Tanya Stewart, MD FAAHPM

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Posts by Tanya Stewart, MD FAAHPM

Boards Just Around the Corner

In an effort to keep you on the edge of your seat, I am finally posting my last summary of Board Review Course – day three! Of course the delay has nothing to do with the craziness of my life and the concept we refer to as life-work tight rope walking. Balance is a bit out of the equation right now.

That aside, here are some highlights from the last day…

Hospice Medicare Benefit (Bruce Chamberlain)

  • Understand the benefit periods and timing of when IDG must review each patient
  • Understand the difference between revocation, transfer and discharge
  • MD must be actively engaged in the Quality Assurance Performance Improvement (QAPI) program- where the hospice actively measures, analyzes and tracks quality indicators
  • What are the different levels of hospice care?
  • What are the medication review requirements under the new COPs?
  • How many medical directors can a hospice have?

Hospice Eligibility (John Manfredonia)

  • At initial certification the attending physician and the hospice medical director must certify the patient’s prognosis is likely less than 6 mo
  • At recertification only the hospice medical director needs to make this statement
  • After January 1,2011- hospice MD or NP must have a face-to-face encounter with each hospice patient within 15 days of recertification prior to the 180th-day certification and each certification thereafter (may be too new to be on this exam- but who knows??)
  • Physician narrative for certification is mandatory

Prognosis (Joseph Shega)

  • MDs overestimate prognosis in general
  • Cancer: if pt spends 50% of time in bed, px about 3 months
  • COPD- BODE index can be helpful when evaluating severity of disease and justifying keeping a patient on hospice
  • Hepatorenal syndrome supports <6mo px in ESLD

Billing (Bruce Chamberlain)

  • GV modifier used by the attending of record- who is NOT the hospice medical director when billing for any care
  • GW modifier used by physician for billing unrelated to hospice diagnosis
  • Hospice medical director never uses GV modifier, even if he/she is the attending of record
  • Hospice medical director cannot bill for plan of care oversight
  • Any physician other than attending of record, seeing the patient for issues related to the patient’s terminal diagnosis must have a contract with the hospice- and bills the hospice directly

Discontinuation of Technological Support (Joseph Shega)

lots of links to Fast Facts and Concepts

Goal Oriented Decision Making (Sean Morrison)

  • 8-Step Protocol for Negotiating Goals of Care
  • What is the differential diagnosis of conflict

Other fascinating discussion in this lecture was unrelated to the boards- but still worth your time: NPR interview with NYU historian Tony Judt

And that’s the summary… Keep the engines running… November 16th, is just around the corner!!

Tanya Stewart MD FAAHPM

Day Two of Intensive Review…

The second day was just as intense as the first- fabulous speakers and a review of important information.
Here are some pearls from the second day of AAHPM board review course:

Dyspnea: (Vincent Jay Vanston)
-Total Dyspnea has 4 domains: Physical, Psychological, Interpersonal, Existential
-Must address all domains to adequately control Dyspnea
-When possible and appropriate, treat the underlying medical cause of dyspnea
-Opioids remain the front line agent for symptom relief
-Little support for benzo’s as front line agent
-Benzos and Opioids used together provide best effect when treating dyspnea

Nausea and Vomiting (Joseph Shega)
-Four pathways of Nausea- chemoreceptor, cortex, peripheral and vestibular
-No medications directly affect the Vomiting Center in the brain
-Know what drugs work on what receptors

Anorexia and Cachexia (Jennifer Reidy)
-Multiple factors contribute to ACS: tumor by-products, chronic inflammation, metabolic/neuroendrocrine/anabolic derangement
-Understand secondary causes of ACS (ex: oral problems, psychosocial issues, functional issues)
-ACS also occurs in non-cancer states such as with cardio-pulmonary disease, CKD, liver disease etc
-Understand difference between ACS and starvation
-Artificial Nutrition and Hydration (ANH) is not food, but medical therapy
-Purpose of ANH is not to improve comfort

Urgent Medical Conditions (Jennifer Reidy)
- Bowel Obstruction med management with analgesics, antiemetics and anticholinergics; anticholinergic drug of choice is glycopyrrolate 0.2mg-0.4mg sC Q6H or 0.02mg/hr infusion; drug of choice as it does not cross the BBB
-Spinal Cord Compression med management with high dose steriods; consider surgery +/- radiation therapy- good topic to look up in detail!!
- Seizures: status epilepticus defined as any seizure exceeding 5 minutes OR two seizures in 30 minutes without recover of consciousness- mortality 21-33%! those at risk: brain tumors, hemorrhagic stroke, h/o seizure, alzheimers, alcohol or drug abuse (w/d risk), liver/renal failure, lyte abnl, neurodegenerative dz, infections
-Seizure medical treatment options: subcut midazolam or phenobarbital; rectal diazepam (most antiepileptics can be given rectally); intramuscular lorazepam, midazolam or phenobarbital; sublingual lorazepam, clonazepam or midazolam; intranasal midazolam

Other topics discussed on day two: depression, delerium, other medical emergencies such as increased ICP/ pathological fractures and hemorrhage, palliative sedation, wound care, dementia, advanced cardiopulmonary disease and care of the imminently dying.

Suggested articles:

1. Abernathy A, Wheller J.Total Dyspnea. Current Opinions in Supportive and Palliative Care, 2008, 2:110-113
2. Del Fabbro E, et al. Symptom Control in Palliative Care- Par II: Cachexia/Anorexia and Fatigue. J Pall Med, 2006, Vol9 (2): 409-21
3. Ripamonti C, Mercandante S. Pathophysiology and management of malignant bowel obstruction. Oxford Textbook of Palliative Medicine, 3rd Edition. Doyle D, Hangs G, et al., eds. Oxford: Oxford University Press; 2003:8:496
4. Abrahm JL, Fanffy MB, Harris MB. Spinal cord compression in patients with advanced metastatic cancer: “All I care about is walking and living my life.” JAMA 2008; 299(8):937-46
5. Stewart AF. Hypercalemia associated with cancer. N Engl J Med 2005;352:373-9
6. Kovacs CS, MacDonald SM, Chik CL, Bruera E. Hypercalcemia of malignancy in the palliative care patient: a treatment strategy. J Pain Symptom Management 1995; 10:224-32
7. Wood, GJ, Shega JW, Lynch B, Von Roenn JH. Managemetn of intractable nausea and vomiting in patients at the end of life. JAMA 2006. 298 (10): 1196-1207

Other resources:

http://palliativedrugs.com website gives nice medication conversions

My thoughts on the final day at the review course will come shortly….

Tanya Stewart MD FAAHPM

Intensive Review Course is Intense!

Day one was an excellent and fast paced day in the dungeon of the Hyatt in downtown Chicago. It appears the leaders at AAHPM have mastered Atul Gwande’s “Checklist Manifesto” as everything appeared smooth from the start.

Over 680 participants and close to 300 on the waiting list; thirteen 30 minute sessions with two 30 minute panel discussions breaking up the day; 7 speakers… really, what could go wrong? If anything did go wrong, the cover up was superb.

Now to the content of the course- great refresher and some excellent new information was shared. For those of you not attending the course or those at the course who experienced post-prandial coma and missed some points- here are a few highlights from a couple of today’s lectures:

v Pathophysiology of Pain (Eduardo Bruera)-

  • Have a clear understanding of incidental pain and how this is different from treatment of break through pain
  • Only area of pain we can measure is “Expression” which has five components: cognitive status, mood, beliefs, cultural, biography
  • Have an idea of inhibitory modulators of nociception and excitatory modulation of nociception

v Pain Assessment and Barriers (Michael Preodor)-

  • Understand the barriers at the Provider, patient/family, system levels
  • Understand difference between addiction, dependence, pharmacologic tolerance, pseudo-addiction and diversion

v Principles of Pain Management (Eduardo Bruera)

  • Pain is multidimensional- if pain is increasing, one must do a complete assessment
  • Risk factors for developing Opioid Induced Neurotoxicity (OIN)include
    • High opioid dose
    • Prolonged opioid exposure
    • Pre-existing delirium
    • Dehydration
    • Renal failure
    • Presence of other psychoactive drugs
  • Diagnosis of OIN
    • Cognitive failure
    • Severe sedation
    • Hallucinosis/ delirium
    • Myoclonus/grand mal seizures
    • Hyperalgesia/ allodynia

v Pediatric Sessions (Jeanne Lewandowski)

  • Start low, titrate quickly
  • Half of all pediatric deaths occur in the first year of life, of which half are in the first month
  • Unable to declare a child dead by neurologic criteria (brain dead) in the first week of life
  • Participation of the ill child in decision making is ideal- term used in “assent”

Articles some of the speakers suggested we read:

  1. Zisook, S, Shear K. Grief and bereavement: what psychiatrists need to know; Work Psychiatry 2009 June; 8(2):67-74
  2. Himelstein, BP: Palliatve Care for infants, children, adolescents, and their families. J Pall Med 9(1) 2006, 163-181
  3. Lo B, Ruston D, Kates LW et al. Discussing Religious and spiritual issues at the end of life: a practical guide for physicians. JAMA 2002; 287(6)749-754
  4. Cassell EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982; 306:639-45
  5. Smith HS. Opioid Metabolism; Mayo Clin Proc 2009; 84(7):613-24
  6. Hanks, G et al. Strategies to manage the adverse effects of oral morphine: an evidence-based report. Journal of Clinical Oncology 19(9); 2542-54, 2001, May

So, we are off to a great start! Let’s see what tomorrow brings….

Tanya Stewart MD FAAHPM

Six month countdown to the HPM Boards!

Lifelong learning is imperative in the medical profession- especially for physicians. Then, every 10 years this knowledge is tested by the American Board of Medical Specialty to assess one’s foundation of knowledge. I understand tests are important, yet rarely have I found them fun and exciting. For me, every board exam causes stress and high anxiety

  • Do I have the right board prep books?
  • Does my study schedule cover everything I need?
  • Will I actually follow the schedule this time?
  • Do I need to take a prep course? If so, did I sign up for the right one?

So, I purchased the 3rd edition of UNIPAC. Seems a bit thin… Does this really have everything I need to know? The 2nd edition was a great supplement when I took the ABHPM Exam. Just in case, I signed up for the review course in Chicago. I love courses!! Brings me back to the simple days of medical school… and forces me to focus exhausting hours with my brain on overload days on end. Yet, I am certain, this too will not be enough. So, I plan on buying the HPM Pass, just to get a few more test questions in. Oh and of course, I have my Oxford Text book of HPM, files of PC-FACs and nauseating long list of web resources http://www.aahpm.org/certification/resources.html ready at the helm to fill in all the gaps.

Is this overkill, or am I missing a major area?

Tanya Stewart MD FAAHPM

Healthcare Reform… Time to Act…

Healthcare Reform… TIME TO ACT!

WE (that means- you, your friends, anyone who cares about Hospic & Palliative Medicine and I) need to be involved in healthcare reform.

Doing nothing is not an option!

Questions to ponder as you peruse this Blog Entry…. (As always comments are HIGHLY encouraged…)

  1. Are you aware, many States are cutting hospice from the Medicaid budget? What’s happening in your State?
  2. Can you name the Academy’s four Advocacy Priorities? Should you care?
  3. How will the FDA/DEA/REMS affect your program’s ability to care for a dying patient?
  4. Are you ready to be an Academy Advocate?

Paul Tatum provides a fabulous summary of Diane Meier’s talk about WHY we must engage in the Healthcare reform conversation- lest be told what to do!!! Please see his blog posts for details on the “why” and “how” to get involved.

The legislative update presented by Drs. Tuch, Muir and Kollas summarized the status of healthcare reform today at the Federal and State level, the Academy’s focus for advocacy and FDA/DEA regulatory concerns specific to our field.

National Healthcare Reform Status:

  • Both the Senate and House passed Healthcare reform Bills
  • The White House is pushing for the House to pass the Senate Bill
  • Budget Reconciliation will begin with the above Bills if the House is unable to pass the Senate version
  • This will likely be a long process….

HPM and the Healthcare Reform Bills

  • Multiple provisions in each Bill and Future Bills:
    • Medicaid concurrent care provision
    • Medicare hospice concurrent care demo (Senate)
    • Hospice Payment Reform (MedPAC*, Senate)
    • National Pain Care Quality Act
    • Quality Reporting/Comparative effectiveness
    • Advance Care Planning resources (House)
    • PCTA** to be re-introduced by Senator Wyden
    • Productivity cuts affecting Medicare providers (hospice programs)

*MedPAC: Medicare Payment Advisory Commission

**PCTA: Palliative care training act

State Healthcare Concerns:

  • Many States have cut or are considering cutting Hospice Benefits from Medicaid
  • States are responsible from implementing national reform
  • Many State level initiatives to improve care-
    • POLST, Adv Dir, Sedation, IV Hydration & Nutrition
  • Continued lack of understanding of HPM

State Advocacy for HPM

Academy’s Four Focused Advocacy Areas

(Just think WARR… or come up with your own mnemonic ☺)

  • Workforce: increase the number of PC specialists
  • Access: improve patient’s ability to get PC when needed
  • Research: grants and funding focus (ex: PACA- academic achievement award)
  • Regulatory: DEA/FDA/REMS- ensure timely access to prescription medications

There are multiple sub-points under each advocacy initiative. For details on WARR :


Regulatory- DEA.FDA.REMS (see Cameron Muir’s post below)
  • DEA is concerned about diversion and abuse
  • FDA is concerned about public safety
  • REMS Risk Evaluation Mitigation Strategy­-
    • Issues addressed surrounding:
      • Access
      • Availability
      • Approval
      • Safety

For detailed information see:


Now that you have the bullet points- What is YOUR role?

Advocacy… You can do this…

  • Speak with one voice –
    • Know the Academy Focus: WARR
    • If you have special concerns- speak to Academy Advocacy Staff
      • Jackie Kosinski and Steve Smith
  • Your Representatives WANT to hear from you
    • TELL YOUR STORY! And relate the story to the Academy’s target one at a time!
    • Always bring the story back to the State level…
    • Use Resources created by the Academy
  • Get involved at the State Level!
    • This is a grassroots campaign- IF Obama did it, so can we!
    • Is your State addressing Adv Dir? POLST? Artificial nutrition and hydration? Hospice cuts?
    • Public Hearings are a great way to provide expert opinion
  • Communicate your concerns to the FDA-
    • AAHPM staff will be drafting a letter for members to send regarding regulatory concerns
    • OpioidREMS@fda.hhs.gov
  • Get involved with the Academy’s Advocacy Leaders

So… back to our questions with a few more from the audience at today’s talk:

  1. Are you aware, many States are cutting hospice from the Medicaid budget? What’s happening in your State?
  2. Can you name the Academy’s four Advocacy Priorities? Should you care?
  3. How will the FDA/DEA/REMS affect your program’s ability to care for a dying patient?
  4. Are you ready to be an Academy Advocate?
  5. Is the Academy coordinating efforts with other organizations? If so- who are they and on what?
  6. Does it really matter if the States give up Hospice Medicaid benefit?
  7. Will the DEA ever lighten up on e-prescribing?
  8. What are you doing in your State or in DC to advocate for HPM?

Let’s get the conversation started……

“How wonderful it is that nobody need wait a single moment to improve the world.”-

Anne Frank

Tanya Stewart MD FAAHPM

Coding and Billing… I finally see the LIGHT!

Billing and Coding is complex and certainly NOT a core medical competency for most doctors. The Precourse discussion by Martha Twaddle, Janet Bull and Christopher Acevedo was both timely and enlightening.

Here are some of the salient points from the talk:

  • Look at complexity BEFORE coding Time!!
  • If the clinician bills only on time you are losing money AND likely billing inappropriately!
  • Use Extender codes if the visit exceeds typical time for the billed visit
  • Always document WHY you are seeing the patient EVEN when making a follow up visit
  • GIP level care cannot be used for caregiver breakdown anymore- this is an old CMS rule that was changed a few years ago; you MUST have a symptom to manage to bill for GIP
  • For prolonged services you MUST use “in and out” times- these are additive: ex: if you see a patient from 9:15-9:45 and again from 3-3:30; total time is 60 minutes

Here are some additional resources from AAHPM on billing:

AAHPM Quick Reference Billing Guide (2006)


Tanya Stewart MD FAAHPM