Search

BACKGROUND: Efforts to better support primary care include the addition of primary care–focused billing codes to the Medicare Physician Fee Schedule (MPFS). OBJECTIVE: To examine potential and actual use by primary care physicians (PCPs) of the prevention and coordination codes that have been added to the MPFS. DESIGN: Cross-sectional and modeling study. SETTING: Nationally representative claims and survey data. PARTICIPANTS: Medicare patients. MEASUREMENTS: Frequency of use and estimated Medicare revenue involving 34 billing codes representing prevention and coordination services for which PCPs could but do not necessarily bill. RESULTS: Eligibility among Medicare patients for each service ranged from 8.8% to 100%. Among eligible patients, the median use of billing codes was 2.3%, even though PCPs provided code-appropriate services to more patients, for example, to 5.0% to 60.6% of patients eligible for prevention services. If a PCP provided and billed all prevention and coordination services to half of all eligible patients, the PCP could add to the practice’s annual revenue $124 435 (interquartile range [IQR], $30 654 to $226 813) for prevention services and $86 082 (IQR, $18 011 to $154 152) for coordination services. LIMITATION: Service provision based on survey questions may not reflect all billing requirements; revenues do not incorporate the compliance, billing, and opportunity costs that may be incurred when using these codes. CONCLUSION: Primary care physicians forego considerable amounts of revenue because they infrequently use billing codes for prevention and coordination services despite having eligible patients and providing code-appropriate services to some of those patients. Therefore, creating additional billing codes for distinct activities in the MPFS may not be an effective strategy for supporting primary care.

PURPOSE To examine whether there are group differences in milestone ratings submitted by program directors working with clinical competency committees (CCCs) based on gender for internal medicine (IM) residents and whether women and men rated similarly on milestones perform comparably on subsequent in-training and certification examinations. METHOD This national retrospective study examined end-of-year medical knowledge (MK) and patient care (PC) milestone ratings and IM In-Training Examination (IM-ITE) and IM Certification Examination (IM-CE) scores for 2 cohorts (2014-2017, 2015-2018) of U.S. IM residents at ACGME-accredited programs. It included 20,098/21,440 (94%) residents, with 9,424 women (47%) and 10,674 men (53%). Descriptive statistics and differential prediction techniques using hierarchical linear models were performed. RESULTS For MK milestone ratings in PGY-1, men and women showed no statistical difference at a significance level of .01 (P = .02). In PGY-2 and PGY-3, men received statistically higher average MK ratings than women (P = .002 and P < .001, respectively). In contrast, men and women received equivalent average PC ratings in each PGY (P = .47, P = .72, and P = .80, for PGY-1, PGY-2, and PGY-3, respectively). Men slightly outperformed women with similar MK or PC ratings in PGY-1 and PGY-2 on the IM-ITE by about 1.7 and 1.5 percentage points, respectively, after adjusting for covariates. For PGY-3 ratings, women and men with similar milestone ratings performed equivalently on the IM-CE. CONCLUSIONS Milestone ratings were largely similar for women and men. Generally, women and men with similar MK or PC milestone ratings performed similarly on future examinations. Although there were small differences favoring men on earlier examinations, these differences disappeared by the final training year. It is questionable whether these small differences are educationally or clinically meaningful. The findings suggest fair, unbiased milestone ratings generated by program directors and CCCs assessing residents.

This cross-sectional study uses data from a voluntary survey that was administered during the American College of Physicians Internal Medicine In-Training Examination to assess whether residents in programs with nocturnists perceived nighttime supervision differently than those in programs without nocturnists.

Purpose: To assess the correlations between United States Medical Licensing Examination (USMLE) performance, American College of Physicians (ACP) Internal Medicine In-Training Examination (IM-ITE) performance, American Board of Internal Medicine (ABIM) Internal Medicine Certification Exam (IM-CE) performance, and other medical knowledge and demographic variables. Method: The study included 9,676 postgraduate year (PGY) 1, 11,424 PGY2, and 10,239 PGY3 internal medicine (IM) residents from any Accreditation Council for Graduate Medical Education-accredited IM residency program who took the IM-ITE (2014 or 2015) and the IM-CE (2015-2018). USMLE scores, IM-ITE percent correct scores, and IM-CE scores were analyzed using multiple linear regression and IM-CE pass/fail status was analyzed using multiple logistic regression, controlling for USMLE Step 1, Step 2 Clinical Knowledge, and Step 3 scores; averaged medical knowledge milestones; age at IM-ITE; gender; and medical school location (United States or Canada vs international). Results: All variables were significant predictors of passing the IM-CE with IM-ITE scores having the strongest association and USMLE Step scores being the next strongest predictors. Prediction curves for the probability of passing the IM-CE based solely on IM-ITE score for each PGY show that residents must score higher on the IM-ITE with each subsequent administration to maintain the same estimated probability of passing the IM-CE. Conclusions: The findings from this study should support residents and program directors in their efforts to more precisely identify and evaluate knowledge gaps for both personal learning and program improvement. While no individual USMLE Step score was as strongly predictive of IM-CE score as IM-ITE score, the combined relative contribution of all 3 USMLE Step scores was of a magnitude similar to that of IM-ITE score.

Introduction Graduate medical education programs and academic health systems have long struggled with providing sufficient training in the regulatory and business aspects of health care. Needs assessments confirm that medical students, medical residents, surgical residents, and faculty all rank the topic of billing and coding as an area of curricular need. Indeed, data demonstrates that incorrect coding by academic medical center learners leads to large financial losses and that educational content is needed to address the financial needs of academic institutions. Nationally, internal medicine curricular milestones have recognized the understanding of coding and reimbursement principles as a curricular milestone toward development of competence in systems-based practice. Superimposed upon these chronic concerns, the national transition to ICD-10 coding increases the need for immediately available teaching content on the importance of diagnosis coding. Methods In response, Diagnosis Coding for Clinicians: Core Knowledge and Transition to ICD-10 provides succinct educational content that can be individually reviewed by graduate medical and continuing medical learners. The content is specifically designed to assist training programs and learners with the transition to ICD-10 coding in a manner that supports accurate and specific medical coding practices. The content is provided as an interactive audiovisual presentation that automatically launches on standard personal computers or handheld devices. The presentation can be loaded on learning management systems or provided on a training website. An accompanying examination may be used to document minimum knowledge achievement for inclusion in a learning portfolio. Results Diagnosis Coding for Clinicians: Core Knowledge and Transition to ICD-10 is now mandatory for all billing physicians, house officers, and midlevel providers at the University of Michigan Health System, where each mandated learner must pass a content exam with a minimum 80% correct score. Discussion The content has been peer-reviewed and approved by a series of physician leaders, hospital executives, and coding specialists at the University of Michigan Health System. Focus groups of learners have found the information clear, relevant, appropriately succinct, and engaging.

Lactobacillus species are gram-positive aerobic bacteria that are ubiquitous and generally nonpathogenic inhabitants of the oral cavity, gastrointestinal tract, and female genital tract. Lactobacilli have been reported to cause various infections in immunocompetent and immunocompromised hosts. We hereby report a case of a mycotic aneurysm of the tibioperoneal trunk as a complication of Lactobacillus casei endocarditis.

Background The microdeletion of chromosome 22q11.2 is the most common human deletion syndrome. It typically presents early in life and is rarely considered in adult patients. As part of the manifestations of this condition, patients can have parathyroid glandular involvement ranging from hypocalcemic hypoparathyroidism to normocalcemia with normal parathryroid hormone levels. The first manifestation of the syndrome might be seizures due to profound hypocalcemia. Case presentation A 40-year-old man without significant past medical history presented with a new-onset generalized tonic-clonic seizure. He had no personal history of hypocalcemia or seizures. Physical examination was remarkable for short stature, hypertelorism, prominent forehead and nasal voice. His initial laboratory examination showed hypocalcemia (Calcium 5.2 mg/dl and Calcium ionized 0.69 mmol/l) with hypoparathyroidism (Parathyroid hormone intact < 2.5 pg/ml. NV: 14–72 pg/ml). Urine Calcium was 3 mg/dl on a spot and 88 mg in a 24-hour urine collection (NV: 100–300 mg/24 hs). The electrocardiogram showed a prolonged corrected QT interval. Echocardiogram, abdominal ultrasound and electroencephalogram were normal. A computer tomography of the brain showed basal ganglia calcification. The subtle physical findings and the presence of idiopathic hypoparathyroidism motivated the performance of fluorescent in situ hybridization which demonstrated a microdeletion on one of the homologs 22q11.2. The patient was treated with calcium citrate and calcitriol with good response. Conclusion Microdeletion of chromosome 22q11.2 is among the most clinically variable syndromes, with more than 180 features associated with the deletion. It has a variable phenotypical expression, requiring a high level of awareness for its early diagnosis. Seizures, related to marked hypocalcemia due to idiopathic hypoparathyroidism, might be the presenting feature in an adult patient with this syndrome.