Better Health through Excellence, Respect, Innovation, and
Train Treat Teach • http://www.youtube.com/watch? v=HEN7VklmtUY Leaders in Readiness, Healthcare, and Education 88th Medical Group Introduction to Air Force Flight Medicine Apr 2015 Matthew Puderbaugh, DO Capt, MC, FS 88th MDG/SGPF [email protected] Better Health through Excellence, Respect, Innovation, and Partnership WARNING Train Treat Teach • This presentation includes an over abundance of pictures of planes. • If you do not like this, too bad. Leaders in Readiness, Healthcare, and Education Objectives Train Treat Teach • Detail what it is like to work as an Air Force flight surgeon • (1) Cite the many disparate tasks which arise for flight surgeons • (2) Discuss how to prioritize • (3) Specify ways in which flight surgeons interact with line commanders and note that this differs from other doctors’ access to the line • (4) Restate the importance of notifying one’s own squadron or group commander after certain interactions with line officers • (5) Emphasize personal stories and provide copious real-world examples Better Health through Excellence, Respect, Innovation, and Partnership Agenda • • • • • • Train Treat Teach What is a Flight Surgeon Types of Roles Available Courses Role of Profiles Professional Development Basics of Coding Better Health through Excellence, Respect, Innovation, and Partnership You were warned Train Treat Teach CENSORED Better Health through Excellence, Respect, Innovation, and Partnership What is a Flight Surgeon? Train Treat Teach • What we are not! -‐ We are not surgeons -‐ We are not pilots -‐ We are not medical residents • What we are! -‐ Primary Care physicians for the folks that put warheads on foreheads and we ensure a fit and figh<ng force. Better Health through Excellence, Respect, Innovation, and Partnership Who are Flight Surgeons Train Treat Teach • How do we get here? – – – – – Med School Internship Residency for some Aerospace Medicine Primary at WPAFB Addi<onal training throughout • Types of Flight Surgeons – GMO Flight Surgeon – Residency Trained Flight Surgeon (ex Neurologist who is also a Flight Surgeon) – Resident in Aerospace Medicine (RAM: a preventa<ve medicine residency, subject maSer experts in aerospace) Better Health through Excellence, Respect, Innovation, and Partnership Understanding the Flyers Train Treat Teach Mohawktober No Hair November Mustache March Better Health through Excellence, Respect, Innovation, and Partnership Flight Surgeon Schedule Train Treat Teach Ideal Schedule Clinical Management Flying Better Health through Excellence, Respect, Innovation, and Partnership Schedule Train Treat Teach A More Realistic Schedule Clinical Management Paperwork Flying Meetings Meetings about meetings Meetings that are literally about meetings about meetings Better Health through Excellence, Respect, Innovation, and Partnership Your Roles Train Treat Teach • • • • • • Clinician First Local Expert in Aeromedical Disposition Medical Standards Officer Profile Officer/Senior Profile Officer Occupational Medical Examiner/Inspector Public Health Physician Better Health through Excellence, Respect, Innovation, and Partnership Flight Medicine and the Line Train Treat Teach • Flight Medicine = Line Medicine • We are the link between Medical and Line side – Communicate through Profiles – Shop Visits – Personal meetings and briefings • Our job is to explain to the line why someone can or cannot do something due to a medical reason Better Health through Excellence, Respect, Innovation, and Partnership Our patients Train Treat Teach Air Traffic Controllers FLYERS Their Families Space and Missile Ops Special Ops Better Health through Excellence, Respect, Innovation, and Partnership Who is a “Flyer?” • • • • • • • • • Train Treat Teach Pilots Navigators Flight Surgeons Air Battle Managers Flight Engineers Loadmasters Flight Nurses/Techs Flight Attendants Physiologists • • • • • • • • • Air Traffic Controllers RPA Operators Parachutists Space Operators Missile Crews Ravens Flight Test Engineers Astronauts Other Aircrew Better Health through Excellence, Respect, Innovation, and Partnership Clinical Responsibilities Train Treat Teach • Generally treating a very healthy population – Always consider: is this person safe to fly/ required to be DNIF (duties not including flying) – Do they meet standards? – Are they on approved medications? • Also treating flyers of other branches – Download references to other branches Better Health through Excellence, Respect, Innovation, and Partnership Clinical Responsibilities Train Treat Teach • Flight Medicine is now PCMH clinic – Future: Air Force Medical Home • Focus is not on type of service, but access to – Understand HEDIS measures • Coding (which you do) – ICD-10: finally starting Oct 2015 – How well you code determines your RVU’s, (determines how well your clinic performs/funded for specialty clinics) • Code appropriate diagnosis • Code appropriate procedures • Code appropriate appointment types Better Health through Excellence, Respect, Innovation, and Partnership Documentation Train Treat Teach • Remember, what they do is just as important as who they are – “48 year old white male” is not enough – “48 yo, ADAF O4, active flight nurse, not DNIF” – You are writing not only for yourself, but everyone else • Plan must include Aeromedical Disposition (AMD): – AMD: DNIF, not DNIF, 1042 issued/not issued – World Wide Qualified: able to be deployed? – Profiles: current 469/422, limitations Better Health through Excellence, Respect, Innovation, and Partnership Waivers Train Treat Teach • Some Cases, people who are medically disqualified can get a waiver – Approves them to be able to fly – Written by the Flight Surgeon – Approved by a Waiver Authority • Each branch maintains separate standards and waiver authorities – Patients can read them – Branch language specific is important! Prototype USAF Aircraft Carrier Better Health through Excellence, Respect, Innovation, and Partnership Train Treat Teach Planes giving birth Better Health through Excellence, Respect, Innovation, and Partnership Profiles Train Treat Teach • Also called Duty Limiting Conditions (DLC) – Forms that allow us to communicate with the line about what a service member can/cannot do medically • Encompass: – Fitness restrictions – Mobility restrictions – Duty restrictions – Pregnancy Better Health through Excellence, Respect, Innovation, and Partnership Profile Process Train Treat Teach • Provider/Tech enters Profile • Provider signs profile • Profile is then reviewed by Public Health/MSME (must match AHLTA documentation) • Profile is then reviewed and signed by Profile Review Officer (Flight Surgeon) – If there are inconsistencies, provider will be contacted Better Health through Excellence, Respect, Innovation, and Partnership Profile Officer Train Treat Teach • Every AFB has Profiling Officers – Typically are Flight Surgeons – Each base has their own standards • Have to be the profile police – Whether someone is gaming the system – Whether provider put in a profile appropriately • This can take up 1-2 hours a day depending on how large the base is Better Health through Excellence, Respect, Innovation, and Partnership Shop Visits Train Treat Teach • Easier than you imagine • Occupational: make sure you have your list of sites and how often • Food: tag along with Public Health – Always keep in mind health implications – If someone cuts their finger, do they have a med kit with bandaids, or is the meatloaf going to taste funny? Better Health through Excellence, Respect, Innovation, and Partnership Casualty Movement Train Treat Teach Mohawktober Better Health through Excellence, Respect, Innovation, and Partnership CASF Train Treat Teach Mohawktober • Contingency Aeromedical Staging Facility (CASF) • Clearance/Prep for Stresses of Flight • Altitude changes • • • • • • • • • Decreased PO2 Volume Expansion Temperature drop Noise Vibration Decreased humidity G-forces (hopefully not) Pain/nausea control Management of Injuries Better Health through Excellence, Respect, Innovation, and Partnership CASF Train Treat Teach • We also categorize patients (because we don’t want psychotic patients at 35K feet running for the door) • Ensure Equipment/Personnel match pt needs • Coordinate with JPMRC/TPMRC for aircraft Better Health through Excellence, Respect, Innovation, and Partnership CASF Train Treat Teach Mohawktober Better Health through Excellence, Respect, Innovation, and Partnership Return Home Train Treat Teach As fast as 72-hours after an injury, we can have our service members back home with their families on the road to recovery. Better Health through Excellence, Respect, Innovation, and Partnership Additional Duties Train Treat Teach • Response to Flight Line – May need to ensure readiness for your team – Provide appropriate triage training as needed for your base • Pharmacy Representative • PRP/bPRP/PSP CMA • Population Health/Public Health Support Better Health through Excellence, Respect, Innovation, and Partnership Shifting Paradigm Train Treat Teach Quadriplegic Woman Flies F-35 with nothing but her thoughts Arati Prabhakar—director of the Pentagon's advanced research arm DARPA—has revealed a breakthrough achievement in machine mind control. Jan Scheuermann, a 55-year-old quadriplegic woman with electrodes in her brain, has been able to fly an F-35 fighter jet using "nothing but her thoughts." Better Health through Excellence, Respect, Innovation, and Partnership Pro Courses Available Train Treat Teach • ACLS/BLS (will need) • AMP 301: – – – – • • • • • • • • ATLS: get at C4 if available Aircraft Mishap Course NVG Medical Review Officer ECAC/SERE: required Emergency Parachute Water Survival EMEDDS/AEPS: deployment specific Global Medicine PRP Top Knife (also for RPAs) Public Health Emergency Officer Course Better Health through Excellence, Respect, Innovation, and Partnership Pro Courses Train Treat Teach Better Health through Excellence, Respect, Innovation, and Partnership Additional Courses Train Treat Teach • Battlefield Acupuncture – www.dvcipm.org – 4 hour course, available at Andrews AFB, sometimes locally • FAA – Offered in OKC and other venues across the country • PALS/PFCCS – For deployment purposes: winning hearts and minds Better Health through Excellence, Respect, Innovation, and Partnership Money Train Treat Teach • Base Pay: will probably get overpaid for first few paychecks • Additional Specialty Pay: – For when you first become a Staff Physician • Flight Pay: will start when you start flying • Board Specialty Pays: make sure finance is updated • Language Bonus: easy money if you speak another language Better Health through Excellence, Respect, Innovation, and Partnership Personal Development/Helpful Tidbits Train Treat Teach • Always keep CV up to date • Bullet statements: write down your activities • Professional Gifts: budget for these • Use Flight Medicine to enhance your career instead of getting sucked down – IE are you able to apply what you’ve learned and how • Never assume that the person before you was doing it correctly Better Health through Excellence, Respect, Innovation, and Partnership Final Reminders • • • Train Treat Teach At work: Air Force Comes First – But always put yourself ahead in the end There will always be more paperwork – Don’t stress. Instead: manage Your techs/medics are a great resource – But only if you take the time to train them that way – 4N and 4NF: equivalent of LPN/EMT – You are their customer and boss (kinda…) Better Health through Excellence, Respect, Innovation, and Partnership Osteopathic Specific Train Treat Teach • Need AOA credit: most military CME transfers over – Still need, can go to AMOPS or go to specialty college conference • Add OMT to your privileges and use it to stay active – Warning: pilots/spouses love OMT Better Health through Excellence, Respect, Innovation, and Partnership Coding Simplified Current (ICD-9) • • • • Train Treat Teach Disease Codes – Things like Lumbago, Allergic Rhinitis Procedure (CPT) Codes – What procedures were done – Ex: Skin Biopsy vs. Colon Resection Inpatient Codes – Dependent on Admission Dx Outpatient Visit Codes – Dependent on: • Complexity of case • How well you documented • How much you did • How much time you spent • What kind of exam (preventative, consult) In October (ICD-10 US) • Disease Codes – Greatly expanded! – More specific and detail oriented – Expected to be more burdensome (double of coding staff) • Procedure (CPT codes) – Largely remaining the same • Inpatient Codes – Dependent on Admission Dx • Inpatient Procedure Codes – New category – Includes better coding for things like cardiac cath • Outpatient Visit Codes – Remains largely the same Better Health through Excellence, Respect, Innovation, and Partnership Charting OMT (as an example) Osteopathic Manipulation Treatment Record Train Treat Teach • As with any procedure, must document consent • Basics must include: • Physical Exam • Somatic Dysfunction (s) • Response to Treatment • Bonus: • Type of Technique Used • Other Findings Date: _______________________ Patient:_______________________________________________________ DOB:_______________________ SUBJECTIVE: CC: Significant PMx: ROS: Musculoskeletal £ Denies weakness, atrophy Rheumatological £ Denies joint pain Neurological £ Denies neurosensory deficits £ Denies joint deformity £ Denies peripheral neuropathy Genitourinary £ Denies Bowel/bladder Incontinence Other £ ________________ £ ____________________ OBJECTIVE: VS: _________________________________________________________________________________ Lungs: CTAB________________ Heart: RRR _________________ ABD: NTTP _________________ Neuro: AAOx3, CN 2-12 grossly intact, MS 5/5 in all myotomes, MSR equal and symmetric, No gross cerebellar dysfunction, normal gait pattern __________________________________________________________________________________________________ OSTEOPATHIC STRUCTURAL EXAM: Cervical Thoracic Rib Thoracic Rib C1 T1 R1 T7 R7 C2 T2 R2 T8 R8 C3 T3 R3 T9 R9 C4 T4 R4 T10 R10 C5 T5 R5 T11 R11 C6 T6 R6 T12 R12 C7 Lumbar Pelvis Sacrum Hip Shoulder L1 Left Shear L on L/ L on R L2 Right Shear R on R/ R on L Knee Elbow L3 Left Anterior BSE/ BSF L4 Right Anterior LSE/ LSF Foot Hand L5 Left Posterior RSE/ LSF Right Posterior L Diag/ R Diag SFT: + R/ + L/ Neg Cranial Pattern: Other: R Torsion/L Torsion SBRL/ SBRR ASSESSMENT: Somatic Dysfunction: C T L S P R UE LE Visceral, Cranium Sprain/Strain: C T L, Shoulder, Elbow, Wrist/Hand, Hip, Knee, Ankle/Foot Pain: C T L, Shoulder, Elbow, Wrist/Hand, Hip, Knee, Ankle/Foot, Cranium Muscle Spasm: C T L, Paravertebral, Psoas, Iliacus, Glulteals, Piriformis Herniated Disc (HNP), Sciatica, Spinal Stenosis, Peripheral Neuropathy, Radiculopathy, Psoas Syndrome, Piriformis Syndrome, Fibromyalgia Vertical/Lateral Compression TREATMENT: Somatic Dysfunction was: £ Unchanged:_____________________________ £ Mild Improvement:_______________________ £ Mod Improvement: _______________________ £ Resolved: ______________________________ Technique(s) used: Still HVLA Cranial Counterstrain Myofascial Release Muscle Energy Other Home Exercises: _______________________________ Tests: ________________________________________ Meds: ________________________________________ Follow Up in: __________________________________ Better Health through Excellence, Respect, Innovation, and Partnership Coding and Regions Train Treat Teach • In Order to Code appropriately in AHLTA need to have the following: ICD-9-CM Code Region of Somatic Dysfunction 739.0 Head (includes occipitoatalantal joint) 739.1 Cervical 739.2 Thoracic 739.3 Lumbar 739.4 Sacral/sacroiliac 739.5 Hip/pelvic 739.6 Lower Extremity 739.7 Upper Extremity 739.8 Rib 739.9 Abdomen • Proper Diagnosis • Are you treating a condition, a Somatic Dysfunction, or both? • Proper Procedure • OMT procedure coding is based on number of regions treated • See next slide • Proper Encounter • See following slide Better Health through Excellence, Respect, Innovation, and Partnership Why we code: RVUs Train Treat Teach CPT 2009 Codes RVU Value (2012) Body Regions Treated With OMT 98925 0.46 1 or 2 98926 0.71 3 or 4 98927 0.96 5 or 6 98928 1.21 7 or 8 98929 1.46 9 or 10 Better Health through Excellence, Respect, Innovation, and Partnership Encounters • Train Treat Teach Outpatient Visits (as an example) – 99211: minor problem, didn’t even need to see a physician • Ex: tech does cryotherapy on a wart that you have already seen before. – 99212: minor problem, provider was with pt for 5-10 min. • Ex: Minor HA treated with Ibuprofen – 99213: moderate problem, provider in with patient for 10-15 min • Majority of visits • Ex: medication adjustment to pt’s hypertension and hyperlipidemia medications – 99214: moderate to complex problems, provider in with patient for extended period of time (30-40 min) • Ex: Multiple medical conditions (HTN, HLP, OSA, DM, Morbid Obesity, and LBP – 99215: complex problems, requiring provider to complex medical decision making or provider emergent care • Ex: pt presents to outpatient clinic with chest pain, discovered on EKG to have acute MI necessitating beginning of ACLS Better Health through Excellence, Respect, Innovation, and Partnership Encounter Type • New Outpatient: Train Treat Teach – 99201-99205: if seeing pt for multiple items, must add Modifer Code -25 to account for procedure • Est Outpatient: – 99211-99215 (same rule on Modifer) – 99499: Used if pt was just to be seen for OMT (additional E and M not otherwise used) • Preventative Health (PHA): – 99395-99396 (same rule on modifer) • Outpatient Consult: – 99241-99245 – Can be used if a patient is referred to you for OMT – Must specify that a letter or a notice was sent to referring provider – In AHTLA: there is a spot for OSTEOPATHIC Consult Better Health through Excellence, Respect, Innovation, and Partnership Sample Case Train Treat Teach • 20 year old ADAF E3, 4N, est pt, presents due to new onset LBP. It is determined to be mechanical in nature and OMT is offered. OMT is performed on their pelvis, sacrum, and lumbar region. They also ask for a refill of their Claritin for seasonal allergies. Better Health through Excellence, Respect, Innovation, and Partnership Sample Case Continued • ICD-9 Code: Train Treat Teach – Lower Back Pain – SD of Pelvis – SD of Sacrum – SD of Lumbar – Allergic Rhinitis • Procedure: – OMT 3-4 Region • Visit: – 99213 with -25 Modifier Better Health through Excellence, Respect, Innovation, and Partnership Summary • • • • • • Train Treat Teach What is a Flight Surgeon Types of Roles Available Courses Role of Profiles Professional Development Basics of Coding Better Health through Excellence, Respect, Innovation, and Partnership 88th Medical Group Train, Treat, Teach [email protected] Better Health through Excellence, Respect, Innovation, and Partnership
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