ImAgypsy

Hello Again SK, Just came across this site ahima.org w/good info; pages 33 on are informative regarding observation/outpatient services and coding; it's a pdf file you can save http://campus.ahima.org/audio/2008/RB102808.pdf#page%3D4 Gypsy, (See what fun I am having on my day off, Sunday Eve!!! The Learning Process is endless in this reviewing business as I imagine it is for you all defending the charges!!! Two sides, same coin!)

Re: NO LUNCH??? NO BREAKS??? Is that common in nursing?????It struck me as I read these posts. The response of "well, you must have problems with time management because you can't get all your work done in ____ time." Hmm, could it be that all nurses everywhere have a common problem with time management? It it like a personality trait or something? I don't think so!!! I'm tired of hearing that as an excuse, and I'm tired of working hard for 0 dollars because I have to clock out at a certain time, and we can't get the extra people we need to get our jobs done on time :angryfire MC3: :yeah: You nailed it! Now, all I can think is that it must be some kind of nosocomial infection that we all catch from our patients & their visitors.... I wonder if we could all file Workman's Comp claims for exhaustion, malnourished, dehydrated from all the bathroom and meal breaks we missed due to catchin this horrific malady at work?

Good Morning "I Love Nursing 2009", re: "...I thought that I could take my NCLEX in Hawaii and become a RN here in Hawaii and then transfer, but according to the CBN website I will still need to give them my transcripts. I feel like there is so much "red tape" to get through; it almost seems impossible to get a license..." ]Unfortunately, Nursing Licenses, RN, ARNP, LPN, & LVN, although issued by each individual state; are not recognized inter-state, as driver's licenses are. So yes, there is alot of "red tape to get through", and money to pay, to get a license in another state after you get your original license. I have been licensed in about a dozen states, some are much slower than others to process the paperwork, and Cali is one of these. Some ask more questions than others on the endorsement application; but almost all that I recall, asked for official transcripts from your nursing school. So, this is the norm in acquiring a license from another state. I got my Cali license with no problems, by endorsement, after sending all they required with the appropriate fees 25 years after I got my original license in CT. ] ]Way back when, some states had less course and hour requirements and others were higher; such as California, so it was more difficult if for example, a nurse from Mississippi, wanted a license in Cali by endorsement to get one; because the Mississippi schools of nursing did not include all that was required in the Cali schools to obtain original licensure. ] ]Over the years, the states and schools of nursing have all raised the bar so that there is not such vast differences in the courses/programs now being offered. ] ]I would suggest contacting the Cali BON and asking them exactly what are their course, clinical, theory, hours requirements before you take your NCLEX; compare those to what your school in HI has required, and if necessary, take whatever courses you are lacking that are required in Cali (if any) BEFORE you sit for the NCLEX. ] ]As long as you pass the NCLEX, and have all the required course and hours that Cali requires, you will then avoid having to do this AFTER you move to Cali to fulfill your career dreams. Good Luck to you.

Hello CapeCodMerMAID: Re: Medicare Charting This is an unrelated aside....why do y'all feel the need to put (male) next to your name? Do we read your posts differently because you are a man? Nurses are nurses male or female and do we really need to differentiate on the basis of gender? ... When are we going to get over the 'male nurse' name tag..." I simply can not resist; but you have set yourself up for this reply; which I am sending with a big smile and laughing heart, not to be cruel at all. My question is, regarding your post: Does not your cyber-pseudonym used here indicate Your gender is female? Unless you actually are a male with a gender-switching cyber-pseudonym.... ???? Okay by me, but "MAID" usually indicates female to the masses. So, you have done what upsets you when another has done such, oh how very human you are! If you go to your profile, options, there is a box to check whether or not you are female, male, or leave unchecked. If you pick one, then the little blue Male emblem or pink Female emblem is displayed by your cyber-name here on the forum. Hope you can see the humor in this. Gypsy. Who chose to reveal herself as a female here simply because "I felt like it" at the time I was checking boxes, not to indicate any female superiority or inferiority complexes!!!

Oh I am SO Happy to hear that. Thanx for sharing. Gypsy.

Dear NICURN001; re: ".... was thinking of writing a reasoned arguement as to why you deserve breaks and how to go about getting them . But frankly it would be a waste of time , as is this thread !. The laws defining what breaks you are entitled came about , by people who had the same level of power you have , working together , risking what they had , to pressure thier legislatures to introduce these laws . we are in the 3rd world if a nurse can't get get to the bathroom in a 12 hour shift ! " In principle, you are quite correct. But personally, I think this thread had been very helpful with offering approaches, suggestions, and solutions to those of us who have forgotten what it was like in the past when there were no labor laws and people organized to get them created. For which I am thankful. Unfortunately, I for one, as many here have posted, have not done "daily battle" over the years to make sure my "rights" per labor laws have been honored. I guess I have chosen other battles to fight; and just need to keep learning how to take care of myself better; in the simplest ways such as using the ladies room during my working hours rather than delaying until I get home where I am uninterrupted. I think the thread has been very useful to me, and hopefully, for the nurse who originated it. Gypsy. PS I'm not located in Cali or any other Unionized State; who works at least 50 hours a week for 40 hours Salary to maintain an income in these "too few jobs to choose from" days. And is grateful to have this job over no job at all right now.

re: Your Nursing Student friend: "...Told me that she didn't remember what she did last week because she was creating beautiful care plans and learning the theory..." Oh LORD IN HEAVEN; is this STILL the way/focus of RN programs? :crying2: (I've been out of the hospitals for the past 8 years so haven't had much interaction w/any student nurses or new grads; I had been hoping that RN programs were providing more bedside and less "make it all look good on paper in theory" in their training.) Will the ANA NEVER Get their Priorities Right? They are the ones that push/lobby for what is important in nursing programs; and as far as I'm concerned, have done little to address the realities of how we nurses can PROVIDE the CARE the patient needs without being stressed for time to document, document, document. The last few years I worked in acute hospitals, I remember joking when stressed and trying to catch up on documenting when call bell rang during the night; "Don't those darn Patients know they are interferring with my paperwork/documentation? :angryfire How can I ever get it done if they NEED something else????" Sad, but true.

Back in the Dark Ages, my first employer was at a Univerity affiliated hospital, one of the Top 10 in the USA. I worked night shifts in Peds; 2 licensed staff, no aides on a night, 16 bed unit. When the on-call Intern for the night found out that a "New Grad" RN (ie. a nurse with less than 1 year experience) was "In Charge" of the unit for the night shift, the Doc would not even go to their sleep room; they would find an empty bed or chair to sleep in on the unit because they knew they would be awoken multitudinous times during the night from the new grad's calls; and save themselves alot of steps back to the unit to respond to the calls. UNLESS the other staff on duty was an experience LPN; then the Doc knew that the LPN had the knowledge and insights as to when it was appropriate to call or wait to call the Doc. From what I observed, the LPN programs provide alot more actual clinical and bedside hours in their preparation than any of the various RN degreed programs currently do. They were much more able to get organized, do the job, and prioritize than any new grad RN's. Many new grads had never even performed a full shift from start of getting report to end of giving report during their years of education. Unfortunately, the absolute BEST RN programs, the 3 year Diploma Nurse programs were killed off by the ANA back in the 70's and 80's; now THOSE were the nurses to learn from and emulate. I fully agree w/the writer who wishes all nurses started at LPN/LVN levels then advance to RN level. Then the best of both worlds would be achieved, in Practice/Clinical and in Theory.

I believe that it is much more difficult for any person to find any job once they hit their 40's and beyond. The reason is that this is the start of the increased percentages and likelyhood of someone becoming a high-cost health risk that affects the company's group health insurance rates when there are claims. Such as all your Cardiac and Cancer illnesses. MUCH more expensive for insurances to pay out than the younger 20-30's aged ladies having a baby now and then. Your year of LPN Graduation is recent; so that SHOULD be on your resume'. Review it an make sure you do not have any more than the past 10 years of Other work or life experience on it; that way, it appears that you MAY be in your late 20's; which may help you get at least some initial responses to your rez. Many of my over 45 year old friends have had a great deal of difficulty getting hired for new jobs after they hit this age; compared to prior. Even though nobody can "prove anything"; the response to excellent resume's and applications plummets. We have found that whenever possible, do not put the years down of High School, Nursing, College Graduations until AFTER an initial personal interview. Same as "Salary Expected/Desire" questions. We just put down "To be discussed upon personal interview" or "$00.00 - $200,000" if it is a numeric request for info. Good Luck to you. And don't rule out applying to Dr. Offices and clinics that advertise for MA's (Medical Assistants). They do not pay as well as LPN, and you can not work within the limitations of knowledge/education as an MA; you must work to the best of your skills/education as a LPN in any situation. But, you may be able to convince a practice that you would be much more valuable to them as a LPN, for maybe a couple dollars more an hour; to get started, experience, and a real LPN job on your rez for the next couple years. Just make sure you get a "Profit Sharing" clause/benefit included as part of your contract if you go w/a private practice. It can really be a nice surprise at the end of each fiscal year when you find out that your little 1-2% of the profits the practice made add up to several thousand dollars.

Metaphysically speaking, over the years, I have come to the conclusion that Nurses are people who do not know how to take care of themselves, so they live out this lack of Self-Caring by caring for others. Until they "Get It"; if they ever do. We are, collectively, quite hypocritical in what we teach and say vs. what we do and practice in our own lives. Bear with me... After (too) many years of Caring For Others before Caring for Myself, I have the battle scars to prove that I a prime example of this hypocrisy.... 50 pounds heavier from my "Q 24 Hour Feeding Whether I need it or not"; an overcaloried one meal a day eating frenzy; or should I call it Inhaling as chewing is seldom remembered? Frequent UTI's the first 5 years of Nursing from not taking Pee Breaks? Developing Diverticulitis, Kidney stones from not keeping well hydrated? Type 2 DM now from the obesitiy and "too tired to exercize" for many years? Smoking Cigs rationalization because "at least I get to leave the unit for 5 minutes..."? Ahh yes, Think about it. For me; this thing we call "Health Care" has been a spiritual journey and we all have our lessons to learn during this life. What about you? What are you telling/teaching others that you are not doing for yourself?

Between you & me, ( and now the world!), Peds cases are hardly ever denied...some unwritten rule that we reviewers and Med Directors honor unless there is absolutely NO medical need found, after many days beyond the recommended length of stays. What I do w/my "problem providers" is print out the criteria of the DX's that they are frequently admitting with that should have been OBS status, at max. Especially the "Chest Pain" and "Abd Pain" work ups. I am very nice about it, telling them I don't expect them to know, remember all the criteria for every DX, blah blah blah, so here is something to help them when they do their initial H&P. I highlight the definitive criteria that is nec for meeting an IN admit status. And I remind them that they can always change the admit status from IN to OBS during the H&P work up if the ER Doc wrote IN. AND if they DO find something in their work up the first day, they can change any OBS to IN. Again, if nec. When they have been given something concrete in their hands, it also alerts them that they are being watched closely and they take it seriously. They take this approach more seriously than any talk of saving tax/insurance dollars; they really don't care about anybody else's money except their own. But to imply they do not know the acuity level of patients hits their ego's! This has been a very good method to get the drug seekers and frequent flyers out of the hospital in 23 hours. By the way, If the patient came to the ER after 3PM, I approve almost all those stays a 48 hour OBS; but that's a personal thing with me. Your Case Managers can always point this out to the Reviewers the next morning that are pushing to "Get 'em discharged today" for cases that are late in the day admits. Personally, I do not think it is "fair" to penalize the facility by requiring them to do a 23 hour work-up in 13 hours for patients that present to the ER at 11PM; so I just ask my Medical Director to give 48 hour approvals for these cases that are not obviously drug seekers or frequent flyers. He concedes this w/me at least 95% of the time. Hopefully, your facility won't suffer too badly w/the RAC Attacks, but if it does, please please please beg your Administrators to deal w/the Docs w/their admits in some type of LOSS-$haring plan, because that's the only way you'll Really get them to pay attention; when THEIR wallets are affected. They can make it part of their terms of admitting priviledges contract, that if their is a pattern of cases that should have been OBS that the hospital is being denied money for now; then the Admitting MD will share a percentage of the losses. The ER Docs should all be admitting (almost) everybody as OBS status except the absolutely worst case "made for ER TV" type of cases; and they can also share in a LO$$ percentage program. There is no reason for the facility to have to eat the total loss of Income; they can only bill/submit claims based upon what the Docs ordered. We have to keep our hospital's open; and RAC has the potential to close alot of doors; so the best we can do is make a more concerted effort to follow the InterQual &/or Milliman Criteria better NOW; because unfortunately; claims can't be re-submitted/changed after the patient is discharged. I don't like that at all; way too harsh as far as I'm concerned. Personally, I think RAC was part of the last ditch efforts of the past administration to make it look like Medicare & Medicaid had alot more money available in the future and not as bankrupt as it is for the incoming regime. And it didn't matter which "party" won/loss this past election, it was simply started to make things appear better than they are; which now, unfortunately, is 100 times worse than we ever imagined.

You're very welcome SKNelson; please just encourage the nurses, case managers, social workers, whoever is doing the initial review to see if the patient meets observation vs. inpatient status to "be brave" and let the admitting provider know. It's better to get some of the observation Medicare Part B dollars than to be totally denied every dollar if it was an inappropriate billing to Medicare Part A. Right? We aren't denying anybody initial services/work ups; just managing the few dollars left for future payments. I am reviewing Medicare & Medicaid cases again, what a nightmare with the latter. No Co-Pays for the Medicaids means alot of abuse of using the ER for visits that they were too impatient to wait for an appt w/their PCP. I wish the Medicaids had to pay something, anything, $5-10/per ER visit. That might cut down on the abuse. Uh,Oh, I better get off my platform! Gypsy

Yes, I am a former CMS RAC Reviewer who reviewed charts from 2003-2007 in the states of Florida and South Carolina during the CMS Pilot Project last year. And, I actually enjoyed doing these reviews and feel very strongly that the RAC is necessary to break the cycle of inappropriate billing by facilities. (Reason why at end of this epistle!!!) As far as any facilities being able to "prepare for a RAC review"; the nature of the review being Retrospective; After it has been submitted to CMS for payment; really puts facilities in bind; so I would recommend that ALL Summaries be in the chart, and especially focus on measurable documentation that led the provider to decide whether or not the patient should have been admitted as Inpatient vs. Observation (also called Outpatient) status. The big lack of knowledge by Providers is that they do not understand or accept that Inpatient Status, which is paid by Medicare Part A funds, Must Be Supported by definitive findings. Such findings, ie. Pt. comes to ER, c/o Chest Pain, second Troponin elevated, some S-T wave changes on EKG; Justifies the Admission Status and Subsequent Care/Work-Up as InPatient. An Inpatient Stay will pay the facility More money, based upon the DRG/ICD-9 Coding for MI, Acute. The facility gets more money because much more care is involved with a patient who has truly had a MI vs. a "Generic Chest Pain" admission. This vs. Your "Generic Chest Pain" admissions, present to the ER, may be c/o all the classic symptoms; but no definitive findings are found. ie, 1st and 2nd Troponin WNL, Non- ST wave EKG aberrations, etc. These folks get to be admitted under the "Observation Status" which is paid for by Medicare Part B funds. Yes, they get a room, a bed, tele, tests, everything; Nobody has to worry "They'll SUE me if I don't admit them".... The work up and stay are simply paid from separate federal funds. If, within the first 24-48 hours of an Observation stay, definitive findings ARE proven, then, the claim/admit status order, Before the Patient has been Discharged; can be ordered & changed to InPatient Status, providing evidence of Intensity of Services was provided to the patient who has now been found to meet the Severity of Illness criteria. These are the types of scenarios that RAC is looking for. There is actually very little that a facility can do months after a patient stay to change the outcome of the review; despite all the appealing done. Either the patient met Severity of Illness and Intensity of Services were delivered, or they did not. Peers, for too many years, Providers have been admitting patients under the wrong status and Case Managers/Administration have not been "aggressive enough" in letting the Provider know that the admission is not meeting both SI (Severity of Illness) AND IS (Intensity of Services) by InterQual Criteria; and this is part of the big problem that has helped to bankrupt the Medicare coffers. Look at it this way; I have two bank accounts. One is for all the "Must Haves" in life; Rent, Utilities, Insurances, Car Payments, Food, Gas. The other is for "Want to Haves"; New Clothing, Entertainment, Trips, Gifts. If I keep taking from Account Number One (Medicare Part A- Inpatient, Truly Sick, Hospital Admissions/Stays) to pay for things I want that I could have most likely done at another time (Medicare Part B- Observation, OutPatient, Ancillary, Procedures, services); Soon I shall have no money in Account One to pay for the "Must Haves". I feel that as nurses, we all need to have the courage to keep educating the admitting providers over and over and over again until they realize the difference in the 2 admitting statuses, and that YES, Their Patient Does Get a BED, They Can Work Them Up, at an Observation/Outpatient admitting Status. If they do not find something within 24-48 hours; then discharge the patient and complete the work-up at outpatient facilities; and have Medicare Part B funds pay for it. The Hospital will get MORE money from Medicare Part A if the work-up actually proves something is wrong with the patient. But not a moment before! Remember, These are all of our Tax Dollars that have been depleted. And I, being one of those "Boomer Year Nurses" am looking forward to some of the dollars I paid into the system being there for me; and not having been wasted on every drug-seeker presenting to the ER c/o "chest pain" who had absolutely NO evidence of having an MI, or other major chest related illness; within their first 24 hours of hospitalization. Of Course there is much more involved than the simple examples I have given. But I do feel that RAC will eventually be seen as corrective, not punitive actions. And, if anyone needs a former RAC reviewer to do it again, please PM me! I like it!