Blog

Corporate Staff

Stephany Carroll – Practice Manager

Dustin – Human Resources Manager

Mark Hefner – IT

Marcus Bowen -IT

Lydia – Billing Manager

Candice Simmons- Western North Carolina Marketing Director

Terry Dooley – Eastern North Carolina Marketing Director

 

Physician Staff

BPUC currently has nine, experienced and caring mid-level providers to visit Assisted Living Communities on a weekly basis.  Each of our physicians work under the direct supervision of our Medical Director, Dr.Samuel Bowen. 

Click the name of each provider to read over their resume.

Connie Kurth, PA-C -serves the Hickory/Lenoir area.

Amy Espinoza, FNP -serves the Fayetteville area.

Leslie King, AGNP -serves the Charlotte/Greensboro area.

Angela Kellermeyer, PA -serves the Charlotte area.

Matt Ward, PA-C –serves the Raleigh area.

Dan Radulescu, ANP-C –serves the Wilmington area.

Joy Ciaccio, FNP-C –serves the Flat Rock/Brevard area.

Pamela “Kat” Schmierer, FNP-C –serves the Wilmington area.

Carolyn Mueller– FNP-C –serves the Lenoir/Hickory/Morganton area.

Services & Info

BPUC offers many services and benefits to your Assisted Living Community.

Weekly visits to the facility with the same provider

At BPUC, the same physician will visit your community every week, allowing for a deeper and more reliable patient/physician/community relationship.  We have providers stationed all over the state so you’ll be getting local care in the comfort of your own room.

24/7 on call customer service and physician

Rest easy knowing we’re always a phone call away. We provide 24/7 on call services with a physician, as well as our customer service, at no cost to your community or your residents.

Electronic Medical Record Database

We have our very own EMR system that is available for your use when you partner up with BPUC. Again, at zero cost to your community or residents this system will introduce yet another level of convenience to your daily practices. Within our EMR program you can view patient charts, create visit schedules, view and print visit notes, correspond with your provider, and store all necessary documents for each resident.

Quick and easy start up

Getting started with BPUC is a quick and smooth process. In addition to the easy sign up process, we have two marketing directors trained to help you get all the necessary paperwork in order. At no cost to you, we can send someone to help gather all of the information on each resident, enter them into the EMR, and schedule the first round of visits. We know how busy Assisted Living Communities get, and we aim to make the process of partnering with BPUC smooth and enjoyable.

Long term support 

In addition to start up support, the marketing directors and customer service team is always available to help you. We offer on-campus EMR training, as well as helping the facilities “close the back door” should state come in. This means ensuring all necessary paperwork is in order and offering a helping hand in any area we are able to assist in.

Partner ships with other convenient services 

BPUC is also partnered with several labs and other services that enable us to provide well rounded care in a timely manner. For more information on these services, please contact our marketing department.

Excellent Recommendations

While BPUC provides only primary care, our excellent reputation has allowed us the opportunity to build valuable connections with other providers that we happily pass on to our residents.

These services provide many different benefits to both the family/resident as well as the community. To read more about these benefits more, click on each link.

Benefits to the family

Benefits to the facility

 

Controlling Influenza Outbreaks

Controlling Influenza Outbreaks

CDC Guidelines:

Interim Guidance for Influenza Outbreak Management in Long-Term Care

Recommended Dosage and Duration of Treatment or Chemoprophylaxis for Influenza Antiviral Medications.

Standard Precautions

Droplet Precautions

When the flu strikes

a facility, it is a potentially life threatening event for the elderly and immunocompromised residents that we care for.  The care team needs to move into a heightened sense of alertness and activity.

Ask the staff to immediately start cleaning all horizontal surfaces and door knobs every 8 hours with a CDC approved cleaning agent.  The least expensive and most effective is a

Dilute Clorox Solution:

Mix 1 cup (240 mL) of bleach in 1 gallon of water.
Wash surfaces with the bleach mixture.
If surfaces are rough, scrub them with a stiff brush.
Rinse surfaces with clean water.
Allow to air dry.

 

Once two confirmed cases have a occurred start chemo prophylaxis on all affected residents.  Tamiflu 75 mg daily x 10 days is commonly used.  Watch news and CDC reports for resistant strains that may need a different drug.

If the resident becomes symptomatic increase to full dose anti-viral (such as Tamiflu 75 mf BID x 5 days).

Check oxygen saturation levels on symptomnatic residents.  Residents with normal oxygen levels can be treated symptomatically. Residents with hypoxemia (88% or less) should be referred for evaluation at the local emergency department.

 

Implement Standard and Droplet Precautions for all residents with suspected or confirmed influenza.

CDC’s guidance titled Prevention Strategies for Seasonal Influenza in Healthcare Settings contains details on the prevention strategies for all health care settings. Specific recommendations are highlighted below.

Standard Precautions are intended to be applied to the care of all patients in all health care settings, regardless of the suspected or confirmed presence of an infectious agent. Implementation of Standard Precautions constitutes the primary strategy for the prevention of healthcare-associated transmission of infectious agents among patients and health care personnel.

Examples of standard precautions include:

  • Wearing gloves if hand contact with respiratory secretions or potentially contaminated surfaces is anticipated.
  • Wearing a gown if soiling of clothes with a resident’s respiratory secretions is anticipated.
  • Changing gloves and gowns after each resident encounter and performing hand hygiene
  • Perform hand hygiene before and after touching the resident, after touching the resident’s environment, or after touching the resident’s respiratory secretions, whether or not gloves are worn. Gloves do not replace the need for performing hand hygiene.

Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a health care facility.

Examples of Droplet Precautions include:

  • Placing ill residents in a private room. If a private room is not available, place (cohort) residents suspected of having influenza residents with one another;
  • Wear a facemask (e.g., surgical or procedure mask) upon entering the resident’s room. Remove the facemask when leaving the resident’s room and dispose of the facemask in a waste container.
  • If resident movement or transport is necessary, have the resident wear a facemask (e.g., surgical or procedure mask), if possible.
  • Communicate information about patients with suspected, probable, or confirmed influenza to appropriate personnel before transferring them to other departments.

 

See the CDC references information above for more specific information.

Conquering the Confusion of Dementia Coding

Conquering the Confusion of Dementia Coding

Conquering the Confusion of Dementia Coding
By Danita Arrowood, RHIT, CCS
Posted on: September 14, 2012

Dementia is a common secondary diagnosis; often coders will quickly assign a “memorized” code for it and move on. However due to its commonality, are we missing something such as a co-morbid or complication code that could influence reimbursement? Or are we over-coding symptoms that are inherent to the dementia disease process?

This casual code assignment is complicated by the fact that, often, documentation related to dementia does not present a clear picture of the neurological symptoms related to dementia or those that are a result of other general medical conditions.
In this article, we will review the different codes listed in ICD-9-CM for dementia and some characteristics of each type of dementia. We will also discuss specific instructional notes associated with the dementia codes and determine when it is necessary to seek physician clarification.

Causes & Symptoms of Dementia
Dementia is not a specific disease but rather a group of symptoms related to a decrease in cognitive and social abilities that eventually interfere with a person’s cognitive efforts in work performance, relationships and social activities. These symptoms are a result of dysfunction in the cerebral cortex or other brain tissue. Dementia usually occurs in people over age 60.
Patients with dementia will develop cognitive impairments in areas of language, reasoning, judgment and problem-solving abilities. Forgetfulness, depression and clumsiness are common in early symptoms of dementia. As the condition progresses, patients often experience agitation triggered by their confusion and frustration, and they may become hostile. In later stages, behavioral disturbances, such as wandering off, physical violence and perversion, may become the most challenging issue for caretakers to handle.
To support a diagnosis of dementia, two or more brain functions must be impaired, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV). Alzheimer’s disease is the most common cause of dementia, but not the only cause. A wide variety of physiological conditions, such as alcohol and substance use, and medication reactions are all known causes leading to dementia.

In instances where dementia exists due to conditions such as traumatic or anoxic brain injury or a history of substance abuse with abstinence, dementia can be a static condition. In other cases where dementia is a manifestation of another disease process (i.e., normal pressure hydrocephalus, diabetes), proper control of the physiological condition may slow or arrest the progression of vascular dementia. Dementia associated with neurodegenerative diseases (i.e., AIDS, Lewy bodies and multiple sclerosis), is progressive and permanent. In some cases, the exact reason some patients develop dementia is not yet understood. One source lists 394 conditions associated with dementia.

Dementia Types & ICD-9 Coding
Now, we will look at how ICD-9 classifies dementia and review some of the associated instructional notes for code selection.
ICD-9-CM classifies dementia into the following subcategories:

290.0
Senile dementia, uncomplicated, NOS

290.1x
Presenile dementia

290.2x
Senile dementia with delusional or depressive features

290.3
Senile dementia with delirium

290.4x
Vascular dementia

292.82
Drug-induced persisting dementia

294.1x
Dementia in  conditions classified elsewhere, with/without behavioral disturbances

294.2x
Dementia, unspecified, with/without behavioral disturbances

331.1x
Frontotemporal dementia

331.82
Dementia with Lewy bodies

Senile & Presenile Dementia (290.0 – 290.3)
Senile dementia occurs after age 65. A diagnosis of dementia with onset prior to age 65 is presenile dementia. Although some decline in cognition and mental capacity is normal as we age, dementia is not a normal part of aging.
As always, coders should look to physician documentation to determine the type of dementia. Senile and presenile are archaic terms, not often seen in current documentation. If the physician has not stated “senile” dementia, it would be incorrect to select a code for senile dementia, simply because the patient is over age 65.

Vascular Dementia (290.40 – 290.43)
Vascular dementia is the second most common type of dementia. Incidences increase with advancing age. A buildup of plaque (atherosclerosis), amyloid protein and other debris circulating in the blood stream causes damage to the cerebrovascular system leading to vascular dementia. Multi-infarct dementia is one type of vascular dementia and develops because multiple mini-infarctions occur, scattered throughout the brain. As new, undetectable infarcts occur, symptoms of impairment associated with the affected area of the brain may change suddenly.
Ex: An 87-year-old male with a history of atherosclerosis presents with sudden onset of confusion and agitation. Workup reveals no infectious processes, labs WNL. Patient near baseline. Discharge Diagnosis: Multi-infarct dementia due to atherosclerosis, suspected mini stroke.

434.91 Cerebral artery occlusion, unspecified
290.43 Vascular dementia with delirium
437.0 Cerebral atherosclerosis

Dementia With Lewy bodies (331.82)
Lewy bodies are abnormal microscopic deposits of protein that settle in the brain and destroy nerve cells. Typical Parkinson’s type symptoms develop, such as tremors, muscle rigidity and dementia. These patients may also experience delusions and depression.
Review the instructional note at category 332 Parkinson’s disease, which excludes code 331.82 Parkinson’s with Lewy bodies. Lewy bodies with Parkinsonism is a more specific diagnosis than just Parkinson’s disease, per Coding Guidelines, assign the code for the most specific diagnosis.
When physician documentation lists Lewy bodies with Parkinson’s disease, the ICD-9 codebook instructional note directs coders to assign code 331.82 Dementia with Lewy bodies, plus an additional code to identify with or without behavioral disturbances (294.10-294.11).

Delirium, Delusional & Depressive Features
ICD-9-CM provides combination codes to identify specific types of dementia with delirium, delusional and depressive features. These codes are CCs that may affect the MS-DRG and reimbursement.
Delirium is a sudden on-set transient bout of altered consciousness and change in cognition most often attributed to a direct physiological condition. Delirium is often confused with dementia; however, delirium dissipates when the underlying general medical condition resolves, dementia is typically irreversible.
Seek clarification from the physician if documentation does not identify the type of dementia and clarify the underlying cause of acute delirium. If the cause of the delirium or type of dementia is unknown, code the conditions separately.
Delusional features are present in many psychiatric disorders including Alzheimer’s disease, personality and mood disorders. Delusions are irrational, unwavering beliefs that are clearly false and have no logical or normal basis of reasoning.
ICD-9-CM classifies the diagnosis of delusional disorders to category 297, in the Mood Disorder section. A Delusional disorder is not the same as a delusional feature.
Depressive features and depressive mood. Depression is an inherent part of the dementia disease process.
When documentation lists dementia and depression separately, without further documentation to indicate the depression is related to dementia, code them separately.

Behavioral Disturbances
Simply stated, a behavioral disturbance is any behavior that puts the patient or others at risk.
Not all patients with dementia have behavioral disturbances, but as the individual ages and dementia progresses, the likelihood increases of behavior problems manifesting and becoming the more challenging aspect of patient care.
Noted under many of the dementia codes is the instructional note “use additional code to identify behavioral disturbances.” You will also find listed under the behavioral disturbance codes, subcategory code 294.1x, the instructional note, “code first underlying physical condition.” These two notes provide code sequence instruction, directing the underlying condition to be sequenced before the 294.1x code.
Ex: An 87-year-old nursing home patient with Alzheimer’s dementia has repeatedly wandered off.
331.0 Alzheimer’s disease
294.11 Dementia in conditions classified elsewhere with behavioral disturbance
V40.31 Wandering in diseases classified elsewhere
Behavior disturbances include a wide array of disruptive behavior. It is the coder’s responsibility to watch for documentation that identifies this type of behavior. Physician documentation may not always specifically state “with behavioral disturbances.” If in doubt, query the physician for clarification.
Conclusion
In this article, we have reviewed the most common types and characteristics of dementia coded in ICD-9 and looked at many of the associated coding conventions. Documentation on dementia as a chronic, pre-existing condition can be vague and disconnected from other neurological traits the patient may have, making it difficult for the coder to select the most accurate code. As always, when documentation is not clear, query the physician for clarification.
Danita Arrowood is anAHIMA -approved ICD-10-CM/PCS trainer and an educator/medical coding educator with Precyse (www.precyse.com), which provides services and technologies that capture, organize, secure and analyze healthcare data and transform it into actionable information, supporting the delivery of quality patient care and optimizing operating performance. Danita develops content materials for ICD-9-CM and ICD-10-CM/PCS and provides clinical documentation improvement education. Danita is also adjunct faculty at Phoenix Community College.

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