Okay, everyone, we can go ahead and get started. I know typically people will still come in, so we'll just let them in as they enter. But thank you all so much for being here today. My name is Gina, I actually serve on staff at HMDCB, and so we're excited to be hosting our second coffee chat of 2022. And we really do want to make this as interactive as possible. So we encourage you to go ahead and ask questions or share comments, either by coming off mute or putting it into the chat box. And we do just want to remind everyone, if you aren't speaking, please keep your microphone on mute just so it helps eliminate all of that background noise. So our chat today will be facilitated by Dr. Amir Termizi. Dr. Termizi actually serves on the HMDCB Board of Directors and practices out of Columbus, Indiana. So Dr. Termizi, thank you so much for leading today's chat, and I'll hand it over to you. Thank you, Gina. So I'll go ahead and start. So my name is Amir Termizi, I work for hospice, it's called Our Hospice of South Central Indiana in Columbus, Indiana. And there I've been working for almost four years. And before that, I've been involved in hospice since 2005. So as Gina said, I'm also part of HMDCB Board, the certification board. So today's my first time with the coffee chat. I've attended coffee chat once last month. And so I have some list of questions forwarded to me by Gina. And I can go through these questions one by one. Let me know if someone has any questions right now. And we can go through those before I go through these submitted questions. Can you hear me? Oh, okay. I'll ask a question because this has just come up recently. I'm with Four Seasons Hospice. We have a lot of physician involvement and a lot of physicians billing for visits, medically necessary visits. We were discussing recently that we have never had any auditing of physician billing, physician visits, but we've seen a lot more audits recently. And I was just wondering if anyone has experienced anyone coming in and auditing physician visit notes and billing by physicians. We haven't here in Indiana, but I don't know if anyone here in the chat has experienced it. I mean, we have had audits off and on, but not any increase in audits and not any recent audits. Has anyone else experienced any excessive audits recently? I could comment on something I've become aware of. You know, the payment for hospice or for physician billing within hospice comes through your Medicare administrative contractor, the MAC, and there's three of them. And one of the MACs, which is called CGS, that covers about, you know, maybe a third of the states, has been issuing some denials for bills for physician visits. Ironically, surprisingly, for patients receiving GIP, general inpatient care. If you think if there's any patient that probably could benefit from a physician visit, it might be somebody sick enough to need GIP. And so we have heard about some, you know, kind of blanket denials occurring around that. And we're working right now with the academy is working with NHPCO and trying to set up a meeting with the CGS medical director to address that. Because obviously you're supposed to be able to make a medically necessary physician visit on a patient who's, you know, got clear medical needs. But interestingly enough, all this stuff's so open to interpretation, that particular medical director just says, well, I think you're just checking on them to see if they're still eligible for GIP. That sounds administrative. That'd be like a face-to-face visit. Why would we pay for that? Okay. We're with Palmetto, who tends to be more lenient. But we have a high percentage of, we do a lot of billable physician visits. So it's just kind of on my radar as a risk. So that's interesting to hear about CGS. Thank you. Could you clarify, are you being audited on visits along with a face-to-face or is your team seeing people more regularly beyond the face-to-face? We see people for face-to-face, but we also see them beyond that. So usually within the first couple of weeks of admission, sometimes depending on needs, it can be fairly frequently. Are the face-to-face visits supposed to be billable? I thought that that was part of the medical director oversight. Yeah. So those are not supposed to be billable, but often what happens is, this has been our model since before I was medical director. So this is why I'm just kind of trying to figure out what other people are doing. So our model is that often when a physician goes to do a face-to-face visit, there is some need that arises. We're often changing medications, having goals of care discussions, and then that visit could potentially also become a billable visit. But the two things are done separately. Like there's a face-to-face note, but then also a physician progress note done. Yeah. We have done that the same for, we're also still listing facility visits and using those visits as twofold. One is face-to-face and one as a regular compliance visit, but writing them as two notes, billing one and not the other. Yeah. I think that's correct. Yes. That's what we do too. Yeah. I think that's a best practice. I think when you're billing for the medically necessary visit, that your documentation should actually very clearly indicate what the medical necessity is, and it should meet all those standards for an E&M visit code, right? All the documentation standards. It wouldn't be a good idea to bill for a visit that says, here to do a face-to-face visit. Yeah, absolutely. Yeah. Here to evaluate uncontrolled pain after three med adjustments. So can I ask a different billing question? Sure, go ahead. We have many patients who are inpatient hospice, and it's in the setting of our hospital environment. From an audit side, we have been told that we are on the far end of the percentile of high amounts of inpatient hospice, and so it's been on our radar, why are we doing it that way? And I think there's some historical misunderstanding of those visits. From a billing standpoint, we get conflicted information from hospice versus the hospital of saying, are those visits billable or not? We are the medical directors for hospice, and we're also inpatient palliative care. How are others billing those visits in their understanding? So if you're seeing somebody not in a freestanding hospice house, but in another facility like the hospital that's inpatient hospice, should hospice be covering that as part of the medical director oversight, or should those visits actually be billed to Medicare as a provider visit? This is Dr. Younger. We have our inpatient units in our hospital as well, so we tend to have a high number of patients that come in for half an hour a day for IPU care because they're acute and can't leave the hospital, so they end up just coming to our IPU, and then they have rapid turnover. I think the issue we run into is it's not necessarily us billing Medicare, it's the hospital billing us. So the notes and stuff that I do, we use that as part of the financial transfer of what the hospital owes us for the services we're providing, as opposed to taking a lot of the per diem that we get from the patient since it's in the hospital setting. That may be how the foundation and the business workings are in our individual hospital, but we use billable visits in order to basically enact a funds transfer from the hospital to our hospital so they don't take the whole per diem. So why would the hospital owe hospice? I don't understand. Because they take the whole thing. They'll take the whole per diem for our, particularly our brief stay patients, when they're only there for 24 hours, they'll take the whole thing, and our community hospice program won't see any of that as part of our budget, even though we're within the same health system. So there is a way to separate it out by the number of hours, that's what you guys are doing? Yeah, and just like that physician time from hospice providing that service, it's basically a billable service, me going to see that patient, so we're able to recoup some of that money that we're losing. Okay. So at my old institution, it was a similar idea where there was a hospital and inpatient hospice patients were managed by the hospitalist or by palliative care providers who did not work for hospice. And so that made sense to me that those visits should be billable to Medicare versus should hospice be paying the charge to the hospitalist and the hospital. I think my current situation, I'm still not even clear what the correct answer is to that, like does it matter whether you're the medical director or whether you are an independent physician seeing the patient on a day of an inpatient hospice day? Does anybody have clarity of who really knows the answer to that? Because I feel like I've been told 27 things by three different institutions. I might comment a little bit about that. So it's super complicated, right? So it depends on a bunch of things, how you're supposed to bill it. It depends on who the attending physician of record is for hospice. It doesn't have to be the same person who's the hospital attending, but the patient chooses an attending of record. It could be a nurse practitioner, for example. So it's who they choose for the attending of record. Then whether that attending is employed by hospice or not makes a difference in how you can bill. It makes a difference if the care is related to their terminal condition or not. And it makes a difference if it's an administrative function versus a medically necessary clinical visit, that makes a difference too. And so this is complicated. And if a hospitalist were chosen by the patient to be their attending for hospice care, and they are not employed by hospice, they could actually bill as the attending not employed by hospice. There's like a GV or a GW code. I mix them up in my head all the time. Or if they were making a visit that wasn't related to the terminal condition, they could use the unrelated code and bill Medicare the way they normally would, not through the hospice. But if you're employed by the hospice, you're the hospice medical director, 100% of the time your bills are going to be submitted by the hospice. And if you're doing a clinically necessary visit and documenting it so, you bill that on top of the per diem. And that's something you can keep even if you're passing the per diem through to the hospital. It gets really complicated fast. If you throw nurse practitioners in there, they can only bill if they are in fact the attending. They can't even cross cover each other and bill for it. I hope I just made it worse, right? I just made it worse for everybody. You make me feel better that we haven't been completely missing something that's obvious. In our situation, it's one big institution. So we're employed by the hospital and we work for hospice. So it's the same institution. So in some ways, it's just who, which pot is it going into? Because I've been afraid from an audit side, you know, the hospital's trying to submit bills that then get declined by Medicare because they say this person's on hospice. It's unclear to me what hospice themselves should be doing. It's helpful to hear that it definitely indeed could be billed on top of the per diem rate because I think that's how our hospice interprets it. I just don't trust that actually anything is being billed correctly and actually getting reimbursed. And you're probably right. It very well may not be billed correctly. I will say this, that just because somebody is in the hospital or just because they're getting GIP does not mean that it's medically necessary for your doctor to visit every day. So you really shouldn't be billing on the basis of I rounded on everybody, so therefore I can bill for everybody. Every single visit you make, if you're going to bill for it, you should be documenting a medical necessity and show that you did something. You didn't just visit because they're sitting in their hospital room or you didn't just visit because they're on GIP. There was an actual medically necessary clinical visit that you made. If there is a medically necessary need to see them, it's hard for me to say they still warrant GIP. Like in the past, we had not been seeing patients every day with the idea that hospice should be managing their symptoms, but then it's hard to say, why are they still in the hospital? How would you justify not seeing a patient on the day, but yet still say they need to be GIP? I mean, I would probably find a good medical necessity for anybody that is on GIP, but you can say, how can you imagine? I'll tell you this, there are plenty of hospices that send patients in for GIP days and they don't submit any physician bills. That's a common practice. So that's not the way I would practice. I'd say you should get a daily doctor visit because you have an unstable medical condition that requires GIP. You could imagine a scenario where somebody's in there for three times daily involved nursing dressing changes that can't be done at home and nothing changed. Their pain is comfortable today, it was comfortable yesterday, they're going to be discharged in four days. Your visit was to say, yep, you still look fine. You might say, maybe I didn't really have to visit that patient, even though they still met a GIP criteria. Okay. Thank you. Okay, there was a question submitted and anyone can jump in. I appreciate Dr. Rotella jumping in and answering most of the questions. Thank you. So the question is, what diagnosis are folks using for dementia that is not Alzheimer's? And must it always be senile degeneration of the brain? I'll use, if there's a diagnosis of vascular dementia, I'll often use cerebral atherosclerosis with the vascular dementia as a related. How about if there's no specific diagnosis that comes with the patient, what are people using, just general decline or senile degeneration of the brain under Alzheimer's? For those patients, we use senile degeneration of the brain. I try to avoid that and find something more specific, but yeah, we have plenty of patients with dementia under that diagnosis. Got it. Okay. Thank you very much. Yeah, we overwhelmingly, we have been using senile degeneration of brain also. I'm sorry if somebody said this already, but if the patient isn't that old, we use, and there's no clear vascular issue, we'll use cerebral degeneration without the senile part. I wonder how long it'll take for Medicare to come down on those diagnoses. I just read, believe it or not, I was on a coding website, that's how deep I was trying to go into this, and there was an alert out that Medicare's probably going to stop allowing those nonspecific diagnoses, so I think that's probably coming. The thing is, there are a lot of old people that haven't been to the doctor in years and there really is no diagnosis, so then what? I feel like I struggle with that on a daily basis where my nurse is out there, there's obvious decline, they probably have weeks or months left, but we have no diagnosis. It's really difficult. Yeah. There's also kind of a double standard playing here that's very frustrating to us. For example, if you'd say, what related treatments does the hospice have to cover, if you follow what Medicare's saying, they'd say virtually everything. They'd say anything related, not just to whatever that diagnosis you put in, but anything that contributes to the terminal condition at all would be considered related. That's the guidance from Medicare. So when it comes to hospice paying for related stuff, virtually everything goes unless it's glaucoma drops or medicine for your prostate or something, or a thyroid pill. However, you have to designate a specific diagnosis and then they're saying you can't use nonspecific stuff like failure to thrive or not doing well. So it feels a bit like a double standard, like I have to shoehorn everything into one specific diagnosis good enough for you. However, when I'm determining their prognosis and their eligibility, I'm supposed to look at everything, not just that diagnosis. And when it comes time to pay for related stuff, I'm supposed to look at everything, not just that diagnosis. It feels like we're hurt on both ends of that proposition. Yeah, I totally agree. And I often thought, what difference does it make? If you're reading my narrative, what difference does it make what I'm putting for a diagnosis? Why can't I put failure to thrive, which of course I know we cannot, but why not? Because what difference does it make? I have a question about that. What would be the problem to diagnose the patient with Alzheimer's at that time? I mean, you see the patient, you've been consulted, you do a dementia test, you don't have any clear indication for vascular. So what would be the issue to say, hey, this patient do have Alzheimer's based on the history and the physical relation right now. I mean, do we have to take in account somebody that knows way in the past? Why don't we do it right now? We have the ability to do it, right? That's my understanding. If we're going to put a patient without a diagnosis, we'll go through the medical record and come up with what we think is most appropriate. Okay, thank you everyone for answering this question. Now, since Dr. Vincent Bonilla just spoke, so he has, he did submit a question. So I'll go to his question first now. So his question is, does hospice covers antibiotics for infection unrelated to admitting diagnosis? Yes. Let me add something there. Thank you. I've been, I'm in Puerto Rico as many of you know already. So I've been having trouble with some patients who, for some reason, their primary care doctor request either a wound culture or a urine culture. And sometimes they came, they come with multi-drug resistant bacteria. For example, I have this patient right now with renal disease, right? Admitted for end-stage renal disease. Probably have about two weeks, but the PCP requested a urine culture. Now the family is questioning, why don't we doing anything? You know, now this is a fight that I don't want to get involved fighting with this at the end of life somebody, right? So they want treatment for that. My question is the only option that I have, for example, it will be an IV antibiotic because it's multi-drug resistant. Do we, did the hospice pay for that? Do we provide that? I know it's not aligned with the goal of care of hospice probably, but getting to a fight with that, you know, it doesn't make sense for me at least. So that's my question. Should I, should I recover that? Should I send it to the pharmacy and have the nurse doing the antibiotics and somebody help me out with that? So, you know, I think the first thing is before such things are ordered, I think the important thing is the family or the patient should be aware, or we should be aware of what their goal is before we order the test. Now, as far as the wound cultures, personally, I don't think they should be ordered. A lot of times they are superficial and we are just treating whatever is on the skin and that's not going to help with the symptoms. So just wound care may help more with symptoms than just ordering wound cultures and giving antibiotics for superficial wound cultures. As far as the urine cultures, I think the first thing is urinalysis, if that suggests there is infection and it's a clear sample without squamous epithelial cells, so it's a clean catch sample. And first, before we even order urinalysis, do they have UTI symptoms or not? If they have symptoms of UTI, then we should order urinalysis. And then if the urinalysis is a clean catch sample without any squamous epithelial cells, and then the cultures are growing something and they have symptoms from UTI, then I think that is covered by hospice because a lot of times our diagnosis of hospice end up by diagnosis. Patients are getting UTIs because they are bed bound or they have other multiple comorbidities that is predisposing them to UTI. So even if it's not related to the admitting diagnosis, it is kind of related because it's causing symptoms and distress. So that's how we have been, like in my hospice, that's how we practice. But before we even order urinalysis, we try to make sure that they have symptoms that we can attribute to UTI. I mean, a lot of times the big problem is when they just have confusion and the family thinks it's just UTI and they have no other symptoms. So that's a little gray area, like do we treat their altered mental status as a UTI or they have other symptoms or not? But once we have established that they have symptoms of UTI, their urinalysis was clean and the urine cultures are growing the multidrug resistant organism that requires IV antibiotics, then in our hospice, we provide it. Most commonly ends up being, I mean, we end up using either, well, meropenem, for example, that's an expensive drug, but we have used it. We have used it because we have established that they have UTI because of their other multiple diagnoses, including the admitting diagnosis, and then we do cover it. Yeah. Hey, Vincent from Chicago, I see Beth is ready to answer. Thanks for having this session. I have to say I'm completely new, but Vincent, it kind of reminds me several years ago, I was thinking about dipsticks, like, you know, bottled dipsticks cost like a couple of dollars and you know, if it was positive or negative, it was positive, I don't know what it is, if it's negative, but you know, I just don't have the bandwidth. I mean, it's like, you know, we all have these great ideas and I think it speaks about even being part of an organization, you know, the education material and whatnot that we can all put together, but just doing it at two o'clock in the morning when I'm tired, I don't want to wake up my kids and my wife and someone asks, can I get a UA? And I say, I will admit, I say yes, and I know what's wrong, you know. And I do that same thing when a nurse calls me, but I make sure that the nurse, and most of our nurses, they're in hospice forever, so they know, they have already asked for the symptoms and whenever they call me with the request for UA, mostly it's appropriate in our case. I feel like no matter what we say or what education we provide, there's always going to be the family who's sure that this is the reason that the patient is dying. Yeah. But I have a question related to this. I mean, if you're talking about something multi-drug resistant, you only have an IV option. So where I practice, it's pretty rural and we can't really provide a lot of IV therapy in the home, at least right now. Would that qualify for GIP level of care? Nice question, yeah. So, yeah, we do. So in our hospice, we have admitted patient for IV antibiotic to our inpatient hospice. If IV antibiotic is required, like, you know, Meropenem every eight hours, something like that. So we have done that because they are having symptoms from UTI and they require symptom control and antibiotic is the way to go. I do oral antibiotics, but we sort of draw the line with IV. We just don't do that. It's more for us, a philosophy, just, again, we're also sort of a rural hospice. We have home health with our hospice company. So if that's really your line of thought, family speaking, you know, if families want IV antibiotics or families want more aggressive treatments, they could be on home health instead of hospice. So in our case, if a patient has been on hospice for a while, and now, unless they're rapidly declining and like, let's say the PPS is 10% or something like that, we are not going to prolong their misery and put them on IV antibiotics, but if someone is very functional and they are not so close to end of life and their symptoms are causing a lot of distress because of the UTI, then that's the time. And there's definitely, there's no oral option, then we use IV. If there's an oral option, we try that, of course. In my case, you know, if somebody has symptoms, I can treat prophylactically, I have no issue with that. I can even put them on probation therapy sometimes. It's just sometimes for some reason, out of my understanding, the PCP decide to request union culture, and then when they get the lab, they just say, hey, hospice should deal with that. I'm like, okay, thank you for that. So that's the main issue. This happened twice already in this month, so I'm like, oh my God. So anyway, thank you guys. You're welcome. So maybe I should go to the next question, and that would be Thomas Criantafillo, who was just speaking from Chicago. So I'll go to his question next. And that is, the question is, any thoughts on palliative care slash hospice hospital certification based on HMBCB while not being board certified? That's the question. Maybe you can clarify. So the question is thoughts on palliative care hospice hospital certification based on HMBCB. Amir, I'm not sure if he's still on. It looked like in the chat he put he needed to connect to a virtual clinic. So he might not be able to clarify that question. So if anyone, yeah. So if anyone has thoughts on that, that would be great. If not, we can definitely move on to the next one. Will it drive you crazy if I have thoughts on that? No, not at all. That would be great. But it looked like somebody else wanted to say something. You go first. Well, I'm not really clear about what the question was. It sounds like they asked about being fellowship trained and practicing palliative care in the community. I'm not sure if that's what it was, but I'll just speak on that. I was a non-traditional medical student and I knew I wanted to get an end-of-life care in medical school. So since then I have done various electives in palliative medicine and residency. I did electives in palliative medicine. So I felt like I had enough training and investment and mentorship to be able to take on some of the tasks. So I actually just resigned from a position where I was the community care medical director and doing great work in the community, preventing hospitalizations and managing acute things with the community palliative care team. So hopefully that adds some clarity to the table. That's great. Thank you for sharing that. I think if I understand the question, it's well, you know, so we know if you wanna be board certified in hospice and palliative medicine, you have to do an accredited fellowship. There's no, you can't grandfather in anymore. And, but there are a lot of people that might be wanting to enter mid-career and they're not ready to do a fellowship or there might be people that aren't gonna really practice it at the specialty level, but they wanna have primary level skills that are better than average or supplemented for palliative care. How do you certify those? And I don't, you know, unlike hospice medical director thing, it's not like it's an area of specialty in and of itself. So what I've seen proposed, for example, is some universities now have a master's degree in palliative care. So it's a master's degree. It doesn't get you a board certification, but you can demonstrate that you've had additional training. There are other courses people can take like an immersion course somewhere, and then they might get a certificate that they have an added skillset in palliative care, but it's not certification of the specialty of palliative care. And then there's also some new kinds of fellowships that are being piloted and tested that might allow mid-career people who still want to practice to do it sort of part-time over several years so they don't actually have to leave their practice to do a full-time fellowship. So there's a lot of things that are, I see being tried because of this sense that if I can't do a fellowship, but I'm going to practice some level of palliative care, how can I get some kind of certification that shows that I'm competent to do that? I see people coming at it from these different angles, and I don't know if that was helpful or not, but I think it's a little different than the hospice medical director certification because honest to God, to get that, you need to know more than what you learn in a fellowship. Okay? It's a very specialized type of knowledge. These questions we've been asking about what diagnosis do you use if they have dementia and it's not Alzheimer's, what do you do about physician billing and coding? How do you handle an audit? You don't learn that in fellowship, but that stuff's really important. And I think that's why it kind of can stand on its own as a type of certification. It's a little harder when you look at just palliative care in general. Yeah, and the HMDC board, when I prepared for that, so I've been practicing as hospice palliative care physician for a while. I took this HMDCB board, I think three, four years ago, and I realized how important it is to take this, to prepare and take this board and how much knowledge you gain regarding the regulatory part and all these different diagnoses. I mean, you don't learn that unless I think you take, you prepare for HMDC, the hospice certification itself. So that's why I'm glad that there's a separate board just for this side of hospice. Okay, do I go to the next question, I guess? So the next question is, any advice on transitioning from community to inpatient hospice? Transferring from where, could you repeat the last part? So the question is, any advice on transitioning from community hospice to inpatient hospice? So they mean GIP? No, so to me, it seems like the way I understand this question, it seems like they're asking, like a physician who works as a community hospice physician and wants to do just inpatient hospice. I don't know, that's what it seems like. And this question is- Yeah, that makes more sense. Yeah, and this question is by Dr. Guidry. I see she's here, unless- So that's the- Oh, that's me. Yeah, so is that your question? So that's the question that- I forgot I submitted that. So I just started my new job today. So I've been in community palliative care and community hospice for three years. And so I'm now gonna be covering a couple of hospitals here in Silicon Valley in Northern California. And so I just kind of will take any advice on the new roles that I'll be in from more experienced folks out there. So anyone has any advice for Dr. Guidry? Or you can message me later, I just welcome it. Well, I guess I will acknowledge having practiced in both settings that every hospital has its own sort of culture. Every setting has its own little quirks. And so actually it's in the community-based environment where we have the least control. And it's really where the patients and families have more of a say in how things go. In the hospital, there's a lot of forces and policies and protocols and power imbalances in the hospital that really kind of mean once you're in the hospital, you do what the hospital makes you do. So that can feel different, I think, as a provider. I think in the hospital setting, you would absolutely wanna understand sort of who are the people you need to befriend and get on your side if you're gonna thrive and do well. And it might not be the obvious people. It could be the evening charge nurse, I don't know who it might be, right? But I would say it's different. It's a different style of practice and the hospital culture will very much shape what you can do or can't do. And so it's not just plug in. I think you wanna get to know some of the key people that you might be working with there. I love that so much. And so for me, that comes to mind, make friends with the social worker. And I only do outpatient hospice, 100%, like home-based. And I would say, you're already coming from that scenario. So make friends with that kind of person, what you are now, right? Like, because when I call, like today, I needed a GIP for one of our home hospice patients. And I just have in my speed dial the palliative care doctor and I talk to her directly. And then of course we have to take it through different channels, but it's the great communication. And I just really love that, that I have that relationship. I also did both, although I left the hospital 17 years ago, something that would make sure it's about what expectations of your service has been set. I think it was Joe who described this really well. I've seen the outpatient, over time, there's a certain pace, there's more flexibility. In the hospital, if you have hospitalists and others, service is defined by timing, it can be 24 seven. So before you step into the hospital, make sure that you understand what kind of service they're expecting. And if you have enough manpower to deliver the service. So you don't want to step in a scenario where cardiologists, surgeons, and others may start expecting something from you that nobody has talked to you about. And that's where the very structure rules and expectations delivering care is preset in hospitals, while in the community is a different place. I would like to say, there's one other really important thing that I think we don't talk about enough, that I think is really important between those differences. And I've practiced community and inpatient my entire career. The place where I work now, we have an inpatient facility that's actually embedded in a hospital. The community experience is often longer in terms of building relationships with families and patients. The inpatient setting is often shorter, often more acute. And many of the patients that come into the inpatient setting, especially if they die there, their time with you and your team is really short. And so we have to acknowledge as the, I try to do this all the time with our teams, that that takes a toll on our team emotionally. When we don't get to develop relationship and it's only an acute event and a patient dies and it's emotional for the family because they weren't expecting it or all the things around that, that's harder for the team. And so inpatient care is a much different experience for the families, the patients, and our team in terms of the care that we're providing. So I just say that so that if you ask that question, you're at least a little bit aware of that. I just thought of one other thing that's a little bit different. If you imagine a hospice unit in a hospital and you'd say for each patient or family, I wanna give them the exact experience they want. But one of the folks you have in there is in there because they have agitated delirium. And so they're screaming every once in a while, they're screaming profanities out into the hallway. Then you'll have these other families coming and saying, you said you would give me a peaceful place. But this guy over here is screaming obscenities. In the hospital, because they're not each in their own little home pod, you actually have to worry about how the patients interfere with each other or interact with each other. And the way this can play out in life is that you could see sometimes hospital units that would say, we can't take your agitated delirium patient. It would be too disruptive to our other patients. But then you would say, but what better place to have this person? And those kinds of tensions sometimes occur in an inpatient setting that you wouldn't see at home. Okay, I guess I'll thank you everyone for answering this question. I'll move to the next question, which is by Dr. Jerry Wilms and I think he's here. And the question is benchmarking regarding compensation structure. That's the question. Yes, I asked the question. I'm to be quite candid, I'm looking for other options. I've been in hospice and palliative care, but primarily hospice for 30 years now. And I'm just looking at opportunities. And I know the AHPM, it's been over 10 years ago, they did a comprehensive study of the hospital's hospital structure. And they found that the hospital structure they did a compensation survey, but I didn't know if HMDCB, or should I reach out to double HPMs if they would consider doing an update or a more current version, or just any thoughts from the group about how to, I guess, see what would appropriate compensation packages might be available if I considered new options. So I know HMDCB, we don't currently have anything, but I wonder if Joe has any insight about AHPM and he's making a face. So Joe, if you have anything you can share in terms of that there's been any updates done, if there are plans, if you're able to share that information. Well, look, yeah, no, it's a really, really, we see the need, it's a really good question. I was actually trying to type in the chat, which is why I was making a funny face. We actually did bring the idea to our board this year about whether this is the time to do a compensation survey. There's a right way to do it. You have to do it in a way that's anonymous and firewalled and won't cause any antitrust concerns and that sort of thing. So you have to hire a consultant, do it the right way. We posed to the board whether this was the year to do that. And with the competing priorities, other things, the disruptions of the pandemic, they just didn't feel this was the year. So we know there's a need and I wouldn't base anything on something that's more than 10 years old, which is the last published survey. So I think your need is heard, but this wasn't the year to do it. I think that makes perfect sense, Joe. So I'll ask a follow-up question. Is there any more informal network or does groups like MGMA or anyone else have thoughts on given that I completely understand that it's probably not the right time for that. Is there any other sources or references that anyone could direct me to? I think you're thinking the right way. MGMA, I think does do a broader survey of multiple specialties, but it may not. Because we're small, sometimes they can't get enough survey responses of HPM specialists that they feel like they can include them. Even Medscape does one that they, every year actually. But I don't know that there's one right now that I could tell you is up to date and really covers our specialty. I think the other thing that's difficult about our specialty is let's say there's 7,000 folks or so that are practicing some form of hospice and palliative medicine as their primary work in our country. We all look so different. Some are medical directors, some are inpatient, some are home-based, some are academic, some are pediatric, some are geriatric. There's such a range among this relatively small number of people that even if you get compensation data, you'll say, well, that's good. But I wanna compare to hospice medical directors who make billable visits and are usually the attending and who have an inpatient unit and who are in a rural setting in the Southeast. That might be an N of one by the time you do that. So I think until we're a larger, we have a larger cadre of folks, we're always gonna come up against this, that we're a little small to get the kind of granular data you really wish you could get. So I wish I had a better answer for that. Okay. There's another question by Dr. Scantzell, but I don't see him in the participants here. But then there are some questions in the chat. Maybe I can bring those up. So there's a question and that's an interesting question. It would be great if in Epic or any other electronic record that we have prognostication tools for COPD board, et cetera. Anyone has developed such tools in their EHR? We have a company called Eclivity that's trying to coordinate our care with sort of the dominant medical center in our area. I don't know how much they're charging. I don't know if it's really gonna be helpful. I don't know if it's gonna happen, but that's a company that seems to be available to try to make that happen. One of the things I do know is an issue is that if you're practicing in a hospice setting, your hospice electronic medical record that's probably created so that the hospice can generate invoices to the Medicare to get paid for hospice days probably isn't Epic. And not only that, it's not interoperable with Epic. And not only that, you probably don't like it as a clinical tool. And so when I hear people say Epic, I immediately think you're probably talking about palliative care outside of the hospice benefit because you can't use Epic to bill hospice days very well. But if you use the hospice specific electronic records, they're not big enough and they haven't gotten enough incentive to become Epic. And so this is one of these other little things where I feel like we're a little bit orphaned that our hospice medical records, if we took the three or four that are most commonly used, none of them function like Epic. We are also in the process to use a Eclivity. That's what you know. And I'm curious, use it for hospice patients or was that more for like your community-based palliative care and other kinds of... Community-based palliative care. Yeah, I think it's a whole different game if you're talking community-based palliative care. I think it's when you're in that hospice setting that hospice is its own little niche in terms of everything that has to be captured to submit a good claim that that's where you get into these problems. Yeah. My understanding is that we were looking at it more for the hospital setting or the community-based primary care settings to identify patients who might be appropriate for referral to hospice. Exactly the same. Now that makes sense. Now that makes perfect good sense. And I hope you can share your best practices with each other. Once they go into hospice, they'll get kicked into some other EMR that nobody can see, unfortunately. In somewhat of a tangential way, this conversation is good, but it's given me extra heartburn because we have... I mentioned I've been in hospice for a long time and we have been with two different organizations. They've always had, as was mentioned by Joe and others, a hospice-based EMR, but our system is now going from Epic, or from Cerner. They were previously Cerner going to Epic. And as we speak, there are supposedly ways that they're gonna make Epic work. And so I... Yeah, I'll have to follow up. So thanks for the conversation. Okay. Another question in the chat was, has anyone used prognostic... Yeah. Does anyone use prognostic tools for dementia other than FAST? I'll sometimes use the mortality risk index for dementia patients that are in facilities. Now, we use ADEPT, A-D-E-P-T, ADEPT. I don't know if anyone has used that, but we also use ADEPT scale for dementia patients. Yeah. Thanks for offering that. I'm sorry, which one do you guys use again? I apologize for interrupting you, though. ADEPT, A-D-E-P-T, ADEPT, for advanced dementia. Okay, thank you. Yeah, that was the one I was interested in and learning more about. I asked the question, and I was really wanting to know if you're having success in submitting bills to the max using alternative tools other than FAST for, I don't know, either additional documentation or if you use it instead of FAST. Just curious to hear people's experience with that. So we use it in addition to FAST, not exclusively ADEPT. So just to make the documentation more, like, presentable or more billable, yeah. I don't know about what other people here are doing, but anyone can jump in and answer if anyone else is using anything other than FAST or anyone using ADEPT or not. And we have not used mortality risk index. I know someone just mentioned about that. Who was that? That's what I'll use, but it's only been validated in nursing home patients. So I'll have to look more closely at the ADEPT tool. Great, well, thank you. Really appreciate it. I dropped a link in the chat to an article about using ADEPT in nursing home patients with dementia that might be helpful. Okay, now there was a question submitted by Dr. Larry Scantrell, who's not here, but I'll go ahead and mention that. So the question is, we are struggling with providing continuous care. Do others have tips on how they make it work? And how often is your hospice offering continuous care? I would like to talk to somebody. In my experience, this is a struggle at a lot of hospices and it's really difficult to make it work. We certainly, I think staffing is the big issue for this one. And so, I think we say we offer continuous care and if it was really needed, I think we could pull something together, but it's not something that we really advertise or do very often. I would say the exact same. May I ask a question? I'm sorry, I was, I didn't realize. Sorry, sorry, sorry, quickly. So everybody prefer to use the GIP instead of the continuous care? That is easier or more appropriate? GIP is easier for us to institute because of staffing. Okay, thank you. Anybody? I have a question for home-based hospice in terms of a medication agreement. I remember one of the meetings a long time back, like we don't call it a narcotic agreement. So we wanna make it seem our contract, it has to be a little more positive sounding and we do this for everybody. And on admission, we have the family or patient go over this agreement that we've come up with that I wrote a couple of years ago and asked the group for any input and someone did send me what theirs was. And I've looked online and sort of tailored it more to a hospice appropriate verbiage. But does anybody have one that they'd be willing to share? Caroline, we have an agreement for the home palliative care. We don't use it in hospice. I'd be glad to share that with you if you want to take a look. But it may be something that may not be as applicable in the hospice setting, but I'm happy to. Thank you. Yeah, for ours, like we don't talk about random urine checks and things like that. It's more of an agreement that you have a controlled substance in your house, and we agree to do this, this, and this. In other words, assess your pain, make sure you have appropriate medication, so on and so forth and you agree that you will write down, keep track of the medicines that you're using and to let us know if your pain is not managed, if you need to in between our visits and you won't sell it or share it and things like that. And basically if medicine is stolen or lost, we're going to, we may report it to the police. So things like that, that we've unfortunately have found over the 30 years that I've been with this company that things really shouldn't shock me anymore, but they still do when people steal people's medicines and they're very sick or give them to their grandchildren for whatever that reason be. But anyway, so it's come to that. Carolyn, if you want to put your email address in the chat, I'll see if I can access what we use and then send it to you. Thank you. Anyone has any other questions? I guess I think we can call it off now. Thank you everyone for attending and jumping in and answering the questions. We really appreciate this and see you guys in the next coffee chat. Thanks so much for leading Amir. Thank you very much everyone for joining. Thank you.

coffee chat session

physician billing audits

Medicare administrative contractors

denials

E&M visit code

inpatient hospice visits

diagnosis coding

benchmarking compensation structures

diversity within the field

prognostication tools