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Alternate facilities in disasters have many
forms. Some have been set up during domestic
disasters such as hurricanes and floods when the
health care infrastructure has been compromised
or outpatient/home care has not been available or
as a place to which special needs and/or medically
fragile individuals have been evacuated. Many
regular disaster shelters are not capable of providing medical monitoring or observation except by
family members provided they have been evacuated to the same shelter. Often persons in these
shelters have not been evacuated with caregivers,
medical records, prescriptions or supplies. These
facilities may be only for medical monitoring or
observation. Other shelters may be places where
some level of active medical observation and
treatment occurs. Those who have acute illness
or problems may need to be transferred to definitive medical care, for example, the emergency
department (ED) or hospital, depending upon
the capabilities of the particular shelter for providing medical care.
The Modular Emergency Medical System
(MEMS)
9,10
(Figure 61.1 MEMS Diagram) is a
system for expanding, in a modular way, community resources to allow community and regional
cooperative expansion to meet specific medical
and public health needs as they occur. Only
needed modules are activated in any particular
disaster or all components may be activated in a
larger disaster. When first envisioned, MEMS was
in response to mass casualty terrorism incidents.
The original design was to address the gap in
casualty care resources that would exist in most
medical care jurisdictions if large numbers of
biological warfare casualties were to present to
area hospitals. The concept is based on rapid
organization of two types of expandable patient
care modules, the Neighborhood Emergency Help
Center (NEHC) for screening, triage, education,
and possible immunization and prophylaxis elements and the Alternate or Acute Care Center
(ACC) for basic medical observation and offhospital medical care. It also includes a medical
Figure 61.1 Modular Emergency Medical Systems
(Michigan Department of Community Health, Courtesy of Linda Scott BSN, MPH, MEMS and Pandemic Planning [Various Conference Materials] Office of
Public Health Preparedness, Lansing Michigan. Diagram used with permission.)
Disasters
066
21:23:50
command and control element, the Medi cal
Coordination Center (MCC), casualty transportation systems (CTS), expanded outreach/homecare
networks, and fatality management systems.
9
The MEMS concept is integrated into the
Incident Command System/National Incident
Management System (ICS/NIMS) under the Unified Medical Branch. The United States National
Response Plan uses the National Incident Management System (NIMS) for incident command.
12
As federal, state, regional, and local planning
has ensued from 2002 to the present, planning
has evolved into all hazards planning. The specter
of Avian flu and pandemic Influenza brought
expanded planning for off-hospital site patient
screening and treatment if the medical infrastructure was overwhelmed. Multiple articles
on expanded ward care facilities, and possible
cohorting of infectious patients, were published
after research and community planning.
5,12,14,15
Planning for expanding supplies and equipment
and personnel including housekeeping and food
service to support these facilities is also needed. In
the process of pandemic planning, it was learned
that multiple agencies were dependent on the
same medical supply chains, which in an emergency would not be able to expand supplies to all
hospitals and facilities.
5
An integrated supply system for all types of
hospital materials from linens to pharmaceuticals
and intravenous (IV) fluids for these expansion
facilities is essential planning for regional and
state efforts before the supplies in the Strategic
National Stockpile (SNS) would be shipped in to
alleviate the shortage and available for backup
(usually estimated as 72 hours).
16
Then local distribution points and personnel to handle and process supplies, as well as a plan for unloading and
moving supplies, would need to be planned.
Setup of Facilities
The ACC serves as an extension of an already
existing facility(s). Planning involves regional hospital groups, state and regional plans, and medical
coordination to plan for population-based ACCs.
Sponsoring hospitals are identified to coordinate
the ACC including identification, setup, and planning for initial staffing prior to mutual aid from
other medical staffs. Pre-identification of facilities
for off-site treatment will need research to secure
appropriate facilities for patient care. Written
interagency and mutual aid agreements and memorandums of understanding/agreement (MOU/
MOA) to operate an off-site facility need to be in
place before an incident. Considerations for ACCs
include parking and access, security, nearness to
public transportation, and vehicle and ambulance
ingress and egress.
The building would need to have total space
for expanding modules of 50 patient “pods” up to
a 250 patient capacity (Figure 61.2 ACC). Security, ingress and egress, heating and air conditioning, electricity, sizes of doorways and corridors,
lighting, floor coverings, ventilation, sanitation
capabilities including hand washing stations, food
service capabilities, refrigeration, communications, and patient tracking systems need to be
evaluated for each facility. Electronic communication systems sharing with a sponsoring hospital
may allow an electronic medical record (EMR) to
be used and those records house d by the sponsoring hospital(s).
13
Determination of Capability and Mission
ACCs may be used for ward type care for infected
patients who would be cohorted or noninfected
patients who do not need ad vanced respiratory
support; they are designed to create an environment where patients can respond to specific
treatments. Patients nee ding advanced airway
support and ventilator support, cardiac monitoring, and intermediate or stepdown care would be
referred to the hospital. General ward care, low
level oxygen in some ACCs and respiratory treatments would be planned for some facilities.
Patients may be cohorted with one particular
disease entity, thereby, requiring similar treatment and limiting exposure to noninfected persons, or for general ward type ca re with limited
templated evaluation and treatment options.
ACCs may also be used fo r hospice patients with
protocol-driven palliative or comfort care. Planning for ACC patients includes templates for
care, especially for personnel who are unfamiliar
with an austere environment, and agreed upon
pharmaceutical supplies such as IV solutions,
limited stocks of antibiotics, antiemetics, and
analgesics. Supply exchange with the sponsoring
hospital(s) or regional or state caches and plans
for supply and resupply, as well as protective
supplies for personnel, will ne ed to be planned
in advance.
Constance J. Doyle
066
21:23:50
Staffing Levels
Planned levels of staffing would be part of the plan
for the ACC including expanded rolls for nursing,
midlevel providers, and students and residents
with plans for supervision. Using nontraditional
providers such as dentists and veterinarians may
be required if personnel resources are scarce.
13
Expanding staffing such as changing 8-hour shifts
to 12-hour shifts can increase staffing by almost
one-third. Just-in-time training, job action sheets,
and templates for treatment can streamline and
standardize care. Lean staffing and consideration
of/utilization of supportive family members, the
caregivers of children and special needs patients,
and volunteers are part of the plan. Expansion of
personnel and roles of others under direction (students, residents, volunteers) should be written into
the plan. Physician and nurse management for
overall operations and designated physician support per shift for each pod and medical staff buyin will be essential for the smooth operation of this
type of facility.
Assurances that a declaration of disaster will
alter the standards of care, thereby, creating alternative or “crisis standards of care” woul d be the
expected care model. Acceptance of altered standards of care would help to encourage the staffing
of alternate care sites. Declaring a disaster would
provide legal relief with the suspension of some
laws such as Emergency Medical Treatment and
Labor Act (EMTALA). Such a declaration would
facilitate staffing by volunteers or assigned staff.
These facilities would only be in operation if a
prolonged disaster occurred, such as a pandemic
Admission/Registraon
Internal Paent Transportaon
Labor Pool
Pharmacy Services Area
Temporary Morgue
Each bed = 50 bed
pod
Supply & Logiscs
Cost Accounng
Time
Procurement
Sta
Rest/Changing
Area
Maintenance
Material Supply
Resource Transportaon
Food Service
Housekeeping
Communicaons Secon
Community Liaison
ACC Administrator
Security/Safety
Local Health Planning
Records/Planning
Finance
Medical Operaons
Recepon Area
Family Services Area
Courtesy of Linda Sco,
BSN, MPH
Figure 61.2 Alternate of Acute Care Center (ACC)
(Michigan Department of Community Health, Courtesy of Linda Scott BSN, MPH, MEMS and Pandemic Planning [Various Conference Materials] Office of
Public Health Preparedness, Lansing Michigan. Diagram used with permission.)
Disasters
066
21:23:50
lasting weeks to months, rather than a traumatic
disaster where care could be expanded for a
matter of hours to care for casualties.
Since patients are in a large ward type venue,
certain patients who may be disruptive to others,
security risks, or require extensive supervision
may not be app ropriate for this type of facility.
The Medical Care or Special Needs
Shelter
Special needs facilities have been authorized by
local jurisdictions and public health during hurricanes and other disasters. Such facilities have been
staffed by medical volunteers, local medical staffs,
National Disaster Medical System (NDMS) teams,
or Medical Reserve Corps (MRC). Medical care
and special needs shelters function under local
emergency management and public health. They
provide shelter for multiple types of nonambulatory or special needs patients, who cannot be
cared for in a shelter where individuals would be
expected to care for their own needs including
their own medical needs.
Medical shelters can provide electricity for
some powered medical equipment and some level
of medical care including medication dispensing,
dressing changes, and triage to a hospital(s) if a
new medical problem or need presents. Dialysis
patients may need special diets and plans for less
frequent intermittent dialysis on an altered schedule. Patients with behavioral needs may need
special sheltering and caregivers. If general shelters could be expanded to include care for special
needs individuals, then special needs shelters may
not need to be established. Mental health needs
will need to be included in these shelters as well.
Tracking of patients/clients and reunification
also needs to be addressed. Special needs individuals or the vulnerable or at-risk individuals need
to be included as part of the overall plan, whether
in a special needs shelter or a medical shelter with
capabilities for addressing their basic requirements or necessities for functioning or if they
are “sheltered in place” with coordination of their
acute medical care, along with their routine daily
medical needs. (Figure 61.3)
Group homes and long-term care facilities
may have limited surge capacity. Disaster plans
may provide plans for shelter in place (including
disasters when there is no power). In some facilities, common areas could surge to take care of
Figure 61.3 Shelter in Florida during a Hurricane Disaster
(Courtesy of CJ Doyle, MD, FACEP, used with permission.)
Constance J. Doyle
066
21:23:50
more patients. Adjusting referral criteria to hospitals during a disaster should be included in
planning along with the education of staff.
13
If
facilities such as group homes or long-term care
facilities need to evacuate and plan on moving
patients, the relatives, regular caregivers, and/or
family may not be available. Transportation may
also not be as available. For homebound special
needs patients with caregiver support, alternate
plans for evacuation may be necessary. Some
overall observation and oversight for these facilities, especially regarding special needs patients
and sheltering and/or alternate care must be part
of community planning.
Some plans in the past have included sending
all residents of facilities such as group homes and
long term-care facilities to local hospitals even if
there is not a new medical need. The problem
may be as simple as a lack of a generator for
electricity for oxygen concentrators or a ventilator. The solution to avoiding the transportation
of such homebound and/or special health care
needs (SHCN) individuals to the ED may entail
the provision of electricity through an alternate
means, for example, a generator, when electrical
power is cut off.
Community planning for long-term care facilities, the homebound, and special needs patients
will help to allocate sheltering and medical
resources for these patients. Integrating long-term
care facilities, group homes, and oversight agencies
for special needs patients into community disaster
plans will aid in sheltering and help distribute
medical care to the most appropriate facility or
even allow SHCN individuals to remain in their
current domicile, whether it is a group home, longterm care facility, or their own home/apartment.
Conclusion
Community, regional, state, and national disaster
plans must do the greatest good for the greatest
number, preserve the medical infrastructure for the
sickest and most injured patients and evenly balance medical care across the entire medical spectrum of observation and acute care. Multiple
venues for observation, along with limited evaluation and treatment at off-site facilities (e.g.,
outside the hospital) with attention to an ethical
and equitable distribution system for all patients
will allow for appropriate, compassionate, patientand family-centered treatment of individuals
including the SHCN or vulnerable, at-risk patients,
and provide quality medical care. Plans made in
advance, agreements across medical and community and state entities tailored to the unique disaster and in a tiered modular surge system can
facilitate the most appropriate distribution and
best care possible for the most patients under the
difficult situation and constraints of a disaster.
References
1. JCAHO. Joint Commission on
Accreditation of Health Care
Organizations. Standards
Requiring Hospitals to be Part
of Community Planning for
Emergencies: Elements of
Performance. Communication
with Deborah Phillips, March
2012. www.disasterpreparation
.net/resources.html.
2. JCAHO. Joint Commission on
Accreditation of Health Care
Organizations. Hospital
Accreditation Standards 2012.
Published by Joint Commission
Resources. Oakbrook, Ill. 2012.
www.ynhhs.com/emergency/
commu/JCAHOProposed
AdditionstoEMIs
3. JCAHO. Joint Commission on
Accreditation of Health Care
Organizations. Health Care at
the Crossroads: Strategies for
Creating and Sustaining
Community-wide Emergency
Preparedness Systems.
Oakbrook Terrace, IL: JCAHO
2003. Recommendations, p. 18.
4. MEMS ACC Plan.
www.edgewood.army.mil/
downloads/bwirp/ECBC_acc_
blue_book.pdf
5. Cinti, S; Wilkerson, W;
Holmes, JG. Pandemic
influenza and acute care
centers: Taking care of sick
patients in a non-hospital
setting. Biosecurity and
Bioterrorism 6(4). 2008. DOI:
10.1089/bsp.2008.0030
6. Waldhorn, Richard. What role
can alternative care facilities
play in an influenza pandemic?
Biosecurity and Bioterrrorism 6
(4) 2008.
7. Assistant Secretary for
Preparedness and Response
(ASPR). Health preparedness
program. www.phe.gov/
preparedness/planning/hpp/
Pages/default.aspx
8. ESF #8 Public Health and
Medical Services. National
Response Framework. National
Response Framework Resource
Center. www.fema.gov/NRF.
Washington DC. Jan 2008.
9. Church, J. Modular Emergency
Medical System: Expanding
Local Health Care Structure in a
Mass Casualty Terrorism
Incident. Prepared in Response
to the Nunn-Lugar-Domenici
Domestic Preparedness Program
by the Department of Defense
June 1, 2002. Department of
Defense www.dqeready.com/
UserFiles/MEMS.pdf
Disasters
066
21:23:50
10. Nunn-Lugar-Domenici.
Domestic Preparedness Acts
1977–2001. (as found in the
federal regist. www.investiga
tiveproject.org/documents/
testimony/190.pdf and www
.gao.gov/archive/1999/ns99016t.
pdf
11. Joint Commission Resources.
Surge Hospitals-Providing
Safe Care in Emergencies.
www.jointcommission.org/
assets/1/18/surge_hospitals
.pdf
12. National Incident Management
System (NIMS). Department of
Homeland Security.
www.dhs.gov Washington, DC,
December 2008.
13. Hanfling, D; Altevogt, BM;
Viswanathan, K; Gostin, LO,
eds. Crisis Standards of Care,
Volume 4: Hospitals and
Alternate Care Systems.
Institute of Medicine, National
Academies Press. Downloaded
August 28, 2012 from
www.nap.edu/catalog.php?
record_id=13351
14. Skidmore,S;Wall,WT;Church,
JK. Concept of Operations for the
ACC. Modular Emergency
Medical System Blue Book 2003.
Homeland Defense Business
Unit, Aberdeen Proving
Ground, 2003.
15. Goulet, R. Modular Emergency
Medical System, A Regional
Response for All- Hazards
Catastrophic Emergencies.
Planning Guide July 2010.
New England Center for
Emergency Preparedness,
Lebanon, NH, 2010.
16. Strategic National Stockpile
(SNS). www.cdc.gov/phpr/
stockpile/stockpile.htm
Accessed March 25,
2012.
17. EMTALA. Emergency Medical
Treatment and Labor Act of
1986 American College of
Emergency Physicians. Best
Practices for Hospital
Preparedness. www.ACEP
.org Accessed March 20,
2012.
Constance J. Doyle
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066
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Part
V
Financial
12:33:30
Subpart VA
Chapter
62
Financial – Coding and Reimbursement
Physician Coding and Reimbursement
Michael A. Granovsky, MD, CPC, FACEP
David A. McKenzie, BS, CAE
Observation Physician
Documentation and Coding
Prior chapters have identified clinically appropriate patients for Observation. The general
trend has been to extend the universe of patients
receiving Observation Services. The concept of
Observation has expanded from solely those
patients with diagnostic uncertainty to include
clinical conditions that classically involved the
need for “admission” or short-term treatment in
the hospital over several days. As such, the time
frame for observation has gradually broadened
to include same-day services, up to 24 hours,
and now may include multiday stays, with the
code sets and reimbursement methodologies
evolving to report these services.
With regard to the length of Observation Ser-
vices that may be compliantly reported, Medicare
states in Transmittal 2282, “In only rare and
exceptional cases do reasonable and necessary
outpatient observation services span more than
48 hours. In the majority of cases, the dec ision
whether to discharge a patient from the hospital
following resolution of the reason for the observation care or to admit the patient as an inpatient
can be made in less than 48 hours, usually in less
than 24 hours. ”
1
Of note, Medicare’s statement relates to hours
and does not take into account that the observation period of 24 to 48 hours may take place over
three or more calendar days. Consider a patient
admitted to observation late on Friday night,
observed all day Saturday and discharged Sunday
morning. That stay, although less than 36 hours,
would span three calendar days. As such the code
sets provided by Current Procedural Terminology
(CPT) have evolved to accommodate reporting
multiday stays.
Justifying the Medical Necessity for
ObservationinYourDocumentation
The Centers for Medicare and Medicaid Services
(CMS) defines Observation Care as a well-defined
set of specific, clinically appropriate services,
which include ongoing short-term treatment,
assessment, and reassessment that are furnished
while a decision is being made regarding whether
patients will require further treatm ent as hospital
inpatients or if they are able to be discharged
from the hospital.
2
Those services furnished on a
hospital’s premises, including use of a bed and
periodic monitoring by nursing or other staff,
must be reasonable and necessary to evaluate an
outpatient’s condition or determine the need for a
possible admis sion as an inpatient.
3
Such services
are covered only when provided by order of a
physician or another indi vidual authorized by
State licensure law and hospital bylaws to admit
patients to the hospital or to order outpatient
tests.
General Documentation
Requirements
“The (Observation) codes are used to report
encounters by the supervising physician with the
patient when designated as Observation status. In
this context, this refers to supervision of the care
plan for Observation and performance of periodic
reassessments.”
4
Based on the aforementioned CMS and CPT
directives, some general conclusions can be reached
regarding the documentation requirements:
Chart documentation must contain a risk
stratification statement and brief plan that
demonstrates the medical necessity for the
Observation stay.
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21:24:06
Example:
42-year-old male with limited risk factors
presenting with vague chest pain. Will place in
Observation, obtain serial cardiac enzymes, and
plan stress test this evening.
A clearly dated and timed order to place the
patient in Observation.
Progress notes demonstrating periodic
assessments. Of note, there is currently not a
proscribed number of progress notes, but
rather the frequency of notes should reflect the
potential variability in the patient’s condition.
Example:
17-year-old female asthmatic:
10:00 Moderate residual wheeze RR 28 O2
saturation 93%
13:00 Improving on Q 1 hour nebs RR 26
17:00 Mild residual wheeze peak flow improved
Coding Scenarios
One of the more confusing aspects related to Observation services is the seemingly myriad of coding
scenarios relating to the timing of a patient’sObservation care. (See Table 62.1 and Table 62.2.) This
discussion will attempt to simplify the scenarios
using the following broad constructs:
1. All the care takes place on 1 calendar day
2. The care spans 2 calendar days
3. The care spans more than 2 calendar days
Scenario 1: All the care takes place on a single
calendar day. For example: the patient is placed in
Observation at 10 a.m. and discharged home at 9
p.m. the same day. The following codes are used
to report the observation services based on the
amount of History (Hx), Physical Examination
(PE), and Medical Decision Making (MDM).
Additionally, whereas CPT typically provides
clinical vignettes for Evaluation and Management
Services, they have not done so for Observation
Services. However, the Relative Value Update
Committee (RUC) has developed formal vignettes
that were submitted to CMS as part of the RVU
valuation process for these services. The specific
codes, their requirements, and the corresponding
RUC vignette are listed here.
The CPT codes for same-day observation
admit and discharge include:
99234 – Observation or inpatient hospital care
for presenting problems of low severity. Documentation requires a detailed or comprehensive
history, a detailed or comprehensive exam, and
straightforward or low-complexity MDM.
RUC Vignette: 99234 – A 19-year-old pregnant
patient (9 weeks gestation) presents to the
emergency department (ED) complaining of
persistent vomiting for 1 day.
99235 – Observation or inpatient hospital care for
presenting problems of moderate severity. Documentation requiresa comprehensive history,a comprehensive exam, and moderate-complexity MDM.
RUC Vignette: 99235 – A 48-year-old patient
presents to the ED with a history of asthma in
moderate respiratory distress. The patient is
admitted for observation and discharged later on the
same day.
99236 – Observation or inpatient hospital care for
presenting problems of high severity. Documentation requires a comprehensive history, a comprehensive exam, and high-complexity MDM.
RUC Vignette: 99236 – A 52-year-old patient comes
to the ED because of chest pain. The patient is
admitted for observation and discharged later on the
same day.
Importantly, Medicare requires 8 hours of care to
report the same-day Observation code set
99234–99236. As stated in transmittal 2822, “When
a patient receives observation care for less than
8 hours on the same calendar date, the Initial Observation Care, from CPT code range 99218–99220,
shall be reported by the physician. The Observation
Care Discharge Service, CPT code 99217, shall not
be reported for this scenario.”
1
Table 62.1 Summary of Coding 1 and 2 Calendar Day
Stays in Observation
Observation
Complexity
Care All on the
Same Day
Care Covers
2 Days
Low 99234 99218 + 99217
Moderate 99235 99219 + 99217
High 99236 99220 + 99217
Table 62.2 Summary of Coding a Multiple Day
Observation Stay
Observation
Complexity
Initial
Day
Subsequent
Day(s)
Discharge
Day
Low 99218 99224 99217
Moderate 99219 99225 99217
High 99220 99226 99217
Michael A. Granovsky and David A. McKenzie
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