignificantpainreductionwhile65%ofthe2-yearpatientshadModeratePainReductionPerformingachi-squaretestonTable5(combiningthelast2columnstoenhancethetest)showsthereisasignificantdifferencein‘monthsofTreatment.(p=.02).PainReductionanalysisresults:Wedemonstratedaverysignificantpain(p=.02)reductionovertimeinourprogram.Astimeparticipationintheprogramincreases(morethan2years),thepainreductionbecomesmoresignificant.
Statisticalanalysis:Sample2NARXScore(riskstratification)andSBIRTprotocolscreeningeffectivenessanalysisThetablebelowhowtheaverageNARXscoreschangeswithMonthsinProgram:Table7NARXScorevsMonthsinProgramAverageMaxNumberPatients<2years3174809>2years29259031
NARXScore(riskstratification)andSBIRTprotocolscreeningeffectivenessanalysisresults(sample2):Enforcingandmonitoringpatientcomplianceisamajorchallengeforpainmanagementprograms.Aswehaveobservedinsample1,inthesample2theaverageandthemaximumNARXscoresreflectthehighriskandtheveryhigh-riskprofileofourpatientpopulation.OurSBIRTprotocolandothertestsandtreatmentdescribedinthestudyiseffectiveinmonitoringandenforcingthehigh-riskpatientcomplianceforprolongedperiodsoftime(morethan23months).
FunctionalImprovementAnalysis:ThetablebelowcomparesMonthsinProgramvsFunctionalImprovement(basedonthePADTandothertools).Giventhelownumberofpatientsinthe‘lessthan2-yeargroup,these3groupsarecombined.
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Table8MonthsinProgramvsFunctionalImprovementSignificant/VerySig/Total<2years5611>2years82533
Table9%ofRowTotalsforthetableaboveSignificantVery<2years45.5%54.5%>2years24.2%75.8%
ThetablebelowcomparesMonthsinProgramvsFunctionalImprovement(basedonthePADTandothertools).Giventhelownumberofpatientsinthe‘lessthan2-yeargroup,these3groupsarecombined.
FunctionalImprovementAnalysisResults:Allthepatientsinthesamplestayedintheprogramfor6monthsorlonger,mostofthepatientsfor2yearsorlonger.Allthepatientsachievedfunctionalimprovementat6monthandcontinuewithasignificantorverysignificantimprovementafterthat.
PainReductionanalysisTable10MonthsinProgramvsPainReductionModerateSignificantVerySigTotal<2years4509>2years0211132
Thedifferencebetweenthe“<2years”groupandthe“2years”groupisstatisticallysignificant(binomialtest,P<.01)Table11%ofRowTotalsforAboveTableModerateSignificantVery<2years44.4%55.6%0.0%2years0.0%65.6%34.4%
PainReductionanalysisresults:
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Wedemonstratedaverysignificantpain(p=.01)reductionovertimeinourprogram.Astimeparticipationintheprogramincreases(morethan2years),thepainreductionbecomesmoresignificant.
Sample3(dischargedpatients):NARXSCORESandDISCHARGEREASONDischargeReasonNumberPatients%TotalPatients3months6Months12Months2yearsAvNARX#PtsCOC1435.9%724136714THC25.1%20001601METH25.1%2000801ETOH1230.8%225344211FENT12.6%1000501ADLTERATIONOFURINE37.7%30002363BUP512.8%40014865
TwothirdsofallDischargereasonswereforCOCorFPC.Dividingthepatientsin3groups,COC,FPC,ALLOthers,thereisnosignificantdifferenceinAverageNARXScoreamongstthe3groups(ttestat.05level).
Dischargedpatientanalysisresults:Datashowsthehighcomplexityandthehighriskstatusofourpatients.Mostdischargedpatienttestedpositiveforcocaine(COC)andETOH(35.9and30.8percent),thehighestNARXscorewasassociatedwithbuprenorphine(486).MostpatientpositiveforFentanylaretreatedintheinpatientsetting,wehadonlyonechartinthesample–theresultsareinconclusiveforFentanyl.
Conclusion:
TheuseoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(76942,64450,64418,20533andothersimilarcodes)showasignificantdocumentedpositiveeffectonincreasingoverallpatientsafety,encouragementofsafecontrolledsubstanceprescribingforpractitioners,maintainingcompliancewithStateandFederallawsandregulations,reductionofpatientoverdosedeaths,earlydetectionandinterventionofsubstanceusedisorder,andimprovingoverallstandardsofcare.
Thevastmajorityofpatientsinthesamplefitthehigh-riskprofilewhichrequiresfrequentSBIRT
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monitoring.CPMISBIRTprotocolisassociatedwitheffectivelong-termmonitoringofcomplianceofthechronicpainpatientsonopioidmedicationsandeffectivediagnosticsofaberrantdrug-seekingbehaviorandreferraltoAddictionMedicineevaluation.
Ourprotocolisbasedonthe“PainManagementBestPracticesInter-AgencyTaskForceReport”,MedicareMLNandLCDOHL36029,Medicareguidelinesforthepresumptiveanddefinitivetesting,MedicareCPTcodedefinitionsandshowsastrongimpactonthe:
Thisstudyhasimportantconclusionsforthethirdpartypayersandclinicians.SBIRTprotocol(GcodessuchasG0397)ismandatoryforacompliantpainmanagementpractice.WithoutproperimplementationoftheSBIRTprotocol(GcodessuchasG0397)asafeandcompliantpainmanagementprogramishardlypossibleandpatientandstaffareexposedtosignificantrisks.
Alcohol/substanceabusestructuredassessmentsandbriefinterventionsof30minutesorlonger,undercodeG0397(SBIRTprotocol)performedatComprehensivePainManagementInstitiute,LLCbyDr.Margolinarebasedontheacceptedguidelinesand"HHSPainmanagementbestpracticesinter-agencytaskreport".TheenclosedreportbyMichaelStaples,CMBIitshowshighcompliancewiththeOhioPainClinic(PMC)licenserequirements,OhioRevisedandAdministrativeCodesandexceedingminimumstandardofcare.TheSBIRTprotocolisclearlydocumentedonallthechartsinthestudyandcompliantwiththeMedicareMLN#andLCDOHL36029.
ThisstudyshowsasignificantpositiveimpactoftheSBIRTprotocolonpainreductionandfunctionimprovementiswelldocumentedinthisstudy.
SBIRTprotocolismandatoryforthecompliantoperationofapainmanagementclinicprovidingmedicalmanagementtothepopulationwithasignificantpercentofhigh-riskpatientsinthehigh-riskarealikeOhio.Denialcoveragefortheseservicesbythird-partypayorsordefiningthemas"unallowablecosts"putsthepracticeinnoncompliancewiththeguidelinesdescribedabovemakingtheethicaloperationofthepracticeimpossibleandputtingpatientsandstaffatconsiderablerisk.
Denialpaymentsfortheappropriatetestingandscreeningproceduresfordrugsandalcohol(suchasoftheSBIRTprotocol(GcodessuchasG0397)requiredbythestateandnationalguidelines)wouldnotonlysignificantlyimpactCPMI’sabilitytofunctionasabusiness,butwouldalsoputanextremelyvulnerablepatientpopulationatrisk.Ourpatientpopulationisuniqueascomparedtomanyofmypeers.Ourpatientsareextremelycomplex;wetakeprideincreatingindividualizedtreatmentplanswhichdorequireasignificantamountoftestingandtimeforscreeningforsubstanceandalcoholuseandothertestsandproceduresdescribedinthisstudy.However,thisallowsourpatientstoavoidriskofmorbidityandmortality(Ohiohasthehighestrateofopioidmortalityper1000populationinthecountry)andachievesignificantpainreliefandimprovementintheleveloffunctionrelativetomanagingtheirpain.
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Manyofourpatientsareopioid-dependent,iftheirmedicationsarenottimelyreviewed,thiscancausepatientmorbidityincidenttoabruptlystoppingtreatment.
Ifleftuntreated,patientsmayturntoillicitmeansofobtainingsubstitutemedicationswhichdrasticallyincreasestheriskofoverdoseanddeath(overdosedeathrateinOhioisthehighestinthenationandisupmorethan800%since2013).
Thequalityofcareweprovideresultedinseveralclinicalawards(i.e.PatientChoiceAward,MostCompassionateDoctorawardsforseveralyears,2019“Top10”OhiophysicianawardinPainMedicine)andreferralswegetfrommajorhospitalssuchasOSUMedicalCenter,Riverside,Grant,MtCarmel,AdinaHealthandUniversityHospitalsinClevelandandevenotherpainmanagementpractices.
Insummary,denialpaymentsfortheappropriatetestingandscreeningproceduresfordrugsandalcohol(oftheSBIRTprotocol(GcodessuchasG0397)andotherservicesinthisstudymakesthethirdpartypayerresponsiblefortherisktoseveralhundredhigh-riskpatientsandourstaff.
Ourpracticeisattheforefrontofthe“opioidepidemic”fight.Wehopetothethird-partypayersasanallyinthisfightactingincompliancewiththeHHS5pointstrategy.
C)Whatisyouropportunitystatement?Statethegoalyouhopetoachieve.
Basedonrecordreviewormeasurementofcurrentperformance,determinewhatkindofimprovementyouhopetomakeandsetatimeframetoachieveit.
OurgoalistoshowasignificantcorrelationtheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(CPTcodes76942,64450,64418,20533andothersimilarcodes)onthefunctionalimprovement,painreductionandcontinuityofcareofchronicpainpatientsbasedonrigorousretrospectivechartreviewof155chronicpainpatients.
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E)WhatInstituteofMedicine(IOM)QualityDimensionswillbeaddressedbyyourproject?
PatientSafety
CareDeliveryEfficiency
CareDeliveryEffectiveness
D)Whatistheunderlyingcauseoftheperformance/qualityproblem?
Gatherandbrainstormwithotherphysiciansandstaffonyourunit/team.What’scausingthisissue?Howdidyoudeterminethecause?
TheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(CPTcodes76942,64450,64418,20533andothersimilarcodes)arecrucialforachronicpainmanagementprogram.
Thisstudyshowsthatourprotocolisindeedassociatedwithsignificantfunctionalimprovementandpainreductionandeffectivecompliancemonitoringwhilemaintainingahighlevelofcompliance.
Thisisacost-effectiveandcost-savingprogramforthirdpartypayors.
Ourdatashowsthatdenialoftheseservicesordefiningthemas"unallowed"wouldinterferewithpatientcare,compliancewiththestateandfederalstandardsandputpatientsandstaffatrisk.
3.)Do:Describethedesiredoutcomesandtherequirementsneededtoachievethem.
A)Whatchange(s)didyouimplement?
Youcanimplementonechange,oryoucanchoosetodoseveralatatime.Bespecificaboutthechangesyoumade.
WeimplementedtheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(CPTcodes76942,64450,64418,20533andothersimilarcodes)basedonthestudyresults.
Wehaveenhancedmonitoringandpatienteducationwithadditionaltools,printededucationalmaterial,30minrecordedvideopresentationonccomplianceandseveraleducationalvideosonthepracticeYouTubechannel.
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4.)Study/Check:Describethemeasurementusedtoassessthesuccessoftheplan.
A)Didyouachieveyourgoalortargetreportedinyouropportunitystatement?Whatdatadoyouhavetosupportyourconclusion?
Thisisasimpleyesorno,andcitetheevidence.Afterthetimeframeindicatedinyouropportunitystatement,reviewyourperformance.(It’sgoodpracticetocheck-inatleastmidwaythroughyourproject,too,toseewhetheradjustmentsneedtobemade.)Didyoumeetthegoalyouset?
Yes,pleaserefertothedataabove.
5.)Act:Change(s)toyourpracticeasaresultofthisproject.
A)Willyoucontinuewiththechangesyouhaveimplemented?
Ifyouachievedyourgoal,describehowyouwillsustainyoursuccess,orhowitledtonewideas.Ifyoudidnotachieveyourgoal,howcouldyoutryagainwithnewtactics?Whatwillbeyournextprocesschangetokeeptheimprovementevolutiongoing?
Wewillcontinuetoimplementthestudyresultsinthefutureusingthecomprehensiveassessmentandmonitoringtoolsdescribedinthestudy.
OurgoalwillbethecontinuationofthesuccessfulimplementationoftheSBIRTprotocol(GcodessuchasG0397),ofthePOCUDS(80307,80304)andminimallyinvasiveproceduresonthepainreduction(CPTcodes76942,64450,64418,20533andothersimilarcodes)basedonthestudyresults.
Oursecondgoalwouldbesharingdatawiththird-partypayors.