HCV medication coverage 2017
HIV medication coverage 2017
BCBSGA
Tricare covered HIV medications (90 days supply costs less)
2017 Medicaid covered HIV medications
NRTI
- Truvada (emtricitabine / tenofovir, FTC / TDF) (no pa or all)
- Descovy (emtricitabine / tenofovir alafenamide fumarate, FTC / TAF) (qll)
- (Ziduvidine + Lamivudine generic) (qll)
- EPZICOM (abacavir sulfate / lamivudine, ABC / 3TC) (no pa or qll)
- ATRIPLA (efavirenz / emtricitabine / tenofovir DF, EFV / FTC / TDF) (no pa or all) Alternate per ART Guideline
- Truvada (no pa or all) + EDURANT rilpivirine hydrochloride, RPV) (pa/qll) (Note: Complera is not covered) Alternate per ART Guideline
PI
- Truvada + NORVIR CAPS, SOLN, TABS (ritonavir, RTV) (no pa or qll) + PREZISTA (darunavir ethanolate, DRV) (pa) Preferred per ART Guideline
- Truvada + NORVIR CAPS, SOLN, TABS (ritonavir, RTV) (no pa or qll) + REYATAZ (no pa or qll) Alternate per ART Guideline
- EPZICOM (abacavir sulfate / lamivudine, ABC / 3TC) + NORVIR CAPS, SOLN, TABS (ritonavir, RTV) (no pa or qll) + PREZISTA (darunavir ethanolate, DRV) (pa) Alternate per ART Guideline
- Truvada + NORVIR CAPS, SOLN, TABS (ritonavir, RTV) (no pa or qll) + PREZISTA (darunavir ethanolate, DRV) (pa) Alternate per ART Guideline
- (Ziduvidine + Lamivudine generic) (qll) + KALETRA (ritonavir-boosted lopinavir, LPV/r, LPV / RTV) (qll)
3 Key
1. Observation vs Inpatient
2. Bill based on time
3. Delays in reimbursement - how to avoid : Documentation is the key
Even if the orders are in, best is to document as auditors can miss the orders if not documented
Chest Pain Work Up: 1/6 patient was inappriately labelled
MS-DRG (Medical Severity - Disease related group)
Observation: Outpatient services
- Patient pays 20 % for each tests ordered if they have Medicare B
- Best, if work up can be treated, and completed in 24 hrs, place in observation
- even HF patients may qualify for this observation
Inpatient:
2013:
- 2 midnight rule was initiated for inpatient vs outpatient
- 1 IP, 1 Obs, 1 ER: Probably met criteria for inpatient
- Still does not work; Only medicare uses it; private insurances do not use it
Interqual (McKesson) Criteria
Milliman and Robertson criteria
We do not know what RAC use
Chest Pain: Ongong Pain, SBP < 100, Abnormal EKG, CXR, CE... If any is present, then it will be Inpatient. If all is normal, then it is outpatient.
- Even when if all is normal, but it is documented clearly the reasoning for alarm, then may still qualify for inpatient
Inpatient
Risk Stratification test . Thought process is enough if written at the time of inpatient orders are placed. Ordering does not matter. If future events changed, and patient was discharged earlier, then patient may still be reimbursed as inpatient
IVR > 125 cc / hr
Cardiology consult if needed will be inpatient if it was because of reasoning
Observation
Monitoring VS Q4
IVF > 125 cc
Administer BB, ASA
ASTHMA
Inpatient
- Failed outpatient treatment for 2 days
- PF < 40 % of personal best
- PF < 80% despite 2 rounds of albuterol
- pO2 < 60
- pCO2 > 50
- Needs steroids, bronchodilator therapy q4h (q6h is an observation dosing)
- Supplemental Oxygen with monitoring (pulse ox, or ABG)
GI Bleeding
- sustained tachycardia,
- Hgb < 8.3 or HCt < 25 %
- PT/PTT > 1.5
- Orthostatic hypotension
- Need of BT if thought will make them inpatient (Q8 or more frequent check)
Observation, same day discharge (DOCUMentation)
Resident role is not to be used for role in the discharge
- Bundled code: (admission and discharge bundled) (reimburses 40 $ more on an average)
- Only if patient has been > 8 hr
- When does the clock start for observation
- When first order is carried out vs order is placed
- Observation clock does not start when resident saw the patient; but is okay when obs status is ordered
Observation, next day discharge
Observation - Initial H and P
Next day Inpatient: Bill for inpatient initial next day. from CMS note.
Medicare patient
Consult or co -management or transfer of care: Initial inpatient code for inpatient patient.
Non-mediare patient:
Some may pay for consult, others may be for inpatient. Consults pay more than inpatient H and P code
To manage: Even the first day. Co-manage.
Medicare: Initial H and P
Non-medicare: Follow up inpatient (for private insurance)
ER Billing codes
ER consults and discharged.
Outpatient consult or outpatient office code
Time based codes
Private insurers can bill based on time
Medicare insurere do not pay by time
Your personal time. Not residents time.
Time does not have to be continuous. It can be scattered. As long as it is documented.
When > 50 % of the total time is in counseling and or co-ordinating patients care
Medicare expects 20-25 % billing by time.
Documentatoin based on time
- Time was face;face or unit / floor
- Amount of time > 50 % for counseling and care
- What was discussed
Time of billing: unit / floor
Critical Care timing
- Document it is Critical Care patient
- Reason for illness
- Time spent
- What did you do during that time
Illness criteria.
active or at high risk of 1 or more vital organs
Treatment
Personal time of attending provide organ or life saving care (calling ICU, mobilizing dialysis, MD's full attention to the patient
Occurs with patient is in patient floor
First hr (30-74 min): 226 $
each additional 30 min (112$)
First 30 min of critical care will be level three visit.
Questions
1. Reviewing records > 45 min later in the day. Resident admission. Can I bill for added time. Medicare: start and Stop time: Face : face only. Non-medicare - unit or floor is okay.
But if it was counseling, then highest level of code is to provided, before adding the counseling.
2. In the immediate vicinity of the care. in the floor, okay for non-medicare but not for medicare. I am reviewing everything in detail. > 35 min.
3. Procedure done by resident. You are in hospital.
4. 1 bill per person / practice / day even if you have nocturnist that provides critical care
5. Patient unstable overnight. Residents take care of it. Cannot bill for critical care.
Career Counseling
CV : Update CV
Publications
- Lots of reading before things are done.
- Take time to write about it
- Not everything you write will be published. DO NOT GET DISCOURAGED
- Meet people; Follow Up
- Once you have given talk, offer it to others for talk
National Committees
- Join the committees that works best for you
- Be active
- Find the leadership roles
- Champion for Morning Report Improvement
- EBM director Department of Internal Medicine
Mentors
- Most important thing of all
- Needs series of mentors
- Division chief is usually not your mentor
- Take time to look at you
- They can be multiple
- Successful, Passionate, Caring, Advocate
- Invest in the relationship
- Know as many people as you want outside the institution
- Talk to the speakers afterwards
Story Board : Career
Refine your strengths rather than working in the weakness alone
- Be important to one area
- Know the rules of promotion at your institution
Learn when to say no, and when to say no
- First thing tell is : I need to ask this to my boss
- No matter how interesting, see if it really matters
- Being a team player
Career Pathway
- Clinician Administrator
- Clinician Educator
- UME
- GME
- Allied health : PA, NP, PharmD
- Clinician Investigator
- Clinical Trials
- Educational Research
- Curriculum Design
I COMPARE - resident research
Groups to Join