I’ve been told by home health agencies that I have to fill out some additional paperwork to get my patients outpatient services. Can you explain to me what these new rules are all about?
Alicia Farrouk, MD
Dr. Hospitalist responds: In June 2010, the Affordable Care Act changed the rules regarding physician orders for durable medical equipment and for certifying or recertifying the need for home health services. Last November, the Center for Medicare & Medicaid Services (CMS) published the final rules in the Federal Register.
The new law went into effect Jan. 1, and I suspect that is why you have been asked to adjust the way you fill out your paperwork. The upshot of the change in the law is that providers can no longer use the discharge plan or transfer form as evidence of “certification” of need for home health services. The ordering provider, as a condition for payment for services, must document an in-person encounter within the 90 days prior or 30 days after the initiation of home health services. The documentation must detail the clinical findings supporting the need for home health services.
If you are a hospitalist and discharging the patient from the hospital but will not be following the patient as an outpatient, you must document the name of the primary-care physician (PCP) who will follow the patient’s need for home health services and initiate the order and plan of care. The PCP will then sign the home health certification and document that they reviewed your note and plan for home health services and agree with the plan.
If you are a hospitalist working in a teaching hospital, the resident can fill out the form, but it must list your name (as attending physician) and your NPI number. This new rule applies only to home health services and durable medical equipment (things that can be used over and over again for medical purposes, such as crutches, walkers, wheelchairs, etc.) but does not include drugs or supplemental oxygen.
HM Model Spreads to Surgical Specialists
I have a friend who told me there is a neurologist in the hospital where he works who I understand is calling himself a hospitalist. What gives? I thought hospitalists were all internists or family physicians.
Bill Mulley, MD
Dr. Hospitalist responds: The vast majority of hospitalists in the U.S. are general internists. There are smaller numbers of family physicians, pediatricians, and medical subspecialists who also work as hospitalists. Although this is the face of HM in America, we are seeing other fields of medicine adopting this model of care.
I know of surgical hospitalists, OB-GYN hospitalists, and yes, even neurohospitalists (see “Generation Next,” October 2010, p. 1). It is hard for some people to get their heads around the notion of a surgeon as a hospitalist because when one thinks of a surgeon, you are thinking of a physician who works in the operating room. But the traditional surgeon also has a clinic where they provide pre- and post-operative care.
Herein lies the difference between traditional surgeons and surgical hospitalists: The surgical hospitalist is, for the most part, only doing work in the hospital—sound familiar? (Think traditional internist vs. internist working as hospitalist.) The traditional general surgeon performs scheduled elective surgeries and typically only does emergency surgeries when they are on call for the hospital. As I understand it, the life of a surgical hospitalist is spending a shift in the hospital waiting for a patient to show up needing emergency surgery.
The hospital CEO today has increasing challenges convincing physicians to take hospital call. Some find themselves paying sizable sums of money for surgeons to take call from home. Some have decided their money is better spent paying for surgical hospitalists to spend nights in the hospital waiting for their pager to go off.
From a patient’s perspective, this seems to be a no-brainer. Having a surgeon in the hospital increases their chances of more timely care. You have to believe the providers in the ED and the medical hospitalist also love having a surgeon in-house, available to provide consults when requested.
I am a bit surprised that we don’t already have a large number of surgical hospitalists in the country. Then again, I have no idea of how many surgeons are working as surgical hospitalists. I am not sure anybody knows that answer.
There is a belief that we are going to see the continued growth of “specialty hospitalists” in the U.S. I believe we are going to see neurohospitalists managing inpatients with stroke and other neurosurgical issues, working side by side with medical hospitalists. I share in the excitement that was pervasive in the early days of the hospitalist movement, even though I’m not sure what we are going to see next.
I never imagined that we would have more than 30,000 hospitalists, as we do today. But while the HM model can help improve care, I will always feel strongly that no system will improve care without the dedication of motivated and compassionate healthcare providers driving the system. TH