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Thursday, May 19, 2011

Guidelines for home BiPAP and oxygen

We in the medical profession do as we are told. That's the general logic we need to maintain our jobs and to help the hospitals we work for to get reimbursed by the Centers for Medicad and Medicair Services (CMS).

When it comes to qualifying someone for home oxygen, we are told we need to walk the patient and to monitor saturation (SpO2). If the saturation gets to 88% or less, the patient qualifies for home oxygen.

Even if you think the patient should have home oxygen, and the SpO2 does not drop to 88% during a walk, then the patient does not lie...

...which sets the ground for a little white lie. If I think someone needs home oxygen, and they only drop to 89%, I might fudge a little on my charting. Sorry, that's just the way life is. And, quite frankly, I'm sure I've saved the lives of more than one patient in this way.

I guess you can say that rules encourage lies.

Another thing we often qualify patients for is home BiPAP. Aside from doping a sleep study, sometimes we have patients that could benefit from home oxygen now, and don't have time to wait for a sleep study.

So, to qualify these patients for BiPAP we are told to chart the following:
Patients requiring BiPAP at home will need the following pulse oximetry test completed @ night prior to their discharge. During the test, the patient is to be on 2 liters of oxygen or their usual FiO2 whichever is greater.

A full five minute pulse ox test as needed, while patient is sleeping. There must be documented proof of 88% or below oxygenation for a full five minutes during the test.

Documentation example: Patient removed from BiPAP at 23:00, sleeping soundly. The patient is currently on 2 lpm oxygen. By 2304 patient pulse ox dropped to 87%. Patient remained @ or below 88% throughout next 5 minutes of test as evidenced by the following findings:

2305: 87%
2306: 86%
2307: 88%
2308: 85%
2309: 85%
2310: Patient placed back on BiPAP @ this time with 30% flow of oxygen. Pulse ox rebounded to 92%

So you can see, this is pretty dimwitted, yet it's how it is. You know in reality this situation will never happen. Nobody is going to be taken off BiPAP and fall asleep that fast. No SpO2 is going to drop and rise that fast. I've never seen it.

So I lie. I make the charting look like they want it to look, and so will you. This is a perfect example of how the people who make the policies, the rules, have no idea how things really work in the medical field.

The people who make the rules should be you and me, the people who know how it works. In reality, it works like this:
Person taken off BiPAP @ 2300. Patient does not fall asleep, yet the SpO2 drops stays at 98% until three hours later when patient falls asleep, yet I'm not around to document. SpO2 now 80%, and I come into room. I put patient back on BiPAP and SpO2 rises to 98%. I document as CMS instructs, although I'm not in room for six minutes watching the SpO2 which does change when I'm in room.

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