May is Better Sleep Month

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2 Produced by Eastern Iowa Sleep Center A Partnership: UnityPoint-St.Luke s Mercy Medical Center Physicians Clinic of Iowa MAY 2015 VOLUME 4 ISSUE 2 Eastern Iowa Sleep Center May is Better Sleep Month Mother s Day, spring flowers, graduations and summer is on the way. We start to pay attention to nutrition, exercise but most tend to forget about the importance of sleep in maintaining wellness. Sleep is one of the pillars of health lifestyle, directly impacting every aspect of our health and well-being. Getting 6-8 hours of sleep can contribute to improved physical and mental health. Learn more at www. eisleep.com. In this issue The Provider s Corner: Insurance, Documentation and Patient Treatment Hot Topic: What Happens When You Sleep? What s New: NSF Sleep Health 2015 What s Coming: Streamlining Service Access: Outreach The Provider s Corner Insurance, Documentation and Patient Treatment Medicare and commercial insurance demands for sleep symptoms listed in the Progress Notes continue to rise. Per Medicare, insufficient documentation caused approximately 97% of the national sleep payment issues. Examples: No valid order for the PSG No provider signature on the procedure note; or No documentation of the patient s conditions, clinical symptoms and signs of a sleep disorder or apnea to support the need for the PSG study. The PSG is a time-consuming and expensive test. Insurances are focusing on the role of screening for in-lab and home sleep studies. Having two sleep symptoms in the progress notes sent to EISC is the key to validating the need for the PSG test and ensuring your patient can receive treatment if needed. Sleep symptoms include but not limited to: witnessed apnea, snoring, nocturnal choking or gasping, frequent awakenings, morning headaches, excessive daytime sleepiness, daytime fatigue and restless sleep. Physicians Clinic of Iowa Neurology & Sleep Medicine welcomes Cynthia Morrison, ARNP, FNP-C! Cynthia has a special interest in sleep apnea and associated conditions including hypertension, atrial fibrillation, heart failure, diabetes and obesity. Cynthia is now accepting new patients and referrals. To schedule an appointment, call (319) EISC Core Values To our patients, their families, and partners, we are committed to uphold the following values: Service that is unparalleled Listening and creating individualized treatment Excellence in quality, professional care Efficient and welcoming, with easy access Patient-centered, innovative & compassionate care Eastern Iowa Sleep Center 600 7th St. SE, 2nd floor Cedar Rapids, IA Phone Fax Office hours: 8am- 4:30pm eisleep.com

3 SleepSmartz MAY 2015 VOLUME 4 ISSUE 2 Hot Topic: What Happens When You Sleep? When we sleep well, we wake up feeling refreshed and alert for our daily activities. Sleep affects how we look, feel and perform on a daily basis, and can have a major impact on our overall quality of life. To get the most out of our sleep, both quantity and quality are important. If sleep is cut short, the body doesn t have time to complete all of the phases needed for muscle repair, memory consolidation and release of hormones regulating growth and appetite. Then we wake up less prepared to concentrate, make decisions, or engage fully in activities. How does sleep contribute to all of these things? Sleep architecture follows a pattern of alternating REM (rapid eye movement) and NREM (non-rapid eye movement) sleep throughout a typical night in a cycle that repeats itself about every 90 minutes. What role does each state and stage of sleep play? NREM (75% of night): As we begin to fall asleep, we enter NREM sleep, which is composed of stages 1-4: Stage 1 Between being awake and falling asleep, light sleep. Stage 2 Onset of sleep, becoming disengaged from surroundings, breathing and heart rate are regular, body temperature drops (so sleeping in a cool room is helpful). Stages 3 and 4 Deepest and most restorative sleep, blood pressure drops, breathing becomes slower, muscles are relaxed, blood supply to muscles increases, tissue growth and repair occurs, energy is restored. Hormones are released, such as: growth hormone, essential for growth and development, including muscle development. REM (25% of night): First occurs about 90 minutes after falling asleep and recurs about every 90 minutes, getting longer later in the night. Consolidates memory and learning, supports daytime performance, brain is active and dreams occur, eyes dart back and forth, body becomes immobile and relaxed as muscles are turned off. Sleep helps us thrive by contributing to a healthy immune system, and can also balance our appetites by helping to regulate levels of the hormones ghrelin and leptin, which play a role in our feelings of hunger and fullness. So when we re sleep deprived, we may feel the need to eat more, which can lead to weight gain. The one-third of our lives that we spend sleeping, far from being unproductive, plays a direct role in how full, energetic and successful the other two-thirds of our lives can be. What s New: NSF Sleep Health 2015 What s Coming: Streamlining Service Currently EISC is working with local DME/HME to streamline processes to improve patient access to treatment. Provider and clinic surveys will be sent out in the near future to help identify ways to shorten the time between the patient s study and receiving treatment while providing quality of care. We look forward to hearing from you! l

4 Quarterly Newsletter July 2015 Issue 16 HIM CDS Newsletter The goal of the Clinical Documentation Staff is to provide a resource to all providers! One of our objectives with documentation is to clarify any ambiguous or conflicting documentation located in the patient s medical record in order to provide a complete and accurate patient story. "To improve is to change; to be perfect is to change often. Winston Churchill A publication of Mercy Medical Center Cedar Rapids, IA Continued Auditing by Payers Wellmark Blue Cross and Blue Shield have recently contracted with Inpatient Claims Review Services to provide post-payment Diagnosis Related Group (DRG) validation for inpatient services. ICRS is reviewing all Wellmark inpatient claim submissions and conducting post payment DRG reviews. They have been requesting records from our facility to validate the coding selection and they can potentially recalculate the DRG selection based on the medical information we provide. The Clinical Documentation Team currently reviews all inpatient documentation for all payers and will continue to do so at this time. The goal is to make sure that we have the clinical indicators to validate all diagnoses that are billed. We ask that you continue to provide clear and complete documentation of diagnoses with supporting treatment when applicable. This solidifies the record and supports the work that all providers do!! Ongoing ICD-10Training and Education 1) Epic supports ICD-10 with the use of the Documentation Calculator, This tool will guide you in choosing the most accurate and specific components of various disease processes. Its current use now reflects ICD-9 codes. Upcoming in summer 2015 will be for use with ICD-10. 2) The Physician Portal is a web site that was designed with you in mind. It houses information that can be helpful as we transition to ICD-10. Look for the ICD-10 tab at the top right of the page. 3) There s an app for that! Check out these helpful tools that are offered by Precyse University. The Doc Guide app provides helpful tip for the specifics that will be required for optimal documentation of various diseases in ICD-10. This is a free app that can be added to any mobile device and is found in the Precyse University app store.

5 TO: Mercy Physicians and Providers From: Julie Netser, M.D., Laboratory Medical Director Date: 4/22/15 Subject: New Hematology Tests Mercy Medical Center Laboratory has recently purchased new, state of the art, hematology analyzers and we are now able to add the following new parameters to further assist you with the monitoring and treatment of hematological conditions. As of May 5 th the following changes and testing will be available to order. Reference Ranges Immature Platelet Fraction (IPF) % Reticulocyte Hemoglobin (RET-He) pg Immature Reticulocyte Fraction (IRF) % Immature Granulocyte Ages 0-2 Days th/mm³ Absolute Count (IG) Ages >3Day th/mm³ Nucleated Red Blood Cells 0.00 th/mm³ Absolute Count (nrbc) More information on each parameter can be found below and in references provided at the end of this memo. Immature Granulocyte Count (IG): Automated differential orders will now be reported with Immature Granulocytes in addition to the standard five part differential (neutrophils, lymphocytes, monocytes, eosinophils and basophils). The IG count includes metamyelocytes, myelocytes and promyelocytes. This is a much more accurate and precise measurement than a manual differential. Additionally, the turnaround time will be much faster than a manual differential. Immature Platelet Fraction (IPF): IPF is the platelet equivalent of the RBC reticulocyte count. It can assist in differentiating thrombocytopenia secondary to consumption from bone marrow failure/suppression. It is typically elevated in ITP, TTP and DIC. It is also an early indicator of marrow recovery in post-chemotherapy and stem cell transplant patients. It is normal or minimally elevated in marrow suppression disorders such as aplastic anemia. Reticulocyte Hemoglobin (RET-He): Because reticulocytes are the earliest erythrocytes released into blood and circulate for only 1-2 days, measurement of the reticulocyte hemoglobin content provides a snapshot of the iron directly available for hemoglobin synthesis and is an early indicator of the body s iron status. RET-He is decreased in iron deficiency and has been shown to be a better predictor of iron stores then ferritin, transferrin saturation or MCV when bone marrow analysis is used as the criterion standard.

6 RET-He is particularly useful in patients with chronic renal disease as an indicator of functional iron deficiency. RET-He content has been shown to be the strongest predictor of iron deficiency and iron deficiency anemia in children. Immature Reticulocyte Fraction (IRF): IRF is a quantitative measurement of RNA content of the reticulocytes. Immature (younger) reticulocytes contain higher RNA content then more mature reticulocytes. It can be used in conjunction with the reticulocyte count to narrow the cause of anemia. For example, a low reticulocyte count with low IRF is associated with severe aplastic anemia or renal failure, while reticulocytopenia with a high IRF indicates repopulating marrow such as after stem cell transplant, chemotherapy or treatment for nutritional anemia. An elevated reticulocyte count with a high IRF is typically seen in acute hemolysis or blood loss. Nucleated Red Blood Cells (NRBC): An automated nucleated red blood cell count will now be reported with each CBC. The use of automated technology allows rapid and accurate detection of NRBC s even at clinically significant low numbers. HOW TO ORDER/WHEN NEW PARAMETERS WILL BE REPORTED RET-He and Immature Retic Count (IRF) will be reported in association with the reticulocyte count. Retic panel includes Retic Absolute, Retic Percent, Ret-He, and Immature Retic Fraction. There is no additional charge for these tests. Order in Epic by searching Retic or LAB296 Immature granulocyte Count (IG) will be reported with all CBC with automated differential orders. There is no separate order. Order in Epic by ordering CBC with Differential or LAB1748 Nucleated Red Blood Cells (NRBC) will be reported with all CBC orders. There is no separate order. Order in Epic by ordering CBC with Differential or LAB1748 Immature Platelet Fraction (IPF) is a separate orderable parameter which includes a platelet count and an IPF. Order in Epic as IPF or LAB References 1. Fernandes B and Hamaguchi Y. Automated enumeration of immature granulocytes. AJCP 2007; 128: Fernandes B. Identification and enumeration of nucleated red blood cells in peripheral blood. SJI 2002; 12(2): Brugnara C, Schiller B, Moran J. Reticulocyte hemoglobin equivalent (RET- he) and assessment of iron-deficient states. Clinical Laboratory Hematology 2006; 18: ). 4. KDOQI Guidelines for anemia management in ESRD patients. American Journal of Kidney Disease 2006;47:S1-S Kickler T, Oguni S, Borowitz M. Clinical evaluation of high florescent platelet fraction percentage in Thrombocytopenia. AJCP 2006: 125: