From the Director
Did you build an ark yet? We managed to make it through a very rainy weekend, busy despite (or because of) the weather. Thanks to all for your hard work and we have it on good authority that the sun will come out … tomorrow (sorry). It was pretty sunny in Philly, and I got a fun Facetime call from alums Sajal Tanna and Allyson Pishko who were being visited by Ryan Huey, Marc Samsky and Sarah Goldstein! Great to see all the amazing interviews our SARs are doing.
Doctoberfest is in full swing. Please be sure to send a note to Jen about your colleagues who are doing great work. We look forward to recognizing them. Kudos this week to Amanda Boyd and sub-I Steph Ngo from Kara Wegermann for an awesome job during 5 hours of CPRS down time, to Mike Dorry for an excellent chair’s conference, with great discussion points brought up by many, including Megan Dupuis, Landon Brown, Winn Seay and more. Also to our very own Dani Zipkin for an outstanding grand rounds! Paul St. Romain also sends kudos to an awesome NF team of Lakshmi Krishnan, David Sermer, Jordan Pomeroy, and Azalea Kim. Final kudos this week go to Kevin Smith from Dr. Lawrence Crawford for writing an amazing discharge summary on one of his patients.
Keep an eye out for the Doctoberfest happenings, including We Care Wednesdays, where our lunch $ are saved and we donate to charities of your choice. Upcoming are pretzels and (root) beer, as well as tacos in the courtyard.
I had a great meeting with our Residency Council last week. Remember to bring any questions or concerns you have to your reps! They are also in charge of the Halloween party as well as the big sib program for recruitment, so stay tuned! We are also making great progress on the Social Action Council project (after hours clinic at Lincoln) so please contact Jenny, Lauren or Dinushika with any questions!
This week’s pubmed from the program goes to Lauren Collins for her recent article ..Salgame P, Geadas C, Collins L, Jones- López E, Ellner JJ. Latent Tuberculosis Infection—Revisiting and Revising Concepts. Tuberculosis (Edinb). 2015 Jul;95(4):373-84.
Have a great week!
Aimee
What did I read this week?
Submitted by Armando Bedoya, MD
Let’s start with a Haiku!
Chris has a Rash
An Initial Encounter
Penicillin G
Now that I have your undivided attention…What is ICD-10??
The International Statistical Classification of Diseases and Related Health Problems (ICD) is a coding system developed by the World Health Organization as an international health care classification tool and is periodically updated. It is currently in its 10th revision. The code set allows more than 155,000 different codes and permits tracking of many new diagnoses and procedures, a significant expansion on the 17,000 codes available in ICD-9. United States has been using the prior iteration (ICD-9) since 1979 and after several delays, the Centers of Medicare and Medicaid Services mandated the transition to occur on October 1st, 2015.
ICD codes are utilized in the United States for not only disease/illness classification, but also for payment justification. This current iteration has made significant changes to the way we code a diagnosis, communicate information, and thus justify payment.
ICD-10 codes are broadly divided into two groups: ICD-10-Clinical Modification (ICD-10-CM), which codes diagnosis and reasons for visits and ICD-10-Procedure Coding System (ICD-10-PCS), which codes for procedures performed in the hospital inpatient setting.
The ICD-10-CM codes have the same type of hierarchy in its structure as ICD-9 codes. All codes have the same first three digits describing common traits, with each character beyond the first three providing more specificity. For example: All neoplastic diagnoses are between “C00-D47.” However, unlike ICD-9 codes, which were only up to 5 digits, ICD-10-CM is alphanumeric with up to seven digits of specificity allowing for more information to be transmitted with each additional digit. Figure 1 is an example of differences between the two coding systems.
Figure 1
One concern with ICD-9 was the lack of specificity of the information communicated in the codes. For example in Figure 2: if a patient had an open fracture of the femur there were only 16 possible codes in ICD-9, which provided limited details of the clinical picture. With ICD-10 there are now 1530 codes, which provide a significant opportunity to convey more information simply through an alphanumeric code. This captures additional detail based on information that physicians intuitively use in delivering patient care. Accurate analysis of this data will help improve the quality and efficiency of delivering patient care, particularly as electronic sharing and exchange of health records grows.
Figure 2
So how does ICD-10 affect residents??
Residents should be aware that ICD-10-CM requires current terminology as well as the need to learn to provide the specificity necessary for diagnosis coding. This increased specificity required in documentation may mean that physicians have to document details that seem obvious to them but would not be obvious to those abstracting the record for coding purposes. In fact, some of the documentation may seem silly, but remember that the individual doing the coding can only use what appears in the medical record. Even though your coder may understand what you meant, that will not satisfy an outside auditor or claims payer. In medicine, we often say, “If you didn't document it, you didn't do it.” In coding, they often say, “If you didn't document it, you can't bill for it.”
For example in the past you could write diabetes mellitus in the note but now documentation should include the type of diabetes mellitus (type 1, type 2, secondary to another disorder), degree of control, whether they are on insulin, and any complications.
In general, if you use the following guidelines, you will get your documentation right and your attending will be able to code appropriately:
- Say time course, e.g. acute, chronic, acute on chronic
- Say laterality/location, e.g. LLL pneumonia
- This one’s tough…say the etiology if possible, e.g. chronic diastolic left heart failure probably secondary to hypertension or COPD due to tobacco use
- Also tough…say the probable bug based on what antibiotics you chose, e.g. LLL HCAP possibly 2/2 pseudomonas (which you obviously think, based on the fact that you are using Zosyn!)
Many diagnoses will be unable to be coded without subsequent query unless the physician provides sufficient detail. The result at many hospitals will be a series of coding queries on specificity that will continue until the necessary detail is provided. Coding queries mean extra work for you on the back end.
In addition to billing, coding accuracy shows how complicated/sick our patients are, which factors in heavily to how we perform on hospital metrics like standardized mortality rate and 30-day readmissions. How great is it that we can improve our performance just through accurate documentation?
Lastly… the first person, who can correctly identify these three codes (all of which occurred to Chris Hostler during his lifetime) and email me back the correct codes will get a pumpkin spiced latte on the house from me:
U327.01A
U327.11A
U327.91A
QI CORNER
Join us THIS THURSDAY at 5:30pm in the Med Res Library for the October meeting of the Patient Safety and Quality Council! This will be your opportunity to get involved in our council's project on improving paging practices and/or to join a high value cost-conscious care team. Several exciting proposals are in the works as the Oct 19th deadline gets closer. See the flier link at the bottom of Weekly Updates or on the Med Res bulletin boards for proposal details.
CLINIC CORNER
Hi DOC Residents—
We are always looking for better ways teach and take care of our patients at the DOC…4 years ago we began a year long process of Redesign work, culminating in the HomeBase program, Natasha, Marigny and Julia arriving, the Stead/clinic groups, and more!
We are now working on Redesign 2 work—continuing and expanding HomeBase, developing more connections with the community and better ways to take care of the medically complex patients. Stay tuned for Redesign 2, or DOC Cares info!
New at the DOC—
Dr Andrew Muir has begun his once a month session, mostly Friday AM, for Hep C. We are working to develop strategies for who he will see, as he has few slots, and there are a lot of patients!
Watch for emails from him..
Remember .docalliance for mental health for Medicaid/uninsured to put in the Patient Intructions.
There is a state plan that covers meds for the uninsured, NC Med Assist, ask Jan or myself.
Integrated Behavioral Health-More Is Better!
Our onsite mental health services developed in our Redesign Work of 2013 have added great value to the DOC. Here is some great news-more is coming. Through the generous support and partnership of Alliance Behavioral Health and Northern Piedmont Community Care (AKA CCNC or Medicaid) with our clinic leadership, we will soon have a number of new services:
Population-wide depression screening using the PHQ2/9
In depth psychosocial evaluation for those individuals who screen positive for depression
3. Depression care management using a collaborative care model.
4. Trauma group led by a PhD trauma expert for those with clinically significant trauma and
5. Peer counseling for those with substance abuse disorders who are ready to change.
We are happy to hear your thoughts and feedback. More detailed information on your role and some guidance and getting the most for your patients to follow next month.
Thanks for your great work at the DOC!
Lynn, Larry and team!
From the Chief Residents
Grand Rounds
Friday, October 9 - Hematology, Dr. Murat Arcasoy
Noon Conference
| Date | Topic | Lecturer | Time | Vendor |
| 10/5/15 |
SAR Emergency Series: Electrolyte Disorders - Hypernatremia & Hyponatremia |
Li Wen Huang |
12:00 | Dominos |
| 10/6/15 | PEAC Q&A Review |
Sharon Rubin |
12:00 | Mediterra |
| 10/7/15 | SAR Emergency Series: Thyroid Disorders and Emergencies |
John Yeatts |
12:00 | We Care Wed - No lunch |
| 10/8/15 | IM-ED Combined Conference: Sickle Cell |
Paula Tanabe |
12:00 | Cosmic Cantina |
| 10/9/15 | Chair's Conference | Chiefs | 12:00 | Firehouse |
From the Residency Office
DOCTOBERFEST IS HERE!
“Taking Care of Our Community and Each Other”
October 1-31, 2015
Join the Internal Medicine Residency Program in our 4th annual Doctoberfest celebration! This year our continued focus will be on building and strengthening our community – with an added focus on taking care of each other and ourselves.
On October 7th with begin our annual “We Care Wednesdays.” Each Wednesday for the month of October we will not provide lunch for Noon Conference, but rather donate the amount usually spent to a charity selected by the house staff. Your Residency Council will be in touch to discuss options for donations.
Have you witnessed an extraordinary act of kindness and compassion in one of your co-workers? If so, please take a moment to nominate them using the link below. Each day during the week of October 5 – 9, we will be awarding one of the nominees a Starbucks gift card and sharing their act of kindness with the program. Take a moment to recognize one of your amazing co-workers!
https://duke.qualtrics.com/SE/?SID=SV_5tETat6uOFhKY61
Join us this Wednesday afternoon for a German Beer-Garden treat - soft pretzles and root beer in the MedRes library! Please check out the PDF at the end of this post for a complete schedule of activities.
Get Your Flu Shot!!
Flu Vaccination Blitz This Week
We kicked off our annual flu vaccination campaign with a 24-hour Duke Medicine Mass Flu Vaccination drill on Thursday, September 17, 2015. Mass vaccination clinics will be available at each of the hospitals and clinics throughout DUHS. Following the drill, we will continue our annual flu vaccination program, during which time we will provide many additional opportunities for you to get vaccinated. A schedule of vaccination clinics will be posted on the employee intranet in early September. This list will be updated throughout the vaccination season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours.
Applications for Medical or Religious Exemption should be submitted before Monday, October 12, 2015. This will allow sufficient time for review and for communication of the review decision. Please note: Due to the availability of an egg-free formulation of the flu vaccine, egg allergy is no longer a valid reason for a medical exemption.
If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW.
Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.
Key points for trainees:
Get this done ASAP.
If you have medical exemption, be sure it shows up on your personal OESO Page—contact EOHW for any questions.
If the flu vaccine is received at any site (including the VA) besides DUH, DRH, or DUKE RALEIGH, you should take a picture of your documentation form (legible name, date, location and lot #) and email it to eohwflu@dm.duke.edu.
Please direct any questions to kathryn.andolsek@duke.edu
BLS Blitz - November 2015
Just a reminder that the bi-annual BLS Blitz is coming up in November. The flier posted at the end of this blog has the dates. REMEMBER - Duke only holds BLS classes during the November and March blitz each yer, so if your BLS is expiring before March, PLEASE sign up for one of the dates in November!!
Global Health-Internal Medicine Residency Program Recruiting Eligible Candidates
Internal Medicine Residents who have successfully completed PGY1 are eligible to apply for the Duke Global Health Residency, an extended residency that leads to a Master of Science in Global Health and a total of nine months providing clinical care and conducting mentored research at a Duke University international partner site.
Please visit our website for an in-depth description of the core curriculum including rotations, global health competencies, and program requirements as well as application instructions:www.dukeglobalhealth.org
Watch current global health resident John Stanifer, MD, discuss his decision to pursue global health training at Duke:
Send all application materials electronically to sarah.brittingham@duke.edu.
Applications accepted on a rolling basis until October 1, 2015. Offers will be made in November.
Now Accepting Applications for Global Health Elective Rotations
The Hubert-Yeargan Center for Global Health (HYC) is now accepting applications for Global Health Elective Rotations for July 2016 and March 2017.
Application is open to Duke Cardiology Fellows (PGY 5 & 6) and Duke residents from the Departments of Medicine and Pediatrics: Internal Medicine (PGY 2); Med-Peds (PGY 3); Med-Psych (PGY 4); Neurology (PGY 2), Pediatrics (PGY 2).
The application is attached and available at http://dukeglobalhealth.org/education-and-training/global-health-elective-rotation.
(For detailed site information, send request to tara.pemble@duke.edu).
Interviews will be held in October. For more information about this opportunity, contact Tara Pemble, Program Coordinator at tara.pemble@duke.edu or 668-8352.
Application Deadline: October 5, 2015
2015 Carolinas COPD Symposium
When: November 20th, 2015
Location: Cone Center, UNC Charlotte; Charlotte, NC
Registration Link: https://continuingeducation.dcri.duke.edu/2015-carolinas-chronic-obstructive-pulmonary-disease-copd-symposium
Cost: $50 for Healthcare Providers; $25 for Public Health Practitioners
Event Contacts: For registration questions, please contact dcri.cme@dm.duke.edu or 919‐401‐1200. For program questions,
please contact Roy Pleasants at roy.pleasants@duke.edu
Opportunities for Wellness
Yoga in the Trent Semans Center
October 7, 2015 - 12:00 pm to 1:00 pm
6th Floor Trent Semans Center
Sponsor
Duke University School of Medicine
School of Medicine
Class lead by Cosette Dechant, MS1. Bring your mat, no charge to participate!
Feeling down? Need to talk to someone?
All trainees at Duke have FREE access to Personal Assistance Services (PAS), which is the faculty/employee assistance program of Duke University. The staff of licensed professionals offer confidential assessment, short-term counseling, and referrals to help resolve a range of personal, work, and family problems. PAS services are available free of charge to Duke faculty and staff, and their immediate family members. An appointment to meet with a PAS counselor may be arranged by calling the PAS office at 919-416-1PAS (919-416-1727), Monday through Friday between 8:00 A.M. and 5:00 P.M. For assistance after hours, residents and fellows can call the Blood and Body Fluid Hotline (115 inside DUH, 919-684-1115 outside) for referral to behavioral health resources. Another resource is Duke Outpatient Psychiatry Referrals at (919) 684-0100 or 1-888-ASK-DUKE.
https://www.hr.duke.edu/pas/
Upcoming Dates and Events
October 30 - Recruitment Kick-off!
November 26 - Turkey Bowl
December 12 - DOM Holiday Party
Useful links
https://intranet.dm.duke.edu/influenza/SitePages/Home.aspx
http://duke.exitcareoncall.com/
Main Internal Medicine Residency website
Main Curriculum website
Department of Medicine
Confidential Comment Line Note: ALL submissions are strictly confidential unless you chose to complete the optional section requesting a response
Opportunities
http://www.ad001.info/blasts/CKS/CKS15_05431/CKS15_05431.html