Provider Representatives and Senior Enrollment: The Vantage

Provider Representatives are a valuable resource for Providers. They can assist you and your staff with our New Online Provider Portal registration & support, claims inquiries, referral/authorization

questions and any other issues relating to your Vantage members.

M a n a g e d b y July 2015

Vantage is one of the largest IPAs in California and the largest IPA in the Inland Empire, which is home to over 1,000,000 Medi-Cal and 450,000 Medicare benefi-

ciaries. Vantage also has a presence in San Diego County. Vantage has contracted with 483 PCPs, has a network of over 4,800 specialists, serving over 300,000

members and is contracted with Blue Shield, Care1st, HealthNet, Humana,

IEHP and Molina. As measured by the number of patients, Vantage is larger than

the next four largest Medi-Cal IPAs in the Inland Empire combined. Vantage’s scale made it a critical partner of man-

aged care plans in the region given that members tend to have stronger relation-

ships with their physicians and physician groups than with their health plans.

Highly-Compelling Value Proposition for Physicians: Vantage’s unique and powerful operating platform provides contracted physicians with the support to improve their clinical and operational efficiency. Providers benefit from the scale, market share

and growth of Vantage which provide greater stability in patient volume. Additionally, physicians benefit from Vantage’s name recognition and sizeable patient base, which drives word of mouth pa-tient referrals from friends and family. Importantly, Vantage’s capabilities have resonated well with

PCPs and a majority of the Vantage’s providers have been with the Vantage for more than five years.

IN THIS ISSUE:

New Provider Web

Portal & Utilization

Management

2

Claims Submissions 3

Quality Management

Access Standards

Initial Health

Assessments

5

Health Education

Services

7

Cultural & Linguistics

Services

8

Compliance Program 10

Choosing Wisely 11

VANTAGE Provider Newsletter

Name Cell Phone & eMail Region

Daniel Bello (951) 317-8227

dbello@ppmcinc.com Senior Member Enrollment (Medicare, Medi-Medi, Duals)

Maria Torres (951) 204-9234

mariat@ppmcinc.com Banning, Coachella Valley, Colton, Hemet, Redlands, San Bernar-dino, Yucca Valley

Karen Polk (951) 333-3928

kpolk@ppmcinc.com Adelanto, Apple Valley, Barstow, Fontana, Hesperia, Ontario, Rialto, Victorville

Tammie Macias (951) 203-5510

tmacias@ppmcinc.com Chino, Corona, Norco, Pomona, Ontario, Rancho, Riverside and Upland

Skyler Moreno (951) 317-2895

dmoreno@ppmcinc.com Moreno Valley

Sonia Martinez (951) 642-2302

smartinez@ppmcinc.com San Bernardino and Coachella Valley

Viviana Koplas (909) 241-1684

vkoplas@ppmcinc.com Lake Elsinore, Menifee, Perris, Temecula and San Diego County

50,000

150,000

250,000

350,000

2013 2014 2015

Vantage Membership Growth

Utilization Management The role of the Utilization Management (UM) Department is to ensure consistent delivery of appropriate and quality health care services to our members. The UM functions include pre-

certification, inpatient concurrent reviews, discharge planning, and retrospective reviews.

The Utilization Management department makes decisions only on appropriateness of care and service, including existence of coverage. Vantage Medical Group does not reward practitioners or other individuals for issuing

denials of coverage or service care. There are no financial incentives that would encourage UM decision makers to make decisions that would result in under-utilization of services.

Practitioners are ensured independence and impartiality in making referral decisions that will not influence: hiring, compensation, termination, promotion, and any other similar matters.

The UM Department uses clinically sound, nationally developed and accepted criteria for

making medical necessity decisions. The following is a listing of the clinical criteria used, but is not limited to:

Clinical Practice Guidelines and Behavioral Health Guidelines

Health Plan Developed Guidelines and Behavioral Health Guidelines Milliman Care Guidelines, 17th Edition

Apollo’s Medical Review Criteria, 2012 CMS Guidelines

Health Plan Benefit Manual American College of Obstetrics and Gynecology The American Academy of Pediatrics

The United States Preventative Services Task Force Standards

To access the health services departments and/or the UM Staff for questions about the UM pro-

cess and how to obtain copies of UM Criteria please call the UM Department at (951) 280-7700 or Toll Free 1-855-257-9964 during our regular business hours of 08:00 am to 5:00 pm Monday through Friday.

Provider Newsletter Page 2

Signup to our NEW Online Provider Portal! Referral Submission - keep track of your referrals and authorizations

Referral Auto-Approval

Claims Status and Payment Inquiry

Provider Dispute Resolutions Status Inquiry

Training is provided over the phone training and/or at your site. To learn more, contact your Provider Representative or visit us at https://portal.ppmcinc.com/Login.aspx

IMPROVE YOUR OFFICE PRODUCTIVITY BY USING OUR ONLINE PROVIDER PORTAL

Register today at: http://www.ppmcinc.com/registration/

Claims Submissions All claims must be submitted within 90 calendar days from the date of ser-

vice for contracted providers unless otherwise stated in the provider

service agreement.

Please submit claims and encounters electronically via Office Ally at

www.officeally.com

For Claims, use payer ID PPM01

For Encounters, use payer ID

PPM02

Clean Claim Definition

A Clean Claim is a complete and accurate claim form that includes all provider and member

information, as well as records, additional information, or documents needed from the member or provider to enable our organization to process the claim. These claims typically contain the following information:

Date of Service

Complete Member Eligibility Valid Diagnosis Codes (ICD-9) - submit with highest level of specificity

Valid CPT, HCPCS, Revenue Codes National Drug Code (NDC) for physician-administered drugs (if applicable)

Anesthesia start and stop time (if applicable) Billed Amount Days and/or Units

Place of Service Code Itemization of Services

Rendering Facility Referring Provider Name and NPI

Rendering Provider Name and NPI Provider Demographic Information (including Tax ID#)

Immunizations and Injectables

Immunizations and injectables must be submitted with the 11 digit NDC (National Drug Code) in conjunction with the customary CPT or HCPCS code. Failure to submit the 11 digit NDC

code will result in claim rejection and delay the processing of your claim. Please refer to the following website for complete instructions on how to submit the correct NDC #: http://

files.medi-cal.ca.gov/pubsdoco/ndc/articles/ndc_9630.asp Immunizations and injectables are reimbursable according to the provider service agreement unless covered by the VFC (Vaccines

for Children) program for Medi-Cal recipients or by another entity. In the event an administra-tion fee is billed on the same date as an office visit, the administration charge will be considered inclusive of the office visit charge. If an office visit is not billed in conjunction with the admin-

istration charge, the administration charge will be allowed separately from the immunization.

Provider Newsletter Page 3

Claims Submissions continued Global Reimbursement and Case Rate

Services that are contracted at a global reimbursement or case rate will be paid accordingly to the service agreement rate. All other services will be denied as inclusive of the global reimburse-ment or case rate unless otherwise stated in the provider service agreement.

Global Surgery Days

AMA guidelines will be applied to determine the surgical follow-up period for all surgeries. Of-

fice and hospital visits related to a surgery and billed during the surgical follow-up period of the surgery, are not separately reimbursable if billed by the surgeon or assistant surgeon. The initial

consult is only payable to the surgeon on an emergency basis to determine the need for surgery.

AB1455 Provider Dispute Resolution Information

As required by Assembly Bill 1455, the California Department of Managed Health Care has set forth regulations establishing certain claim settlement practices and the process for resolving claims disputes for managed care products regulated by the Department of Managed Health

Care.

Provider Dispute Resolution Process

A provider dispute is a written notice from the contracting provider that:

Challenges, appeals or requests reconsideration of a claim (including a bundled group of similar multiple claims) that has been denied, adjusted or contested

Challenges a request for reimbursement for an overpayment of a claim

Seeks resolution of a billing determination or a contractual dispute

Effective January 1, 2004, provider disputes must be submitted within 365 calendar days from the date of Vantage Medical Group’s claim determination. Please mail or fax Provider Dispute Resolution (PDR) forms to the following address:

Vantage Medical Group

2115 Compton Avenue, Dept. 300

Corona, CA 92881

Fax: (951) 280-8206

The Provider Dispute (PDR) form is available at www.ppmcinc.com.

Provider Newsletter Page 4

Fraud Waste & Abuse Resources: Centers for Medicare and Medicaid Services (CMS):

www.cms.hhs.gov

Fraud & Abuse General Information:

www.cms.hhs.gov/MDFraudAbuseGenInfo

Office of Inspector General, Provider Compliance Training:

www.oig.hhs.gov/newsroom/video/2011/heat_modules.asp

Vantage Medical Group Quality Management uses the

following guidelines to make sure our contracted providers

have industry standard telephone access.

Our goal, based on industry standards, is to reach 100% com-

pliance for all of our primary care providers. We want to

help you achieve a reduction in avoidable emergency room

visits to your members—Providing urgent care access is

critical in this reduction.

They are published as follows:

Telephone Availability Access Standards

Telephone Access Type Standard

Telephone Answer Time All telephone calls to PCP or Specialist must be

answered within 6 rings

Telephone Hold Time A member must NOT be kept on hold for more

than 5 minutes

After Hours PCP Access 24/7 – 24 hours, 7 days a week

Appointment Availability Access Standards

Type of Visit Standard / PASS

(RIGHT ANSWER)

FAIL (WRONG ANSWER)

Dr. Availability Yes No

On Hold Less than 5 minutes More than 5 minutes

Urgent Care Same Day Not the same day

Non Urgent/Routine Within 14 calendar days More than 14 calendar days

Physical Exam Within 30 business days More than 30 business days

Well Child Within 14 calendar days More than 14 calendar days

Child Immunization Within 14 calendar days More than 14 calendar days

120-day Initial Health

Assessment Completed Yes No

Ancillary Within 15 days More than 15 days

Provider Newsletter Page 5

Quality Management

Committed to Excellence

Quality Management continued

Initial Health Assessments As a Primary Care Physician, you must ensure that all of your newly assigned members have the

Comprehensive Initial Health Assessment (IHA) and that you comprehensively assess the mem-ber's current, acute, chronic and preventive health needs. These IHAs must be completed by 120 calendar days of enrollment as required by the Health Plan and must be documented in the mem-

ber medical record.

The effective date of enrollment is the first day of the month following notification that a member is eligible to receive services from the IPA/PMG, for which capitation will be paid, and the mem-

ber is not on “hold” status.

Newly born Infants to Members: The Date of Birth is the date of enrollment.

Retroactively Enrolled Members: The Date of VMG is notified of the retroactive enrollment is the effective date of enrollment.

Exceptions to 120 DAY IHA Timeframe

All elements of the IHA have been completed within the 12 months prior to the member’s effective date of enrollment:

If the new PCP did not complete this IHA, the PCP must document that the previous

IHA was reviewed and updated accordingly.

Members not continuously enrolled.

Members disenrolled before IHA could be performed.

Providers shall make reasonable attempts to contact a Member and schedule an IHA. All attempts shall be documented. Documented attempts that demonstrate Provider’s unsuccessful efforts to

contact the member and schedule an IHA are considered evidence of meeting the IHA require-ments.

IHA/IHEBA Outreach efforts:

VMG will make all efforts to ensure new members receive their initial health assessment with-

in the time frame of compliance and annually.

A new member list provided by VMG will be sent to the providers with their monthly new member eligibility list. The provider offices will use the list to contact new members and

schedule appointments within the required time frame.

On a monthly basis, VMG will generate a list from encounter data to identify members en-rolled within the last 90 days who have not received an IHA. Also providers may identify

these new members through specific Health Plan website portals. (Care 1st, Anthem Blue Cross) This monthly list will be sent to the provider offices to schedule an appointment.

The office staff should document all attempts to schedule a member appointment and imple-

mentation of IHEBA. At least two attempts must be made by either speaking to the member or guardian or leaving a voice message. Documentation will be included in the medical record

and a log.

If the patient has not received the initial health assessment within 90 days of enrollment, a letter will be sent to the member. This will also be documented in the log.

Provider Newsletter Page 6

Health Education Services Please review the following Department of Health Care Services (DHCS) requirements for health education. If you need clarification on any of the requirements, please call the health plan

directly or you may call Vantage Medical Group Health Education/Cultural & Linguistics De-partment for assistance.

Health Education Services

Please document referrals to health education services in your patient’s medical record. Health education services include classes, individual counseling and support groups.

Patient Education Materials

All health education materials you provide to your Medi-Cal patients need to be between 2nd and 6th grade reading level. Additionally, these materials need to be medically accurate, cultur-ally sensitive and linguistically appropriate. The materials we provide you have been reviewed

by the health plans and meet these requirements.

Ordering Materials

A copy of a health education materials order form is available if you need to order materials.

All materials listed have been reviewed for reading level requirement, medical accuracy, and cul-tural and linguistic appropriateness. Health Education materials are available on the following

topics: Age Specific Anticipatory Guidance, Asthma, Breastfeeding, Dental Health, Diabetes, Exercise/Physical Activity, Family Planning, HIV/STD Prevention, Hypertension, Immuniza-

tions, Injury Prevention, Nutrition, Obesity/Weight Management, Parenting, Pregnan-cy/Perinatal, Substance Abuse, Tobacco Prevention and Cessation, and Women’s Health.

Individual Health Education Behavioral Assessment (IHEBA) formerly called the Staying

Healthy Assessment Tool

As a reminder, Medi-Cal patients need to complete the IHEBA form in the appropriate age cate-gory during their Initial Health Assessment (IHA) and once at each new age category thereafter.

Please review the completed form with your patients. Document any interventions and file the completed form it in their medical chart. A few words of advice from you can have a significant impact on changing your patients’ high-risk behavior. If a patient refuses to complete the assess-

ment, note it on the form and file it in their medical chart. Please use the updated forms. Forms are available in English (9/05), Spanish (9/05), Russian (9/05), Vietnamese (9/05) and Chinese

(1/06). Tip sheets are available in all county threshold languages. You can download IHEBA forms and Tip Sheets at our contracted health plan websites or you can visit our website at

www.vantagemedicalgroup.com

Breastfeeding Promotion

The American Academy of Pediatrics (AAP) supports breastfeeding as the optimal form of nu-

trition for infants. We encourage you to support this position by continuing to promote breast-feeding services to your patients. Also, please continue to refer your Medi-Cal patients to WIC.

Infant Formula Logos

Please do not distribute infant formula samples, educational materials or promotional materials with formula logos to Medi-Cal patients, as per MMCD Policy Letter 98-10.

There are many other tools and resources available on our website to help you when consid-ering health education options for our members. Some of these include Hospital Based Health Education Class listings and Health Plan-Sponsored Programs and Services. Please visit our website at www.vantagemedicalgroup.com to access these resources or call us at (951) 280-7700 for more information.

Provider Newsletter Page 7

Cultural and Linguistics Services

The following is a summary of state (Language Assistant Program for CA law SB 853) and federal regulatory requirements as well as LA Care and MRMIB contract requirements. Please call our Customer Service Department at (951) 280-7700 or toll free at (855) 257-9964 if you need clarification or tools to implement the requirements.

Language Preference

Record each non-English speaking patient’s language preference in his or her medical record.

Interpreting Services Poster

Post a sign in a visible place informing your LEP patients that they can get free interpreting services.

Free Interpreting Services for Providers & Members:

Interpreting services are available to your Limited English Proficient (LEP) patients and hard-of-hearing or deaf patients:

Over-the-Phone:

During business hours:

Over-the-Phone, Face-to-Face and American Sign Language Interpreting Services are provid-ed at no cost to providers and members through the members’ health plan.

Hard-of-hearing or deaf patients:

If your hard-of-hearing or deaf patients need sign language interpreting services for their appointments, please call our Customer Service Department at (951) 280-7700.

If your office staff want to call a hard-of-hearing or deaf patient:

California Relay Service at 1-888-877-5379 (Voice users) or 1-888-877-5381 (Spanish).

If your hard-of-hearing or deaf patients need assistance when calling your office, please let them know that they can reach you by using the

California Relay Service at 1-877-735-2929 (TTY users) or 711.

After business hours:

If your patients need interpreting services after office hours, please call Vantage Medical Group at (951) 280-7700 or toll free at (855) 257-9964.

Important!!

If your office has After Hours Answering Services:

Please ensure that their staff members can speak languages other than English;

Please ensure that they have the ability to connect to an interpreter over the telephone.

Vantage Medical Group at (951) 280-7700 or toll free at (855) 257-9964.

If your office has On-Call physicians/nurses:

Please ensure that they know how to connect to an interpreter over the telephone. Please call Vantage Medical Group at (951) 280-7700 or toll free at (855) 257-9964.

If your office has an answering machine, please ensure that your answering machine includes instructions to let patients know how to get an interpreter after hours.

Continued on Next Page

LA County Threshold Languages

Armenian Korean

Chinese Russian

English Spanish

Farsi Tagalog

Khmer Vietnamese

Provider Newsletter Page 8

San Diego County Threshold Languages

English Spanish

Cultural and Linguistics Services continued Face-to-Face & American Sign Language (ASL):

All requests must be made with a minimum of 5 to 7 working days advance notice, please

contact our Customer Service Department at (951) 280-7700 or toll free at (855) 257-9964.

Request or Refusal of Interpreting Services

Do not use minors to interpret for adults unless there is an emergency. Also, discourage pa-tients from using friends and family members as interpreters.

If your patient requests or refuses an interpreter after being informed of the service, please file

a complete Request or Refusal of Interpreter Services form in the patient’s medical chart.

Request or Refusal forms are available in many languages other than English. Please call our

Customer Service Department at (951) 280-7700 if you would like these forms in another

language.

Cultural & Language Related Complaints and Grievances

Have patients with language related complaints or grievances, complete a grievance form.

Grievance forms are available in many languages other than English. Please call our

Customer Service Department at (951) 280-7700 or toll free at (855) 257-9964

Referrals to Culturally Appropriate Community Resources & Service

If you have a patient that needs services from a community based organization or a social ser-

vice agency, please call our Customer Service Department at (951) 280-7700 or toll free at

(855) 257-9964.

Document the referral in the patient’s chart.

Bilingual Providers & Staff

Maintain a “Language Capability Self-Assessment” form, certification of language proficiency

or interpreter training on file for you and office staff providing interpreter services.

Bilingual staff providing medical interpreting services are encouraged to take a language pro-

ficiency test by a qualified agency to determine if candidate is qualified for medical interpreting.

Bilingual staff with limited bilingual capabilities should not provide interpreter service to

patients.

The ICE approved self-assessment tool is available upon request.

Availability of Qualified Member Informing Materials & Alternative Format

If your patients need information in their preferred language and/or alternative format (i.e.

Audio, Braille and Large Print, etc.) please call us at (951) 280-7700 or toll free at (855) 257-

9964.

Cultural Competency Training

We encourage your office staff and you to attend cultural competency training programs that are offered through Health Plans, LA Care, IPAs, or other agencies that provide information

on improving awareness of cultural competence including. Cultural competency training is designed to assist in the development and enhancement of interpersonal and intra-cultural

skills to improve communication, access and services, and to more effectively serve our diverse membership including Seniors and People with Disabilities (SPD).

Provider Newsletter Page 9

Provider Newsletter Page 10

Did You Know about - Compliance Hotline?

Violations of the code of conduct, ethics or any fraud, waste or abuse must be reported.

Not reporting fraud or suspected fraud can make you a party to a case by allowing the fraud to continue. Everyone has the right and responsibility to report possible HIPAA

violations or fraud, waste, and abuse.

Remember:

You may report anonymously and retaliation is prohibited when you report a concern in good faith.

For questions or concerns you may call (951) 280-7810 and speak with the Compliance Of-ficer or report anonymously using the compliance hotline: (951) 280-7766.

Compliance Program The Centers for Medicare & Medicaid Services (CMS) require health care organizations that

provide services to Medicare members have an established compliance program in place. In 2011, PPMC created a Compliance Department and program to help further raise awareness

and provide mechanisms to detect, prevent, and correct any identified non-compliance. Adopting a Compliance Program demonstrates our commitment to honesty and responsible

corporate integrity, resulting in reducing the risk of fraud, abuse and waste, while providing quality services and care.

The Compliance Program is based on 7 core elements:

1. Written Standards of Conduct: PPMC’s Code of Conduct policy promotes our commitment to

compliance and addresses specific standards for all employees and contracted providers.

2. Compliance Officer: PPMC has appointed Ana Lisa Santiago as the Corporate Compliance

Officer. She is charged with the responsibility and authority of operating and monitoring the

compliance program.

3. Effective Compliance Training: Training is provided for all employees and providers on an an-

nual basis on the subject of Compliance, Fraud Waste & Abuse, and HIPAA and

Confidentiality Laws. Additionally other training is provided on topics relating to specific programs and needed updates.

4. Internal Monitoring and Auditing: PPMC’s Compliance Program uses risk evaluation tech-

niques and audits to monitor compliance and assist in the reduction of identified problem areas.

5. Disciplinary Mechanism: Established policies enforce standards and address dealing with indi-

viduals or entities that do not adhere to compliance requirements or are excluded from participating in CMS programs.

6. Effective Lines of Communication: Includes a system to receive, record and respond to

compliance questions, or reports of potential or actual non-compliance, while maintaining confidentiality.

7. Procedures for Responding to Detected Offenses and Corrective Action: Procedures are in place to

respond to and initiate corrective action to prevent similar offenses including a timely, reasonable inquiry.

Provider Newsletter

Five Things Physicians and Patients Should Question From the American College of Radiology

1. Don’t do imaging for uncomplicated headache. Imaging headache patients absent specific risk factors for structural disease is not likely to change management or im-

prove outcome. Those patients with a significant likelihood of structured disease requiring immediate attention are

detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines

concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-

being.

2. Don’t image for suspected pulmonary embolism (PE) without moderate or high

pre-test probability. While deep vein thrombosis (DVT) and PE are relatively common clinically, they are rare in the absence of elevated

blood d-Dimer levels and certain specific risk factors. Imaging, particularly computed tomography (CT) pulmonary

angiography, is a rapid, accurate and widely available test, but has limited value in patients who are very unlikely,

based on serum and clinical criteria, to have significant value. Imaging is helpful to confirm or exclude PE only for

such patients, not for patients with low pre-test probability of PE.

3. Avoid admission of preoperative chest x-rays for ambulatory patients with unre-

markable history and physical exam. Performing routine admission or preoperative chest x-rays is not recommended for ambulatory patients without specif-

ic reasons suggested by the history and/or physical examination findings. Only 2 percent of such images lead to a

change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or

there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 who has not had cheat radi-

ography within six months.

4. Don’t do computed tomography (CT) for the evaluation of suspected appendicitis

in children until after ultrasound has been considered as an option.

Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as

good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consid-

eration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by

CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitiv-

ity and specificity of 94 percent.

5. Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

Simple cysts are hemorrhagic cysts in women of reproductive age are almost always physiological. Small simple cysts

in postmenopausal women are common, and clinically inconsequential. Ovarian cancer, while typically cystic, does

not arise from these benign-appearing cysts. After a good quality ultrasound in women of reproductive age, don't rec-

ommend follow-up for a classic corpus luteum or simple cyst <5cm in greatest diameter. Use 1 cm as a threshold for

simple cysts in postmenopausal women.

For more information on how these list were created, source, footnotes, and disclosure and conflict of interest policy can

be found at www.choosingwisely.org.

Page 11

Provider Newsletter

For more information or to see other lists, visit www.choosingwisely.org

1. Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial

evaluation of patients without cardiac symptoms unless high-risk markers are present. Asymptomatic, low-risk patients account for up to 45 percent of unnecessary “screening.” Testing should be performed

only when the following findings are present: diabetes in patients older than 40-years-old; peripheral arterial disease; or

greater than 2 percent yearly risk for coronary heart disease events.

2. Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as

part of routine follow-up in asymptomatic patients. Performing stress cardiac imaging or advanced non-invasive imaging in patients without symptoms on a serial or

scheduled pattern (e.g. every one to two years at a heart procedure anniversary) rarely results in any meaningful

change in patient management. This practice may, in fact, lead to unnecessary invasive procedures and excess radia-

tion exposure without any proven impact on patient’s outcomes. An exception to this rule would be for patients more

than five years after a bypass operation.

3. Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-

operative assessment in patients scheduled to undergo low-risk non-cardiac surgery. Non-invasive testing is not useful for patients undergoing low-risk non-cardiac surgery (e.g., cataract removal). These

types of tests do not change the patient’s clinical management or outcomes and will result in increased costs.

4. Don’t perform echocardiography as routine follow-up for mild, asymptomatic na-

tive valve disease in adult patients with no change in signs or symptoms.

Patients with native valve disease usually have years without symptoms before the onset or deterioration. An echocar-

diogram is not recommended yearly unless there is a change in clinical status.

5. Don’t perform stenting of non-culprit lesions during percutaneous coronary inter-

vention (PCI) for uncomplicated hemodynamically stable ST-segment elevation

infarction (STEMI).

Stent placement in a noninfarct artery during primary PCI for STEMI in a hemodynamically stable patient may lead

to increased mortality and complications. While potential beneficial in patients with hemodynamic compromise, inter-

vention beyond the culprit lesion during primary PCI has not demonstrated benefit in clinical trials to date.

Five Things Physicians and Patients Should Question From the American College of Cardiology

The mission of the ABIM Foundation is the advance the medical professionalism to improve the health

care system. We achieve this by collaborating with physicians and physician leaders, medical trainees,

health care delivery systems, payers, policymakers, consumer organizations and patients to foster a

shared understanding of professionalism and how the can adopt the tenets of professionalism in practice.

To Learn more about the ABIM Foundation, visit www.abimfoundation.org.

Page 12