Wednesday, September 30, 2015

L.Ac. Occupational Code Comparison Chart, demonstrating most similar to privileged provider professions

keywords:  privileging, credentialing, LIP status, occupational codes
related blogposts:
LIP status and Acupuncturists and related Meridians article
Acupuncturist Occupational Code
Credentialing, privileging, and professional practice evaluation (FPPE, OPPE)

Provider type status (when credentialing and granting privileges) for 
East Asian Medicine Practitioners/Licensed Acupuncturists (L.Ac.s):
U.S. Department of Labor Occupational Codes Comparison Chart
2015 revision

This chart compares the following professions:
Physician (MD, DO), Advanced Registered Nurse Practitioner (ARNP), Licensed Acupuncturist (LAc), Physical Therapist (PT), Chiropractor (DC), Clinical pharmacist (PharmD), Physician Assistant (PA), Ultrasound technician, and Physical Therapy assistant.

The chart compares the following factors:
minimum degree required to practice
duration of training
federal occupational code:  delineation, job zone, core tasks
Licensed Independent Provider (LIP) status:  has NPI?  need supervision?
Note:  Chart does not fit well on blogpost at this time.  Contact this blog's editor for a copy.

Source:  O*Net, the Bureau of Labor and Statistics’ tracking system for new professions in the U.S. and
The Bureau of Labor and Statistics’ Occupational Code Handbook

Foot note 1 = “Level 1” vs. “Level 2” privileged provider exists within the U.S. military (DoD) medical system, when credentialing providers.  “Level 1 privileged provider status” in CHCS and AHLTA is allowed only for MDs and DOs.  All other privileged providers fall under “Level 2 privileged providers” in the U.S. military medical system.  In the civilian system, there is no “level” distinction among privileged providers.  In the civilian system, providers are “privileged” if they practice independently or not privileged.  Technicians are not privileged providers.

Friday, September 25, 2015

Explaining Credentialing and Privileging Process in the Hospital part 1

keywords:  credentialing, privileging, Joint Commission, LIP

related blogposts:  recognition of L.Ac.s as LIP, traditions of credentialing and privileging, the tradition of “medical staff” designation

Please see previous post: 
Semantics: Explaining Credentialing, Privileging, and the Licensed Independent Practitioner from May 2015

covers the following topics:
Basic credentialing and privileging terminology
Fictional example of the credentialing process and privileging process

The Sponsor Issue--Acupuncturists and their Hospital Sponsor

The Hospital Sponsor issue
revised and updated 12.08.2015

keywords: credentialing, privileging, hospital admin, PCMs, peer record review, supervision, licensed independent practitioner (LIP), ACAOM-accredited programs

related topics:  dual-licensees, professional practice evaluation (FPPE, OPPE, peer record review), recognition as an LIP

The Ideal Hospital Sponsor Relationship for an L.Ac.

To get started in a hospital, it has been the experience of successful hospital-practice L.Ac.s to date that they need a Sponsor.

A sponsor is a hospital physician, already established at your medical center, who is willing to support you to be hired.  This person advocates for you through the credentialing process.  This may even be the same person who writes your position description (job duties).  The Sponsor takes on responsibility for you and your potential for better or worse. 

The sponsor understands hospital culture, navigates it easily, and protects you from the political intricacies while mentoring you to work within it.

Ideally, you have more than just your Sponsor who advocates for you at your hospital.  It is your job to make your Sponsor’s “advocacy” as easy as possible.

Eventually, the ideal is that the hospital will see what a wonderful asset you and your medicine are and more L.Ac. providers will be hired and incorporated in more departments and areas of patient care and admin and research.  And someday, enough that an Acupuncture/EAM department may be useful, if such is the case that the hospital is large enough to have physical therapy department or a psychology/behavioral health department.

How are Hospital Sponsors/Advocates grown or cultivated?

Unknown.  There is a wide variety of examples.

However, one common thread I hear through all these shared stories and experiences is that they (sponsors) believe in what we do.  Usually through personal experience or from hearing and seeing positive feedback and results from patients who receive care from an East Asian Medicine Practitioner/Acupuncturist.

Some physicians have also taken a medical acupuncture course or auriculotherapy course.  This is not, however, the majority.

A small number of sponsors are also L.Ac.s.  These are our rare MD-L.Ac.s or DO-L.Ac.s or ARNP-L.Ac.s.  For easier terminology, I will call them “dual-licensed L.Ac.s”.

Peer Record Review, LIP, and the Sponsor

L.Ac.s, as licensed independent practitioners (LIP), require only administrative supervision, not practice supervision.  L.Ac.s can, by education and training standards, receive practice supervision from someone of the same level of ACAOM-accredited education, another L.Ac.  This is consistent with being an LIP.  LIPs, in the hospital setting, must participate in peer record review, a professional performance evaluation standard (FPPE/OPPE).  If an L.Ac. is the only L.Ac. at a facility, this is a challenge.  See related posts on Who supervises the work of an AcupuncturistPeer Record ReviewOccupational Code, and the Meridians article.  

The Sponsor, if he is a dual-license L.Ac., could also be the peer reviewer, by virtue of his ACAOM-accredited training and L.Ac. licensing.  This would be a work-around until more L.Ac.s could be hired.  See Dual-licensee post for more information.

Example of Hospital Sponsor relationship

A PCM with a medical staff appointment (usually a physician) at a medical center takes an interest in wanting to hire an L.Ac.   This person will hereon be called the “hospital sponsor”. This usually comes from one (or more) of the following motivators:

  • Interest in non-drug pain management options (possible push from Joint Commission’s standard if med center has a pain management program)
  • Interest in integrative medical therapies
  • Has had patients request Integrative Medicine (IM) therapies, particularly acupuncture, and is interested in bringing related staff on-board as employees to help fill the need and patient requests
  • Is interested in a PCMH model that incorporates IM
  • The state’s interpretation of the Affordable Health Care Act includes insurance coverage of acupuncture as practiced by L.Ac.s  [affordable health care act post/worker’s comp coverage of acupuncture post]  
  • Great need (or interest) in medical center for non-drug treatment option such as acupuncture that decreases ER return rates, inpatient hospital stay length, and surgery recovery statistics [see Allina example of incorporating EAMPs/L.Ac.s in the ER]  

Hospital Sponsor is Innovator and Synergist, more than your average Administrator
The hospital sponsor is usually a physician who has some administrative time allowed in schedule or is incredibly motivated.  The hospital sponsor will next do one of the following:

  1. Request to hire one L.Ac., in her area of hospital.  For example, the hospital sponsor is main provider at a OB clinic and wants to add an L.Ac. to her staff.
  2. Request to hire multiple L.Ac.s as part of a creation of a specific Integrative Medicine (IM) clinic or healthcare system-wide creation of IM clinics, such as for pain management and/or IM rehabilitation clinics

Among other things, the hospital sponsor will have to do the following:
Get idea approved by hospital admin
Create a position description for the L.Ac.
Create a hiring package with HR for the L.Ac.
Create a credentialing package for L.Ac., working with the credentialing department
As part of hiring process, present credentialing packet and drafted delineation of clinical privileges to the hospital credentialing committee on behalf of the soon-to-be hired L.Ac. employee

When working with Credentialing department specialist to create packet, the following is often helpful:
Useful items when working with the credentialing department and credentialing committee:
The state’s scope of practice for practitioner
Position description created for L.Ac.

Once L.Ac. is hired, and if she is the first L.Ac. ever to be hired by this medical center, the hospital sponsor:

Works with the L.Ac. to develop basic SOP (standard operating procedures) based on her industry standards and experience. 

The L.Ac. is able to direct her hospital sponsor to her national standard organizations to find the best and most current standards and regulations that may apply.  Contact your national EAM/AOM standard organizations and see your EAM/L.Ac. Hospital practice group on social media for examples.

IM = integrative medicine
PCMH = patient-centered medical home
L.Ac./EAMP = state license titles for Acupuncturist.  "Licensed Acupuncturist (L.Ac.)" and "East Asian Medicine Practitioner (EAMP)".  Most common state title is L.Ac. 

Read more about how to Get Your Foot in the Door of Hospital-based Practice: First Steps, a new (2019) publication on the website and its companion resource, The Workbook

related blogposts: 

Peer Record Review
updated 2017
keywords:  peer record review, supervision of an L.Ac., quality assurance measures, licensed independent practitioner (LIP), Joint Commission, credentialing, privileging, focused and ongoing professional practice evaluation (FPPE and OPPE), professional standards, quality assurance, quality improvement (QI)

Peer Record Review and Joint Commission
Peer review process is a usual professional standard required by The Joint Commission (formerly JCAHO or Joint Accreditation Commission of Hospital Organizations). 

Peer Review process and Provider vs. Technician status
Peer Review process is a standard that goes back to quality assurance.  Credentialing is a vetting process and a quality assurance tool.  Maintaining credentialing relates back to quality assurance.  

A provider who is not credentialed is a technician.  A technician does not get credit for the workload he or she generates.  Instead the technician’s supervisor gets the credit.  I believe this goes with the idea that the supervisor takes the responsibility for the work and hence garners the credit for the work.  

Peer Record Review and the East Asian Medicine Practitioner (EAMP)/Acupuncturist (L.Ac.)
In our profession, as East Asian Medicine Practitioners/Licensed Acupuncturists (acupuncturists), we are responsible for our own work (master’s level training, national board certification), and have LIP status (as defined by TJC) in most states, and so, when working in hospitals, we are providers (LIP-type provider), not technicians.  And, as LIPs, are credentialed and granted a delineation of privileges.  As part of being a credentialed provider, we participate in peer record review.  Peer record review is a periodic review of a practitioner's charting, reviewed by a peer in that provider's discipline.  For example, a licensed acupuncturist (LAc) quarterly reviews another licensed acupuncturist's chart records, following the facility's standard form.  This goal of this review, part of FPPE or OPPE, is a quality assurance check for gross lack of charting, improper charting or patient care.  The goal of FPPE and OPPE is to flag providers who are performing below standard.

Peer Review and SOAP Note Standard
Our profession has SOAP note standards.  When we do Peer Record Review, we are able to do so using our standard.  The standard has been general and based on TCM, as per national certification standard guidelines (NCCAOM board exam).  For more specific guidelines and training on proper SOAP noting and how this relates to our modern health care delivery system, see the upcoming Coding and Charting Manual/Handbook Resource and related blog.

Hospital Practice and Standards
Peer record review (which, at its core, follows a general profession-specific standard for charting) is an essential quality assurance measure for hospitals.  This is part of the quality assurance measures that make the facilities eligible to renew their Joint Commission accreditation.

The ability to participate in peer record review, a component of focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE), is also an essential delineation between providers who must be credentialed and those who practice as technicians.  A professional health care practitioner, such as an EAMP/LAc, participates in peer record review. 

Peer Record Review and need for minimum of  two EAMPs/L.Ac.s per facility
As licensed independent practitioners (LIPs), acupuncturists participate in a peer record review process.  Peer record review process is best accomplished in a timely manner when a minimum of 2 LAcs work within the same medical center (that uses the same electronic charting system, etc). Peer record review is done between two professionals who have the same specialty training (i.e.ACAOM-accredited master's or doctorate level education, passed the NCCAOM board exam).

An acupuncturist (LAc) is an LIP who signs his/her own notes.  An acupuncturist is a provider who refers to and consults with appropriate providers as needed.  An LIP requires only administrative supervision.  No practice supervision required. In a medical system, all providers work as part of a larger team. An acupuncturist, like other professional-level health care practitioners, participates in peer record review, a quality assurance process, with another acupuncturist (LAc), ideally within the same medical center. 

Similar LIP profession types who typically participate in peer record review as part of OPPE in hospital-based practice include physical therapists, health psychologists, and licensed clinical social workers.

Thursday, September 10, 2015

Physical exam training for Acupuncturists

keywords:  hospital practice, KSAs, physical exam skills, charting, SOAP, electronic health record (EHR), evaluation and management (E&M), practice standards

Physical exam training.  This was required part of schooling and part of the biomedicine board exam.  Both Western physical exam skills (such as Range of Motion) and Eastern physical exam skills (tongue, pulse, palpation, abdominal/Hara diagnosis, etc).  This is an important part of the objective measures section of the SOAP note.  The Objective measures section in the SOAP note will be more thorough during initial evaluations and re-evaluations/re-exams.  Re-evaluation is always done at scheduled discharge.

*only use the physical exams that are appropriate to the patient, as the patient case presents.

Evaluation and Management
Evaluation and Management (E/M) codes and standards are kept by the Center for Medicaid and Medicare.  For more information on current standards expected for evaluation and management as related to E/M codes and modifiers used (which are the codes you use when you do an initial visit and when you do a re-evaluation or re-evaluation/discharge), see this manual from CMS website.  It is a free federal resource, as part of the CMS's "Learning Network (MLN)".

Hospital practice L.Ac.s find that they need to keep their physical exam skills, both Eastern and Western, updated regularly.  

Medicare Learning Network (MLN)

Western Physical Exam resources
 Bates' Guide to Physical Examination and History Taking
Bates Visual Guide to Physical Examination
Hoppenfeld's Physical Examination of the Spine And Extremities

Eastern Physical Exam resources
Well, any of the references listed for the NCCAOM board exam
Barbara Kirshbaum's Atlas of Chinese Tongue Diagnosis
Maclean and Lytteton's series of Clinical Handbook of Internal Medicine:  the Treatment of Disease with Traditional Chinese Medicine
The standard red CAM book:  Chinese Acupuncture and Moxibustion edited by Cheng Xinnong

In the comments section, please list your favorite resources for Western physical exam skills or Eastern physical exam skills.  Please also provide a link to the resource.  Thank you!

Related blogposts
What is CMS?

Prescribing in the Hospital setting: Pharmaceuticals, med review, Neutraceuticals, Self-Care

keywords:  hospital practice, prescribing, medical review, SOAP notes, CHM, self-care, practice standards, documentation standards


Pharmaceuticals.  L.Ac.s do not prescribe or advise on pharmaceutical medications.  However, an L.Ac. must know what medications a patient is taking because it affects the larger TCM diagnostic picture.  Example:  symptoms of fatigue as side effect of medication 

Medication Review.  Medication review must be done at first visit.  Recommend updating this review when patient reports a new med added or removed.  Recommend updating the med review during TCM re-evaluations.

Neutraceuticals and Chinese Herbal Medicine L.Ac.s can prescribe Chinese Herbal Medicine (CHM) when they have

a.  the required training and NCCAOM board certification status (see point #2 on CHM practice in hospitals)

b.  it is in their scope of practice at the hospital.  Can be an add-on to credentialing paperwork.

c.  see related section on CHM practice in hospitals for more details

d.  see related state license for “neutraceuticals”

Self-care.  L.Ac.s can prescribe self-care/home care to patients that may include but is not limited to:  acupressure, tai chi, qi gong, meditation, breathing exercises, TCM nutrition recommendations, reflexology homework, self-care massage, hot/cold therapy, orthotic devices, movement therapy  . . .

Practicing Chinese Herbal Medicine in a Hospital Setting

keywords:  hospital practice, CHM practice, specialty practice

Practice of Chinese Herbal Medicine in a hospital setting by an L.Ac.

Training/Credential Guidelines:

  • Practitioner must have current/active diplomate status from NCCAOM as:
    • Dipl. Oriental Medicine (includes Chinese Herbal Medicine board exam) or
    • Dipl. CHM
      • *however, as of 2015 NCCAOM is making it easy to update from Dipl. C.H. to Dipl. O.M.
  • So, I recommend to keep it at Dipl. O.M. since practitioners can now change their certificates over to O.M.  Sticking with one diplomate certificate (when it is an easy change to make for a practitioner trained and who has passed the herbal board exam) makes explaining a new process to credentialing simpler.
  • Current state license
  • Experience—minimum 2 years experience in 20 hours/week AOM practice at min prescribing CHM to patients.

Recommend the following:

  • Understanding and/or taking CEUs in herb-drug interactions, pharmacodynamics and kinetics
  • Understanding and training, including CEUs beyond the formal schooling, prescribing individualized formulas as well as patents.
  • If working with a specialty population, such as pediatrics, recommended practitioner show he/she has additional training in prescribing CHM to that population with hours in class as well as shadow/internship, no matter how informal.  Letter of verification or recommendation from shadow/internship supervising practitioner.

Galina Roofener, a 2015-2016 member of the NCCAOM Hospital-based Task Force, is a pioneer in this at the Cleveland Clinic.  She also teaches classes on herbal practice safety in the hospital setting. The May 2014 Acupuncture Today article about this clinic by Shellie Rosen, DOM, mentions that requirements also include an "NCCAOM approved course on FDA 'Dispensary and Compounding Guidelines' ".

Who supervises the work of an Acupuncturist?

keywords:  supervision, hospital employment, credentialing and privileging, LIP, Joint Commission, the Hospital Sponsor

Supervision of an L.Ac.  
related topics include:
  • the Hospital Sponsor
  • working as part of a team
  • referring to appropriate providers, red flags, etc.

In hospital practice, the following question, “Who supervises the work of an L.Ac. at our hospital/medical center?” is common.  Here is a good answer and some talking points.

Direct Answer

The supervision of an L.Ac. is limited to administrative review.  Practice review (TCM practice review) can only be done by another L.Ac.  L.Ac.s, therefore, as health care professionals, must participate in the Peer Record Review process.  [Quality Assurance review aka Peer Record Review and the assessment of any scope of practice can only be determined by a supervisor and/or senior clinician with the same license and training (master’s or doctorate degree from ACAOM accredited program and current NCCAOM diplomate status).]

Special case:  L.Ac. Internship or preceptorship:  The supervision of an L.Ac.’s clinical work can be done by another L.Ac. as may be the case during an internship or preceptorship.

L.Ac.s are independently practicing providers with graduate health education* and degree(s).  The state law term is "licensed independent practitioners (LIP)". The Joint Commission uses the term "licensed independent practitioner" (LIP) for this class of provider. **  Acupuncturists should be credentialed as professional health care providers, eligible for a “delineation of clinical privileges”.  L.Ac.s are not primary care providers as primary care physicians or advanced registered nurse practitioners are.  L.Ac.s are LIPs similar to clinical psychologists, physical therapists, pharmacists, and chiropractors. 

Why Peer Record Review vs. practice supervision

Simple answer:  L.Ac.s are health care professionals, not technicians.  Hence, they participate, as other credentialed and privileged professional health care practitioners do, in the peer record review process as well as other professional practice evaluation processes (FPPE, OPPE).

*Graduate health education. Acupuncture education is a graduate master's or doctorate degree program accredited by the ACAOM (which is recognized by the U.S. Department of Education). As of January 2018, the Bureau of Labor and Statistics published the Standard Occupation Code (SOC) for the profession, 29-1291 Acupuncturist, which recognizes acupuncturists as health-diagnosing professionals. [update added 5.21.2019]

**LIP is a state law/scope of practice term. It is not a term that translates well in hospital setting. No professional in the hospital practices "independently". Every professional in the hospital has a chain of command (line of management). 

Review:  Health care professionals (LIPs) vs. technicians

Licensed Independent Practitioners (LIP), a state law term, are health care professionals, not technicians. 
Professional work “requires the exercise of discretion, judgment, and personal responsibility for the application of an organized body of knowledge that is constantly studied to make new discoveries and interpretations, and to improve data, materials, and methods.”[1]

Licensed Independent Practitioners (LIPs), a state law term--Joint Commission recommends these types of providers be credentialed
Can be credentialed. Are NOT privileged.
Has a national provider identifier (NPI)
Does not bill insurance. Does not have an NPI
Able to practice clinically with only administrative supervision
Carries out the treatment plan their supervisor, the provider, creates
Has training and education to evaluate a patient
Cannot sign notes; does not take full responsibility for treatment
Can create a treatment plan
Clinical work is directly or indirectly supervised
Can modify a treatment plan
Does not have ability or authority to evaluate patient
Can re-evaluate patient
Does not have ability or authority to change or modify treatment or procedure
Can adapt treatment procedures

Reads research literature in the field, including evidence-based clinical guidelines and recommendations. Able to discern and incorporate clinically relevant information into current practice

Participates in peer record review, an OPPE process and standard
Does not participate in peer record review
BLS occupational code delineates as “health-diagnosing professional”
Example: 29-1291-Acupuncturists
Group 29-0000 is the major group, “healthcare practitioners”
Group 29-1000 is the minor group, “health diagnosing and treating practitioners”

References for table:

[1] p.7, “Distinguishing Between Professional and Technical Work”, Professional Work in the Medical and Healthcare Group, 0600, Office of Personnel Management (U.S.A.), published September 2017. Retrieved 5.22.2019.

Related blogposts: