Monthly Archives: August 2014

How Often Can I See My Patients?


As we have all experienced, our patients are getting discharged from the hospital “quicker and sicker.”  While a typical rounding SNF doctor will have a mix of patients more and more are coming from the hospital with significant acuity and suffer from multiple co-morbidities.  They may be recovering from CHF or COPD exacerbations, and their condition can turn on a dime.  Such patients need to be seen sooner upon admission, ideally within 24-48 hrs, and require much closer monitoring.

The question which many doctors have in the back of their minds for such patients is this:  How often am I allowed to see my patients and bill?  Will I get in trouble for seeing them too frequently?

The short answer to this is:

You may see your patient as often as medically necessary.  While this may sound like a non-answer, what this means is that if you are able to document a medical need, then you can see and bill for patients weekly, several times a week, or occasionally more often than that during a particular timeframe.  Obviously you’ll need to provide justification for this in your progress note, and the level of severity of the visit will reflect the acuity and complexity of the case along with the completeness, breadth, and depth of your interim history questions and physical exam.  CMS clarifies below:

Medicare will pay for E/M visits, prior to and after the initial physician visit, that are reasonable and medically necessary to meet the medical needs of the individual resident (unrelated to any state requirement or administrative purpose), but will not pay for additional visits that may be required by state law for an admission or for other additional visits to satisfy facility or other administrative purpose.[1]

It’s true that reviewers and surveyors don’t want to have doctors who appear to be seeing patients daily without reason.  Also, if one bills for more visits than seem reasonable for one human to perform in a day, one may have charts reviewed.  CMS calls these “gang visits.”

“Gang visits” (claims for an unreasonable number of daily E/M visits by the same physician to multiple residents at a facility within a 24-hour period) may result in medical review to determine medical necessity for the visits.[2]

When examining charts for medical necessity, billing accuracy, and physician involvement, surveyors and reviewers will look skeptically when a note appears to be “cut and pasted” from the previous visit, where there is little variation from the previous several notes, and where there are  no changes in condition or course of therapy.

Nevertheless, the presence of notes which have details in proportion to the billing code used, and which clearly state the reason for the visit are viewed favorably in terms of patient care.  The CHF patient on a multitude of medications with renal insufficiency whose  fluid control must be delicately managed may  warrant very close monitoring, even  some consecutive daily visits (though perhaps not all high-acuity coding) if that makes the difference between getting through this difficult period and having a readmission for a worsened condition.  As the patient improves, appropriately tapering the visits to weekly would then happen.

A diabetic patient with pneumonia being treated with IV antibiotics and steroids may require weekly visits to follow a rapidly changing condition.

The days of seeing every patient upon admission and then only every 30 days are becoming a thing of the past.  I’m not saying that every patient needs to be seen weekly.  What I am saying is that we need to reframe what we do relative to patient need.  Ultimately, that is what this is all about.  The vast majority of patients and their families will appreciate more frequent visits as well.



[1]CMS, MLN Matters, MM4246, Jan 16, 2006, p.2


[2] ibid, p. 3.

Hydrocodone Changes to Schedule II


Earlier this month, the FDA announced that it will change hydrocodone from a Schedule III to Schedule II controlled substance.  This will take effect on October 6, 2014.  The reason for this change is the significant amount of outpatient drug diversion involving hydrocodone and hydrocodone containing products.  You will still be able to prescribe hydrodocone containing products, such as Vicodin®.

However,  prescribing and dispensing will be subject to the same constraints that apply to other Schedule II drugs such as Oxycodone/APAP (Percocet®), including but not limited to the inability to write for refills, and the need to provide a written prescription by fax to the pharmacy within seven days of a verbal emergency supply order.

As with any Schedule II medication, you will need to provide a faxed prescription to the dispensing pharmacy for a continuing supply.   All Schedule II prescriptions should be written for a 60 day supply with no refills.

The pharmacy will send a partial supply of no more than 30 doses in a punch card or a one day supply if dispensed from the Automatic Dispensing Unit in selected AlixaRx serviced centers.  Your consultant pharmacist should be able to give you further guidance if you would like to consider alternative medications.  You should receive a request for a new prescription from all pharmacies prior to October 6, 2014 for any hydrocodone containing medications to be used after October 6, 2014.

Meet Dr. R. Brookes Peters, GLC – Tarboro Medical Director


Last year, Golden LivingCenter – Tarboro received the AHCA/NCAL Gold – Excellence in Quality Award, AHCA’s highest honor for skilled nursing facilities. This achievement was the result of the outstanding team in the Tarboro LivingCenter, and Dr. R. Brookes Peters has been an integral part of that team serving as Medical Director since 2009.

For GLC – Tarboro, Dr. Peters accepts all new admissions for the center, which enhances the admission process. For the team, he is knows to be consistent and a team player, as well as humble to a fault. He gives of his time and resources in a ‘behind-the-scenes’ way while getting the job done no matter what.

Effie Webb, the Executive Director of GLC – Tarboro has worked with Dr. Peters for over 43 years at the Edgecombe General Hospital and always has found him to be extremely knowledgeable, forward thinking, compassionate and an advocate for healthcare in all aspects for Edgecombe County.

“Dr. Peters has a gift for communicating with patients and families that can summarize their medical condition in a considerate manner,” said Webb. “He not only educates them but also relieves their anxiety, so they can make an informed decision.”

When nominating Dr. Peters for the Golden Living Medical Director of the Year Award last year, Webb went a step further.

“I give him the highest compliment by stating that he is a True Friend to Golden Living and one of the greatest assets to our Tarboro team,” Webb added.

Dr. Peters was born and raised in Tarboro, North Carolina. After graduating from Tarboro High School, he went to the University of North Carolina where he earned his undergraduate degree with a B.A. in Chemistry/Religion. He continued his study at the University of North Carolina Medical School. Then he completed an internship at Carolina Medical Center in Charlotte, North Carolina and his residency in Carolina Medical Center. He is Board Certified in Family Practice.

His passion is mountain climbing in Utah with his sons, going to a Bruce Springsteen concert with his newest passion holding his first grandchild, Lillie.

Divalproex Sodium (Depakote®) Update


By Steve Hord, RPh, Golden Living, Director of Pharmacy

Over the past few months there have been sporadic and localized shortages of Divalproex (Depakote).   As you are aware, Divalproex is indicated for use for certain types of seizure disorders, migraine headaches,  and  mood stabilization in bipolar disorder.  There has also been off-label use for dementia patients with behavioral symptoms.

Fortunately the major pharmacy suppliers to Golden LivingCenters have been able to mitigate the shortage by purchasing quantities of the medication from alternate sources and move product, as needed, between pharmacies to avoid medication availability issues that impacted our residents.

We do expect the shortages to lessen in the coming months but should there be a serious supply issue you will be contacted by the pharmacy with either alternate dosage forms of Divalproex or alternate therapeutic agents for your consideration.

The Next Step in the Medical Director/Executive Director/DNS Partnership


By Michael Yao, MD, CMD

Let me start off this month with a few questions.  See how many of these you can answer.

  • How many Stars does your LivingCenter have in the CMS 5 Star rating system?
  • How many tags did your LivingCenter get in the last Survey? Do you know what they were in and what level the most significant tags were?
  • How is your LivingCenter doing in the antipsychotic medications quality measures?
  • What is your 30- day readmission rate?
  • What performance improvement programs are currently ongoing in your LivingCenter?

If you can answer these questions right away, clearly you know what’s going on, and must be attending and paying attention in the QAPI meetings.  You probably are engaged in a dialogue with your Director of Nursing and Executive Director about what is going on in your facility.

If you can’t answer these questions, then you probably could be more involved in your LivingCenter.  Times have changed.  Over the past several years, the responsibilities and expectations of Medical Directors around the country have increased.  It’s no longer good enough to go to take good care of one’s patient roster and show up for a few meetings. The American Medical Directors Association (AMDA) has been urging medical directors to be more involved as leaders in their facilities.  Still, across the country, when questioned as to whether a true partnership exists between our medical leaders in Skilled Nursing Facilities around the country and their administrators or Directors of Nursing, the answer varies widely.

Some Medical Directors feel like they would like to get involved, but are not asked for their opinion.  Perhaps meetings are scheduled without thought as to when they can attend.  Other Medical Directors, who feel the squeeze of time devoted to filling out their office EHR (Which was supposed to save them time),  keep up with their practice organization’s RVU requirements and making rounds think that there just isn’t time to do everything they’d like to do the LivingCenter.


At Golden Living, there has been a concerted effort to improve communications with Medical Directors.  Each new Executive Director and Director of Nursing attends a two-hour session during their orientation about how they need to interact with their Medical Director.  There is a Medical Director handbook,  regular e-mail communication, and of course this newsletter.  There are some local as well as a national Golden Living Medical Director meeting at AMDA, and there is a medical director evaluation tool used by facility leaders.

The time has come to build on this foundation.  While much information about “how to be a good medical director” from AMDA as well as from the Golden Living Medical Director Handbook, there are frankly so many things that a Medical Director cannot possibly do everything suggested and still maintain a busy medical practice.  Can a medical director really talk to the resident council, write an article in the local paper, develop a local physicians advisory meeting, work with the local hospital on a readmissions reduction plan and help with a pharmacy system roll-out all at the same time?  Maybe one can, but probably not all in the same month.  Furthermore, Executive Directors and Directors of Nursing have not always been on the same page as their doctors as far as establishing goals to work toward together.

Working together with our operational leadership, we are developing a new approach to this.  Instead of just listing about 30 or 40 things a good medical director might do and hoping for the best, we are looking to get you together with the ED and DNS to decide on what is most needed for the facility.

As a medical director this makes sense – you may have insights which could really benefit the center- such as the knowledge about a Cardiology program being developed at  your local hospital, for example, or the development of an ACO.  You may be able to advise the ED and DNS on what clinical programs and directions are most needed for your LivingCenter.  You may be able to provide unbiased feedback about how staff is performing in areas such as communication of change in condition, or relate concerns that you have over certain clinical competencies.

This summer, my Regional Medical Directors and I attended each of the region’s ED/DNS meetings around the country.  Working together with our operational and marketing leadership, we are proposing a very straightforward way of forging this MD/ED/DNS leadership alloy.   Each year, the three leaders of the facility will meet and discuss the LivingCenter’s needs.  Then the three of you will decide upon what four or five objectives you would like to accomplish in the upcoming year.  Some may be short-term (such as arranging a meeting with local hospital leaders) , and some may be more long-term (such as decreasing falls with injury).  In any case, they will be things which all of you can agree upon, and will be based on the needs of the facility and what you feel you have the ability, interest, and time to deliver.

While you’ll be responsible for achieving these goals, all three of the leaders will be accountable for the results.  They will need to provide you with what resources you need to be successful, and the objectives would need to be something that you believe is realistic and achievable.

What we’re looking to accomplish is to have medical directors who are willing to serve as advocates for their LivingCenter.  You ought to be able to say “yes, I’d admit a family member here.”  If you cannot say so comfortably, then we want to hear why, and need your help in identifying what improvements need to be made, and leadership in helping us get the facility where it needs to be.   We’re emphasizing to our Executive Directors that that a medical director being an advocate is not about just admitting patients to the facility, but rather helping the facility develop itself to the fullest, and helping the community be aware of what strengths the LivingCenter has.

Whenever I hear the testimonials of the national American Medical Director of the year at the AMDA meeting, I am struck not just by the quality and dedication of the Medical Director, but how effective they were in working with their leadership team to make improvements in their facility.  With our new initiative, I think that we can approach this ideal in your facilities.