Ochsner Health Network shares the latest physician-centered content in healthcare value: clinical best practices, documentation tips, physician features, research articles and educational resources.

On May 1, physicians and advanced practice providers (APPs) in OHN/OACN who manage value-based patients will receive an official email notifying them that their 2024 Physician Scorecard is live and available for viewing.

Ahead of that go-live date, we want to make sure you know what to expect, how to access, and the best ways to use your scorecard to its fullest potential. Please review the details below and connect with your clinical care coordinator or performance improvement coordinator with any questions.

As you may know, clinically integrated networks are federally required to maintain a performance management system that tracks each physician’s performance and participation. To accomplish these reporting requirements, and to equip you with real-time insight into your performance, the Physician Scorecard was developed. Our goal was simple: Make it easy to access and easy to interpret with actionable next steps.  

Beginning May 1, you can access your scorecard any time through Tableau or OH Links. You will also receive a copy of your scorecard each month via email.

Scorecard Breakdown

Your scorecard provides a weighted breakdown according to the following categories:

Participation Criteria (30%)

Gated Metrics – must be completed to be eligible for performance year annual distribution payment.‍

• Complete OHN/OACN Compliance Module in OLN (available soon)
• Complete Annual Participation/Performance Attestation in OLN
• Complete Represented Provider Acknowledgement (available soon)

Participation Metrics – must be completed to receive participation points which contribute to total annual performance.

• Complete all additional annual learning modules assigned in OLN.

Performance Metrics (70%)

Quality Metrics – clinical quality measures are assigned according to physician specialty. These measures are worth a total of 70 points and are based on individual performance. The quality measures use integrated payor claims, information in EPIC including Care Everywhere, and select external EMR data to calculate physician performance.

Below are specialty-specific scorecard templates. The rows highlighted in green indicate quality or cost & utilization measures that are different from last year.

• Engaged PCP (image)
• Advanced PCP (image)
• Engaged Pediatrician (image)

Panel Reports

In addition to your scorecard, your panel reports provide an added view of your patient panel, helping you understand where gaps in care may be happening, along with actionable steps to take. This tool is currently accessible through Tableau or Ochsner’s instance of Epic, and you can also request a panel report from your performance improvement or clinical care coordinator.

Key features of the dashboard include ability to:

• Refer patients into programs like Outpatient Case Management and Digital Medicine
• Identify patients who frequently visit the emergency department and those who have recently been discharged from the hospital
• Generate patient lists to close care gaps for quality measures
  

For questions regarding your scorecard, please contact your performance improvement coordinator or your clinical care coordinator, or email ohnadmin@ochsner.org.

Independence and Success in Private Practice

When it comes to driving value, quality experts say it’s worth looking into Dr. Bill Cefalu’s orchard.  He’s an independent physician, double-boarded in internal medicine and obesity medicine, and his practice produces an all-green scorecard covering a 2,000-deep patient panel.

Looking back, the Morgan City native never dreamed he’d be leading one of the largest top-performing primary care practices in South Central Louisiana.

“I didn’t exactly have the best grades in my early college years.”

Cefalu worked atop the hot summer rooftops of South Louisiana, without much interest in his college coursework, he admitted. But thanks to his best friend, he landed a job as a radiology patient transporter and welcomed the air conditioning. Surprised that the opportunity revealed his curiosity for medicine, he found himself spending increasingly more time with radiologist Dr. Tim Haley, thirsting for more knowledge. Though Cefalu felt he did not quite have the intellect to become a doctor, Haley disagreed. Relentlessly, Haley encouraged him to go for it.

Twenty years later, there’s proof he made the right call.

Today, Ochsner Health Network physician member Bill Cefalu tops the charts with blood pressure control; A1c control; depression screening and follow-up; HCC recapture; PCP visits; and discharges. When you look at his scorecard, it’s covered in green.

When asked how he ended up “getting on the (value) bus,” he reflected that he was young enough in his career to see the payment models beginning to change.

“I’ve always strived to stay ahead of what’s coming in medicine, so I thought the push for “value” would improve the way I documented my work and improve payor relations… and I didn’t realize just how much our patients and our team would benefit.”

Cefalu admits that he took a “leap of faith,” in some ways. He was skeptical about the results, rewards and incentives promised by the administrative value “champions.”  But the addition of a dedicated quality expert to his team, solely focused on identifying gaps in patient care, was indeed a game-changer.

“OHN’s performance improvement coordinator Margot Bourgeois has been a Godsend for us,” Cefalu emphasized.

Bourgeois equips Cefalu’s team with robust reports and resources to fill the gaps in care - “the kind of granular, actionable information that enables us to take better care of people,” he noted.

“Having Margot aboard is like having a daily consultant, and OHN has been a great partner, full of the resources I need to improve value for my patients.”  

The financial leap of faith has “paid off in spades,” Cefalu commented.

Though a physician, he also considers himself a businessperson, self-employed. And the partnership with OHN is “the difference that has enabled us to take our clinical and financial performance to the next level.”

“Going from volume to value is not for the faint-hearted,” Cefalu quickly added. The process of adopting Epic, the new PCP scorecard, and the utilization of OHN’s data tools took his team about a year. But he firmly believes the burden of change and forcing new habits are worth the fruits of clinical results, the return of joy in work, the financials savings for patients, and the clinician incentives that follow.

But some of the greatest fruits in his career happen at the bedside for Cefalu – metaphorically and literally. When asked about how he beats burn out, he humbly noted the privilege of returning home to take care of people, and says he feels like he’s “a member of 2,000 families.”  He quickly followed that answer with his passion for gardening.

“As I’ve gotten older, I’ve become more selective in my hobbies. I love sharing the harvest from my orchard with my patients. It takes up the entire back lawn of my practice.”

Whether gardening or taking care of patients, Cefalu appreciates what it takes to cultivate the fruits of success in work, and in life.

Dr. Bill Cefalu, alumni of ULL (undergraduate) and LSU-New Orleans (medical school), resides in Morgan City. He maintains an independent, private primary care practice with three clinic locations where he aggressively focuses on prevention as well as fighting obesity, high blood pressure, diabetes, cancer and cardiovascular disease. He and his wife Abby, a veterinarian, have three children Ellis (11), Amelie (9) and William (6).

The ability to serve as the first point of contact in a patient’s care and to deliver coordinated, comprehensive and continuous care—as well as cultivate meaningful relationships over each patient’s lifetime—used to be the hallmark of primary care. However, as demands on primary care providers have increased—including larger patient volumes, additional metrics and administrative burdens—many PCPs are experiencing burnout or “moral injury,” according to Kenny Cole, M.D, System VP of Clinical Improvement and an internal medicine physician at Ochsner Health.

“It started to feel like there weren’t enough hours in the day, that no matter how fast I was running, I couldn’t keep up,” Dr. Cole says. “I was always saying I’m sorry. I’m sorry I’m running late, I’m sorry I couldn’t get you in sooner, I’m sorry it’s taken five days to get you your lab results. The mission of primary care is so ideal and so noble, but when all you have is 15 minutes to see a patient, there is not enough time to think about and diagnose complex issues or develop relationships. Because of this mission failure, there is more PCP moral injury, there are more PCPs leaving the practice and there are fewer medical students choosing primary care.”

One study that really brought the issue home, according to Dr. Cole, noted that it would take a PCP 27 hours to complete all of the recommended preventive, chronic and acute care, and documentation and administrative tasks expected of them in a day. But that same study also showed there is a remedy: team-based care.

That led Dr. Cole to design and help develop Ochsner 65 Plus: freestanding community clinics built upon a foundation of value-driven care. These clinics take a team-based, holistic and proactive approach to care for a population that needs more care, frequently presents with more complex issues, and benefits from more time with providers.

The 5 M’s of Taking Care of Older Adults

The Ochsner 65 Plus clinics are built around the “5 M’s” of taking care of the senior population: mobility, mentation, medication management, what matters most to each patient, and multi-morbidity, according to Dr. Cole.

“Here, they’re not just seeing a PCP; they’re surrounded by an interdisciplinary care team,” he says.

That team typically includes physicians, advanced practice providers, RN care managers, medical assistants, health coaches, licensed clinical social workers, dietitians, fitness instructors, clinical pharmacists and physical therapists. The care team provides patients with physical, mental and social care.

Patients benefit from extended time with their physicians and custom care plans that focus on the “5 M’s.” They have full access to workout equipment, dedicated staff and exercise classes offered in the 65 Plus fitness center. Social and educational activities are available daily in the 65 Plus community room.

“I believe the most important thing we’re giving patients and physicians is more time,” Dr. Cole says. “We have time to think through diagnostic complexity and detect issues at a point where we can intervene clinically and therapeutically to prevent complications. All patients, at least once a year, get a ‘Timed Up and Go’ test and a 30-second sit-to-stand assessment. Immediately following those assessments, we can connect patients with physical therapists or fitness instructors and get them in the gym to prevent a potentially hip-fracture-causing fall.”

What Is the Ochsner 65 Plus Clinics’ Formula for Success?

Offering a differentiated primary care experience for people aged 65 and older, these clinics have a high growth potential through multichannel marketing. Clinics educate Medicare-eligible patients about the advantages of Medicare Advantage plans and value-based healthcare delivery, which benefits payers.

Physicians and other care team members spend more time with patients—because no provider’s patient panel size exceeds 500 patients. The team creates customized, goal-oriented care plans for each patient, then follows up to evaluate. A "worry score” is assigned to each patient and reevaluated at every visit to ensure patients are receiving the right level of care, timely follow-ups and other appropriate outreach.

The clinics achieve high HCC recapture rates through coding and documentation excellence, prompting gap closures and high-quality patient experiences. Total cost of care is reduced through health outcome improvements and avoidance of inappropriate use of emergency departments and hospital readmissions.

“It’s a unique model of care that can be scaled and replicated in other markets,” Dr. Cole says. “We seek to deliver a very patient-centered experience, focusing on what matters most to each patient and their individual health-related goals, as well as how to overcome obstacles to achieving those goals.”

Ochsner 65 Plus clinics also offer education and guidance about advanced care planning and end-of-life care to ensure patients’ wishes are honored.

Designed to Promote the Best Possible Patient Outcomes

Even the clinics’ interiors feature an intentional, patient-centered design. The lighting and flooring chosen for each location reduce glare that may mimic holes or obstacles to aging eyes and create a tripping hazard. Handrails along the walls further reduce the risk of patient falls.  

There is a clear focus on fitness, nutrition and holistic health, with resources available to help patients improve everything from their heart health to their balance.

“The community room is very intentional, because the only risk factor that’s a more powerful predictor of morbidity and mortality than social isolation and loneliness is cigarette smoking,” Dr. Cole says. “Everything offered there—from arts and crafts, to card games, to healthy cooking demonstrations and educational sessions—is focused on improving the health and well-being of our patients.”

Improving Performance, Patient Experience and Physician Satisfaction

Ochsner 65 Plus clinics measure their success by maintaining their targeted patient panel sizes and reducing readmission rates and emergency department utilization.

At this point, patient experience scores in the clinics are in the 90th percentile, greater than 76% of patients have their diabetes under control and greater than 82% have high blood pressure under control. Completion of annual wellness visits exceeds 80%, and the HCC recapture rate is greater than 86%.

“Essentially, what we are trying to do at these clinics is allow PCPs to connect with a deep sense of purpose about why they went into primary care in the first place and to deliver incredibly coordinated, team-based, comprehensive and continuing care,” Dr. Cole says. “This reduces the burden of moral injury and restores the joy of practice to provider and offers patients opportunities to achieve their best possible outcomes.”

Ochsner 65 Plus clinics are now open to serve older adults in Covington, Baton Rouge, Metairie, Pensacola and Ridgeland, and more are planned in coastal markets in the Carolinas, Georgia and Florida. If you are interested in working with Ochsner 65 Plus in one of those markets, or know a primary care physician who might be, reach out to Rachael Kermis, M.D, System Medical Director for Ochsner Health 65 Plus, at rachael.kermis@ochsner.org.

We are proud to present the Circle of Excellence Award winners for March and April 2024. Our Circle of Excellence Awards are given monthly to an outstanding advanced practice provider (APP), primary care physician and specialist nominated by their CDE educators. Along with the recognition here in the OHN Newsletter, these clinicians will also receive the CDE Circle of Excellence lapel pin pictured above, an Ochsner Ovation for Excellence from CDE Leadership and an acknowledgement on our CDE SharePoint site (https://ochsnerhealth.sharepoint.com/sites/OHNCDE).

Our March winners are:

Ruth Darg, M.D, Primary Care

Dr. Darg, a senior physician at Ochsner Health Center – Covington, was nominated by her CDE Nurse, Lauren Brettner, who noted that she is “dedicated, engaged and a joy to meet with.” Dr. Darg finished 2023 with an HCC Recapture Rate of 88% and an HCC Reconciliation Rate of 95%, meaning that she addressed 95% of all chronic conditions attributed to her value-based patient panel. In 2024, she has continued this success with a BPA action rate of 81%, and she has become a strong advocate for CDE in the Northshore. Dr. Darg consistently provides quality supporting documentation for her diagnoses that reflects how she has monitored, evaluated, assessed, and treated each patient. During meetings of the CDE Focus Program, Dr. Darg poses excellent questions and provides actionable feedback, and it is obvious that she cares about maintaining documentation quality.

Carter Davis, M.D, Hematology/Oncology

Dr. Davis is a senior physician in the Department of Hematology/Oncology at Ochsner Medical Center – Jefferson Highway, an associate program director in the Section of Hematologic Malignancies and Stem Cell Transplant, and an associate program director of the Ochsner Hematology/Oncology Fellowship Program. He was nominated by Hem/Onc CDE Nurse Lisa Schmidt because he has been very receptive to ambulatory CDE education since its initiation. Dr. Davis has readily incorporated Epic tools into his daily workflow. His CDE Encounter Action Rate increased from 45.81% at the end of 2023 to 66.45% this year, to date, and he has a BPA Action Rate of 21.71%. These rates exceed the Hem/Onc specialty averages of 51.89% and 14.18%, respectively. He achieves these metrics while maintaining a large and complicated patient panel within one of the most active specialty groups at Ochsner Health.

Liz Buras, NP

Buras is a family nurse practitioner at Ochsner Health Center – Abita Springs. She was nominated by her CDE Nurse, Lauren Tallo, for being highly engaged and consistently expressing an eagerness to learn about HCCs and risk adjustment to provide better quality care to her patients. Buras began working with the CDE team in October 2022 within the CDE Focus Program, and she always asks appropriate questions to make sure she is doing things in the most accurate and compliant way. She helps educate other clinicians if questions arise in her clinic, and she regularly exceeds her metric goals. Buras ended 2023 with an HCC Reconciliation Rate of 94%, six points above the system goal of 86%. The CDE team is extremely grateful to work with her, as she makes chart reviews a breeze by capturing an accurate picture of her patients with each visit encounter, truly displaying documentation excellence.

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Our April winners are:

Fayne St. John, M.D

Dr. St. John is a senior physician at Ochsner Health Center – Elmwood, and was nominated by her CDE nurse Becky Guidry, RN. Dr. St. John began the CDE Focus Program as one of the pilot clinics in early 2022. During the first session, we realized there were some technology and workflow challenges hindering her use of the BPA. Her Encounter Action Rate (EAR) at the beginning of the education sessions was 23.37%. She vowed to keep an open mind and we promised to help her with day-to-day documentation challenges of incorporating the BPA. Dr. St. John stayed positive and determined throughout the entire process, always striving for excellence. She even insisted on extra education sessions to make sure her workflow was fully incorporated into her daily use.

Upon compiling a quarterly clinician report in late 2023, Dr. St. John's EAR was over 90%! She finished the year exceeding the system reconciliation goal of 86% with a Reconciliation Rate of 92.33%. Plus, she further exceeded the system EAR goal of 42% with an EAR of 89.6%!

Chandana Keshavanmurthy, M.D

Dr. Keshavanmurthy is a senior physician for the rheumatology department at Ochsner Main Campus and was nominated by her rheumatology CDE Nurse Jessica Glaspell.  She was first introduced to the specialty aspect of CDE in a group education session.  Even before this group session, Dr. Chandana Keshavanmurthy had a CDE EAR of 59.78% with a BPA usage of 44.73%. At the completion of 2023, her EAR increased to 66.18% with a 54.09% BPA usage, all above the specialty average and goals. More recently, her 2024 numbers are EAR of 95.58% with a BPA usage of 79.65%. It is also a clear indication Dr. Keshavanmurthy understands the importance of addressing these chronic conditions for her and her peers’ patients as she is noted to be a champion within her department, assisting with BPA questions and documentation requirements from OMC rheumatologists. Dr. Keshavanmurthy truly exhibits the Ochsner values of compassion, excellence, and teamwork and we are honored to be partnered with her.

Mamie Keller, PA

Keller is an APP at Ochsner Health Center – River Parishes and was nominated by her CDE Nurse Lisa Ballard for her dedication and engagement with CDE. Because she is primarily focused on Enhanced Annual Wellness Visits (eAWVs), Keller asked if we could review the proper requirements for this type of encounter. We continued her APP education for a few weeks, and she was very engaged and dedicated to doing the right thing for her patients. Keller's initial EAR was 66.43% with a BPA action rate of 50.43%.  Her documentation was excellent with the supporting MEAT (Monitor, Evaluate, Assess, Treat) needed for the addressed diagnoses. Just a month after beginning education, we scheduled an eAWV review and her documentation was excellent!  Her EAR was above 98% in both V24 and V28 models, and she had a BPA action rate of 81% in V28 and 86% in V24. Mamie is a dedicated clinician, both with her documentation and with her patients. She is definitely a model of success for clinical documentation!  

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‍OHN is dedicated to providing the knowledge, resources, processes and technology you need for success in value-based care so you can do more of what you love – taking care of patients. In the months to come, we’ll share one coding tip and highlight one best practice advisory (BPA) each month to help to support your clinical documentation efforts.

Additionally, the clinical documentation excellence (CDE) team is here to support you – email riskadjustment@ochsner.org with any questions.

Capturing and Coding Major Depression

Rationale

• The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) of the American Psychiatric Association (APA) advises that major depression is a mental disorder, marked by a depressed mood and loss of interest or pleasure in all activities, that lasts for at least two weeks and represents a change from previous functioning.
• Prevalence of Major Depression increased 27.6% due to the COVID-19 pandemic (NIH, 2021)
• Symptoms are experienced by 18.4% of 65 and older population (CDC, 2019)
• Roughly two-thirds of all cases of Major Depression in the US are undiagnosed or unspecified (NIH, 2017)

The DSM-5 provides detailed and specific criteria that must be met to diagnose major depression or major depressive disorder. For example, these specific criteria include the following excerpt:

A.   Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day
3. Significant weight loss when not dieting, or weight gain, or decrease or increase in appetite
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
8. Diminished ability to think or concentrate, or indecisiveness
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide

B.     The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

C.     The episode is not attributable to the physiological effects of a substance or to another medical condition.

How to Code & Document

Subjective

• In the subjective section of the office note, document the presence or absence of any current symptoms related to major depressive disorder.

Objective

• The objective section should include any current associated physical exam findings (such as “flat affect,” weight loss or gain, etc.).
• Include results of related diagnostic testing.

Assessment

• Specificity: Describe each final diagnosis clearly, concisely and to the highest level of specificity. Use all applicable descriptors, including the following:
• Episode – single or recurrent
• Severity – mild, moderate, severe
• Presence or absence of psychosis/psychotic features
• Remission status – partial or full

Current vs Historical

• Do not use the descriptor “history of” to describe current major depression that is still present, active and ongoing. In diagnosis coding, the phrase “history of” means the condition is historical and no longer exists as a current problem.
• Major depression that isin remission but still has impact on patient care, treatment and managementshould be included in the final assessment or impression with the currentstatus noted as “in remission.” Specify whether remission is partial or full.

Plan

• Document a specific and concise treatment plan for major depression, including date of next appointment.
• Clearly link the depression diagnosis to any medications that are being used to treat it.
• Document to whom or where referrals are made or from whom consultation advice is requested.

Coding Major Depression

Major depressive disorders are coded from categories F32 and F33. Fourth and fifth characters provide further specificity (see below). Codes in these two categories that represent major depressive disorder are as follows:

F32 Major depressive disorder, single episode

• F32.Ø - Major depressive disorder, single episode, mild
• F32.1 - Major depressive disorder, single episode, moderate
• F32.2 - Major depressive disorder, single episode, severe withoutpsychotic features
• F32.3 - Major depressive disorder, single episode, severe withpsychotic features
• F32.4 - Major depressive disorder, single episode, in partialremission
• F32.5 - Major depressive disorder, single episode, in fullremission
• F32.9- Major depressive disorder, single episode, unspecified. Includes: Depressionnot otherwise specified (NOS), Depressive disorder NOS, Major depression NOS

F33 Major depressive disorder, recurrent

• F33.Ø - Major depressive disorder, recurrent, mild
• F33.1 - Major depressive disorder, recurrent, moderate
• F33.2 - Major depressive disorder, recurrent, severe withoutpsychotic features
• F33.3 - Major depressive disorder, recurrent, severe withpsychotic symptoms
• F33.4 - Major depressive disorder, recurrent, in remission
• F33.4Ø - Major depressive disorder, recurrent, in remission,unspecified
• F33.41 - Major depressive disorder, recurrent, in partialremission
• F33.42 - Major depressive disorder, recurrent, in full remission
• F33.9 Major depressive

BPA Spotlight - Major Depression Suspect BPA

To help providers identify patients with a potential Major Depressive, Bipolar or Paranoid Disorder (HCC 59) diagnosis, the clinical documentation excellence (CDE) team in collaboration with clinical leaders have created logic within the HCC Best Practice Advisory (BPA) based on the following criteria:

HCC 59 – Major Depressive, Bipolar and Paranoid Disorders

(1 and 2) or (3 and 4)

1. Patient age is greater than or equal to 18
2. PHQ-9 score of 5 or greater in last 1 year
3. Patient age is 12-17
4. PHQ-9 score of greater than 9 in last 1 year

Identifying the Suspect BPA

• Morbid Obesity Suspected BPAs will always have a header above the condition with the language “Probable Condition Based on Epic Documentation – Major Depression” in a Grey Bar.
• Any Suspected Conditions will populate towards the top portion of the BPA tool.
• Similar to the standard Recapture Chronic Conditions in the BPA, the provider will always have the button selections of “Add Visit Diagnosis” to add the condition; “Do Not Add” to suppress the alert to the next appointment; or “N/A to Patient” to disagree and remove the condition from the tool.
• To refer to the logic outlined above, the provider can select the “link” hyperlink from the “For more information on Ochsner / Epic Probable Condition Logic click this link.”

To assist you in identifying patients with a potential ostomy (HCC188) diagnosis, OHN’s Clinical Documentation Excellence (CDE) team, in collaboration with clinical leaders, have created a logic model within the HCC Best Practice Advisory (BPA) tool. The model uses billed CPT codes for supplies in Epic to identify potential diagnoses and present these within the BPA to you, the clinician.

You can find information regarding suspected diagnoses within the Epic “probable condition logic” hyperlink in the BPA, including the information listed below.

HCC 188—Ostomy Logic Process Explained

Due to lack of specificity as to the type of ostomy suspected to be present, you will be given the ability to specify the diagnosis in the HCC BPA and document the diagnosis using the steps below. Please be as specific as possible when coding a diagnosis.

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3. 1. In the BPA below, the suspecting condition can be identified by the gray bar, which reads “Artificial opening status, unspecified.”

1. 2. To specify the ostomy type, click the “Change Dx” hyperlink.

1. 3. Select the appropriate diagnosis from the Epic IMO search bar. In this example, gastrostomy is used. The other most common ostomies include, but are not limited to, urostomy, colostomy and ileostomy.  

1. 4. After you have chosen the appropriately specified diagnosis, add your assessment and plan note in the BPA. Once your documentation is complete, click "Accept" to close the BPA.

HCC 188 – Logic for Ostomy (Artificial Opening Status)

A potential ostomy (HCC 188) diagnosis will be triggered if one of the following CPT Codes was billed internally or externally in the last three years.

a. A4379 OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, PLASTIC, EACH

b. A4380 OSTOMY POUCH, URINARY, WITH FACEPLATE ATTACHED, RUBBER, EACH

c. A4381 OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, PLASTIC, EACH

d. A4382 OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, HEAVY PLASTIC, EACH

e. A4383 OSTOMY POUCH, URINARY, FOR USE ON FACEPLATE, RUBBER, EACH

f. A4391 OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED (1 PIECE), EACH

g. A4392 OSTOMY POUCH, URINARY, WITH STANDARD WEAR BARRIER ATTACHED, WITH BUILT-INCONVEXITY (1 PIECE), EACH

h. A4393 OSTOMY POUCH, URINARY, WITH EXTENDED WEAR BARRIER ATTACHED, WITH BUILT-INCONVEXITY (1 PIECE), EACH

i. A4431 OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED, WITH FAUCET-TYPE TAP WITHVALVE (1 PIECE), EACH

j. A4432 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH NON-LOCKING FLANGE, WITHFAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH

k. A4433 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE (2 PIECE), EACH

l. A4434 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH LOCKING FLANGE, WITHFAUCET-TYPE TAP WITH VALVE (2 PIECE), EACH

m. A5071 OSTOMY POUCH, URINARY; WITH BARRIER ATTACHED (1 PIECE), EACH

n. A5072 OSTOMY POUCH, URINARY; WITHOUT BARRIER ATTACHED (1 PIECE), EACH

o. A5073 OSTOMY POUCH, URINARY; FOR USE ON BARRIER WITH FLANGE (2 PIECE), EACH

p. S9340 Home infusion therapy enteral nutrition per diem

q. S9342 Home infusion therapy enteral via pump per diem

r. S9343 Home infusion therapy enteral bolus

s. A4361OSTOMY FACEPLATE, EACH

t. A4362 SKIN BARRIER; SOLID, 4 X 4 OR EQUIVALENT; EACH

u. A4363 OSTOMY CLAMP, ANY TYPE, REPLACEMENT ONLY, EACH

v. A4366 OSTOMY VENT, ANY TYPE, EACH

w. A4367 OSTOMY BELT, EACH

x. A4368 OSTOMY FILTER, ANY TYPE, EACH

y. A4371 OSTOMY SKIN BARRIER, POWDER, PER OZ

z. A4372 OSTOMY SKIN BARRIER, SOLID 4 X 4 OR EQUIVALENT, STANDARD WEAR, WITH BUILT-IN CONVEXITY, EACH

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Cashmir Lavigne, a nurse with Nurse On Call, took a call from a patient who said he had visited his doctor a few days prior for symptoms including fatigue and had received a diagnosis. Despite following his doctor’s advice, he was still having symptoms and was feeling worse. Using the standard triage process and her swift assessment and critical thinking skills, Lavigne zeroed in on a few specific details the patient had mentioned––including a history of uncontrolled diabetes––and recognized that he was exhibiting signs of a liver problem.

She advised the patient to head to an emergency department for care, and he was admitted for cirrhosis of the liver and an elevated Hgb A1c. The patient was later discharged with a plan of care and follow-up appointments for his new liver diagnosis, as well as a thorough education and management plan for his diabetes.

“A few days after he was discharged, the patient’s wife called Nurse On Call in tears, expressing her gratitude that Lavigne had saved her husband’s life.”

Background

Biologic pharmaceuticals are used to target difficult-to-treat disease states for vulnerable patient populations. Even though they only account for about 2 to 3% of prescription drug utilization in the United States, they are responsible for between 40 and 50% of drug spending. By 2025, however, 17 big-name-pharma biologic molecules prescribed to treat conditions like cancer, chronic skin diseases, diabetes, inflammatory bowel diseases, kidney disease and arthritis will lose their exclusivity, potentially curbing their $60 billion annual sales trends.

Biosimilars are biologic drugs highly similar to those already on the market, with no clinically meaningful differences in safety, purity and potency. As their availability increases, patient access to these more cost-effective alternatives to the “parent compound” (original biologic drug) will decrease the cost of care in the form of reduced copays and insurance deductibles. According to a January 2022 RAND Corporation study, adoption of expanded biosimilars could drive down prices for expensive biologic medications, resulting in a savings of $38.4 billion, or 5.9% of projected total U.S. spending on biologics, from 2021 to 2025.

Safety First

Because biologic compounds are typically created in cells, there are inherent variations that result from the manufacturing process. That means in both biologics and biosimilars, there may be millions of slightly different versions of the same therapeutic protein—like a monoclonal antibody—in a single lot. This inherent variation can be expected during the manufacturing process of both the reference product and biosimilar.

Biosimilar products are manufactured and evaluated to perform within the historic safety, quality and efficacy standards of the parent compound, and products approved by the FDA as “interchangeable” must be tested for multiple switches (at least three) against the parent compound to ensure those standards are not compromised.

Thus far, there are more than 100 FDA/EMA (European Medicines Agency)-approved biosimilars on the market, all of which had to pass analytical testing for similarity, clinical pharmacology testing and animal toxicity testing. Biosimilars approved as interchangeable can be expected to produce the same clinical result as the reference product with no greater safety or efficacy risk than if patients were continuously treated with the parent compound.

Substitution of these products is regulated by the state. In both Louisiana and Mississippi, a pharmacist may substitute a biosimilar for a prescribed biologic if the FDA has determined it is interchangeable, the patient consents to the substitution and if the prescribing physician or APP has not indicated that substitution is prohibited for some reason.

There are already some examples of cost savings associated with a switch to biosimilars. In 2021, the Ford Motor Company adopted five biosimilars and saw an 88% conversion in their PPO plan that resulted in $4.8 M in plan savings and no patient complaints or disruptions.

At Ochsner Health, there has been good adoption of oncolytic agent biosimilars through the employee health plan. Through May 2023, there was a 59% adoption rate of the rituximab biosimilar, 79% adoption for the bevacizumab biosimilar and 100% adoption for the trastuzumab biosimilar.

But Savings are an Important Perk

“Savings to the Ochsner Employee Plan last year due to biosimilars was about $350,000, and our utilization is in line for this year as well,” says Matthew Malachowski, Pharm.D, MHA, BCPS, System Director of Population Health and Ambulatory Care Pharmacy at Ochsner Health. “These oncolytic agents are administered under the medical benefit, and we are starting to see opportunities in the pharmacy benefit for adalimumab (Humira) biosimilars as well. Biosimilar utilization is one way we can ensure our employees and family members get the care they need while keeping our insurance premiums as low as possible. This same benefit is imparted to our patients when we prescribe these agents for them.”

Proactive Adoption Keeps Our Physicians and Advanced Practice Providers at the Forefront of Treatment Decisions

Biosimilars for biologics covered under the pharmacy benefit are also now showing up in Real-Time Pharmacy Benefits, a digital tool that alerts physicians and APPs at the bedside if a lower-cost alternative to prescribed medication is available.

“This tool offers clinical decision support for our physicians and APPs, helping them select cost-effective medications that will save their patients money out of pocket,” says Malachowski. “When writing a prescription, they are prompted if there is an interchangeable drug that would save the patient at least $6 per month. This helps identify comparable products with lower insurance tiering, such as moving from a brand to a generic agent or to a preferred branded product. If the physician or APP decides to write a prescription for that drug, they can flip the script to the new product with equivalent dosage and frequency adjusted based on the measurements of the original product.”

This component of patients’ electronic medical records was originally designed to highlight cost-effective generic alternatives to higher-cost brand names. Ochsner Health Network’s Pharmacy & Therapeutics Committee is working on the medical side to help physicians and APPs using a particular therapy select the most cost-effective medication for their patients and the organization.

Kyle Kalanta, Financial Director of Pharmacy Operations, investigates biosimilars on the market on a quarterly basis to see which ones can be added to Real-Time Pharmacy Benefits to reduce costs for patients and OHN.

When a new biosimilar enters the market, the producer is allowed six months exclusivity, so it takes a while for the price of the agent to drop enough to produce significant cost-savings.

“For the rest of 2023, insurances will—in most cases—continue to cover the parent compound for many biologics. Pharmacy benefit managers will continue pushing patient coverage into the biosimilar market and so it’s probably better—from a patient education standpoint and to reduce disruption—for physicians and APPs to have these conversations with patients now versus later,” Malachowski says. “Expressing that biosimilars are safe, they’re not scary, and that the design of the package may change but everything will be OK, seems like a good strategy. New interchangeable products also empower our Pharmacy Teams to support our physicians and APPs with this conversion to lower cost agents without disrupting their clinic or adding another responsibility for them to manage. If we begin to address this with patients, face biosimilars head on, and manage the transition ourselves, that allows our care teams to keep oversight of what treatments are best for our patients as opposed to what is mandated by external insurance carriers.”

OHN provides the knowledge, resources, processes, and technology you need for success in value-based care so you can do more of what you love –taking care of patients. Each month, we share one coding tip and highlight one best practice advisory (BPA) to help to support your clinical documentation efforts.

Additionally, the clinical documentation excellence (CDE) team is here to support you – email riskadjustment@ochsner.org with any questions.

Capturing and Coding Rheumatoid Arthritis

Rationale

-- Rheumatoid arthritis is a chronic, systemic inflammatory disorder that primarily affects the joints, causing pain, swelling and stiffness.

-- It is an autoimmune disease in which the body’s immune system attacks the body’s own tissues.

-- While the inflammatory response of rheumatoid arthritis primarily affects joints, it is a systemic inflammatory disorder that can also impact organs, such as the skin, eyes, heart, lungs and blood vessels.

-- Rheumatoid arthritis usually begins after age 40, but it can occur at any age.

-- The exact cause of rheumatoid arthritis is not known. Some of the possible causes include:

• Genetic factors (inherited from parent to child)
• Environmental triggers
• Hormones (rheumatoid arthritis is more common in women)

-- Some people with this disease experience periods in which symptoms get worse (flares) or better (remissions).

-- Others have a severe form of the disease that is active most of the time, lasts for many years or a lifetime, and leads to serious joint damage and disability.

-- Symptoms can include:

• Joint pain, warmth, redness and swelling
• Joint stiffness, in the morning or after inactivity, that can last for hours
• Fatigue
• Occasional fever
• Firm lumps (called rheumatoid nodules) that grow under the skin close to affected joints
• Loss of appetite and weight loss

How to Code & Document

Subjective

• In the subjective section of the office note, document any current symptoms of rheumatoid arthritis reported by the patient (joint pain, swelling or stiffness, fatigue, episodes of fever, etc.)

Objective

• Include any current associated physical exam findings, such as joint deformity, and related laboratory or diagnostic imaging test results.

Assessment

-- Specificity: Describe the final rheumatoid arthritis diagnosis to the highest level of specificity, including whether the patient is seropositive or seronegative, which joints are affected, whether there is a lateral presentation, and the patient’s current status – active versus in remission.

• Clearly link associated conditions or manifestations of rheumatoid arthritis by using linking terms such as “due to,” “secondary to” or “associated with.”
• Include the patient’s current status, such as stable or improved.
• Document details of any organ involvement.

-- Abbreviations

• Limit – or avoid altogether – the use of acronyms and abbreviations.
• While “RA” is a commonly accepted medical abbreviation for rheumatoid arthritis, this abbreviation can have other meanings (for example, reactive arthritis).
• The meaning of an abbreviation can sometimes be determined based on context, but this is not always true.
• Spell out the condition’s name in full when first mentioning it in the office note, with the abbreviation in parentheses, i.e., “rheumatoid arthritis (RA).”
• You can use the abbreviation “RA” in subsequent mentions, except in the final assessment, where the diagnosis should again be documented in full.

Suspected vs. Confirmed

• Do not document rheumatoid arthritis as a confirmed condition if it is only suspected and not truly confirmed.
• Document signs and symptoms in the absence of a confirmed diagnosis.
• If rheumatoid arthritis is a confirmed diagnosis, avoid describing it with terms that imply uncertainty, such as “apparently,” “likely,” “consistent with,” “probable,” etc.

Treatment Plan

-- Document a specific and concise treatment plan, which includes elements like:

• Referral to rheumatologist
• Laboratory tests and diagnostic imaging
• Patient education, including self-management
• A date or time frame for the patient’s next appointment

Treatment With Disease-Modifying Anti-Rheumatic Drugs (DMARDs):

-- The American College of Rheumatology advises that patients with an established diagnosis of rheumatoid arthritis should be treated with a DMARD, even in the first six months after the diagnosis, unless a contraindication, inactive disease or patient refusal is documented.

-- For your patients with rheumatoid arthritis, document:

• Specific details of current DMARD therapy in the treatment plan section of the record – not simply in the medication list – with clear linkage of the medication to rheumatoid arthritis OR
• Specific information describing any contraindication to DMARD therapy
• A notation that the patient’s rheumatoid arthritis is inactive
• A statement of patient refusal of DMARD therapy and the reason for refusal

Coding Major Depression

Rheumatoid arthritis and its associated disorders classify to the following categories:

-- MØ5 Rheumatoid arthritis with rheumatoid factor, excludes rheumatic fever (IØØ)

• Juvenile rheumatoid arthritis (MØ8.)
• Rheumatoid arthritis of spine (M45.-)

-- MØ6 Other rheumatoid arthritis

-- Fourth, fifth and sixth characters are used with categories MØ5 and MØ6 to further specify the type of rheumatoid arthritis, as well as the particular joint affected with laterality (left, right or unspecified).  

Severe joint pain is a characteristic of rheumatoid arthritis and should not be coded separately from an already confirmed rheumatoid arthritis diagnosis.

Avoid coding rheumatoid arthritis as a confirmed condition if it is documented as suspected and not truly confirmed. Rather, code the signs and symptoms in the absence of a confirmed diagnosis.

Seropositive vs. Seronegative Rheumatoid Arthritis

-- Seropositive– category MØ5

• In most cases of rheumatoid arthritis, the patient’s blood tests positive for rheumatoid factor and/or certain other antibodies (anti-CCP antibodies).
• Positive blood tests indicate the patient has seropositive rheumatoid arthritis, meaning the patient possesses the antibodies that cause an attack on joints and lead to inflammation.

-- Seronegative– category MØ6

• Patients can develop rheumatoid arthritis without the presence of these antibodies. This is referred to as seronegative rheumatoid arthritis.
• Seronegative patients are those who do not test positive for rheumatoid factor or anti-CCPs.

Rheumatoid Arthritis in Remission

• Rheumatoid arthritis is a chronic and incurable systemic condition that affects the patient for the rest of their life.
• With early and aggressive treatment, many patients can achieve long periods of remission in which inflammation is greatly reduced or absent with no active signs of disease.
• Thus, rheumatoid arthritis described as “in remission” should be coded when it requires or affects patient care, treatment or management – as long as there are no contradictions or conflicts elsewhere in the record that suggest rheumatoid arthritis is not a true or confirmed diagnosis.

Long-Term (Current) Use of Immunosuppressant Drugs

-- Immunosuppressant drugs are commonly used in the treatment of autoimmune diseases such as rheumatoid arthritis.

-- A code for adverse effect code is not assigned when the medication has achieved its intended result in lowering the patient’s immune response to rheumatoid arthritis.

• Rather, assign code D84.821 Immunodeficiency due to drugs.

-- ICD-10-CMdoes not provide a specific code to identify long-term use of immunosuppressant drugs.

• Assign code Z79.899, Other long-term (current)drug therapy, to report long-term use of immunosuppressant drugs.

Rheumatoid Arthritis With or Without Organ Involvement

• When a medical record documents a current diagnosis of seropositive rheumatoid arthritis of a specific joint(s) and there is no mention of any type of organ involvement, the default is “without organ involvement.”
• Assign a code for “with organ involvement” only when the record documents organ involvement.

Opting for Outpatient

The advent of new technologies and minimally invasive techniques has made it possible for more surgeries to be performed on an outpatient basis. That means fewer procedures require a prolonged stay afterward – whether at the hospital or ambulatory surgical center. Instead, an increased number of patients are recovering at home after the effects of anesthesia wear off.

Data gathered by Cedar Gate Technologies from more than 12 million commercial insurance members show that inpatient surgeries decreased 7.33% from 2019 to 2021, while utilization rates for non-inpatient facilities increased. Hospital outpatient surgery volume increased 3.1%, and ambulatory surgical center utilization rates rose by 10.26%.

Experts say the greatest number of procedures shifting from inpatient to outpatient right now are concentrated in orthopedics, cardiology, and radiology service lines, including procedures like percutaneous coronary interventions (PCI), total hiparthroplasty (THA), total knee arthroplasty (TKA), spinal fusion, spinal decompression, and laparoscopic cholecystectomy (gallbladder removal). These procedures are more complex than those traditionally performed in ambulatory settings.

Additionally, patients requiring treatments like dialysis or infusions traditionally performed at outpatient centers are increasingly offered opportunities to receive these treatments in the privacy and comfort of their own homes.

“In this era of care, we are seeing more procedures and treatments moving from inpatient to outpatient and from outpatient to home,” says Philip M. Oravetz, MD, MPH, Chief Population Health Officer at Ochsner Health. “Moving care, when appropriate, ‘checks all the boxes’ in terms of goals for value-based care. This transition often provides equal or better care quality and outcomes and greatly improves patients’ experience, and the side effect is lower cost. This transition is also a great way to engage specialists and community providers. They can help fuel the movement by assisting in the care redesign process.”

How Do Outpatient Surgeries, or Home Treatments, Meet the Definitions of Value-Based Care?

While outpatient options have been increasing for many years, the COVID-19 pandemic played a definite role in patient choice. Many avoided hospitals altogether in 2020 and 2021, opting to cancel or delay elective procedures due to fear of infection. Once these patients were ready to resume their treatment plan, they seemed to seek options that would keep them out of the hospital for an extended basis.

For many types of non-emergency surgeries, outpatient procedures offer patients the convenience and comfort of recovering at home. Because the patient is not spending time recovering in the hospital, the risk for a hospital-acquired infection is much, much lower.

Patients undergoing dialysis and certain infusions at home also report a much-improved experience, as the transition allows for the convenience of scheduling treatments that fit their routine and a greater degree of control and independence when it comes to managing their health. An environment that helps them feel comfortable and relaxed promotes healing, and they don’t have to worry about the stress of traveling to a center, giving them more time back to do the things they love. Certain types of home dialysis allow patients to sleep during the procedure or do more frequent, shorter treatments, both of which can improve patient outcomes and reduce dietary restrictions. Patient education, especially when it comes to proper safety and sanitation protocols is, of course, essential.

“By offering outpatient options for many of the surgeries our highly skilled providers perform, we are creating better patient outcomes and experiences at a lower cost, which also translates to shared savings for those surgical providers,” says Dr. Oravetz. “All of our surgeons use the latest tools, technologies and evidence-based protocols to determine if patients are eligible for outpatient procedures and deliver the highest quality care during those procedures. Patients can then recover in the comfort of home, surrounded by a familiar environment and the people they love, which most people prefer.”

Of course, some procedures cannot be performed on an outpatient basis, and if a patient has complex health issues that might put them at high risk, an inpatient surgery and stay might be the better option even an outpatient option is available. The same holds true with determining patient eligibility for at-home dialysis and infusions.

If a patient is eligible for an outpatient procedure, there is also always a small chance that a complication or emergency might make a transfer and an overnight stay necessary. But complications are uncommon, and a significant number of people each year undergo outpatient procedures.

At physician-owned ambulatory surgical centers, the surgeons and physicians have a great deal of control over how the center is used, who they hire, and what technologies and products they use. Because surgical patients are seen and treated in a controlled environment, these outpatient centers can use business intelligence and metrics to effectively measure the outcomes of surgical procedures and identify areas for improvement. Data-driven refinements to surgical techniques can reduce complications and improve patient outcomes. These are defining elements of value-based care.

Data collected by these outpatient centers also includes information about patient recovery times, patient education, pain management and what steps are taken after surgery (post-op care, rehabilitation and therapy, etc.). This patient health and satisfaction data helps inform future protocols, improve patient outcomes and reduce the risk of complications in defined populations.

There’s already been an aggressive move to outpatient for joint replacements, and other procedures are sure to follow.

“Same-day discharge hip and knee replacement had been going on for several years, but was not very widespread,” says George Chimento, MD, System Chair, Orthopedic Surgery at Ochsner Health. “When the Centers for Medicare & Medicaid Services took total knee replacement off the inpatient-only list, same-day joint replacement gained more traction. This was accelerated by the pandemic, as across the nation, hospital capacity was at a maximum, and they were filled with COVID patients.”

In order to be able to have hip or knee replacement surgery, patients needed to go home the same day.

“A study from the University of Utah showed that prior to the pandemic, 15% of their patients went home the same day. By the end of the pandemic, they were sending more than80% of patients home the same day,” Dr. Chimento says. “The key point here is that there was no decrease in quality, such as complications and readmissions.”

He says regional anesthesia, multimodal pain control and widespread adoption of tranexamic acid, which decreases blood loss, were the main factors that made the transition relatively seamless.  

“Surgeons had already developed tissue-sparing, less invasive techniques, and these other factors complemented those in such away that patients can be safely discharged on the same day,” Dr. Chimento says. “There are also obvious financial incentives for surgeons and hospitals to decrease the length of stay, and this shows that surgeons from both academic and private practice, as well physicians from different specialties, can work together for a common goal in safely redesigning care in a way that brings more value to patients as well as the healthcare system.”

Physicians Are This Movement’s Natural Leaders

In all cases, providers need to meet at the table to understand which patients are the best candidates for either outpatient or home treatments.

“As chronic kidney disease prevalence increases, it becomes more important to find new and innovative ways to keep patients healthy and home,” says Sean Roberts, MD, a nephrologist at Ochsner. “Specifically, providing more dialysis services in the patient's home is a major step in improving the quality of life for ESRD patients and helps keep them with their families in familiar surroundings with the least impact on their quality of life.  Leveraging new technology along with our EMR is how we will achieve this goal to provide quality care in the comfort of the patient's home.”

“As providers, we have a responsibility to our patients to get involved in the care redesign process and help to move care when it’s appropriate,” adds Dr. Oravetz.

Article acknowledgements:
Thank you to OHN physicians who contributed their time and expertise to this article.

Amanda Callegan-Poche’, MD, says some of her most rewarding moments at work come when she can put a patient’s mind at ease. Whether it’s simplifying her description of a condition or diagnosis to ensure they understand it or celebrating their achievement of a lower A1C, Dr. Callegan-Poche’ says those are the moments that bring her joy.

“I’ve always loved helping people, and while I didn’t have family in the medical field, I was always drawn to the help doctors provided to various family members with health issues,” Callegan-Poche’ recalls. “I love kids, so I knew I wanted to pursue pediatrics. But I also found I really liked the complexity of internal medicine, working with older patients, and helping them manage conditions like hypertension and diabetes. I was thrilled when I found out I could do both.”

Callegan-Poche’s journey to becoming an Internal Medicine-Pediatrics (Med-Peds) provider began in the small, south Louisiana town of Plaquemine where she grew up. With only one pediatrician’s office in town, you can imagine how busy the doctors were. As a patient, the rushed feeling of her appointments never fazed her until she began having recurring headaches as a young teenager. She began to feel that her concerns weren’t being heard or addressed and asked her parents if she could find a new doctor.

“My new physician, Dr. Kevin Dean, really took the time to listen to me and address allof my concerns,” Callegan-Poche’ says. Ultimately, an MRI was ordered, and theyfound out she had atypical migraines. “My overall experience w sh a positive one. It felt good to be heard andto finally understand what was going on.”

Dr. Dean was a Meds-Peds physician. “I don’t think he knows the impact he made on the trajectory of my career and how I practice medicine today! Maybe I should send him this article and let him know,” laughs Callegan-Poche’.

Today, Callegan-Poche’ sees patients three days a week and says making time to build and sustain a relationship with her patients is a top priority. Whether it’s anew patient or someone she’s cared for over many years, getting to know them on a personal level can often be the key to a successful diagnosis. Understanding their family dynamics, jobs and even what hobbies they enjoy provides invaluable insight and strengthens the doctor-patient connection.

“I’ve alwaysbeen a huge proponent of preventive care, so the recent industry shift to andfocus on keeping patients healthy and out of the hospital has been an intuitiveone for me,” Callegan-Poche’ says. She believes that if patients see theirphysicians regularly and get all their screenings done, they can prevent theearly onset of many illnesses and the bad outcomes that follow. She believesthat primary care physicians play an integral role in both preventive care andin coordinating whatever specialty care a patient may need.

Callegan-Poche’ says the resources she has access to through Ochsner Health Network help ensure her patients are getting the right care at the right time.

“Penny Parks, our clinical care coordinator, certainly makes my job a lot easier," Callegan-Poche’ says. “She goes through our patient lists and helps schedule important screenings like mammograms; she gets records release forms from patients and makes sure they get to me; she also sees to it that we’re meeting important care guidelines and quality measures. Our lead physician at Ochsner LSU Shreveport, Dr. [Lauren] Beal, has also been instrumental in providing educational opportunities to make these shifts as easy as possible for us. All-in-all, not much of my practice has changed because we were already paying attention to a lot of the preventive care guidelines.”

When she’s not seeing patients, she is teaching medical students and residents at Ochsner LSU Health Shreveport School of Medicine, a gig she enthusiastically accepted upon completion of her Med-Peds residency at the same school. “Teaching is another passion of mine. I tutored kids when I was in middle school, high school and even in college. Seeing that lightbulb moment never gets old, no matter what age the student is. It’s such a privilege to play a small part in their journey toward becoming a doctor!”

Dr. Callegan-Poche’ teaches medical students and Internal Medicine and Med-Peds residents and supervises residents in clinic a couple of days each week. “I enjoy helping prepare students and residents for their exams and helping them make connections between lectures and clinical experience,” she says. “Helping them learn how to be good doctors, how to listen to their patients and really understand their needs, is very rewarding.”

Fulfilling another lifelong dream, Dr. Callegan-Poche’ is also a mom. She shares three beautiful boys – Kinkade, 6, Kameron, 4 and Keegan, 6 months, with her husband, Kodi. The family loves visiting national parks “especially if mountains are involved," hiking and tending to a vegetable garden and a butterfly and hummingbird garden. Dr. Callegan-Poche’ also enjoys coaching her oldest son’s youth baseball team. “I’m the official coach and the unofficial team doctor!" she jokes.

If you would like to be featured in an upcoming OHN Physician Spotlight, or you’d like to recommend another provider with an interesting story to share, email carlie.boudreaux@ochsner.org

OHN provides the knowledge, resources, processes, and technology you need for success in value-based care so you can do more of what you love –taking care of patients. Each month, we share one coding tip and highlight one best practice advisory (BPA) to help to support your clinical documentation efforts.

Additionally, the clinical documentation excellence (CDE) team is here to support you – email riskadjustment@ochsner.org with any questions.

Capturing and Coding Chronic Obstructive Pulmonary Disease (COPD)

Rationale

-- Chronic obstructive pulmonary disease (COPD) is a broad term that represents a group of chronic, progressive lung diseases that obstruct the airways in the lungs, making it difficult to breathe.

-- There are two main types of COPD, and most people with COPD have a combination of both conditions:

• Emphysema – a slowly progressive destruction of the lung tissue, which loses its elasticity and ability to expand and contract
• Chronic bronchitis – a long-term, chronic inflammation and cough with mucus, resulting in narrowing and blockage of the airways

-- COPD includes a range of chronic, progressive, obstructive lung diseases usually caused by smoking and other environmental factors.

-- Bronchiectasis is NOT a type of COPD. COPD and bronchiectasis are two separate chronic lung conditions that can coexist. Although there are some similarities between the two, there also are some important differences and the conditions are treated differently.

-- Bronchiectasis is usually caused by inflammation and infection of the small airways (bronchi), which results in thickening and scarring of the airway walls. This airway damage prevents the natural clearing of mucus; thus, mucus accumulates and creates an environment in which bacteria can grow. This leads to a recurring cycle of inflammation and infection that can cause even more damage to the airways. Over time, the damaged airways lose their ability to effectively move air in and out, resulting in lack of adequate oxygen reaching vital organs. This can lead to serious health problems, such as respiratory failure and heart failure.

-- The American Hospital Association (AHA) Coding Clinic advises that COPD is a chronic, systemic condition that almost always affects patient care, treatment or management. Therefore, it is appropriate to document the COPD diagnosis in the final assessment as a current, coexisting condition, even in the absence of specific treatment of the condition on an individual date of service.

How to Code & Document

Subjective

• In the subjective section of the office note, document the presence or absence of any current symptoms related to chronic obstructive pulmonary disease (such as shortness of breath, cough, fatigue, etc.).

Objective

• The objective section should include all current associated physical exam findings (such as decreased breath sounds, wheezing, etc.) and related diagnostic test results, such as pulmonary function tests (PFT).

Assessment

• Even when the COPD condition is being followed and managed by a different provider, it is important to include the diagnosis in the final assessment. For example: “Chronic emphysematous bronchitis followed and managed by pulmonologist, Dr. Jane Smith.”

• Specificity: Describe each final COPD-related diagnosis to the highest level of specificity. A diagnosis of “COPD” is broad and nonspecific–it does not identify the particular type of COPD or any associated conditions. Include the current status (stable, worsening, improved, etc.)

Suspected vs. Confirmed

• Do not document a suspected COPD condition as if it is confirmed. Instead, document the signs and symptoms in the absence of a confirmed diagnosis.
• Do not describe a confirmed COPD diagnosis with terms that imply uncertainty (such as “probable,” “apparently,” “likely” or “consistent with”).

Treatment Plan

• Document a clear and concise treatment plan for COPD, linking related medications to the diagnosis.
• Include orders for diagnostic testing.
• Indicate in the office note to whom or where the referral or consultation requests are made.
• Document when the patient will be seen again, even if only on an as-needed basis.

Coding COPD

COPD and its associated conditions classify to the following categories:

• J43 Emphysema
• J44 Other chronic obstructive pulmonary disease
• J45 Asthma

COPD classifies to category J44 with a fourth character required as follows to provide further specificity:

• J44.Ø COPD with (acute) lower respiratory infection
• J44.1 COPD with (acute) exacerbation
• J44.9 Chronic obstructive pulmonary disease, unspecified
• COPD with unspecified asthma is included in category J44 and codes to J44.9.

When the type of asthma is further specified, two codes are assigned: A code from category J44 for COPD; and a code from category J45 to report the type of asthma. Four-character subcategories under J45 include the following:

• J45.2x Mild intermittent asthma
• J45.3x Mild persistent asthma
• J45.4x Moderate persistent asthma
• J45.5x Severe persistent asthma
• J45.9x Other and unspecified asthma

Fifth and sixth characters are added to report whether asthma is uncomplicated, with exacerbation or with status asthmaticus.

• J45.9x Other and unspecified asthma

·COPD with acute bronchitis (an acute infection) is coded:

• J44.Ø Chronic obstructive pulmonary disease with (acute) lower respiratory infection
• J2Ø.9 Acute bronchitis, unspecified

Emphysema classifies to category J43 and is a more specific type of COPD. A fourth character is required to specify the particular type of emphysema.

• J43.Ø Unilateral pulmonary emphysema (MacLeod’s syndrome)
• J43.1 Panlobular emphysema
• J43.2 Centrilobular emphysema
• J43.8 Other emphysema
• J43.9 Emphysema, unspecified

Please note:

• Emphysema documented with coexisting chronic bronchitis classifies to category J44.
• Emphysema without mention of chronic bronchitis classifies to category J43.

To assist you in identifying patients with a potential emphysema (HCC 111) diagnosis, OHN’s Clinical Documentation Excellence (CDE) team, in collaboration with clinical leaders, have created a logic model within the HCC Best Practice Advisory (BPA) tool. The model uses natural language processing (NLP) in EPIC to identify potential diagnoses and present these within the BPA to you, the clinicians.

You can find information regarding suspected diagnoses within the EPIC “probable condition logic” hyperlink in the BPA, including the information listed below. In cases where NLP is used, a smart link will give you specific information concerning the suspected diagnosis, including the type of radiologic study, the date of the study, and a quote from the study which includes the word or statement that triggered the BPA tool.

HCC 111 Emphysema Logic Process Explained

If the radiologist’s reading of a CT image of the lungs includes words such as “emphysema” or “emphysematous,” a suspected diagnosis will be triggered.

Since this logic is based on string-matching algorithms of the imaging result, there could be a limited number of false positives if the radiologist’s reading contains the word “no” prior to the trigger words mentioned above.

If a patient meets both the emphysema and COPD logic, a suspected emphysema diagnosis will appear within the HCC BPA.

OHN provides the knowledge, resources, processes, and technology you need for success in value-based care so you can do more of what you love –taking care of patients. Each month, we share one coding tip and highlight one best practice advisory (BPA) to help to support your clinical documentation efforts.‍

Additionally, the clinical documentation excellence (CDE) team is here to support you – email riskadjustment@ochsner.org with any questions.

Capturing and Coding Cardiomyopathy

Rationale

• Cardiomyopathy is a disease of the heart muscle that impairs the function of the heart.
• Cardiomyopathy can be classified as primary or secondary and ischemic or nonischemic.
• Primary cardiomyopathy is a noninflammatory disease of the heart muscle, often of obscure or unknown cause, which occurs in the absence of other cardiac conditions or systemic disease processes.
• Secondary cardiomyopathy is caused by a known medical condition, such as hypertension, valve disease, congenital heart disease or coronary artery disease.
• Ischemic cardiomyopathy is caused by coronary artery disease and heart attacks, which result in lack of blood flow to the heart muscle that leads to damage of the heart muscle.
• Nonischemic cardiomyopathy is a type of cardiomyopathy that is not related to coronary artery disease or poor coronary artery blood flow. The three main types of nonischemic cardiomyopathy are:
• Dilated cardiomyopathy (also known as congestive cardiomyopathy) – the most common type of cardiomyopathy in which the heart’s main pumping chamber, the left ventricle, becomes enlarged(dilated), and its pumping ability becomes less forceful, so blood doesn’t flow as easily through the heart
• Hypertrophic cardiomyopathy –abnormal growth or thickening of the heart muscle, particularly affecting the muscle of the left ventricle, which often causes the heart to stiffen and the pumping chamber to shrink in size, interfering with the heart’s ability to deliver blood to the body
• § Restrictive cardiomyopathy – the heart muscle becomes rigid and less elastic, meaning the heart can’t properly expand and fill with blood between heartbeats

How To Code & Document

Subjective

• In the subjective section of the office note, document current related patient complaints and symptoms. If there are none, this note should show that the patient was screened for current related complaints or symptoms.

Objective

• Include any current associated physical exam findings – such as edema/swelling of the lower extremities, abdomen or neck veins – and related diagnostic testing results.

Assessment

• Specificity: The term “cardiomyopathy” is broad and nonspecific. It is important to describe the particular type of cardiomyopathy to the highest level of specificity.

Abbreviations

• Limit, or avoid altogether, the use of abbreviations. There are several commonly used medical abbreviations for different types of cardiomyopathy (e.g., CM, CMP,HCM, HOCM), but some of these abbreviations have other meanings.
• Document the specific type of cardiomyopathy by spelling it out in full.

Current vs Historical/Transient

• Do not use the descriptor “history of” to describe current cardiomyopathy. In diagnosis coding, “history of” means the condition occurred in the past and is no longer a current problem.
• Temporary or transient cardiomyopathy that occurred in the past and is no longer present should not be documented as if it is current.

Treatment Plan

• Document a specific and concise treatment plan.
• Clearly link the cardiomyopathy diagnosis to any medications being used to treat the condition.
• Document referrals to specialists or other providers.
• Include the date of the patient’s next appointment.

Treatment Options

Lifestyle changes:

• Heart-healthy diet
• Weight control
• Stress management
• Physical activity and exercise
• Smoking cessation

Medications:

• Blood thinners to prevent clots
• Antiarrhythmics to control heart rate and rhythm
• Antihypertensives for blood pressure control
• Diuretics (“water pills”) to remove excess sodium and reduce excess fluid in the blood

Nonsurgical procedures:

• Alcohol septal ablation, in which a type of alcohol (ethanol) is injected through a tube into the small artery that supplies blood to the thickened area of heart muscle. The alcohol shrinks the thickened heart tissue to a more normal size, allowing blood to flow freely through the ventricle of the heart, which results in improved symptoms.
• Cardiac device implantation: Pacemaker, Cardioverter-defibrillator, Left ventricular assist device

Surgical procedures:

• Heart transplant – a last resort for severe, end-stage cardiomyopathy that cannot be controlled by other means

Coding Cardiomyopathy

Many of the most common cardiomyopathies classify to category I42, Cardiomyopathy. A fourth character is required to specify the particular type of cardiomyopathy.

• The broad and nonspecific final diagnosis of “cardiomyopathy” leads to the broad and nonspecific diagnosis code I42.9, Cardiomyopathy, unspecified.
• Code I42.9 should be assigned only when no information in the medical record identifies the particular type of cardiomyopathy.

Hypertensive cardiomyopathy classifies to categoryI11, Hypertensive heart disease, with an additional code of I43, Cardiomyopathy in diseases classified elsewhere.

Congestive cardiomyopathy is also known as dilated cardiomyopathy. Both of these descriptions classify to code I42.Ø, Dilated cardiomyopathy.

• Congestive cardiomyopathy often is associated with congestive heart failure and has basically the same symptoms.
• Treatment typically focuses on management of the congestive heart failure; therefore, heart failure (category I5Ø) is reported as the principal diagnosis with an additional code for the cardiomyopathy.

Hypertrophic cardiomyopathy can be obstructive or nonobstructive.

• I42.1 Obstructive hypertrophic cardiomyopathy
• I42.2 Other hypertrophic cardiomyopathy
• Includes nonobstructive hypertrophic cardiomyopathy

Takotsubo cardiomyopathy is a reversible form of cardiomyopathy that classifies to code I51.81, Takotsubo syndrome. This code includes the following conditions:

• Reversibleleft ventricular dysfunction following sudden emotional stress
• Stress-induced cardiomyopathy
• Takotsubo cardiomyopathy
• Transient left ventricular apical ballooning syndrome

Dilated cardiomyopathy and ischemic cardiomyopathy are classified to different codes. When a medical record documents a current diagnosis of ischemic dilated cardiomyopathy, both codes are needed to fully capture this condition:

• I25.5 Ischemic cardiomyopathy
• I42.Ø Dilated cardiomyopathy

Nonischemic cardiomyopathy with no other description and no mention of cause codes to I42.8.

HCC Best Practice Advisory: CHF/Cardiomyopathy

To assist you in identifying patients with a potential CHF/cardiomyopathy (HCC 85) diagnosis, OHN’s Clinical Documentation Excellence(CDE) team, in collaboration with clinical leaders, have created a logic model within the HCC Best Practice Advisory (BPA) tool. The model considers a combination of medications, echo results, EKG results, symptoms, physical exam findings and lab tests to find potential diagnoses and present these within the BPA to providers.

HCC85 CHF/Cardiomyopathy Logic Process Explained

Criteria must include items 1, 2 and 3; at least one in 4 through 7; and 8.

1. Last EF < 45%
2. Cardiomyopathy in the problem list
3. Problem list reviewed last year
4. Abnormal echo in the past three years
5. Abnormal basic metabolic panel in the past three years
6. Abnormal EKG in the past three years
7. Active prescription in the ACE inhibitor or ARB medication class
8. Any of the following symptoms documented in the last three years

• Orthopnea
• Paroxysmal nocturnal dyspnea (PND)
• Dyspnea
• Dyspnea on exertion
• Leg swelling
• Rales/crackles
• Breath sounds normal
• Edema
• Gallop rhythm

Care management has emerged as a key program in most value-based and population health strategies due to its capacity to improve health outcomes, create a better experience for patients and healthcare providers, and reduce costs. The problem most clinics face is the ability to offer this additional level of care on top of already overwhelmed workloads. The good news? When you joined Ochsner Health Network (OHN), you gained access to industry-leading care management programs like Ochsner’s Outpatient Care Management (OPCM) program.

What is OPCM?

This program – and its team of nurses, social workers and community health workers – was developed to help you manage your most complex patients. Some interventions of the OPCM program include:

• Advanced Care Planning & Aging in Place Plans
• Complex Care Coordination
• Community Resource Referrals & Assistance
• Financial
• Transportation
• Nutrition
• Equipment
• Housing
• Health System Navigation
• Chronic Disease Education & Management
• Medication Compliance
• Lab Compliance
• Medication Reconciliation & Education
• Self-Management Action Planning

“Population health data and predictive modeling are key to success in this program,” said Philip Oravetz, MD, Ochsner Chief Population Health Officer.

“From identifying patients on your panel who are at a high risk, to gathering and analyzing data and measuring the effectiveness of the program, our OPCM program is producing significant clinical and financial results for patients and physicians.”

Identifying patients who are eligible for OPCM is made easy for you, courtesy of OHN’s expert analytics team. For physicians on Ochsner’s instance of Epic, a best practice advisory (BPA) identifies the patients on your panel who are eligible. OPCM eligibility information is also available in the "Patient Programs" section of the Longitudinal Plan of Care. For Network providers not on EPIC, the Healthy Planet link and your OHN Scorecard provides a similar patient list. On average, we work with patients for about 90 days and will communicate with you and other care specialists as needed.

In addition to being an available clinical resource for your patient’s medical needs, OPCM serves as an important connector to community resources that can help improve their lifestyle and eventually their health. Those services include food assistance, emergency housing, transportation, mental health resources and more. For instance, an elderly patient with limited income may have to choose between getting their prescriptions filled or buying food. The OPCM team works to connect the person to local agencies that provide food assistance, Medicaid and other programs. This allows patients to afford their needed medications, which, in turn, could prevent a visit to an emergency department and a possible hospitalization.

“OPCM's goal is to meet the patient where they are,” said Alison Glendenning-Napoli, MSN, RN-BC, Assistant Vice President of Outpatient Case Management at Ochsner Health System.

“Once the patient elects to enroll in the program, our team does a thorough assessment and, with the patient, we develop a care plan and mutually determined goals that will lead them toward achieving self-care management.”

Program Outcomes

Based on a program evaluation of patients enrolled in 2021, Ochsner’s OPCM program has seen clinically significant results. Almost 1,000 patients were evaluated. In the first 60 days, there was a 63 percent reduction in inpatient care and hospital admissions for the evaluated group. There was also a 52 percent reduction in emergency room visits. After one year, about a quarter of OPCM patients were kept out of the hospital. Nearly three-quarters of these patients were able to maintain control of their HgbA1C and blood pressure. Their body mass index (BMI) also improved.

Patient Story

Just last year, a 52-year-old female patient enrolled in the OPCM program to help manage her diabetes. At the time, her A1C was 9.5. The OPCM team devised a care plan for chronic pain and diabetes. OPCM connected her to a diabetes care specialist who worked with the patient on a care plan. Ten months later, her A1C is down to 7.5. The OPCM team was also able to connect the patient with a smoking cessation program, and the patient has since quit smoking. Our team also helped the patient coordinate physical therapy and specialist visits, order grab bars for the bathroom, and sent resources for counseling and low-income housing. The OPCM program is now working to transition the patient to another level of care management for ongoing follow-ups.

Expanding OPCM to Network Physicians

The program is available across Ochsner Health Network. This year, we plan to provide targeted education to generate patient referrals to the OPCM program. We will begin this education for OHN providers at Slidell Memorial Hospital; Lafayette General Medical Center; Titus Regional Medical Center in Mount Pleasant, Texas. Later in the year, the program will provide the targeted education for our Shreveport, Terrebonne and Morgan City providers.

If you have any questions about Ochsner’s OPCM program, please contact us via email at opcm@ochsner.org or by phone at (504) 842-0802. You can also reach out to your Performance Improvement Coordinator (PIC) with any questions.

Contact OPCM

If you have any questions about Ochsner’s OPCM program, please contact us via email at opcm@ochsner.org or by phone at (504) 842-0802. You can also reach out to your Performance Improvement Coordinator (PIC) with any questions.

Capturing and Coding Chronic Kidney Disease

Rationale

Chronic kidney failure (disease) has no cure, but treatment can help control signs and symptoms, reduce complications and slow the progress of the disease. The first priority is controlling the condition responsible for the kidney failure and its complications (e.g., controlling diabetes or high blood pressure). Other treatments include:

• Proper diet (protein management along with salt, potassium and phosphorus restrictions may help slow disease progression)
• Daily exercise
• Avoidance of dehydration
• Avoidance of smoking and other tobacco products, alcohol and illegal drugs
• Avoidance of substances that are toxic to the kidneys, such as non steroidal anti-inflammatory drugs
• Treating complications

In end-stage kidney disease (when kidney function is reduced to 10-15% or less of capacity), conservative measures as outlined above are no longer enough. Dialysis or kidney transplant become the only options to support life.

How to Code & Document

Subjective

• In the subjective section of the office note, document the presence or absence of any current symptoms related to chronic kidney disease (e.g., fatigue, weakness, changes in urine output, etc.).

Objective

• Any current associated physical exam findings (e.g., elevated blood pressure, edema, weight loss, etc.)
• Related diagnostic test results
• Presence of a surgically placed arteriovenous shunt for the purpose of dialysis, along with related exam findings (e.g., presence of a thrill or bruit)

Assessment

• Describe the final chronic kidney disease diagnosis to the highest level of specificity.
• Document the specific stage of chronic kidney disease. Remember that medical coders are not allowed to calculate the stage of CKD based on documentation of the GFR; rather, the specific stage must be stated in the medical record.
• Include the current status of CKD (stable, worsening, improved, etc.).
• State the cause of CKD, if known. Use linking terms or descriptors that clearly show cause and effect

Terms of uncertainty:

• For a confirmed diagnosis of chronic kidney disease, do not use descriptors that imply uncertainty (such as “probable,” “apparently,” “likely” or “consistent with”).
• Do not document suspected chronic kidney disease as if the diagnosis is confirmed. Document the signs and symptoms in the absence of a confirmed diagnosis.

Current vs Historical

• Do not use the descriptor “history of” to describe current chronic kidney disease. In diagnosis coding, the phrase “history of” means the condition is historical and no longer exists as a current problem.
• Do not document past/resolved chronic kidney disease as if it is current when the condition is truly historical and no longer exists as a current problem. (Example: history of CKD that was resolved with a kidney transplant)

Plan

• Document a specific, concise treatment plan for CKD.
• Include specific details of current dialysis status (hemodialysis, peritoneal dialysis, frequency, etc.).
• If referrals are made or consultations requested, the office note should indicate to whom or where the referral of consultation is made or from whom consultation advice is requested.
• Include the date or time frame for the next appointment.

Coding Chronic Kidney Disease

CKD classifies to category N18. This category includes instructional notes advising to:

Code first any associated:  

• Diabetic chronic kidney disease (EØ8 ‒ E13 with .22)
• Hypertensive chronic kidney disease (I12.-, I13.-)
• Use additional code to identify kidney transplant status, if applicable (Z94.Ø)

ICD-10-CM classifies CKD based on the severity of the condition as follows:

• N18.1 Chronic kidney disease, stage 1
• N18.2 Chronic kidney disease, stage 2 (mild)
• N18.3- Chronic kidney disease, stage 3 (moderate)
• N18.3Ø Chronic kidney disease, stage 3 unspecified
• N18.31 Chronic kidney disease, stage 3a
• N18.32 Chronic kidney disease, stage3b
• N18.4 Chronic kidney disease, stage 4 (severe)
• N18.5 Chronic kidney disease, stage 5 > Excludes 1 CKD stage 5 requiring chronic dialysis (N18.6)*
• N18.6 End stage renal disease > Includes CKD requiring chronic dialysis*, use additional code to identify dialysis status (Z99.2)
• N18.9 Chronic kidney disease, unspecified

*These instructional notes indicate CKD requiring chronic dialysis classifies to N18.6 even when the condition is not specifically documented as end-stage renal disease.

N18.9, Chronic kidney disease, unspecified includes:

• Chronic renal disease
• Chronic renal failure NOS (not otherwise specified)
• Chronic renal insufficiency
• Chronic uremia NOS (not otherwise specified)
• Diffuse sclerosing glomerulonephritis NOS (not otherwise specified)

If both a stage of CKD and ESRD are documented, assign code N18.6 only.

HCC Best Practice Advisory: Chronic Kidney Disease

To assist providers in identifying patients with potential Chronic Kidney Disease (HCC 136,137,138) diagnoses, the Clinical Documentation Excellence (CDE) team, in collaboration with clinical leaders, have created logic within the HCC Best Practice Advisory (BPA) tool. In this case, EPIC lab values are used to find potential diagnoses and present these within the BPA to clinicians. Within the EPIC “probable condition logic” hyperlink in the BPA, users will find information for all suspecting logic including that listed below:

HCC138 – CKD 3a

• Last GFR, within 12months, = 45-60.
• The next GFR, that was 3 months or greater since the last GFR, is less than 60.
• All GFRs between the last GFR and the GFR in line 2, will also be less than 60.

HCC 138 – CKD 3b

• Last GFR, within 12 months, = 30-44.
• The next GFR, that was 3 months or greater since the last GFR, is less than 60.
• All GFRs between the last GFR and the GFR in line 2, will also be less than 60

HCC 137 – CKD 4

• Last GFR, within 12 months, =16-29.
• The next GFR, that was 3 months or greater since the last GFR, is less than 60.
• All GFRs between the last GFR and the GFR in line 2, will also be less than 60.

HCC 136 – CKD 5

• Last GFR, within 12 months, <=15.
• The next GFR, that was 3 months or greater since the last GFR, is less than 60.
• All GFRs between the last GFR and the GFR in line 2, will also be less than 60.

A diagnosis of CKD5 will typically trigger an HCC Charge Correction in-basket message upon closure of the chart to clarify if the patient is on dialysis or not. If this should occur, simply respond as clinically appropriate.

BPA Spotlight - Major Depression Suspect BPA

To help providers identify patients with a potential Major Depressive, Bipolar or Paranoid Disorder (HCC 59) diagnosis, the clinical documentation excellence (CDE) team in collaboration with clinical leaders have created logic within the HCC Best Practice Advisory (BPA) based on the following criteria:

HCC 59 – Major Depressive, Bipolar and Paranoid Disorders

(1 and 2) or (3 and 4)

1. Patient age is greater than or equal to 18
2. PHQ-9 score of 5 or greater in last 1 year
3. Patient age is 12-17
4. PHQ-9 score of greater than 9 in last 1 year

Identifying the Suspect BPA

• Morbid Obesity Suspected BPAs will always have a header above the condition with the language “Probable Condition Based on Epic Documentation – Major Depression” in a Grey Bar.
• Any Suspected Conditions will populate towards the top portion of the BPA tool.
• Similar to the standard Recapture Chronic Conditions in the BPA, the provider will always have the button selections of “Add Visit Diagnosis” to add the condition; “Do Not Add” to suppress the alert to the next appointment; or “N/A to Patient” to disagree and remove the condition from the tool.
• To refer to the logic outlined above, the provider can select the “link” hyperlink from the “For more information on Ochsner / Epic Probable Condition Logic click this link.”

Sammy Khatib, a fellowship trained cardiologist and electrophysiologist at Ochsner Health, was born in Michigan to Syrian immigrants. His mother, a hematopathologist, and his father, an infectious disease specialist, raised two boys in an environment focused on medicine.  The dinner table conversation always centered around cases of the day, and his parents would challenge them to think critically. His father (and mentor) drilled into their heads that effort and attitude – not necessarily innate ability – were the differentiators that enabled one to work through just about anything in life.    

Khatib was always drawn to cardiology because of its complexities and the promise of innovations on the horizon.  He was fascinated with the pace of change in the field. He was in awe of the logic and beauty of the cardiovascular anatomy. He finished undergraduate training at Wayne State University, residency at Georgetown, and fellowship training at the Washington DC VA Medical Center and University of Florida, Gainesville.

Fast forward, decades later. Khatib is a practicing electrophysiologist and head of Cardiology for the John Ochsner Heart and Vascular Institute for Ochsner Health. He’s also section head of the Electrophysiology department. He says he spends two-thirds of his time practicing medicine, and one-third in his leadership role... though some days, he chuckles, “feels like 75/75!”

“I genuinely love being a physician. But being a leader is vastly different. Good leadership is actually a departure from how we were trained as physicians,” reflects Khatib. “We were taught a rather autocratic style: we were raised to be the expert. But in leadership, we can’t solve every problem, nor should we. Sometimes we don’t necessarily have the answers. But it’s our job to ask the right questions… to support the team around us… to empower them… to unlock their brilliance to find solutions that work best for the team, and best for our patients… to share in the decision-making process.”

Perhaps that discernment, as a physician leader, explains (at least in part) the success behind his teams’ efforts over the years to embrace healthcare transformation. “The healthcare trajectory has reached an unsustainable point. The note on overutilization in the past has come due,” he claims.  

To illustrate, he gave the example of his father-in-law who received yearly stress echocardiograms from his local cardiologist. This was despite multiple negative tests, no prior history of coronary artery disease, and being low risk. He was running half marathons without problems. But in his son-in-law’s eyes, more problematic was his father-in-law’s happiness to receive the unnecessary testing every year.

“We cannot sustain this kind of unnecessary, overutilization of care.  We will go over a cliff,” asserts Khatib.

Under Khatib’s leadership, the Ochsner Health heart and vascular team has worked diligently to identify and shift the indicators that impact care efficiencies, cost, quality and outcomes the most.  Rates of same day discharges in the Cath and Electrophysiology departments have favorably skyrocketed in the last several years, averaging between 90% and 100% across the board. His teams reduced risk-adjusted mortality (RAMI) by 59% over 3 quarters in 2022. Expected versus observed mortalities decreased nearly 2% over that same time period. It’s not a coincidence that patient experience scores hover in the 90’s, with some consistently at 100.  The results? The right care, at the right time, in the right place… with happier patients, and happier clinical teams delivering highly reliable, more affordable care.

“This is a transformation, going from volume to value. It’s a change in everyone’s mindset. And it’s a privilege to be a leader forging the change,” commented Khatib.  “As a physician, the one-on-one care we provide and experience with the patient is special. And at Ochsner Health Network, knowing the work we are doing is reaching hundreds of thousands… well, that’s really special. I feel tremendous gratitude for that --- it feeds the fire on tough days.”

When asked if he ever feels burned out, Khatib says, “Without a doubt. It happens from time to time. When you are doing something complex, something difficult, with conflicting objectives and factors that you do not control, burnout is inevitable. For me, I have found Ochsner really helpful in offering tools to deal with personal burnout.”

He has learned that the first step is internally recognizing patterns of thinking and response that result in warning signals, or even certain actions. That recognition within can lead to making a decision to manage the burnout.  For Khatib, he takes time to enjoy his friends and family. He and his wife Gina, a retired teacher and native of Costa Rica, have one daughter, Carolina (16) who attends Sacred Heart. To zone out, he dives into his hobbies (reading and exercise) and takes small breaks to help reframe and re-energize.  

His all-time favorite reads are on the lives of Winston Churchill, Teddy Roosevelt and Malcolm X.  The common denominator among the three? They each had major challenges in their lives, but they overcame them and converted them into strengths. “They were all about action, constantly moving, doing and changing - not just thinkers,” Khatib points out.  And while quite controversial, he admits his fascination with the story of Malcolm X. “He worked with great passion and purpose, but initially, he was going about his work in all the wrong ways. Then he evolved spiritually, genuinely tried to change, and unfortunately died while trying.”

Perhaps Khatib identifies with (and appreciates) the journey of continuous self-improvement in his own life. He shared that “being a physician leader is often challenging, but it’s good.  I love challenging myself. Not only has it made me a better physician, it has made me a better father, husband, and friend.” Khatib is now reading “A Compass to Fulfillment” by Kazuo Inamori, a Japanese industrialist and management leader who became a Buddhist monk and infused his work with spirituality. Sounds like Khatib’s own compass to fulfillment is indeed pointing true north.

Follow Dr Khatib on Doximity, LinkedIn, and Twitter.

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BPA Spotlight - Morbid Obesity Suspect BPA

To help providers identify patients with a potential Morbid Obesity (HCC 22) diagnosis, the Clinical Documentation Excellence (CDE) Team has created logic within the HCC Best Practice Advisory (BPA) based on the following criteria:

HCC 22 - Morbid Obesity  - (1 and 2)

• Patient is greater than or equal to 18  
• BMI is over 40  

Severe Obesity with Comorbidities  (1 and 2 and 3)

1. BMI less than 40  
2. BMI greater or equal to 35
3. Has comorbidity on problem list, encounter dx, or invoice dx  

• Hypertension
• Dyslipidemia  
• Cardiovascular Disease  
• Stroke Primary Diagnosis Cohort  
• Obstructive Sleep Apnea  
• Ischemic Heart Disease  
• Gallbladder Disease  

Identifying the suspect BPA

• Morbid Obesity Suspected BPAs will always have a header above the condition with the language “Probable Condition Based on Epic Documentation – Morbid Obesity” in a Grey Bar.
• Any Suspected Conditions will populate towards the top portion of the BPA tool.
• Similar to the standard Recapture Chronic Conditions in the BPA, the provider will always have the button selections of “Add Visit Diagnosis” to add the condition; “Do Not Add” to suppress the alert to the next appointment; or “N/A to Patient” to disagree and remove the condition from the tool.
• To refer to the logic outlined above, the provider can select the “link” hyperlink from the “For more information on Ochsner / Epic Probable Condition Logic click this link.

“My dad died in pain on his 66th birthday. I vowed that no one should ever be allowed to suffer as he did,” Dr. Susan Nelson, palliative, geriatric, and hospice care specialist, recalls.

From the Latin word “cloak,” palliative care is intended to comfort, not necessarily cure. Commonly, many misperceive palliative care as medical care that helps patients with how to die.  

“Actually, our goal with palliative care focuses on helping patients with how to live… and live life to the fullest, as they see it,” affirms Nelson.  

One in every two Americans has at least one chronic disease (CDC, Boersma, 2020).  The US has the highest disease rates among comparable countries, and the gap is widening.

“My dad spent his final days in a chair and couldn’t move. He was not given ample pain relief. It was then I became a huge advocate. I knew that in my career I wanted no one to suffer, and that we needed more attention to making sure patients had as many good days as possible,” Nelson added.

Diagnosing and managing patients with chronic illness, as well as supporting their well-being, hopes fears and dreams, should be discussed in the context of how we can help make life better.

“As palliative care clinicians, we infuse more evidenced-based tools into how we care for, and talk to, those with chronic disease and illness.”

On the bright side…

“Visiting the palliative care specialist was the single most helpful, cathartic and thorough physician visit my dad and I had ever participated in during his 20-year battle with Parkinson’s, and now, Lewy Body dementia,” shared Nicole Kleinpeter, daughter of end-stage Parkinson’s patient Ron Boudreaux. The doctor asked and answered raw-and-real questions that addressed Dad’s fears, worries, and wishes.

Nelson, practicing geriatric medicine now 35 years, likens the evolution of the palliative care field to more than clinical medicine. She acknowledges that the distress of chronic disease and illness requires spiritual as well as psychosocial nurturing.

“Daddy’s biggest fear following his diagnosis was that he would die from choking or suffocating,” Kleinpeter added candidly. His doctor talked in detail about many scenarios, and the approaches and medicines that could help ease his discomfort, suffering and anxiety.  She also addressed his goals, what made him happy, and the bucket list items that would give him a fulfilling life, despite terminal illness on the horizon.  

“The visit addressed so much more than clinical topics,” Kleinpeter pointed out.

Through tears and laughter, they discussed and planned parts of Dad’s life that had nothing to do with medical care, and everything to do with his social and emotional well-being.  

“Perhaps that made the most impact for us and changed our mindset around how we navigated the next two (and very full) decades.”  

Kleinpeter’ s father, though now in end stages, played tennis, traveled the world, played with his grandchildren, did Tai-chi, Pilates and boxed until about two years ago. He lived long enough to receive the lifetime achievement award last year from the Louisiana Psychological Association for his research, training, and programs that “put child and family mental health services on the map” for underprivileged children in schools and communities throughout the state.

As for Nelson, she admits that she does not often get burned out.  Her work in making patients’ and families’ live better is what “keeps her going.” “Making any symptoms better –whether pain, psychosocial or spiritual distress – is rewarding.”

In a recent blog, Nelson wrote:

While palliative care is a relatively “new” specialty, the principles are not. We are a whole team made up of many disciplines, who provide an extra layer of support for people with serious illness and their families. The goal of this type of care is to manage pain and other symptoms, navigate the many confusing aspects of the health care system and to have conversations about what makes life enjoyable to develop a specific plan! We want our patients to have the best quality of life that is possible.

If you get to know Nelson, she seems to walk her own talk. She lauds her mother for insisting that “can’t” cannot be found in the dictionary! She emphasizes “making memories, not buying things, spending time with good friends, and enjoying family.”

In her spare time, perhaps due to a promise to her mother and idol, Nelson reads at least one book a month. Right now, she’s reading Confederacy of Dunces and a new book by Siddhartha Mukherjee The Song of the Cell: An Exploration of Medicine.

She and her husband Robert Hart, MD, Ochsner Health Chief Physician Executive and President of Ochsner Clinic, have two sons – Nicholas, a civil engineer, and Geoffrey, doctoral student of physical therapy. One daughter-in-law is completing a cardiovascular anesthesia fellowship in Houston while the other teaches in Luxembourg.

In addition to incorporating Nelson’s wisdom into practice, perhaps we can all reflect while listening to Tim McGraw’s country hit again from 2004 “Live Like You Were Dyin” (lyrics below).  It must have been the longest running #1 country song that year for good reason.  

For more tools on how to talk plainly to patients and families about palliative care, check out this podcast.

"Live Like You Were Dyin'"

Lyrics by Tim Nichols and Craig Wiseman

‍

He said, "I was in my early 40s,

With a lot of life before me,

And a moment came that stopped me on a dime.

I spent most of the next days

Lookin' at the X-rays,

Talkin' 'bout the options

And talkin' 'bout sweet time."

I asked him, "When it sank in that this might really be the real end,

How's it hit you, when you get that kind of news?"

Man what'd you do?"

And he said,

"I went sky divin',

I went rocky mountain climbin',

I went 2.7 seconds on a bull named Fumanchu.

And I loved deeper,

And I spoke sweeter,

And I gave forgiveness I'd been denying."

And he said, "Someday I hope you get the chance

To live like you were dying."

He said, "I was finally the husband

That most the time I wasn't,

And I became a friend a friend would like to have.

And all of a sudden goin' fishing

Wasn't such an imposition.

And I went three times that year I lost my dad.

Well I finally read the good book,

And I took a good long hard look

At what I'd do if I could do it all again.

And then...

I went sky divin',

I went rocky mountain climbin',

I went 2.7seconds on a bull named Fumanchu.

And I loved deeper,

And I spoke sweeter,

And I gave forgiveness I'd been denying."

And he said, "Someday I hope you get the chance

To live like you were dying."

OHN is dedicated to providing the knowledge, resources, processes and technology you need for success in value-based care so you can do more of what you love – taking care of patients. In the months to come, we’ll share one coding tip and highlight one best practice advisory (BPA) each month to help to support your clinical documentation efforts.

Additionally, the clinical documentation excellence (CDE) team is here to support you – email riskadjustment@ochsner.org with any questions.

Rationale

The NIH definition of morbid obesity:

• Being 100 pounds or more above ideal body weight; or
• Having a BMI of 40 or greater; or
• Having a BMI of 35 or greater and one or more comorbid conditions:
• High blood pressure and hypertension
• High cholesterol and triglycerides
• Type2 diabetes mellitus
• Metabolic syndrome
• Heart disease
• Stroke
• Kidney disease
• Sleep apnea
• Cancer
• Fatty liver disease
• Gallbladder disease
• Osteoarthritis

How to code & document

Subjective

• Document the presence or absence of any current symptoms related to obesity, morbid obesity, overweight, etc.

Objective

• Document the patient’s height, weight and BMI. (The medical coder is not allowed to use the patient’s documented height and weight to calculate the BMI and assign a corresponding ICD-10-CM code. Rather, the healthcare provider must specifically document the BMI in the medical record.)
• In the physical exam, describe to the highest specificity any current associated observations (such as overweight, obese, morbidly obese, etc.).

Final assessment/impression

• Specificity: Document the overweight or obesity diagnosis to the highest level of specificity, as in “morbid obesity”, “severe obesity”, “obesity due to excess calories”, etc.
• Abbreviations: Limit or avoid altogether the use of abbreviations or acronyms. Best practice is to spell out each final diagnosis in full.
• Associated conditions: Document clear linkage between underlying conditions that caused the overweight or obesity condition and between the BMI and other diagnoses for which the BMI has clinical significance.
• Current versus historical: Do not describe a current obesity diagnosis as “history of.” In diagnosis coding, the phrase “history of” means the condition is historical and no longer exists as a current problem.

In summary

• Physicians use multiple resources and criteria to define and diagnose obesity-related conditions.
• BMI is a screening tool only. It is not the only criterion used to diagnose obesity/morbid obesity.
• Diagnosis code assignment is based on the physician’s clinical judgment and corresponding medical record description of the specific obesity condition.

Coding obesity

1) Overweight and obesity classify to subcategory E66:

• E66.Ø-Obesity due to excess calories
• E66.Ø1 Morbid(severe) obesity due to excess calories
• E66.Ø9 Other obesity due to excess calories
• E66.1 Drug-induced obesity
• E66.2 Morbid (severe) obesity with alveolar hypoventilation
• E66.3 Overweight
• E66.8 Other obesity
• E66.9 Obesity, unspecified
• Use an additional code to identify BMI if known (Z68).

2) Individuals who are overweight, obese, morbidly obese, etc., are at risk for certain medical conditions when compared to persons of normal weight. Therefore, these diagnoses always are clinically significant and reportable when they are documented and supported in the medical record as current conditions.

Returning to her hometown during the pandemic height, oncologic breast surgeon Angela Buonagura, MD, balances the emotional toll with the joys of how far we’ve come in cancer care. She feels naturally drawn to taking care of patients with breast cancer. As a woman, she feels and understands the deep emotional stress of such a scary diagnosis, not to mention the trauma from enduring the visible changes of breast surgery, treatment side effects and their prolonged, residual impact. Candidly, Buonagura admits the work she does is very stressful most days.  But perhaps it’s her grateful inner spirit that keeps her going: “Throughout my 21 years in practice, I have seen huge changes. Changes for the better. We are helping so many more patients now, often with a complete response to malignancy. It’s the only way I have been able to sustain working with such a difficult diagnosis.”

“We’ve come so far,” Buonagura emphasizes.

‍Time back on our side

‍Early in her career, the timetable - from diagnosis to treatment plan, to treatment - was just too long.  And sadly, in many cases, the patient response was lackluster. Now, with a greater sense of urgency that patients deserve - within 7 days of diagnosis - we schedule follow-up appointments, have verbal discussions, and complete any additional diagnostic tests.  And in most cases, on the same day, all clinical disciplines meet with our patients to craft a personalized, succinct, multi-step plan.  This time-saving approach sets our clinical teams up for optimal outcomes, and equally importantly, brings a peace of mind to our patients and their families.

‍Tools in the toolbox

‍For years, the oncologic community simply did not have the medical research nor the arsenal of options for our more aggressive cases. In her two-plus decades of practicing as an oncologic surgeon, Buonagura attributes groundbreaking techniques, treatments and therapies to the recent explosion of genetic research and clinical trials.

‍Teamwork makes the dream work

‍More heads are better than one, especially when they are working together at the same time, under one roof.  St. Tammany Health System’s approach accelerates multidisciplinary treatment planning (surgical oncology, genetics, medical oncology, and radiation) in the clinic with our patients – same day, most times.

‍Focus on value

‍“Doing what is best” for cancer patients means value - improved outcomes, less complications, better survival chances. In turn, the cost curve of a notoriously expensive field of healthcare will bend.  Embracing multidisciplinary, evidence-based approaches and protocols, combined with continuous and collaborative monitoring through our tumor conference, undoubtedly lowers total cost of care. Furthermore, St. Tammany’s integrative, high-risk experts focus on supporting patients and survivors manage a host of challenges that breast cancer treatment can create - hot flashes, night sweats, mood swings, joint aches, neuropathy (numbness), lymphedema (swelling), and emotional difficulties.

‍Life outside work

‍Angela Buonagura, MD, a New Orleans native, trained at LSU, practiced in Arkansas for 10 years, and now lives on the Northshore where she spent most of her formative years. She’s happily married to her “sweetheart” Matthew, and they have a daughter Mary Katherine, age 10. She acknowledges how difficult and demanding her work can be at times, constantly struggling with work-life balance - but she’s grateful for her family’s understanding and compassion. She extends that same gratitude to her team for their support and dedication, too. At the end of the day, she finds comfort in the warmth, kindness, and appreciation through her interactions with others, labelling that her “booster shot to keep going.” To help “let go,” Buonagura enjoys tennis, reading, piano, swimming, travel, biking, hiking, and watching movies. She loves Indiana Jones, Top Gun… and last but not least, Star Wars.  No doubt, for Angela Buonagura, MD, the force is with her, too.

The Ochsner Accountable Care Network, LLC (OACN) achieved its sixth consecutive year of top-ranking results in both clinical performance and healthcare savings for Louisiana's and Mississippi's Medicare population. Its network of physicians and providers who support the Medicare Shared Savings Program (MSSP) lowered expected cost of care by nearly $24 million for more than 40,000 Medicare beneficiaries in 2021. Over the last six years, OACN has improved the health outcomes for our beneficiaries and reduced healthcare spending by more than $100 million.

Why are these results significant?

In 2020, the Center for Disease Control (CDC) estimated 41% of U.S. adults delayed or avoided medical care during the pandemic because of concerns about COVID-19, including 12% who reported having avoided urgent or emergency care.

Despite making up for care delays that accumulated during 2020's COVID-19 public health emergency and a 33% growth in OACN's beneficiary population, our clinicians lowered expected care costs in 2021 by $24 million, which places OACN in the nation's top 5% of Medicare Shared Savings ACOs.

Congratulations to our OACN clinical teams and support staff for another year of success!  We look forward to sharing the savings through distribution checks, expected to release later this Fall. For more on the 2021 MSSP results, click here.

Breast Cancer Coding Tips

Current Vs. Historical Breast Cancer

Do not use the phrase “history of” to describe a current primary breast cancer. In diagnosis coding, “history of” means the condition is historical and no longer exists as a current problem.

In the final impression, do not document a simple statement of “breast cancer” to describe a historical primary breast cancer that was previously excised or eradicated and for which there is no active treatment and no evidence of disease or recurrence.

In this scenario, it is appropriate to document “history of breast cancer,” along with details of past diagnosis and treatment.

Breast cancer site(s) – primary and secondary

• Document whether current breast cancer is primary, secondary or in situ. Also, document:
• Laterally (right or left)
• The specific site of primary cancer, including the location within breast (areola, nipple, upper outer quadrant, central portion, etc.)
• The specific secondary site(s)

Treatment Plan

1. Document a clear and concise plan of care.
2. Clearly indicate whether current therapy represents:

• Active treatment of current breast cancer
• Palliative treatment of current breast cancer
• Surveillance of a historical breast cancer to monitor for recurrence
• When adjuvant therapy is used, clearly state its purpose (whether the goal of adjuvant therapy is curative, palliative or preventive).
• If referrals are made or consultations requested, indicate to whom or where the referral is made or from whom consultation advice is requested.
• Document when the patient is to be seen again.

Coding Breast Cancer as Current

Coding Breast Cancer as Historical

Breast cancer is coded as historical (Z85.3) after the breast cancer has been excised or eradicated, there is no active treatment directed to the breast cancer and there is currently no evidence of disease or recurrence.

New Suspect BPAs:

‍Hyperparathyroidism – The trigger criteria is HCC 23 – Hyperparathyroidism (1 and 2)

• Last Intact PTH Lab > 65 (within last 3 years)
• Second to last intact PTH Lab > 65 (within last 3 years)

Immunodeficiency to drugs

The trigger criteria is:

1. Has active med from grouper -OHS RX IMMUNOSUPPRESSANTS 2 [480000117] (See Below)
2. Is not a Transplant Patient

• ABATACEPT
• ABATACEPT/MALTOSE
• ACALABRUTINIB
• ADALIMUMAB
• APREMILAST
• AZATHIOPRINE
• BORTEZOMIB
• CAPECITABINE
• CARBOPLATIN
• CISPLATIN
• CYCLOPHOSPHAMIDE
• DECITABINE/CEDAZURIDINE
• DIMETHYL FUMARATE
• DOCETAXEL
• DOXORUBICIN HCL
• ETOPOSIDE
• EVEROLIMUS
• FLUOROURACIL
• GEMCITABINE HCL
• GEMCITABINE HCL IN 0.9 % NACL
• HYDROXYCHLOROQUINE SULFATE
• HYDROXYUREA
• IBRUTINIB
• IDELALISIB
• IMATINIB MESYLATE
• LEFLUNOMIDE
• LENALIDOMIDE
• MERCAPTOPURINE
• METHOTREXATE SODIUM
• MYCOPHENOLATE MOFETIL
• MYCOPHENOLATE MOFETIL HCL
• MYCOPHENOLATE SODIUM
• PACLITAXEL
• PACLITAXEL PROTEIN-BOUND
• PALBOCICLIB
• RITUXIMAB
• RUXOLITINIB PHOSPHATE
• SULFASALAZINE
• TACROLIMUS
• TEMOZOLOMIDE
• TOCILIZUMAB
• USTEKINUMAB

Two new Suspect Best Practice Advisories (BPAs) were implemented into the Hierarchical Coding Category (HCC) BPA tool in Ochsner’s instance of Epic this month. Additionally, CDE Query is now in the BPA window. Click here for the updated workflow.

Why biosimilars save billions

The US spent $407 billion on prescription drugs in 2021. But a big blow to the pharmaceutical industry is fast approaching. By 2025, 17 big name pharma molecules will lose their exclusivity, sunsetting their $60 billion annual sales trends. To take advantage, competing pharma companies created “biosimilars” – equally safe, effective and less expensive drugs comparable to their brand names.

What is a biosimilar?

A biosimilar is a biological product that is “highly similar” to and has no clinically meaningful differences from the reference product in terms of safety, purity, and potency. This is generally demonstrated through human pharmacokinetic (exposure) and pharmacodynamic (response) studies, as well as an assessment of clinical immunogenicity. To be considered “highly similar,” the biosimilar manufacturer must compare characteristics of both products, such as purity, chemical identity, and bioactivity. Minor differences between the reference product and the proposed biosimilar product in clinically inactive components are acceptable, which is why they are not required to be “identical” or “generic.” These can include differences in a product’s stabilizing agent or buffers.

Why use biosimilars?

While biosimilar “specialty” drugs make up only two to three percent of prescriptions, they account for between 40 and 50% of total drug spending. To reign in these unsustainable trends, provider adoption of biosimilar agents may help alleviate financial pressures and access challenges felt by patients and the industry.

At the pharmacy counter, preferred biosimilar products can provide less expensive copays than their reference counterparts. They also aim to lower overall cost, decreasing patient premiums and the PBM burden on employers. This expansion of options, combined with emerging high-volume biologics, such as adalimumab and etanercept, could potentially save patients and industry service providers $38.4 billion between 2021 and 2025.

In a recent Drug Channels blog written by Adam Fein, PhD, he states that “pharmaceuticals are the only part of the U.S. healthcare system in which the difference between list and net prices is monetized as rebates and redistributed by PBMs to payers. The distortions associated with this industry structure have been well reported.” (For example, see Section 9.3. 2021 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers .)

Biosimilars address two big challenges patients and providers face globally in healthcare – affordability and access. These alternative drugs thwart out-of-control brand name drug costs, and therefore give patients more options and better access to life-changing treatments for these six complex conditions:

• Diabetes
• Cancer
• Chronic skin diseases like psoriasis
• Digestive diseases like Crohn’s ulcerative colitis
• Kidney diseases
• Arthritis

What can you do now?

Start discussions with your patients currently on specialty agents, like Humira, to reduce issues or confusion in the future.

References:

FDA: Biosimilar and Interchangeable Products https://www.fda.gov/drugs/biosimilars/biosimilar-and-interchangeable-products

Express Scripts: The $250 Billion Potential of Biosimilars http://lab.express-scripts.com/lab/insights/industry-updates/the-$250-billion-potential-of-biosimilars

IQVIA.com: Medicine use and spending in the U.S.: a review of 2017 and outlook to 2022 https://www.iqvia.com/insights/the-iqvia-institute/reports/medicine-use-and-spending-in-the-us-review-of-2017-outlook-to-2022

On burnout, value-based care and rural medicine

Every single day in the year 2019, at least one doctor committed suicide. Family physicians are in the top five specialties at the highest risk for burnout, and about 60% of them won’t seek help.

“That’s what motivates me.”

Dr. Chris Foret, top-performing family medicine physician in rural St. Tammany parish, serves as an American Academy of Family Physicians “Leading Physician Wellness Scholar.” He joins 120 of his fellow AAFP physician colleagues around the country seeking to harness tools to combat burnout, improve clinical teamwork and promote higher value in healthcare.

“The physician can’t do this alone.”

Foret recently gave a talk at the LAFP Annual Assembly held in New Orleans, LA. He says that much of healthcare’s responsibilities fall on the shoulders of physicians…

“You don’t have to ask a physician to know whether he or she is burned out…”

That’s where communication and teamwork come in. These aspects of operational medicine are the keys to cultivating joy at work, and at the same time, advancing care and outcomes for patients.

If you talk to Dr. Chris Foret on the phone, you can almost hear the smile in his voice. How is that possible? “Improvement begins and ends with our staff,” Foret explains. They make his job easier and better, and so he tries to  extend gratitude towards them every five to six days. He also acknowledges that mindfulness, good sleep, exercise, and a healthy diet reduce the effects burnout.

In addition to practicing gratitude and living well, the AAFP recommends that physicians should seek to rediscover purpose in their work. When asked what he’s passionate about, Foret points to population health and the emphasis on primary care. As a high-scoring rural practitioner and member of OHN, he’s excited about bringing value-driven care to his patients, rather than expecting patients to travel away from home for important services. He and his staff take pride in teaching patients how weight control, diabetes management and cancer screenings can not only save lives, but also save money on their healthcare bills. He's particularly pleased with St. Tammany Parish Hospital’s “Be Well” bus – a mobile mammography unit – where hundreds of his at-risk patients have been screened for breast cancer. Also, the uptick in compliance with fecal immunochemical testing – a seemingly “easier-to-sell” and lower-cost alternative to colonoscopy – has made early detection of colon cancer a reality for many in his community.

Foret, married 28 years and father of a third-year medical student, enjoys traveling, Cross Fit, pickle ball, and jogging. He also reads – his favorites include Phone Calls from Heaven, by Mitch Albom, anything by James Patterson, and the wisdom of Brene’ Brown.

Foret’s approach to his career, dedication to reversing the burnout trends among his fellow physicians and work-life balance are commendable. Perhaps there’s nothing like a daughter following in her father’s footsteps to inspire physician champions like Chris Foret. “We owe it our young doctors to get this right,” he concludes.

For more tools on burnout, read AAFP’s latest information.

(Pictured: Three generations of Foret physicians!)

3 top clinical questions answered

Whether due to race, ethnicity, gender or low socioeconomic status, health inequity is a complex issue that requires careful investigation and novel solutions. In 2020, when Ochsner Health announced the Healthy State by 2030 initiative, chronic kidney disease (CKD) was identified as a focus area in order to improve Louisiana’s high rate of people living with multiple chronic conditions. Delivering on that commitment, Ochsner Health and Ochsner Health Network removed race from CKD calculations beginning August 1, 2022, a move that will ultimately lead to earlier detection and treatment of CKD in our communities. One in seven Americans suffer from CKD. Practicing physicians in the deep South – whether in primary, specialty, or emergency care – see patients pervasively with both obvious and not-so-obvious risks. And yet a staggering forty percent of the at-risk population remain unaware of their condition. (CDC.gov/kidneydisease)

Black/African American patients experience higher risk for developing kidney disease, especially among older age groups. Furthermore, factoring race, technically a social construct and not a biological one, has been shown to skew accuracy of CKD diagnosis… the standard eGFR (estimated Glomerular Filtration Rate) overestimates kidney function among African Americans, and, in turn, studies have shown impediments to diagnosis, delays in treatment and transplantation, and poor outcomes.

“Removing race from the clinical formula to evaluate kidney function marks another stride in Ochsner’s quest to improve healthcare access for all, with inclusivity at the heart of our mission,” commented Ochsner Health Chief Population Health Office Phil Oravetz, MD.

Below, Oravetz discusses the need-to-know facts for Ochsner Health Network clinicians regarding this great step towards removing racial disparities in medical diagnostics and scaling better access to top quality healthcare:

1. What’s the issue with using the traditional eGFR for evaluating kidney function?
   Recently, healthcare studies showed that factoring race into CKD diagnostic calculations, namely the eGFR, led to delays in specialty referral care, kidney transplantation and poorer outcomes among Black/African American patients.
   
   Data indicate that Black/African American patients experience higher risks for developing chronic kidney disease (CKD), including the development end-stage renal disease (ESRD). Old diagnostic equations reported different values for Black/African Americans and non-Black/African American patients, assuming that Black/African American patients had higher muscle mass. In turn, studies point to under-diagnosing CKD and ESRD among Black/African American patients, leading to greater risk, progression of disease, and worsened outcomes.
   
   
2. What can patients and clinicians expect with the new eGFR?
   Now live in EPIC, removing race from the eGFR value will increase the sensitivity of the calculation for patients with chronic kidney disease.
   
   Practical Implication : More patients, particularly Black/African Americans, will appear to have lower eGFRs than prior to this change by approximately 16%, and this may cause some anxiety for the patients with a new “abnormal” lab value.
   Clinical Implication: Patients being considered for renal transplant will be more likely to reach transplant evaluation threshold and in a shorter time when the race parameter is not used, as guidelines advise an eGFR threshold of <20 mL/min before moving to transplantation evaluation.
   
   
3. What will the potentially higher CKD incidence among my patient panel mean for performance data?
   Our physician and clinical advisory groups agree that this is the absolute “right thing to do.” While prevalence rates might increase initially, we expect to see improvements overall… using Ochsner Health Network’s population health tools and support services, metrics in disease management, outcomes and mortality rates should trend more favorably.

Studies estimate that 27% of medical malpractice claims result from poor doctor-patient communication. Despite the best intentions and thorough explanations of diagnoses, tests, results and treatments, patients can walk away from discussions with their provider without a good understanding.

The American Medical Association is taking on common clinical topics facing physicians today and what they wish their patients knew. Topics range from monkey pox to mask-wearing, and vaccinations to Colo-rectal screening guidelines. Get the AMA’s latest releases below:

What doctors wish patients knew about monkeypox

What doctors wish patients knew about wearing N95 masks

What doctors wish patients knew about colon cancer screening

What doctors wish parents knew about kids' COVID-19 vaccine safety

What doctors wish patients knew about prior authorization

To follow the AMA’s series “What Doctors Wish Patients Knew,” click here.

For resources on advancing clinical communication skills, get the Agency for Healthcare Research and Quality (AHRQ) downloadable guide.

AMA survey reveals MD burnout hack

“My sense of purpose for going into medicine has been severed.”

That’s how Dr. Kenny Cole characterizes the emotional underpinnings of professional burnout many physicians feel.

Half of doctors are burned out. Chances are, you are, too. The AMA discusses two “biggies” that fuel the flames. And as you read on, you’ll discover the one common activity that reduced physician burnout by 59% and what three of your fellow Ochsner Health Network physician colleagues have to say about it.

Physician burnout can be characterized by emotional exhaustion and depersonalization.

Emotional exhaustion: refers to feelings of being emotionally overextended and drained by others.

Depersonalization: a distant or indifferent attitude towards work.

These dynamics rear their ugly heads in the forms of negative, callous, and cynical behaviors; or interacting with colleagues or patients in an impersonal manner. Furthermore, the AMA self-scoring quiz on physician burnout gets at 12 dynamics through their short, self-scoring survey tool:

• Working constantly, spending little time and with friends or family
• Problems in personal relationships, issues with co-workers, feeling underappreciated
• Lacking compassion, patience, prone to overreaction or outbursts
• Dreading going to work, lacking enthusiasm, negative talk about patients, co-workers and/or procedures
• Losing confidence, self-esteem, sensing a lack of control over personal and professional issues
• Chronic psychological, emotional or physical fatigue
• Lacking concentration or attention
• Increasing use of alcohol, drugs and decreasing health coping habits
• Lacking engagement in healthy activities like exercise, outdoor fun, relaxation
• Talking about giving up medicine, retiring early, or regret for choosing medical career
• No interest in planning or taking vacations, time off or other outside activities
• Losing interest in family, financial and/or retirement planning

NOW READ THIS!

A recent AMA survey found that physicians who reported reading books also reduced burnout by as much as 59%. Here’s what three of your physician colleagues Ochsner Health Network had to say about reading:

Dr. Chaillie Daniel on reading:

“We take ourselves too seriously, sometimes,” says Dr. Chaillie Daniel, primary care physician, father of six children ages 12-24, and grandfather of one baby girl. His current favorite book series, by G.K. Chesterton, is a play on humanity through theology. “Whether it’s flying or reading, the time-out allows me to get away from the world, almost like fantasy.” He also relies on the internet for reading anything and everything – whether it’s how to fix something or finding out whether Cinco de Mayo is really Independence Day for Mexico!

Dr. Wanda Robinson on reading:

“When I do get time to read, I mostly choose the Bible,” comments Dr. Wanda Robinson, family physician in the Greater New Orleans area. In other parts of the country, Duke University recognized the power of confronting physician burnout through faith. They offer a CME course designed to help reconnect physicians with their calling to medicine through faith-based tools and teachings. No matter the spiritual roots, connecting one’s faith or belief system with their professional calling can breathe new life into the work mindset.

Dr. Kenny Cole on reading:

“Reconnecting with that deep sense of purpose and restoring the joy of practice is something I strive for every day. Reading, both for relaxation as well as self-improvement, are essential to that process,” reveals Dr Kenny Cole, infectious disease specialist and System VP of Clinical Improvement for Ochsner Health. Happily married and father of two children - ages 28 and 23— Cole takes time to read, among other pass times like cooking, spending time family, and connecting with friends. His favorites reads are The Engaged Caregiver, Dr. Tom Lee; Finding Joy in Medicine, Dr. Reza Manesh, and How Physicians Can Fix Healthcare, Chris Tremble.

Click below to take the quiz for yourself or a colleague whom you may be concerned about.

AMA self-scoring quiz on physician burnout

“Some of my patients didn’t make it,” recounted Tyler Perrin-Bellelo, MD, Lafayette internist and mother of three, all under the age of five.

By nature, many of us in medicine try to be heroic. We sometimes try to do “too much.” COVID-19 wreaked havoc on her hospital patients, and for Perrin-Bellelo, chair of general medicine, she faced tremendous stress taking care of inpatients while managing a busy outpatient primary care clinic.

She and her colleagues lost patients, despite their best and tireless efforts. Perhaps it was the strength she gained from her twins, born shortly before the pandemic and her eldest daughter who was three at the time that kept her going. “I knew I had to keep going for my girls, just as I had to keep going for my patients. Abandoning ship was absolutely not an option.” She also shared that her support system – friends, parents, staff – are who helped her endure the struggle she was facing.

Perrin-Bellelo admits that at times, the stress was overwhelming, but a few difference-makers enabled her to overcome the chaos:

• Support network: Perrin-Bellelo says that she learned the repercussions of spreading herself too thin… so she actively and gratefully enlists the help of others, including a nanny for her children. She also attests to the power and efficiencies that come with running a practice with a nurse practitioner. Her patient satisfaction scores are soaring, and claims “joy in work” – all amidst post-COVID staffing shortages and the obligations of family life.
• Partnership: Whether it’s her husband who she jovially claims “takes care of everything,” or Ochsner Health Network who provides access to physician specialist experts, Perrin-Bellelo recognizes that doctors MUST be able to give patients what they need and deserve – expertise, access and emotional support. Perrin-Bellelo agrees that happier patients make happier doctors, who make happier partners and parents, in turn, and vice versa.
• Self-care, self-talk: Perrin-Bellelo knew that she needed to do something during the height of pandemic losses and stress at work. She maintained that she would be the “voice of gratitude and comfort” for her amazing patients, colleagues and staff. And in order to do that, she remembers repeating to herself “this stress won’t last forever” and “this too shall pass.” She also made herself “get out” to clear her mind, so she started tennis lessons for exercise and social enjoyment.

Without a doubt, Perrin-Bellelo’s attitude towards work (and life in general) is a shining example. With two feet firmly planted on the ground, and a sense of resounding gratitude, she remains optimistic about some of the painful-yet-necessary hurdles physicians face – adjusting to EPIC’s ever-changing and ever-improving electronic medical record and interfaces; leveraging the real-time, transparent data her physician dashboard and scorecard provide; and owning the role of “bus driver” that primary care patients so desperately need.

“With change, comes pain. But I try really hard to find joy in little victories every single day. COVID has helped me appreciate people and progress more. Life is so precious.”

Chair of General Medicine for Ochsner Lafayette General, Tyler Perrin-Bellelo, MD, has been serving patients since 2015. She practices inpatient and outpatient internal medicine in Lafayette, Louisiana, where she lives with her family – husband Bryan, and daughters Mia (5), Madeline (2), and Chloé (2).

Dr. Nigel Girgrah shares story with AMA

Answer the following questions:

• Are you deeply driven?
• Are you highly conscientious?
• Do you doubt yourself at times?
• Do you get anxious?
• Do you suffer from self-imposed guilt?
• Do you sometimes feel overwhelmed, like work is getting “out of control”?

We all have our own burnout stories. Physician specialist Nigel Girgrah, MD, has his own, too. Struck by the death of a friend who committed suicide in 2009, he began his own journey to research and understand mental health challenges in the workplace, the seeds of his career as Chief Wellness Officer at Ochsner Health.

Recently, Girgrah sat down with the AMA to discuss physician burnout and the importance of destigmatizing mental health for physicians in the workplace. He notes that being open, honest and vulnerable in how we communicate with colleagues in the workplace, especially when we are burned out, is paramount. He adds that communicating authentically is character-building, and builds healthier cultures at the same time.

Today, start small with addressing your own burnout. Consider taking a walk, going for a bike ride, or on your car ride home, play Girgrah’s podcast “Creating a Culture That Supports Well-Being” with the American Medical Association.

Many eligible patients report no statin offer

A JAMA meta-analysis indicated that when prescribed to patients with coronary heart disease (CHD), statins reduced ischemia by 61%. But more than half of statin-eligible patients reported never being offered by their doctor. Among those offered, side effects were the most common concern, and most were willing to consider (or reconsider) if their doctor offered.

To reduce risk among patients battling chronic disease, or those on the cusp, check out OHN’s best practice protocols and coding tips for statin use. Stay tuned for support and outreach offerings from our Pharmacy team coming soon!

Statin Use Measures

The latest from the AMA

Dr. Devang Sanghavi, an intensivist and medical director of the medical intensive care unit (ICU) at Mayo Clinic in Jacksonville, Florida, has treated 100 patients to date with long Covid. He recently reported more information on the three types and what doctors wish patients knew.

Long Covid occurs in at least 10-30% of post Covid patients, including children. The symptoms – all over the map – can mask as other similar conditions. “There's a whole slew of symptoms affecting a variety of organ systems,” Dr. Sanghavi said. “No organ system is spared from long Covid, just like how Covid affects all these organ systems during acute illness.”

From gastrointestinal issues to cardiac symptoms to functional kidney difficulties, long Covid must be carefully evaluated. The symptoms, complicated by cognitive challenges and mental health struggles, are clustered and sometimes masquerade as other conditions, making diagnosis difficult. Sanghavi points out that many healthcare organizations have established post Covid clinics to focus attention on this complex condition, which happens to affect more women, middle aged, than men. Here’s the audio inside scoop on life inside a post Covid clinics.

For a compelling personal clinical narrative on the importance of listening while treating invisible illness and long haul Covid-19, published by the AMA’s Journal of Ethics, click here.

In light of today’s growing pervasiveness of long Covid, OHN physicians are encouraged to hardwire the scheduling of annual wellness visits (AWV), paying additional attention to compliance among patients who have tested positive for Covid-19, and potentially battling long Covid.

CMS’s new ACO model announced

In hopes of improving health equity and participant experience, The CMS Innovation Center recently unveiled its answer to the original ACO model: ACO Realizing Equity, Access, and Community Health (ACO REACH) Model. “As a national leader in ACO performance, Ochsner Accountable Care Network (OACN) is encouraged by the new REACH model’s intent to better align risk-based payment models, including MSSP; empower provider-led organizations; and leverage data to support provider care coordination, especially among underserved and high needs beneficiaries,” commented Beau Raymond, MD, OACN Medical Director. “Our clinically-led board and leadership team continue to study the new proposed model and will keep providers informed on developments.”

The new REACH model will retain core features of the original model, including allowing providers to take on higher levels of financial risk and reward for their traditional Medicare patients, while adding focus on health equity and social determinants of health by addressing the additional needs of underserved beneficiaries in several ways:

• Health Equity Plans: Each participant ACO will be required to develop a Health Equity Plan and annually report on plan progress and plan outcomes.
• Beneficiary Engagement Incentives and Beneficiary Enhancements: Participant ACOs can provide beneficiaries with engagement incentives and in-kind benefits to encourage better management of chronic conditions. An example of a beneficiary in-kind benefit is, potentially providing a hypertensive patient with a blood pressure cuff for home use.
• Demographic Data Collection: ACO REACH participants are required to capture and report beneficiary reported demographic data, including race, ethnicity, language, gender identity and sexual orientation.

CMS plans to go live with participation beginning January 2023. OACN looks forward to sharing more with provider participants as it considers REACH’s potential for caring for our own Gulf South communities.

To learn more, click here for CMS’ resource page.

Matt Malachowski, Pharm.D., sizes up fenofibrate formulations. With little clinical variation but big price differences, selecting this recommended dose could help save patients hundreds of dollars each month.

“The Dose” is a monthly pharmacy message from Ochsner Health Pharmacy’s System Director ofPopulation Health and Ambulatory Care, Matthew Malachowski, Pharm.D., MHA, BCPS. In the first edition, Matt evaluates fenofibrate formulations that have little clinical variation but big price differences.

In conjunction with diet and exercise, fenofibrates are indicated for the treatment of adults with hypertriglyceridemia and hypercholesterolemia. Fibrate therapy can reduce TG levels by as much as 50 percent. When choosing a fibrate, fenofibrate has some advantages over gemfibrozil such as fewer drug-drug interactions, and better patient compliance due to once-daily dosing. Fenofibrate is associated with a lower incidence of myopathy when used in conjunction with statins.

One of the major differences between generic formulations of fenofibrate is the cost. In the chart below, you can see how slight changes in dosage (and little to no change in efficacy) can increase the cost up to 97%. "While there’s no one-size-fits-all dose, the next time you prescribe fenofibrate to a patient, consider the 134 mg, once daily micronized capsule" says Malachowski. An estimated 30 days’ supply is only $13.

Fibrates can inhibit the metabolism of warfarin and should be used with caution when prescribed concurrently. Clinicians should monitor liver enzymes in patients taking fenofibrate.

Changes double people eligible for lung cancer screening

The United States Preventative Task Force (USPSTF) has updated their 2013 recommendation on lung cancer screenings for people who do not have signs or symptoms. The newly published recommendation lowers the age for starting annual screenings from 55 to 50, and it updates the definition of a 'heavy smoker' from a 30- to a 20-pack-year history, doubling the number of people eligible for screening. Read full details of the final recommendation. 

And remember that through the state's Smoking Cessation Trust, your patients have free access to resources.

• To connect your patients with nearby smoking cessation services, call toll free 1.844.371.5806.
• To automate the referral process in EPIC, select REF100 or email tobaccofree@ochsner.org for help.
• For community physicians interested in more information, contact Lindsey White, Director of Smoking Cessation at 504.842.7490.

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Launched last month, Ochsner Health Network's (OHN) new physician dashboard has a wealth of analytics geared to support scorecard goals and help us move the population health needle.

One new feature - for primary care providers who are part of an OHN value-based contract - is the ability to pull timely and actionable reports around emergency department overutilization. A quick glance at the dashboard above your physician scorecard gives you a snapshot of the total number of attributed patients you currently have loaded in the scorecard who are part of a value-based contract.

You can drill down even further to see:

• ED encounter details. Just hover over "Num of ED Visits" to see
• medical record number
• patient name
• age, sex
• communication preference
• number of ED visits
• last & next primary care appointment
• OPCM eligibility
• digital medicine eligibility
• last inpatient discharge
• which value-based contract they are a part of
• link to the patient chart for outreach or more information

Stay tuned to Provider Network News to learn more about the features and functionality of the new OHN scorecard and dashboard. As always, OHN performance improvement staff are available for clinical and technical support – questions can be emailed to OHNAdmin@ochsner.org.

Ua/c now the ADA medical standard

The National Committee on Quality Assurance (NCQA), American Diabetes Association (ADA) and National Kidney Foundation (NKF) recommends an estimated glomerular filtration rate (eGFR) and urine albumin/creatine (Ua/c) ratio to evaluate kidney function in Diabetic patients. The urine microalbumin (Ualb) screening test is no longer considered best practice.

Get the Standards in Medical Care for Diabetes with additional practice resources here, and please ensure that your order set includes this screening test.