ACP 2016

HCV medication coverage 2017
HIV medication coverage 2017

Tricare covered HIV medications (90 days supply costs less)
2017 Medicaid covered HIV medications

  • 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
  • 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)
  • GENVOYA (qll) Preferred per ART Guideline
  • Truvada  + ISENTRESS (pa/qll) Preferred per ART GuidelineTruvada  + TIVICAY (qll) Preferred per ART Guideline
  • TRIUMEQ (qll) Preferred per ART Guideline

  • 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 

    • 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 

    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

    Monitoring VS Q4
    IVF > 125 cc
    Administer BB, ASA

    • 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) 
        • 99234
        • 99235
        • 99236
      • 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

    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.  


    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 
    • 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 
    • 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 
    • Fill in the gaps
    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 

    1. Clinician Administrator
    2. Clinician Educator 
      • UME
      • GME
      • Allied health : PA, NP, PharmD
    1. Clinician Investigator
      • Clinical Trials
      • Educational Research 
      • Curriculum Design 
    I COMPARE - resident research 

    Groups to Join 
    • ACP
    • SGIM
    • AAIM
    • AAMC