Sunday, December 13, 2015

Physicians freshen up your coding and documentation today before it costs you thousands!

General Findings 258 services were evaluated as part of this audit Under current guidelines * 90 (35%) of the services reviewed were properly billed and documented. * 18 (7%) of the services reviewed contained billing and/or documentation errors which Resulted in potential overpayments (under documented). * 150 (58%) of the services reviewed contained billing and/or documentation errors This resulted in actual underpayments (under billed). Under new/proposed guidelines * 109 (42%) of the services reviewed were properly billed and documented. 30 (12%) of the services reviewed contained billing and/or documentation errors Which resulted in potential overpayments (under documented)? * 119 (46%) of the services reviewed contained billing and/or documentation errors resulted in actual underpayments (under billed). Evaluation and Management Services 117 Evaluation and Management (E&M) services were evaluated as part of this audit. Under current guidelines * 36 (31%) of the services reviewed were properly billed and documented. * 14 (12%) of the services reviewed contained billing and/or documentation errors Which resulted in potential overpayments (under documented)? * 67 (57%) of the services reviewed contained billing and/or documentation errors Which resulted in actual underpayments (under billed)? Under new/proposed guidelines * 55 (47%) of the services reviewed were properly billed and documented. * 26 (22%) of the services reviewed contained billing and/or documentation errors Which resulted in potential overpayments (under documented)? * 36 (31%) of the services reviewed contained billing and/or documentation errors which resulted in actual underpayments (under billed). Specific Documentation/Billing Errors * the chief complaint is not always clearly stated. * Exams are a little to brief to support the codes appropriate for this practice. * Billing of established patient visits is too conservative. * Injections are not properly documented. * Injections are not properly billed. Documentation Problems Noted & Recommended Solutions Problem: The chief complaint is not always shown. On several, it is just implied. For instance, on one visit dated 2/23/05, the note states “Female doing well. In for lab results.” This leaves the medical need for the visit in question. Since the chief complaint justifies the need for the visit and any testing that may be ordered, it should be clearly and specifically stated at the beginning of the note to avoid confusion. Recommendation: Make it a habit to specifically state the medical problem or symptom to be addressed. While the problem may be a continuation of one addressed at the previous visit (as in this case), every note should be documented to stand alone on its own merit. Thus, should an audit occur, it is not necessary to provide notes other than the ones in question, minimizing an auditor’s access to other notes with potential errors. We also suggest that you make it a habit to include one fact about the chief complaint and a review of one system on every patient with an acute problem. This will help support the level of visit most appropriate to that situation. For instance, the history for a patient with a simple infection might read “Sore throat x 3 days. No fever.” This translates into an expanded history (99202 on new patients and 99213 on established). Problem: Using the proposed guidelines, the exam is occasionally too brief to support the codes appropriate for your care. Judging from your notes, it is obvious that the care is provided. However, some of the details of that exam are missing. For example, one child was seen on 2/2/06 for pulling at her ears. She had an ear infection, which warrants a level III (99213). To properly document that code, you need 6 exam findings. You gave 4. “ENT: TMs red. Pharynx unable to visualize. Lungs CTA. Heart RRR.” Recommendation: Be careful how you state your exam. Did you check the nasal mucosa? Did you check the lymph nodes in the neck? The addition of those two facts would have brought your documentation up to appropriate levels. Strive for 6 exam findings on all patients with simple, acute problems. Note: Your medical assistant doesn’t always get three vital signs. Usually, just 2 were listed. If she were to make it a habit to get 3 vitals on every patient, rather than 2, that would count as one exam finding for you. Problem: You are too conservative in your billing. The majority of services are billed as level II follow-up visits (99212). However, the majority of these visits qualify for level III (99213). This is a loss of approximately $10-$15 for each of these visits. In fact, there were several visits documenting your involvement in the exam and decision-making that were billed as level I follow-up visits (99211). This is the lowest level visit code and is intended to be used when you provide a minimal service (without an exam or counseling) or direct incidental services provided by a nurse or medical assistant. All of these visits warranted a level II (99212) or level III (99213). The improper use of 99211could amount to a considerable loss of revenue over a period - perhaps as much as $30- 40,000 a year. Recommendation: No follow-up visit should be billed lower than level II if you examine or counsel a patient. Bill level I only if you or your nurse or medical assistant provides a minimal service such as checking blood pressure, monitoring a patient’s weight, or changing a dressing. Level II should be used for those patients who present for minor problems (cold, insect bite, skin rash, etc.) that you treat with over-the-counter meds, ice packs, or bandages. It would also be appropriate for patients who are returning for rechecks after completing a course of treatment. Such patients seldom require more than a focused exam of one system. The majority of your acute-care follow-up visits should have been coded as level III (99213). This represents those patients seen for acute, uncomplicated problems or a stable chronic illness in which prescription drugs are ordered or changed. (Note: Medicare representatives have said that simply continuing current meds is not management.) Included in this level would be those patients with sprains, acute infections, stable diabetics, etc. These patients usually require an exam of 2 systems with 6 exam findings. Level IV (99214) should be used for those patients who have multiple medical problems to be considered, who have a chronic problem which is worsening or who have an acute problem with complications. Complicated injuries also fall into this category. Treatment May involve drug management or major surgery and may include extensive testing. Such conditions usually require an in-depth evaluation of twelve elements from two systems. Level V (99215) should be used with great care for patients in crisis. This would include patients with multiple medical problems that are worsening or people in life-threatening circumstances. Usual treatment at this level includes drug management with monitoring or consideration of high-risk surgery. In these circumstances, a comprehensive exam must be included. Problem: No entries were made about the amount of time spent in counseling. There were several patients for whom no exam or history was noted but who obviously received a lot of counseling. Failure to record counseling could result in significant underpayments. Recommendation: Recognize situations in which counseling is likely to play a major role. This could be patients with Alzheimer’s or depression, patients in for test results, or those who are non-compliant with therapy. When more than 50% of the time you spend face-to-face with the patient is for counseling, you can bill based on time - in spite of any other documentation which may or may not be recorded. You must document the total time spent with the patient, the amount of time spent in counseling and a brief description of the conversation. Thus, a “25-minute visit more than half of which was spent discussing the importance of diet, exercise and weight control in the management of diabetes” becomes a level IV (99214) visit - even if you did not record a history or exam. Problem: Injections were not always documented correctly. The chart entries did not always note the type of drug given, the dosage administered, how given, or the site of administration. Not only will an auditor consider these services undocumented without all of this information, but also such omissions often lead to improper or omitted billing. Recommendation: The physician is responsible for documenting the order for the injection. However, whoever administers the injection should record the exact name of the drug used, dosage, method, and site of administration. The name of the drug, dose, and method of administration should also be noted on the charge ticket since that information is necessary to properly bill for the service. Note: Several of the injections were noted as “Deca /Depo”. This is inappropriate documentation. Deca what? Depo what? What doses? It is never appropriate to use this type of shortcut in documentation. It can lead to inappropriate treatment and be used against you in a malpractice suit, not to mention the problems it can cause in an audit situation. Problem: Injections were inappropriately billed throughout this audit. Many were blatantly misbilled by circling the wrong drugs on the charge ticket. Others were not billed at all. Many were billed in dosages smaller than those administered were. Administration was often either not billed (when it may have been appropriate) or billed with incorrect codes. The error ratio on injections is near 100%. This not only represents actual losses to the practice, but also could lead to problems should an audit arise. Recommendation: (all of the following changes must be made to correct this problem) 1. The charge ticket should be revised to include the dosage represented by the codes shown. For instance, your charge ticket shows that Rocephin is to be coded as J0696. It fails to show, however, that this code represents only 250 mg. Many practices Administer much more than this to their adult patients. 2. You cannot substitute one drug for another in billing. If Lincocin is billed, that must be what is given and documented. If you give a drug not listed on the charge ticket, you must list the exact name of the drug given and the dose. 3. Always be sure to indicate the dose administered on the charge ticket. If you do not, the code is billed “times one”. Failure to do so resulted in a 75% loss on 14 injections we reviewed. The biggest loss came on Toradol. Code J1885 represents only 15mg, But you gave 60mg. Additional losses came on Lincocin, which is indicated on the charge ticket to represent 300mg, but you gave 600mg. 4. There should be a charge for every injection given and for every service provided. There were 25 services in this audit for which no fee was made - 18 of those injections. This is not only a loss of revenue; it creates an expense and liability to the organization. 5. Administration may be billed separately to some private carriers. While Medicare and other Government plans consider the administration of injections to be ‘bundled’ into the allowable for the office visit, some private carriers do not. Check with those Carriers to see when they allow you to bill separately. 6. Administration of injections and infusion therapy should never be coded as 99211. This is a misrepresentation of the service provided and has been identified by HCFA as one of the most abusive situations existing in Medicare today. For that reason, they Will look at claims billed with 99211 and drugs to determine who is abusing the system. Don’t let this mistake make you a victim. Utilize the correct code for IM administration (90782). As for infusion, using 99211 represents a loss, since the correct code for infusion therapy (90780) actually pays more than 99211. Note: The notes for 03/12/10 do not show what agent is being infused. That is an absolute necessity to properly document this service. Please pull this chart and make this addition/correction. Your documentation is excellent, but it is important your billing technique change since it is obvious, as stated above, you are under-billing visits the majority of the time. We understand that many practitioners tend to bill at lower levels because they feel that: 1) Billing low codes safeguards them from an audit or 2) They practice in a rural community and want to save the patients money. These are based upon misconceptions, however. First, any billing practice (high or low) that is aberrant can target you for an audit. Billing the lower code (99212) just guarantees you a loss to your practice. In addition, you are not really saving your patients a great deal of money when you bill a lower code. Most of your patients have insurance that either a) pays 80% of the bill or b) has set co-pay for each visit - regardless of the code billed. If you reduce your code from 99213 to 99212 to save the patient money, you failed. If their plan has fixed copay, the patient pays the same amount, but you saved the insurance company $10. If their Plan pays 80% (as in Medicare), you save the patient $2 (20% of $10) and the insurance carrier $8. You, however, lost the whole $10. That’s why the most significant problem for you to address is your coding. Your documentation needs only minor adjustments. A third point to make is that HMO & PPO plans often make judgments about the level of care provided their patients based upon the codes submitted. If you only bill the lower level codes, they may assume that their patients are not receiving adequate care and either a) suspend your contract or b) reduce future capitated payments to you. I hope the information provided because of this audit is helpful to you. Should you have questions about the audit or results, please feel free to contact me at (323) 603-8333. Sincerely, Troy Lair The Compliance Doctor, LLC Patient: 216597-5 Coded as 99212 and under-documented Documentation to support 99212 could be: History: (need CC & HPI) History: (need CC & HPI) CC: General ?up - f/u difference in home BP CC: HBP f/u - difference in home BP Machine Machine HPI: 2 point difference, some fatigue HPI: 2 point difference, some fatigue Exam: (Need 1 finding) Exam: Wt, BP, & pulse rate/regularity Only Wt & BP shown (inadequate Need 3 vitals) Dx: None Given DX: HBP stable Plan: None Given (just shows needs annual) Plan: Continue meds which are --- By simply including the highlighted information, the code billed (which was appropriate For the condition treated) would be supported by the documentation. Failure to include That information created an overpayment of approximately $12-$15. Patient: 336789-5 Coded as 99213, but under-documented Documentation to support 99213 could be: History: (need CC, HPI & ROS) History: (need CC, HPI & ROS) CC: F/U HBP, GERD & anxiety CC: F/U HBP, GERD & anxiety HPI: On Xanax (modifying factor) HPI: On Xanax (modifying factor) ROS: No SOB Exam: (Need 6 findings) Exam: Wt & BP shown (inadequate - need 3) 1. Wt, BP, & pulse rate/regularity 1. Chest clears 2. Good color 2. No edema 3. Relaxed, no anxiety 4. Lungs CTA 5. HRRR 6. No edema Dx: None Given DX: HBP, GERD, anxiety stable Plan: Refill Xanax & get flu/pneumonia shots Plan: Refill Xanax & get flu/pneumonia shots By simply including the highlighted information, the code billed (which was appropriate for the condition treated) would be supported by the documentation. Failure to include that information created an overpayment of approximately $12-$15.

Wednesday, November 18, 2015

The things you need to know before you decide to build and construct a new ambulatory surgery center.

     Certification of an ambulatory unit by Centers for Medicare and Medicaid Services (CMS) is essential for any facility that wants to be reimbursed by Medicare and Medicaid for patient services.

     Accreditation of the facility is recommended to verify that the center meets the specific criteria that are indicative of high quality care. Construction Operating Rooms The number and size of the ORs in the unit must be determined first.

    Each OR should have a substerile room adjacent for entry and scrub sinks in the immediate area. There should be one scrub sink per two ORs. In the OR, there should be sufficient space for sterile supplies and equipment as well as an anesthesia machine (if desired) and anesthesia supplies.

     In general, approximately 3000 sq ft of surgery center space is needed for each OR, with each OR providing 1000-1500 cases per year. In addition, three preoperative and three postoperative bays per OR should be included in the design for maximum efficiency. The OR size should range from 14 × 16 to 14 × 20 sq ft. Remaining open floor space is the most important factor after considering all equipment, plumbing, air conditioning, cabinets, etc.

     Selection of floor and wall coverings may impact costs of maintenance and cleaning. Iodine-based prepping solutions and various dyes may stain certain floors. Tile walls will facilitate terminal cleaning of ORs. Preoperative Holding Areas Two or three preoperative holding areas per OR are generally needed to keep adequate processing and flow of patients into the OR. There should be a planned restroom for the patients in this area for voiding prior to OR. There should be lockers available for the patients to secure their clothes and personal possessions.

     Recovery Rooms two or three recovery room beds per OR are needed to achieve optimum efficiency of the facility. This area must be staffed by nursing for postoperative monitoring. It is acceptable to use the preoperative admitting rooms for second-phase recovery.

     Handwashing stations in the recovery room are essential. Support areas in the postanesthesia care unit for medication preparation, supply storage, soiled linen, and equipment storage must also be considered. Storage space, along with suction and oxygen, should also be available at each bay. Typically, all medications for the facility (particularly controlled substances) are kept in one area located within the recovery room as this area is readily available to staff and under continual observation.

     Individual lighting for each bay allows for optimal patient comfort. Some access to natural light while providing privacy (such as clerestory windows) also promotes a sense of wellbeing for patients and staff. In addition, recovery areas must have a designated “kitchen” area to provide oral intake for patients after surgery. Specific requirements for food preparation vary from state to state, so these laws should also be considered when designing the recovery area. 2012 Operating Room Design Manual Operating Room Equipment Storage An OR equipment storage area must be planned to store supplies and OR equipment (e.g., mayo stands, kick buckets, etc.).

     Obtaining the footprint for large storage items (e.g., cribs, mobile x-ray equipment, video towers, wheelchairs, lasers, microscopes, etc.) prior to design will help ensure that storage areas are sufficiently large for anticipated current use and potential expansion. Moving electronic equipment may cause expensive damage, so locating storage areas in close proximity to ORs both for efficiency and to minimize breakage is advised. Additional Areas Control center. It is advised to designate a central location in the OR suite where all activities in the ORs are monitored. The area must be situated to allow visualization of all pedestrian traffic entering the restricted area. Soiled utility room. An area is required for dirty supplies and linens as well as providing a space for waste receptacles. Sterilization center.

     There should be a separate area for cleaning and decontaminating instruments for sterilization. Space should be allotted for sterilizing equipment needed for the procedures. Laboratory. It is desirable to have a small area located near the preoperative area for laboratory testing (e.g., blood glucose or pregnancy testing) that might need to be performed on the morning of surgery. In general, tests that do not require separate inspection and accreditation by the state should be selected.

     This list varies from state to state. Anesthesia workroom. The workroom provides an area where all excess anesthesia supplies are stored. Extra monitoring equipment should be stored in case of breakage so that a patient’s heart rate, blood pressure, cardiogram, and oxygen saturation can always be monitored in the perioperative period. Locker rooms. Areas for staff to change into scrubs must be available, with a bathroom and break or lunch room attached. This area should have direct contact to the surgical suite. Bathrooms. The bathrooms should be located near the OR and recovery room. Handicap access to the restrooms is essential. An emergency call bell should be placed in each patient toilet. Waiting rooms. There should be sufficient space planned for family waiting. This area should have an information counter and a restroom in the vicinity. A public telephone and accessibility to drinking water should be considered.

     Office space.
                            There should be adequate space for the business office, medical director’s office, and consultation room. There should also be an area for medical record storage. 2012 Operating Room Design Manual Communications. Communication systems must be included in the design process. These include telephone and fax systems, emergency lights, call lights, paging systems, networking (both internal and Internet), and systems for electronic information management and billing. Sterilization and Space Heating Sterilization requires 60 psi of steam. Sterilizers may be purchased with self-contained electric heat or separate electric steam generators if an onsite boiler is not available. Most offsite ambulatory centers do not have an onsite steam boiler system since it requires maintenance staff, space, and steam-to-hot water converters. There are small, 60-psi natural gas boilers that are available for sterilization. The essential electrical system must serve the flash sterilizers. Space heating in most small offsite ambulatory centers is provided by hot water heating systems or electric duct reheating systems since little space and maintenance personnel are required for these systems. The essential electrical system must supply the HVAC space heating in the ORs. HVAC and Humidification The HVAC heating and supply, return, and exhaust ventilation in the OR is supplied by the essential electrical system. The HVAC system chosen for a facility requires special attention to space requirements, maintenance, installation costs, and temperature control. The HVAC controller involves locating a thermostat, a humidistat, and a recorder in the OR. Alternatively, the recorder may be located in a remote location outside of the OR. There should be, at a minimum, two exhaust air grills. If there are more than two exhaust grills, they should be centered on the walls of the OR. If there are only two exhaust grills, they should be located opposite each other. Humidifiers are required in the ORs and can be powered by any fuel source. Medical Gas and Vacuum Systems The National Fire Protection Association (NFPA) has set guidelines for electrical systems as well as medical gas and vacuum systems in the health care center. Their recommendations are the basis for a number of joint commission and CMS standards and regulations.

                            Ambulatory ORs require level one or level two piped gas and vacuum systems. A level one system is one in which interruption of the piped gases and vacuum system would result in imminent danger of morbidity and mortality to the patient. A level two system is one in which interruption of the piped gases and vacuum systems would place patients at a manageable risk of morbidity and mortality. A level three system is one in which the interruption of the gas and vacuum supply would have no detrimental effects on the patient. Most free-standing centers would be either level one or two since the administration of general anesthesia frequently occurs. In addition, the use of supplemental oxygen usually accompanies regional anesthesia and monitored anesthesia care. 2012 Operating Room Design Manual Level one systems have multiple pumps to ensure continued flow of the medical gases and vacuum systems. Another difference between the three systems is the alarm features, which are more sensitive in the level one system. There is no code or requirement for the number of medical gas and vacuum outlets per OR.

Guidelines have been set by the American Institute of Architects for the total number of outlets for medical gases and vacuum systems. The Joint Commission has made recommendations as well. General recommendations include one oxygen and one vacuum station for minor surgery ORs, two oxygen and two vacuum stations for intermediate surgery ORs, and two oxygen and three vacuum stations for major surgery OR stations. Each station must have an adequate flow rate for proper delivery to the patient and adequate functioning of connected equipment. The free-air allowance CFM (l ft3/min) at 1 atmosphere for “major A” OR (e.g., transplant and open heart) is 3.5 (100) per room, “major B” OR (all other major cases) is 2.0 (60) per room, and minor cases is 1.0 (30) per room. All medical piped gases must be identified by a color coding system. Color coding for piped medical gases in the United States is as follows: oxygen (green), nitrous oxide (blue), nitrogen (black), air (yellow), and vacuum (white). Medical gas and vacuum piping can be delivered through surgical ceiling columns. They can be either rigid in design or retractable.

When designing the facility, the ceiling columns should be placed at opposite ends of the OR table to provide easy access for the anesthesiologist. Extra electric outlets as well as grounding receptacles can be placed on these columns for convenience. Medical booms that descend from the ceiling typically include hoses for medical gases and suction as well as electrical outlets. The placement of these booms may critically impact patient throughput as well as safety for staff and patients. The anesthesia machine is routinely placed behind and slightly to the right of the OR bed, so the gas outlet and circuit is to the right of the anesthesiologist. Therefore, the boom should be located to the right and behind the anesthesia machine and the door to the OR to the left. With this configuration, neither the patient nor the staff need to walk through or around the boom to access the OR table or equipment. The total oxygen needs and consumption for the facility must be calculated. One must consider the procedures done at the facility, number of oxygen stations, and the number of procedures to be performed monthly. In the acute care setting, consider oxygen utilization to be 1000 ft3 (28 m3)/bed/month. Any facility requiring more than 35,000ft3/month must have a bulk storage system of oxygen. Those requiring less than 35,000 ft3/month can use a cylinder manifold system for oxygen supply. The common source for nitrous oxide is the cylinder manifold system. Nitrous oxide should not be stored in a cold environment, as the lack of heat for vaporization will occur, and it will be unable to maintain the line pressure. Medical compressed air can be delivered to the facility via a cylinder manifold or a medical air compressor system. 2012 Operating Room Design Manual Essential Electrical Systems The NFPA defines the need for a Type 1 essential electrical system as a facility with critical care areas or electrical life support systems. Any Type 1 essential electrical system must have emergency electrical power. The NFPA requires a minimum of three automatic transfer switches for any facility with an essential electrical load of more than 150 kVA. If the load on the essential electrical system is less than 150 kVA, the NFPA only requires one automatic transfer switch. Thus, a facility must project their kVA usage to determine the number of automatic transfer switches needed. The most common system of emergency power has been the engine-generator configuration. Whatever method of emergency power is used, the need for a supply of 60-HZ (AC) power to the essential electrical system must be established within 10 seconds of power failure. Battery-operated OR lights are required to prevent danger to a patient during the potential 10 seconds of darkness. For ambulatory units that do not have electric life support systems or critical care areas, the NFPA defines the need for a Type 3 essential electrical system. A Type 3 system would require power for life safety and the termination of the current procedures. Life safety is battery power for lights, fire alarm systems, and emergency exits.

The NFPA requires that the life safety power remain for 1.5 hours after interruption of normal power. Ground Fault Interrupters Isolated power systems are essential in ORs that are considered wet areas, where the interruption of power is not acceptable to patient safety. Even routine procedures in the ambulatory setting have saline, urine, and a number of other fluids in the OR suite. These wet- procedure locations have the potential to have electrical equipment come in contact with the fluids and result in electrical shock. Ground fault interrupters are used to prevent people from an electric shock in wet-procedure locations. The problem with ground fault interrupters is that once a fault current is detected, power to all downstream equipment is disrupted. This is of particular concern when that equipment is a ventilator or other type of patient life support. Isolated power systems contain the ground fault interrupter while maintaining the downstream power needed in critical care areas. A line isolation monitor will alarm at the first signs of a potential fault current and allow the problem to be addressed. Equipment Instruments and pieces of equipment for ambulatory ORs may number in the thousands and may require purchases from hundreds of manufacturers.

Many capital purchases, including defining specifications, manufacturer, shipping, installation, biomedical certification, and training of personnel in use, require lead times of several months. Furthermore, equipment specifications should be given to architects, engineers, and contractors prior to beginning the design process so that appropriate electrical, plumbing, space needs, and building code requirements are addressed. 2012 Operating Room Design Manual Whether freestanding or attached, the initial phase of equipment procurement should be determination of types of procedures, surgical specialties, and anticipated volume. Staff (i.e., surgeons, anesthesiologists, and nurses) should be queried as to preferences and minimum quality required to meet standards. Cost and availability should also be considered. For ASUs attached to larger facilities, a survey of existing equipment will help determine how much additional equipment must be purchased.1 Emergency Equipment All facilities must meet the standards set by the NFPA in regards to fire safety. Fire extinguishers and fire alarms should be placed in all facilities, and documented fire drills should be performed.

All ambulatory surgery facilities should be prepared for the management of life- saving emergencies. All monitoring equipment, such as blood pressure, cardiac monitor, thermometer, and pulse oximeter, should be present. A stethoscope, Ambu bag, oxygen, oral airways, laryngoscope, and various sizes of endotracheal tubes should always be present. Intravenous (IV) fluid and IV catheters should also be on hand. A defibrillator and crash cart with all emergency drugs, including dantrolene, should be prepared and routinely checked for expiration dates. All staff should be trained in advanced cardiac life support and pediatric advanced life support if the facility treats children. The proximity of the facility should be within minutes of a hospital that can accept any transfers. Amenities The single biggest draw for ASC/ASU facilities is the convenience and ease for patients and the convenience and efficiency for surgeons. To this end, adding certain amenities to the facility as part of the design process will contribute to the overall satisfaction of both patients and staff and ultimately optimize center efficiency. Some of these issues are: • A private, pleasant registration area that accommodates the patient and family with appropriate soundproofing to meet Health Insurance Portability and Accountability Act compliance • Generalized soundproofing in patient and staff areas to decrease noise pollution • Natural daylight in patient and staff areas to promote wellbeing, mood, and faster recovery • Parking areas that are flat (i.e., no curbs), well lighted, and at least partially covered for patient pickup • Hand washing stations that are readily visible to patients and conveniently located for staff • A separate anesthesia office space that allows for storage of references and resources as well as some privacy for conferring with staff or colleague 2012 Operating Room Design Manual Reference 1. Hampton L. Equipping your new surgery center. Outpatient Surgery Magazine. 2003(Jan):98-101. Resources 1. Iveerson R. Patient safety in office-based surgery. The ASF Source. Ambulatory Surgery Facilities. 2003; 10(2). 2. Kerckhove K. Re-evaluating the isolated power equation. Electrical Products and Solutions. 2008. 3. Mercier D, Philip B. Is your ambulatory surgery center licensed, accredited or certified?

ASA Newsletter. 2008(Oct). 4. Nash H, Birch N. Outpatient facilities-the clinical conundrum called ambulatory care. NLB Engineering. ASHE Update. 2004(July/Aug). 5. Philip B, Twersky R. Ambulatory surgical and office based care: demonstrating quality. ASA Newsletter. 2002(Nov). 6. Serbin S. Before you break ground. Outpatient Surgery Magazine. 2003(Jan); 114-5. 7. Springman SR, ed. Twersky R. Ambulatory Anesthesia: The Requisites in Anesthesiology. Philadelphia, PA: Mosby-Elsevier; 2006. 8. Watkins P. New surgical construction from A to Z. Supplement to Outpatient Surgery Magazine. 2008(Jan); 16-23. 9. Phillips P. eMedicine. Outpatient Surgical Suite. 2006(Dec). 10. Wentink K, Jackson R. Medical gas vacuum systems. Plumbing Systems and Design Magazine. 2006(Jan/Feb). 11. Yerden T. Planning and construction: design and development for dummies. Supplement to Outpatient Surgery Magazine. 2008(Jan); 10-12. 12. National Fire Protection Association Code 101. 13. National Fire Protection Association Code 99 (Standard for Healthcare Facilities). 14. American Institute of Architects’ guidelines for design and construction of hospital and health care facilities. 82 2012 Operating Room Design Manual 15. AORN standards. Available at: 16. Centers for Medicare and Medicaid. Available at: 17. AORN. Available at: 18. American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). Available at: 19. Accreditation Association for Ambulatory Health Care (AAAHC). Available at: 20. Joint Commission (formerly JCAHO). Available at: 21. US Green Building Council (LEED certification). Available at: 22. Green Guide for Healthcare. Available at:

Saturday, May 23, 2015

The Allergy Sticker and How to use it for the outpatient surgical patient or in the Ambulatory Surgery Center.

we all know and love those ____ stickers!  Right?  But, down deep inside we also know that they potentially save lives of many each and every year.  Without a means to quantify such numbers that would have otherwise been of a demise, we stubbornly go over them with new staff and we trust they will always remember to ask and document those allergies/sensitivities but, we know they can be missed from time to time.  No doubt the three times in one year that Susie Q. missed them, that would be the one chart the surveyor would ask for overtime.  LOL.  

Here is a sticker I developed, it has all the portions that you need in order to be compliant, and because of the size, I think it is really hard not to notice one is missing on a chart, you think?  Try it out, see how you like it.  Maybe the staff would enjoy using it more than the one you currently use.  Regardless mine, yours, or some else's, there must be one and it can be very problematic when missing not to fail to mention, it could be the difference between life and death. 

                                  feel free to reproduce this as you wish.

Tuesday, March 24, 2015

These 65 nursing related questions to ask of potential new applicants will sure suffice at securing the better of the staff that apply.

1. Where do you see yourself in 3 years?
2. What do you bring to this position? How do you stand out from the other applicants?
3. What attracts you to this facility? To this position? What do you hope to get out of the experience?
4. How would you describe your ideal job? Your ideal work environment?
5. Why are you leaving your current position?
6. What did you particularly like about your last position?
7. What's your most important professional achievement?
8. Who are your career role models and why?
9. How do you set priorities in your work?
10. Do you have any time-management tricks other nurses could benefit from?
11. What are the most important lessons you've learned in your career?
12. How much supervision do you want or need?
13. What professional organizations do you belong to?
14. How have you participated in the professional organizations you belong to?
15. What nursing publications do you subscribe to?
16. Have you attended any national conferences? If so, how did you benefit from the experience?
17. Have you ever done any volunteer work? If so, what was it like?
18. How do you keep up with the latest information in your field?
19. What are your goals in terms of going back to school, becoming certified, taking on management responsibilities?
20. Can you give an example of a time you were a leader?
21. Can you give some examples of your problem-solving skills?
22. What do you think are the most challenging aspects of meeting patients' needs?
23. How do you handle a request you disagree with?
24. What happened the last time you put your foot in your mouth?
25. What actions would you take in your first month on the job?
26. Can you give some examples of your creativity?
27. Who is the most difficult person you've ever worked with and why?
28. What type of management style do you work with best?
29. Can you describe a time when you had to intervene for a patient, what you did, and why? What was the outcome?
30. How would you rate yourself in communicating with patients—and with families?
31. Can you describe a situation in which you dealt with a difficult family member?
32. How do you motivate patients?
33. Can you describe a time you went beyond the call of duty?
34. Can you describe a situation in which you thought that you were right and others were wrong—and what you did about it?
35. Can you describe a situation in which you were supposed to work with a person you didn't like and how you handled it?
36. Have you ever been in a situation in which a co-worker put a patient in jeopardy? If so, what did you do about it?
37. What would you do if you were asked to float to a specialty area you weren't familiar with?
38. Can you describe a time your work was criticized and how you handled it?
39. How do you handle delegation issues with unlicensed assistive personnel?
40. How would your co-workers describe you?
41. How would you describe your role in a recent code?
42. How do you handle stress?
43. Have you ever been fired or asked to resign?
44. What would a background check on you show?
45. Would your previous employer recommend you?
46. What would you do if you were caring for an alert patient who suddenly got acutely confused and disoriented?
47. What would you do if you found an elderly patient on the floor in his room? How would you document it?
48. Have you worked with many foreign nurses? If so, what did you do to help them?
49. How would you handle a situation in which you couldn't read a prescriber's orders?
50. If you were offered your last job again today, would you take it?
If you're returning to nursing after not working in the profession for a while:
51. How long has it been since you worked as a nurse?
52. What have you been doing since you've been out of nursing?
53. How have you prepared to return to nursing?
54. Did you take a refresher course? How did it help?
55. How have you kept up with changes in the profession?
If you're a student applying for your first position:
56. What's your most important achievement as a student?
57. When do you plan to take your NCLEX? Have you taken a course to prepare for it?
58. Where did you get your clinical experience? What units?
59. Did your clinical experience include putting in a urinary drainage catheter or starting an intravenous line access? Inserting or removing a nasogastric tube, or caring for a patient with one?
60. What was your favorite clinical experience? Least favorite? Why?
61. What types of charting systems have you used? What do you like about them? What do you dislike?
62. What do you think is a reasonable orientation time?
63. Have you worked with an electronic medication administration record? Bar coding?
64. What new technology have you used in school, such as personal digital assistants (PDAs)?
65. Are you on-line often? What are your favorite sites for reliable health care information?

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Providers and suppliers can apply to enroll in the Medicare program using one of the following two methods:   Internet-based Provider Enrol...

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