- Comment
- Billing
- Hip Fractures
- Crisis
- Antibiotics
- Community
- Reprocessing
- BBP
- W.S.I.B.
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nother season has passed; a new set of sports injuries is due for repair. Things change around us but the battles of orthopaedics stay the same.
Our College continues to be a noose around our necks, with them looking for more reasons to decrease our numbers. The blood borne pathogen saga continues with another proposal from us that the CPSO meet their proposed requirement for a truly independent expert panel. See Dr. Wilson’s note in this newsletter.
We continue to battle for you, our constituents, on the billing front with further attempts to find money to modernize and improve our Schedule of Benefits while still getting increases in our consult fees. Currently we are trying to simplify the undisplaced fracture codes and the closed reductions fees. On an emergency basis we are in negotiations with the Ministry through the PSPC to try to correct a major discrepancy in shoulder arthroscopy. We hope this correction will happen and spread to the other arthroscopic procedures with similar problems. We will keep you informed - this month there is another billing forum in the newsletter.
In a parallel move, we are approaching the WSIB to have them look at third party billing to facilitate the care of the injured worker, much as in BC or Alberta. See Dr. Mackinlay’s note.
Unfortunately there are many more problems on the horizon. Have you seen the changes in your local hospital, are you feeling like a peon to the lords of the administration? That is a product of the new bylaws they may be enacting on the advice of the OHA. If that is happening you should be contacting the legal arm of the OMA for their expert assistance.
Another problem is the apparent cut back in surgical hours.
It appears that many of the administrators of hospitals have recognized a savings in cutting Operating Room time and elective surgery by both reducing time in a day as well as reducing the number of surgical weeks in a year. With the incentives for increased admissions from the medical side we are losing beds as well.
This has been brought to the attention of the OMA but it will probably have to be public outcry that will change the program.
Perhaps it is just my old cynical mind but I think the medical system does have to be fixed. Perhaps it is the time to start a “Cambie” surgicenter in Ontario -anybody know someone with deep pockets and guts?
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| Dana Fleming MD, President, OOA |
Ihave been asked to clarify as much as possible the billing with the new special visit premium codes. I will use the examples given and try to elucidate the codes.
Case 1:
Surgeon called in from home on a weekday to see a little old lady with a hip fracture – admit. Special visit fee travel code K960 (sacrifice office K961) + special visit premium weekday during day K990 (sacrifice office K992); Consult A065 or C065 if admitted; surgery done in DOTR - surgical fee F**; hospital visits C062 X 2 (maximum); Discharge to Rehab - fees C124 if going to a different hospital billing code (not if Rehab is the same hospital billing code) + E083 if MRP. Total fees K960 + K990 + A065 + F** + C062 X 2 + C124/E083 (if intertrochanteric fracture then payment should be $762.08 approximately.
Case 2:
Surgeon called to the emergency room for consult. If from home then during day K960 (travel maximum 2 X per day period) + K990 (first pt.)[Subsequent patient up to 10 during day K991] + A065. If from office K961 (travel max 2/day period) + K992 (1st pt) + A065. After hours K962 (travel 2X/evening) + K994 (1st pt, if more up to 10/evening K995) + A065. Weekends are like unsociable hours K963 (travel) + K998 (1st person) + A065. If you run an emergency clinic for call (not “booked” per se) you can charge similarly using U (outpatient) codes. This is on page GP 57-58 in the schedule; I suggest you print out those two pages.
Case 3:
I throw to all of you - you admit the patient but he is transferred to another surgeon for care, all of the above fees will apply to you except the surgery, visit and discharge fees. We are not allowed to charge a C122/123 code unless surgery is delayed longer than 48 hours, but if there are medical delays and you remain the MRP then C122/123 apply, particularly if you are not doing the surgery as there will be no confusion then.
Now if you have not operated on a patient but accept them as their MRP out of the ICU you can charge a C142 for the first day and C143 for the subsequent day. If you have treated the patient surgically, in the wisdom of the MOH/OMA, you are not eligible for these fees.
Further questions about fees – If you charge the E555 fee, this would appear to apply to external fixation application. As a 50% premium to closed reduction it is likely inadequate since applying an external fixator particularly an Ilizarov fixator is as difficult if not moreso than applying a plate in many circumstances. We will take this under advisement as we are attempting to modify the Schedule of Benefits as it applies to fractures right now.
E556 extensive debridement of an open fracture must be described in detail in your operative note as there is a high chance that it will be manually reviewed.
Finally, a case was recently presented to me where one of our members spent in excess of 5 hours fixing a difficult fracture. I was asked how to maximize the billing such that the time was not given gratis. The fee in the Schedule was less than $600. Nothing may work but perhaps we should learn from our oncology specialists as they frequently perform multiple hour procedures. I suggest that a detailed OR note be dictated that breaks the procedure down into its component parts, particularly into billable parts, then bill each of those and ask for a manual review. This means a 6 month delay in payment but a possibility that you will be paid for your procedure.
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| Dana Fleming MD, President, OOA |
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Hip fractures are costly to the healthcare system, involve a high risk of medical complications, and are often associated with failure of fracture fixation (Figure 1). While we as surgeons might blame failure on patient comorbidity, poor bone quality, patient “non-compliance”, or other variables beyond our control, a careful analysis of adverse outcomes often identifies factors that are indeed modifiable.
The objective of this brief communication is to highlight three key factors (timely access to surgery, post-operative weight bearing and optimal surgical fixation tactics) with respect to the surgical management of hip fracture patients that may improve medical and surgical outcomes, and over which we have some control.
I: Hip Fractures Should Be Fixed As Soon As Possible (Within 48 Hours)
Timely hip fracture fixation reduces mortality and morbidity, improves patient rehabilitation, and reduces overall healthcare costs. We must work with our medical and anaesthesia colleagues, as well as hospital administrators, to implement the requisite policies, resources, and attitudinal changes to ensure that all hip fracture patients receive timely access to surgery.
Hip fracture patients often have comorbid conditions that require them to take Plavix (clopidogrel), an antiplatelet agent. For elective surgical procedures, it is often recommended to stop Plavix for one week prior to surgery to minimize the risk of perioperative hemorrhage. Hip fracture surgery should NOT be delayed for patients taking Plavix.
In fact there is evidence to suggest that operating as soon as possible despite Plavix results in LOWER transfusion rates, fewer major complications and shorter hospitalization.
II: Hip Fractures Should Be Allowed Weight Bearing As Tolerated Post-operatively
Some surgeons continue to forbid post-operative weight bearing as tolerated in some hip fracture patients despite an extensive body of literature that shows that this practice;
a) does not decrease forces across the fracture and does not prevent failure of poorly fixed fractures (Figure 5b),
b) delays patient rehabilitation,
c) increases healthcare costs and
d) increases patient morbidity and mortality. All elderly patients should be allowed to be up weight bearing as tolerated after hip fracture fixation without exception
See next newsletter - Surgical Strategies for Hip Fracture Care.
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| Dr. Hans Kreder |
Are you being paid for all you bill to OHIP right now? Check your reconciliation!
It has come to our attention that a number of orthopaedic surgeons are being short changed on their billings right now. This is highly variable across the province, even in one OHIP billing office. This is particularly true in the area of arthroscopic surgery, the more complex the coding, the more likely to be “cheated”.
You are not alone. We are aware of the problem and trying to negotiate a settlement that will be in our favour. We are working through the OMA, two committees, the MSPC who have direct involvement with our fee schedule and the PSC who negotiate with the government.
Many of us have been working on this for the better part of three years. Unfortunately someone in the Ministry has taken it upon themselves to unilaterally change the fees billed. Probably this means that we need to get precise and accurate descriptors in the Schedule of Benefits so they cannot interpret them incorrectly. It also means that we will have to fix some of our codes so that they apply to modern orthopaedics.
We will keep you posted.
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| Dana Fleming MD, President, OOA |
How often have you been asked to provide your position on the use of prophylactic antibiotics after arthroplasty or internal fixation by either patients or medical personnel? What types of prostheses, which internal fixation and for how long are prophylactic antibiotics required? Are you aware of the position of the American Academy of Orthopaedic Surgeons and our dental colleagues on the necessity of prophylactic antibiotics and arthroplasty?
Your Ontario Orthopaedic Association executive is also concerned. We are in the process of initiating a position paper on the routine use of prophylactic antibiotics in arthroplasty. We feel this should this be a Canada wide project. As a result we will be addressing this with our colleagues at the Canadian Orthopaedic Association. If you have any suggestions or comments on the matter, it would be greatly appreciated.
Yours sincerely,
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| Robert G. Josefchak, M.D., F.R.C.S. (C) |
North Simcoe-Muskoka
Ten orthopaedic surgeons currently service a catchment area of approximately 500,000 people. There are seven surgeons in Barrie, one in Orillia, and two in Collingwood. Barrie is the primary referral site for trauma from hospitals in Gravenhurst, Bracebridge, Huntsville and Midland.
We are all coping with many of the same issues that are facing members of other LHINs throughout the province. Dealing with developing and maintaining an appropriate Arthroplasty Intake Clinic, a model for LHIN-wide hip fracture management, and functioning in an atmosphere of ever increasing fiscal restraint.
Initially our Arthroplasty Intake Clinic (AIC) encompassed diagnoses of hip and knee arthritis and was supported by a physiotherapist, a nurse, and clerical staff. It expanded to accept diagnoses including shoulder arthropathy. The clinic travelled from its administrative home in Barrie to the local surgeons in Orillia and Collingwood. Ministry funding was tentative. Our clinic model has adapted to mirror others in existence to follow “best practice” and financial limitations. Currently staff consists of a physiotherapist and clerical staff. The physiotherapist is becoming an Advanced Practice Physiotherapist to triage and streamline surgical referrals. Funding remains tentative especially in light of uncertain WTIS funding.
Our recent proposal is for a LHIN-wide hip fracture sitting at a senior leadership level at all of our partner hospitals. We need 4 dedicated trauma beds to facilitate transfer into Barrie coupled with a repatriation agreement that is respected. A “central” registry for trauma patients plans to facilitate referral to the LHIN orthopaedic centers and expedite trauma care.
The completion of construction and opening of our new Cancer Center in April 2012 will increase our available ORs from 8 to 10. However, only 7 of our 8 ORs have been funded this past year due to budget balancing spending cuts.
Expert and timely care for our elective and trauma orthopaedic patients remains a requirement. This is difficult to sustain in these times of limited staff, resources, and finances. The cooperation of the MOHLTC, the OMA, and the OOA will provide us with options and directions to develop and maintain functional care programs.
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| John O’Sullivan, OOA Board |
In an effort to control cost, many of our hospitals have begun reprocessing several items which have been previously labeled as one time use.
These are being sent to a company in the States where they are cleaned, sharpened, and resterilized. Items currently being sent include drills, saw blades, arthroscopic shaver blades, etc.
Recent articles have brought forth several concerns with using reprocessed shaver blades. Examination of reprocessed blades showed structural damage to theses blades which increased with increased reprocessing (1. 2.).
Of even more concern, a significant percentage showed detectable levels of protein and detectable levels of nucleic acid (1. 2.)
Health Canada has warned hospitals that they may be putting patients at risk by reusing medical devices meant for single use only (3.)
1 .M. Kobayashi, et al, Structural Damage and Chemical Contaminants on Reprocessed Arthroscopic Shaver Blades, American Journal of Sports Medicine, Vol. 37, No.2
2. J. King, et al, Assessment of Reprocessed Arthroscopic Shaver Blades, Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol. 22, No. 10 (Oct.), 2006
3. T. Blackwell, Hospitals told to end risky habit: Health Canada warns reuse of medical devices ‘hazardous’, National Post, Thu 12 Aug. 2004
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| Duncan MacKinlay, OOA Board |
On March 5 Dr. Bob Josefchak and I had a telephone conference with the V.P. of W.S.I.B. and others for the board to discuss the possibilities of Expedited Care for their patients in Ontario. The V.P. was not against the idea but felt that she would be unable to discuss fee changes with Sections. The plan was for her to check with the Ministry of Health and their lawyers and get back to us.
At the recent AGM of the OMA in London, Dr. Fleming and myself discuss this situation with Dr. Scott Wooder who confirmed that the current agreement with the MOH excludes the OMA from discussing anything but Form Fees with W.S.I.B. They are currently renegotiating this contract and hope to include the ability to negotiate fees for Expedited Care. This is supposed to be complete within the month. Stay tuned.
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Duncan Mackinlay
OOA Board |
In an effort to control cost, many of our hospitals have begun reprocessing several items which have been previously labeled as one time use.
These are being sent to a company in the States where they are cleaned, sharpened, and resterilized. Items currently being sent include drills, saw blades, arthroscopic shaver blades, etc.
Recent articles have brought forth several concerns with using reprocessed shaver blades. Examination of reprocessed blades showed structural damage to theses blades which increased with increased reprocessing (1. 2.).
Of even more concern, a significant percentage showed detectable levels of protein and detectable levels of nucleic acid (1. 2.)
Health Canada has warned hospitals that they may be putting patients at risk by reusing medical devices meant for single use only (3.)
1 .M. Kobayashi, et al, Structural Damage and Chemical Contaminants on Reprocessed Arthroscopic Shaver Blades, American Journal of Sports Medicine, Vol. 37, No.2
2. J. King, et al, Assessment of Reprocessed Arthroscopic Shaver Blades, Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol. 22, No. 10 (Oct.), 2006
3. T. Blackwell, Hospitals told to end risky habit: Health Canada warns reuse of medical devices ‘hazardous’, National Post, Thu 12 Aug. 2004
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| Duncan MacKinlay, OOA Board |
On March 5 Dr. Bob Josefchak and I had a telephone conference with the V.P. of W.S.I.B. and others for the board to discuss the possibilities of Expedited Care for their patients in Ontario. The V.P. was not against the idea but felt that she would be unable to discuss fee changes with Sections. The plan was for her to check with the Ministry of Health and their lawyers and get back to us.
At the recent AGM of the OMA in London, Dr. Fleming and myself discuss this situation with Dr. Scott Wooder who confirmed that the current agreement with the MOH excludes the OMA from discussing anything but Form Fees with W.S.I.B. They are currently renegotiating this contract and hope to include the ability to negotiate fees for Expedited Care. This is supposed to be complete within the month. Stay tuned.
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Duncan Mackinlay
OOA Board |
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