1) Quoting directly from the manual... "When Counseling and/or coordination of care dominates (more than 50%) the physician / patient... encounter, then time may be considered...
2) The actual code 99215 (level 5 existing patient office visit" reads "Physician's *typically* spend 40 minutes face-to-face". That statement only is applicable if #1 above applies. If not "...requires 2 of three key components". Typical doesn't mean every visit. Also I quoted the 5 minute visit for a level 4 visit. In a stable diabetic, treating a skin infection (for instance) may only take 5 minutes, which is enough time for a detailed history of the illness and the medical decision making which is of moderate complexity -- thus its a 99214 if all the physician does is write an antibiotic script.
Medicare alone has about 250 pages on how to code an E&M (office) visit, from two separate policy manuals, and most insurance companies (every one I've ever dealt with) use Medicare's definition. The CPT manuals I've looked at usually just barely touch the surface of the full regulations.
With the exceptions of psychiatrists and some relatively rare situations (direct management of a code, etc.), doctor's rarely bill on time -- and are usually not allowed to.
They bill on a combination of three items -- history taken (or updated from last visit), medical complexity of the visit, and the physical exam done. For new patients the level of visit is based on the least comprehensive of those three items. For existing patients its based on the middle of the three.
Its entirely possible to bill a legitimate level 4 visit (on a scale from 1-5) for a patient with diabetes (for instance) during a 5 minute visit. There are "time" codes listed in the coding manuals, but their use is restricted to when doctors are primary providing counseling (diet and exercise, etc.) during a visit.
In most cases, all the suing party will have to do is submit a copy of his guilty plea. The arguments will be about damages.
A civil trial doesn't require much in the burden of proof ("50% plus a feather"), so his guilty plea in open court will meat the is he liable portion. Then its about damages.
I'd put the mapping of the Human Genome (2003), or creating new organs from stem cells (2008), or Synthetic Biology creating a cell with a fully artificial genome (2010) all up there as well. Don't forget faster than light neutrino's (confirmed a second time), or a vaccine for HIV. That's in the last 10 years, much less 20.
Tipping in fast food is not customary, and very few do it -- and many places don't allow it.
Servers in tipped positions make $2.13 / hr (although they are guaranteed min. wage if tips don't make up the difference -- although they probably will be fired).
I've worked in both -- including a stint as a full time job in creating / working with dashboards and report generation in Cognos, etc. for an insurance company with 5000+ employees. We still had to pay IT via interdepartmental billing.
There are some things that RDMS's are just bad at. If I need to generate reversing entries and allocations to close out a month, a RDMS is slow and not very capable -- and Excel is great at it. I would still upload the final product to the database at the end of the day. If I had to write software to do the same, it would take much longer -- especially since much of the business logic changed every month. It would of been possible, and maybe an enterprise with 100,000 users instead of 5,000 may have found it worthwhile, but it would have taken years to break-even vs. using excel.
There is no question that these desktop solutions *sometimes* outgrow their original tools (ie enterprises dependent on a single spreadsheet) -- and that maybe happening in the grandparent, but for every 1 of those that IT sees, there are 50 or more of those that plug along and do their job reasonably well -- and only require 1 hour of an accountant's time, vs 100 hours of programming time (probably 30% of that is due to accountants explaining and detailing what has to be done). Accountant's jobs cannot always be broken down into easily generated programming logic -- even for relatively repetitive tasks like basic taxes or multi-jurisdictional reporting.
This still doesn't address things like data analysis. Sure a stored procedure can generate what you need, but that requires a higher level of expertise and a lot more time in many cases. If I want to perform a T-Test or statistical analysis beyond the basics, do something like a median (I just had this problem), do advanced graphing, etc. Many / most of the database and reporting tools are inferior to Excel and F9.
Department of Interior has multiple police agencies (National Park Rangers, etc.). They also have access to things like medical records from the Indian Health Service, etc. They also deal with items such as business plans, etc. which are not subject to FOIA and contain proprietary information.
That being said, I don't have a problem with cloud services. No one has convinced me why Google or Microsoft is a less safe place to store data than my IT department. In many cases (although given enterprises maybe the exception), those two entities have much more experience than most companies in running a datacenter. Its their core business, its not the interior departments of joe blow's widget manufacturer.
*may* suck in the real world for a variety of reasons.
For X amount of data (less than a few million rows), excel is a perfectly adequate flat file database if don't need a relational database -- and many items don't. This isn't VisiCalc anymore on computers with 640k of memory.
Ajax? REALLY???? Most people I know who use Excel heavily are not programmers -- they are accountants. I know of about 1 in 50 accountants have any idea what the hell Ajax is, much less any ability to do anything with it. Why should I pay an IT consultant / IT department 1000's when I can do something that meets my needs in 10 minutes.
I'll grant that Access *might be* a better solution, but depending on analysis and presentation needs it may not be -- or again it may require programming in VBA or 10's of hours of work to get what you need.
Databases suck at analysis. SQL based crosstabs can be useful, but they also have major limitations if you are not going to drop to a programming language. God forbid you try something like finding a median of a dataset. Instead of =Median(data), its a 100 lines of code.
For smaller datasets Excel is a much better solution in many / most cases than a database solution if you don't need the relational mechanisms, joins, etc. -- which 90% of spreadsheets don't.
Libre Office's spreadsheet sucks. They cannot even get basic UI functionality that has been in all spreadsheets since VisiCalc, much less come close to the quality of Quattro of 15 years ago.
Ok, let's say I'm not amazon, I'm a small tractor supply store in MN. I sell a lawn tractor to a MS resident. Problem is, there are 3 different taxes for "lawn tractors" depending on various factors. If I'm Home Depot I've hired a lawyer to figure this out, but lawn company in MN can't do that for every one they sell. MS by the way is a comparatively easy state to collect in.
Now, think of a state like Louisiana. The state, parish, every town, and often other political entities (special taxation districts) all can level sales taxes. So you can have a different tax rate in the same town and zip code by crossing a street. On top of that, every jurisdiction exempts different items or taxes them at different rates. How the hell is someone in California supposed to figure this out? On top of that, I'm supposed to file separately with every entity I'm subject to taxation from, so one sale could easily land me with 3-4 tax returns to complete. Oh yea, and if I sell that tractor to a farmer the thing maybe exempt, but I still have to file on their specific paperwork, etc.
The reasonable way to do this (and I'm not opposed) is for the states to simplify the collections. This could be accomplished in many ways -- for instance an interstate compact or federal law. However, states need to have a uniform rate within their jurisdiction, uniform exemption standards (at least from the merchants perspective) and all states need the same definitions as to what is taxable. They also need to allow for proxies to file / pay the tax. Then a merchant would be responsible for knowing 1 set of rules, and submitting up to 50 returns -- which they could do through a proxy (for instance if I'm a small seller I can send my sales records to salestaxcompliance.com and they will take care of the filing paperwork, etc.).
Use taxes have been around forever -- in fact they usually predate or come up along side of sales tax. Sales tax is just the state requiring businesses in the state to collect your use tax. For instance, in CA the first use tax was passed at the same time as the first sales tax -- 1954.
in the public domain. VISTA is the Veteran Administration's EMR which has generally gotten very good reviews by physicians. However, it is an unbelievably archaic on the back-end (uses M, predates relational databases, etc.). In addition there is no emphasis on charge capture, so it often is useless for billing purposes.
Very unlikely to happen in the US. The administration hasn't even submitted it to congress for ratification yet. Also, remember treaties need 2/3 support of the senate, and there are an easy 34 senators that oppose this.
Their special advantage is active directory integration, and ownership of office. No one else has anything that even comes close at this point in time. The question is whether they can leverage it correctly.
I've implemented and consulted with many physicians on EMR systems for almost 10 years -- and I generally agree with you.
EMR's can be unbelievably useful, especially when the entire community is on the same database. For instance in one rural area I work with, there is only one hospital, and almost every physician in the community (including those in private practice) is integrated into the system.
No more consult notes faxed over, the ED can access the EKG done in the primary care office, primary care can access every drug prescribed for the last year by any physician (essentially) in a 20 mile radius, previous studies and xrays, hospital records, labs, etc.
The one issue is security, and I'm not sure I completely agree with their methods -- although its still fairly good. The security is very fine grained for non-physician staff, for instance a medical assistant can only access patients who their physician is treating, and only notes generated by their office, floor nurses can only access notes from the current visit for patients on their floor, etc. That being said, any physician (not NP or PA) can access any record in the system.
The only non-electronic notes in the community are the nursing / progress notes from behavioral health, but even then prescriptions, diagnosis, visit dates, and consult and admitting / discharge summaries are available.
It also is very good for public health and at implementing disease management protocols. Vaccines are almost never missed, diabetic's are prompted for foot care, cholesterol, HgA1C if needed, etc. (Physicians can design their own templates or the hospital will pay for someone else to do it according to their protocols).
As you mentioned the big problem is entering data, and that is a challenge esp. for free form notes. There are anatomical diagrams available, as well as voice recognition and other modes of entry. But a lot of physicians still do dictation (although they dictate to the note and its routed to the transcriptionist). Most of them have tablets, and in addition their are laptops on carts all over the place.
although some paper work can be eliminated after 4 years, other needs to be retained much, much longer. Supporting documents for tax returns -- especially those not reported by third parties to the irs -- should be kept for a minimum of 3 years AFTER you file the return. Six years if you have under-reported or taken aggressive deductions that may reduce your taxes due by more than 25%.
In addition you should retain every receipt for the purchase and capital improvements to your house until (see above) years after you sell the house -- this includes new roofs, AC, appliances, remodeling expenses, etc.
Stock records should be kept as above.
Contracts (esp. big ones) should be kept until the contract is completed, and at least until the statue of limitations runs out.
This doesn't even get into business property -- where you can be audited on a desk you purchased up to 14 years later (in theory). Property related to assets (vs. expenses) should almost be retained indefinitely.
Senator's who have TS clearance do go through a background check. The House Armed Services Committee & Intelligence committee's require background checks on member's. The difference is that the Senate can decide to appoint someone to a committee regardless of the results as its up to the political process. That being said, I would be highly surprised if they did.
Cabinet Secretaries also go through background checks (usually) as part of their confirmation process. Although in theory the Senate could confirm w/o one, they do require them before hearings even take place.
The president / vice-president are the only ones who truly go through no official background check. However, the publicity and media surrounding a campaign almost guarantee's that everything will come up. If the people decide (regardless) that they don't have a problem, then its not the FBI's (or anyone else's) place to tell them no.
This really depends on the state. In Mississippi for instance the medical records are considered physician work product and state law explicitly states they are owned by the physician. This doesn't change the fact that the patient must have access to them in most cases (but not all).
Lab's and outside reports (radiology, etc.) are even more problematic.
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Umm.... I'm not so sure about that. Especially in civil wars, high ranking officers are often friends with each other.
US Grant and Robert E. Lee is the classic example, but there are numerous others.
That's not what the book says...
1) Quoting directly from the manual... "When Counseling and/or coordination of care dominates (more than 50%) the physician / patient... encounter, then time may be considered...
2) The actual code 99215 (level 5 existing patient office visit" reads "Physician's *typically* spend 40 minutes face-to-face". That statement only is applicable if #1 above applies. If not "...requires 2 of three key components". Typical doesn't mean every visit. Also I quoted the 5 minute visit for a level 4 visit. In a stable diabetic, treating a skin infection (for instance) may only take 5 minutes, which is enough time for a detailed history of the illness and the medical decision making which is of moderate complexity -- thus its a 99214 if all the physician does is write an antibiotic script.
Medicare alone has about 250 pages on how to code an E&M (office) visit, from two separate policy manuals, and most insurance companies (every one I've ever dealt with) use Medicare's definition. The CPT manuals I've looked at usually just barely touch the surface of the full regulations.
With the exceptions of psychiatrists and some relatively rare situations (direct management of a code, etc.), doctor's rarely bill on time -- and are usually not allowed to.
They bill on a combination of three items -- history taken (or updated from last visit), medical complexity of the visit, and the physical exam done. For new patients the level of visit is based on the least comprehensive of those three items. For existing patients its based on the middle of the three.
Its entirely possible to bill a legitimate level 4 visit (on a scale from 1-5) for a patient with diabetes (for instance) during a 5 minute visit. There are "time" codes listed in the coding manuals, but their use is restricted to when doctors are primary providing counseling (diet and exercise, etc.) during a visit.
has had this for over 2 years. It logs onto windows using facial recognition, and different users are logged in under their respective username.
Not quite true.
NeXTStep was issued in an i386 form for a few years -- I know I bought a copy circa 93-94 so I could run Mathematica.
According to the link, IE on Windows XP does not support TLS+SNI -- including IE 8.
Until this is fixed or sufficient number of people migrate to a newer OS, TLS+SNI is still not viable for most websites.
In most cases, all the suing party will have to do is submit a copy of his guilty plea. The arguments will be about damages.
A civil trial doesn't require much in the burden of proof ("50% plus a feather"), so his guilty plea in open court will meat the is he liable portion. Then its about damages.
Greatest discovery in physics....
I'd put the mapping of the Human Genome (2003), or creating new organs from stem cells (2008), or Synthetic Biology creating a cell with a fully artificial genome (2010) all up there as well. Don't forget faster than light neutrino's (confirmed a second time), or a vaccine for HIV. That's in the last 10 years, much less 20.
Its not a matter of thinking...
Its a matter of observation. Before the ADA, many doctor's offices weren't handicapped accessible, much less restaurants, etc.
Tipping in fast food is not customary, and very few do it -- and many places don't allow it.
Servers in tipped positions make $2.13 / hr (although they are guaranteed min. wage if tips don't make up the difference -- although they probably will be fired).
I've worked in both -- including a stint as a full time job in creating / working with dashboards and report generation in Cognos, etc. for an insurance company with 5000+ employees. We still had to pay IT via interdepartmental billing.
There are some things that RDMS's are just bad at. If I need to generate reversing entries and allocations to close out a month, a RDMS is slow and not very capable -- and Excel is great at it. I would still upload the final product to the database at the end of the day. If I had to write software to do the same, it would take much longer -- especially since much of the business logic changed every month. It would of been possible, and maybe an enterprise with 100,000 users instead of 5,000 may have found it worthwhile, but it would have taken years to break-even vs. using excel.
There is no question that these desktop solutions *sometimes* outgrow their original tools (ie enterprises dependent on a single spreadsheet) -- and that maybe happening in the grandparent, but for every 1 of those that IT sees, there are 50 or more of those that plug along and do their job reasonably well -- and only require 1 hour of an accountant's time, vs 100 hours of programming time (probably 30% of that is due to accountants explaining and detailing what has to be done). Accountant's jobs cannot always be broken down into easily generated programming logic -- even for relatively repetitive tasks like basic taxes or multi-jurisdictional reporting.
This still doesn't address things like data analysis. Sure a stored procedure can generate what you need, but that requires a higher level of expertise and a lot more time in many cases. If I want to perform a T-Test or statistical analysis beyond the basics, do something like a median (I just had this problem), do advanced graphing, etc. Many / most of the database and reporting tools are inferior to Excel and F9.
Department of Interior has multiple police agencies (National Park Rangers, etc.). They also have access to things like medical records from the Indian Health Service, etc. They also deal with items such as business plans, etc. which are not subject to FOIA and contain proprietary information.
That being said, I don't have a problem with cloud services. No one has convinced me why Google or Microsoft is a less safe place to store data than my IT department. In many cases (although given enterprises maybe the exception), those two entities have much more experience than most companies in running a datacenter. Its their core business, its not the interior departments of joe blow's widget manufacturer.
*may* suck in the real world for a variety of reasons.
For X amount of data (less than a few million rows), excel is a perfectly adequate flat file database if don't need a relational database -- and many items don't. This isn't VisiCalc anymore on computers with 640k of memory.
Ajax? REALLY???? Most people I know who use Excel heavily are not programmers -- they are accountants. I know of about 1 in 50 accountants have any idea what the hell Ajax is, much less any ability to do anything with it. Why should I pay an IT consultant / IT department 1000's when I can do something that meets my needs in 10 minutes.
I'll grant that Access *might be* a better solution, but depending on analysis and presentation needs it may not be -- or again it may require programming in VBA or 10's of hours of work to get what you need.
Databases suck at analysis. SQL based crosstabs can be useful, but they also have major limitations if you are not going to drop to a programming language. God forbid you try something like finding a median of a dataset. Instead of =Median(data), its a 100 lines of code.
For smaller datasets Excel is a much better solution in many / most cases than a database solution if you don't need the relational mechanisms, joins, etc. -- which 90% of spreadsheets don't.
Libre Office's spreadsheet sucks. They cannot even get basic UI functionality that has been in all spreadsheets since VisiCalc, much less come close to the quality of Quattro of 15 years ago.
Ok, let's say I'm not amazon, I'm a small tractor supply store in MN. I sell a lawn tractor to a MS resident. Problem is, there are 3 different taxes for "lawn tractors" depending on various factors. If I'm Home Depot I've hired a lawyer to figure this out, but lawn company in MN can't do that for every one they sell. MS by the way is a comparatively easy state to collect in.
Now, think of a state like Louisiana. The state, parish, every town, and often other political entities (special taxation districts) all can level sales taxes. So you can have a different tax rate in the same town and zip code by crossing a street. On top of that, every jurisdiction exempts different items or taxes them at different rates. How the hell is someone in California supposed to figure this out? On top of that, I'm supposed to file separately with every entity I'm subject to taxation from, so one sale could easily land me with 3-4 tax returns to complete. Oh yea, and if I sell that tractor to a farmer the thing maybe exempt, but I still have to file on their specific paperwork, etc.
The reasonable way to do this (and I'm not opposed) is for the states to simplify the collections. This could be accomplished in many ways -- for instance an interstate compact or federal law. However, states need to have a uniform rate within their jurisdiction, uniform exemption standards (at least from the merchants perspective) and all states need the same definitions as to what is taxable. They also need to allow for proxies to file / pay the tax. Then a merchant would be responsible for knowing 1 set of rules, and submitting up to 50 returns -- which they could do through a proxy (for instance if I'm a small seller I can send my sales records to salestaxcompliance.com and they will take care of the filing paperwork, etc.).
Use taxes have been around forever -- in fact they usually predate or come up along side of sales tax. Sales tax is just the state requiring businesses in the state to collect your use tax. For instance, in CA the first use tax was passed at the same time as the first sales tax -- 1954.
http://www.boe.ca.gov/sutax/taxrateshist.htm
in the public domain. VISTA is the Veteran Administration's EMR which has generally gotten very good reviews by physicians. However, it is an unbelievably archaic on the back-end (uses M, predates relational databases, etc.). In addition there is no emphasis on charge capture, so it often is useless for billing purposes.
Very unlikely to happen in the US. The administration hasn't even submitted it to congress for ratification yet. Also, remember treaties need 2/3 support of the senate, and there are an easy 34 senators that oppose this.
Yes and no...
Their special advantage is active directory integration, and ownership of office. No one else has anything that even comes close at this point in time. The question is whether they can leverage it correctly.
I've implemented and consulted with many physicians on EMR systems for almost 10 years -- and I generally agree with you.
EMR's can be unbelievably useful, especially when the entire community is on the same database. For instance in one rural area I work with, there is only one hospital, and almost every physician in the community (including those in private practice) is integrated into the system.
No more consult notes faxed over, the ED can access the EKG done in the primary care office, primary care can access every drug prescribed for the last year by any physician (essentially) in a 20 mile radius, previous studies and xrays, hospital records, labs, etc.
The one issue is security, and I'm not sure I completely agree with their methods -- although its still fairly good. The security is very fine grained for non-physician staff, for instance a medical assistant can only access patients who their physician is treating, and only notes generated by their office, floor nurses can only access notes from the current visit for patients on their floor, etc. That being said, any physician (not NP or PA) can access any record in the system.
The only non-electronic notes in the community are the nursing / progress notes from behavioral health, but even then prescriptions, diagnosis, visit dates, and consult and admitting / discharge summaries are available.
It also is very good for public health and at implementing disease management protocols. Vaccines are almost never missed, diabetic's are prompted for foot care, cholesterol, HgA1C if needed, etc. (Physicians can design their own templates or the hospital will pay for someone else to do it according to their protocols).
As you mentioned the big problem is entering data, and that is a challenge esp. for free form notes. There are anatomical diagrams available, as well as voice recognition and other modes of entry. But a lot of physicians still do dictation (although they dictate to the note and its routed to the transcriptionist). Most of them have tablets, and in addition their are laptops on carts all over the place.
You can????
No, you cannot order corporations to destroy records they create on transactions with you, pictures they take in a public place, etc.
Sorry if I wasn't clear.
I was replying the the parent thread which indicates you can throw away everything away in 8 years.
Digitizing is not a problem at all, and I never meant to indicate it was.
although some paper work can be eliminated after 4 years, other needs to be retained much, much longer. Supporting documents for tax returns -- especially those not reported by third parties to the irs -- should be kept for a minimum of 3 years AFTER you file the return. Six years if you have under-reported or taken aggressive deductions that may reduce your taxes due by more than 25%.
In addition you should retain every receipt for the purchase and capital improvements to your house until (see above) years after you sell the house -- this includes new roofs, AC, appliances, remodeling expenses, etc.
Stock records should be kept as above.
Contracts (esp. big ones) should be kept until the contract is completed, and at least until the statue of limitations runs out.
This doesn't even get into business property -- where you can be audited on a desk you purchased up to 14 years later (in theory). Property related to assets (vs. expenses) should almost be retained indefinitely.
Senator's who have TS clearance do go through a background check. The House Armed Services Committee & Intelligence committee's require background checks on member's. The difference is that the Senate can decide to appoint someone to a committee regardless of the results as its up to the political process. That being said, I would be highly surprised if they did.
Cabinet Secretaries also go through background checks (usually) as part of their confirmation process. Although in theory the Senate could confirm w/o one, they do require them before hearings even take place.
The president / vice-president are the only ones who truly go through no official background check. However, the publicity and media surrounding a campaign almost guarantee's that everything will come up. If the people decide (regardless) that they don't have a problem, then its not the FBI's (or anyone else's) place to tell them no.
This really depends on the state. In Mississippi for instance the medical records are considered physician work product and state law explicitly states they are owned by the physician. This doesn't change the fact that the patient must have access to them in most cases (but not all).
Lab's and outside reports (radiology, etc.) are even more problematic.
is available usually very cheaply. That would meet the insurance requirement.