Monday, April 22, 2019
The Executive Suite: Coding for care on the clock
The Executive Suite: Coding for care on the clock: Q: You have described a 99354 as “a 99214 that just won’t end.” Do you have to have at least 31 minutes, or is it one of those codes where t...
Sunday, April 21, 2019
The Executive Suite: Getting to zero: strategies to reduce patient bala...
The Executive Suite: Getting to zero: strategies to reduce patient bala...: As health plan deductibles and monthly premiums continue to rise, the increasing financial obligations patients have is something all medica...
Saturday, April 20, 2019
Getting to zero: strategies to reduce patient balances
As health plan deductibles and monthly premiums continue to rise, the increasing financial obligations patients have is something all medical practices need to be aware of. While not all patients will be able to make their full payment up front every time, practices simply can’t afford to forego attempts to collect patient payments. It’s estimated by Medical Economics that 33 percent of a practice’s revenue comes directly from patients, so medical practices that want to stay financially sound need to pay attention.
How can your practice strike that delicate balance of collecting payment in a way that preserves the practice-patient relationship? Here are four simple steps to impact this delicate—but critical—part of your practice’s financial health.
Without verifying a patient’s coverage, including how much of their deductible has been met, your practice won’t know what to collect—or if there is anything to collect from the patient. Failing to verify eligibility can also hurt the practice-patient relationship. This is one major cause of patient’s receiving unexpectedly high medical bills, which can lead to eroded trust.
By checking eligibility, you know when something isn’t covered, and you can let the patient know how much they’ll need to pay. Willimantic, Conn.-based The Foot Group increased their rate of eligibility verification by almost 6 percent within one month simply by making this a focus.
As patient financial obligations continue to increase, practices shouldn’t expect every patient to pay their balance in full every time. That said, it’s worth trying. Each patient should be asked to pay in full when they come in.
If they can’t, your practice will need to send statements. Many practices only send statements once a month, which creates a delayed billing process and increases the time it takes to collect patient balances. Instead, statements should be processed daily and sent within three days of the claim adjudication. The longer it takes a patient to receive a bill, the less likely your practice is to collect at all. According to the Healthcare Business Management Association (HBMA), there's less than a 30 percent chance of collecting money from a patient if that balance reaches 90 days.
Just five years ago, healthcare and technology were not as intertwined as they are today. As consumers experience more comprehensive technology in every area of their life, they are beginning to demand the same in healthcare. It’s easier than ever for practices to implement technology that allows the patient to check-in via their smartphone or with a tablet in the office as well as pay their past due balance through either of those methods.
Check-in stations make the process much quicker and less painful. Practices that implement new digital check-in technology have the most success getting patients to embrace the new system by removing the option of checking in with paper altogether.
When patients have the option of paying with their preferred method, whether that’s credit card, debit card, HSA, or cash, the proof is in the numbers. We’ve found patients are often more likely to pay past due balances if they have access to the types of technology they use in every other aspect of their life.
Patients aren’t the only ones who benefit from new technologies. Less paperwork reduces stress on physicians and staff—and cuts down on those after-office hours that contribute to burnout.
Increasing patient financial obligations can necessitate a change in your staffing requirements. As more responsibilities arise, you may find that your practice is understaffed and not capable of handling the increased demands and effort that need to be put on the front end to collect patient’s money.
Analyzing your practice staff is important to ensure you have appropriate staffing levels as well as high-quality staff in every role. Part of this analysis is to ensure you have the appropriate staffing competence for each role and responsibility. For example, entering medications, past medical history, and allergies are all time-consuming tasks that take up the time of highly competent staff away from tasks that are more critical.
Using technology to handle low-skill, low-value tasks can also allow staff the time they need to follow up on claims, pre-certify insurance coverage, and check authorizations. These are the things that will lead to fewer aging patient balances and a happier staff.
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How can your practice strike that delicate balance of collecting payment in a way that preserves the practice-patient relationship? Here are four simple steps to impact this delicate—but critical—part of your practice’s financial health.
1. Make eligibility verification part of the patient check-in process.
Without verifying a patient’s coverage, including how much of their deductible has been met, your practice won’t know what to collect—or if there is anything to collect from the patient. Failing to verify eligibility can also hurt the practice-patient relationship. This is one major cause of patient’s receiving unexpectedly high medical bills, which can lead to eroded trust.
By checking eligibility, you know when something isn’t covered, and you can let the patient know how much they’ll need to pay. Willimantic, Conn.-based The Foot Group increased their rate of eligibility verification by almost 6 percent within one month simply by making this a focus.
2. Attempt to collect payments at the time of service.
As patient financial obligations continue to increase, practices shouldn’t expect every patient to pay their balance in full every time. That said, it’s worth trying. Each patient should be asked to pay in full when they come in.
If they can’t, your practice will need to send statements. Many practices only send statements once a month, which creates a delayed billing process and increases the time it takes to collect patient balances. Instead, statements should be processed daily and sent within three days of the claim adjudication. The longer it takes a patient to receive a bill, the less likely your practice is to collect at all. According to the Healthcare Business Management Association (HBMA), there's less than a 30 percent chance of collecting money from a patient if that balance reaches 90 days.
3. Implement new technologies that improve the patient experience.
Just five years ago, healthcare and technology were not as intertwined as they are today. As consumers experience more comprehensive technology in every area of their life, they are beginning to demand the same in healthcare. It’s easier than ever for practices to implement technology that allows the patient to check-in via their smartphone or with a tablet in the office as well as pay their past due balance through either of those methods.
Check-in stations make the process much quicker and less painful. Practices that implement new digital check-in technology have the most success getting patients to embrace the new system by removing the option of checking in with paper altogether.
When patients have the option of paying with their preferred method, whether that’s credit card, debit card, HSA, or cash, the proof is in the numbers. We’ve found patients are often more likely to pay past due balances if they have access to the types of technology they use in every other aspect of their life.
Patients aren’t the only ones who benefit from new technologies. Less paperwork reduces stress on physicians and staff—and cuts down on those after-office hours that contribute to burnout.
4. Analyze your staffing roles and responsibilities.
Increasing patient financial obligations can necessitate a change in your staffing requirements. As more responsibilities arise, you may find that your practice is understaffed and not capable of handling the increased demands and effort that need to be put on the front end to collect patient’s money.
Analyzing your practice staff is important to ensure you have appropriate staffing levels as well as high-quality staff in every role. Part of this analysis is to ensure you have the appropriate staffing competence for each role and responsibility. For example, entering medications, past medical history, and allergies are all time-consuming tasks that take up the time of highly competent staff away from tasks that are more critical.
Using technology to handle low-skill, low-value tasks can also allow staff the time they need to follow up on claims, pre-certify insurance coverage, and check authorizations. These are the things that will lead to fewer aging patient balances and a happier staff.
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Thursday, April 18, 2019
The Executive Suite: Do you value your patient as a person?
The Executive Suite: Do you value your patient as a person?: Psychologist Abraham Maslow is perhaps best known for creating Maslow’s Hierarchy of Needs, which defines five levels of needs that must be ...
Wednesday, April 17, 2019
Do you value your patient as a person?
Psychologist Abraham Maslow is perhaps best known for creating Maslow’s Hierarchy of Needs, which defines five levels of needs that must be satisfied. He theorized that when all five levels of needs are met, people reach self-actualization, meaning they achieve their full potential.
For those who may not be familiar with the five levels, they are:
Some of the hierarchy levels reference value, but what does value mean? According to the Oxford Dictionaries, value is defined as “the regard that something is held to deserve; the importance, worth, or usefulness of something.” As a verb, value equates to a good or service’s monetary worth.
Through sympathetic and empathetic patient care, physicians can positively impact and create an environment for better outcomes by asking patients whether their needs are being met.
If someone is struggling financially, then food and shelter may be issues of concern. The solution might be to involve a social worker who can help connect patients to available resources.
For adults or children who experience verbal, physical, or sexual violence, level two needs are not being met. The solution might be to refer patients to the appropriate mental health professional, encourage the practice of yoga and meditation, and alert the appropriate authorities as necessary.
Level three needs of love and belonging may be less visible but are no less important. The solution might be to refer patients to outside resources and mental health professionals. You might also focus more of your time and attention with those patients. Indeed, the facet of imparting a caring and loving environment should be inherent in the physician’s own practice.
Meeting people’s level four needs of self-esteem can be challenging. As a physician or a medical professional, ask yourself, “How do I value my patients?” The monetary aspect may come into play with value-based care, but that is not the answer. Instead, ask yourself these questions:
Am I making patients part of the discussion about their care and treatment plans?
Am I providing positive reinforcement when patients change habits that can lead to better health outcomes?
By involving patients, you are showing the valuable role they have in their health and reinforcing that they know their bodies best (even if they don’t always do what is best for them).
By cultivating a caring environment and valuing your patients, physicians can help patients achieve better health outcomes. That, in turn, leads to improved patient satisfaction, patient compliance, patient outcomes, and value-based care scores. And, as others have found, happier patients are more likely to make referrals and leave better online reviews, which can lead to more new patients. All of these translate into great economic value for you and your practice.
Reframing the patient encounter by focusing on need can be a win-win-win for physicians, patients, and the healthcare industry.
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For those who may not be familiar with the five levels, they are:
- Level one – physical survival needs, e.g., food, clothing shelter, and oxygen
- Level two – physical safety needs, e.g., the need to feel safe from personal dangers and threats
- Level three – love and belonging, e.g., family or belonging; acceptance and understanding; and loving and affection, both giving and receiving
- Level four – self-esteem needs, e.g., people need to feel of value and to count for something
- Level five – self-fulfillment/self-actualization. People can develop to their fullest potential in all aspects of life only after attaining the previous four levels of physical, emotional, social, and spiritual well-being.
Some of the hierarchy levels reference value, but what does value mean? According to the Oxford Dictionaries, value is defined as “the regard that something is held to deserve; the importance, worth, or usefulness of something.” As a verb, value equates to a good or service’s monetary worth.
Through sympathetic and empathetic patient care, physicians can positively impact and create an environment for better outcomes by asking patients whether their needs are being met.
If someone is struggling financially, then food and shelter may be issues of concern. The solution might be to involve a social worker who can help connect patients to available resources.
For adults or children who experience verbal, physical, or sexual violence, level two needs are not being met. The solution might be to refer patients to the appropriate mental health professional, encourage the practice of yoga and meditation, and alert the appropriate authorities as necessary.
Level three needs of love and belonging may be less visible but are no less important. The solution might be to refer patients to outside resources and mental health professionals. You might also focus more of your time and attention with those patients. Indeed, the facet of imparting a caring and loving environment should be inherent in the physician’s own practice.
Meeting people’s level four needs of self-esteem can be challenging. As a physician or a medical professional, ask yourself, “How do I value my patients?” The monetary aspect may come into play with value-based care, but that is not the answer. Instead, ask yourself these questions:
Am I making patients part of the discussion about their care and treatment plans?
Am I providing positive reinforcement when patients change habits that can lead to better health outcomes?
By involving patients, you are showing the valuable role they have in their health and reinforcing that they know their bodies best (even if they don’t always do what is best for them).
By cultivating a caring environment and valuing your patients, physicians can help patients achieve better health outcomes. That, in turn, leads to improved patient satisfaction, patient compliance, patient outcomes, and value-based care scores. And, as others have found, happier patients are more likely to make referrals and leave better online reviews, which can lead to more new patients. All of these translate into great economic value for you and your practice.
Reframing the patient encounter by focusing on need can be a win-win-win for physicians, patients, and the healthcare industry.
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The danger in treating patients as customers
The individuals I take care of on a daily basis are my patients. They are neither my clients nor customers. For several years, I have been mortified at the implication that I provide a service akin to selling a car. Referring to patients as customers shifts the focus solely onto customer service and the transactional nature of exchanging goods for money. When administrators with their business training subtly adjust the language, it profoundly changes the physician-patient relationship. As a physician, I feel it demeans the actual time and effort I take in caring for my patients. Recently, I realized what it does to my patients is even worse.
The word client implies someone with a need that can be satisfied through an agreed upon payment to the provider of the service. To some extent, there is a balance of power. Clients have the ability to choose where to spend their money and can often use that as leverage to gain a desired level of service. Service providers want to attract customers who are likely to spend money. Significant time and money go into advertising and gimmicks that will bring in the right customer. Individuals who cannot or will not spend money are quickly pushed to the side to make way for paying customers. Service providers have a priority on profits. The goal of customer service lies in keeping customers happy so they will spend more money.
Medical care has been pushed more and more into a business model looking to reap profits. The rising costs of healthcare in this country attest to our nation’s inability to curb medical costs. In a business model, when costs go up, the price of services is passed on to the consumer. When the price of a car goes up, customers can buy a cheaper make or model, but healthcare is rarely as flexible. Customers have the ability to take their business elsewhere, but patients often do not. They are limited by insurance coverage or lack thereof. Barriers to care prevent mobility, as does access to reliable and convenient transportation. A client can usually live without a car, but lack of healthcare can—and does—kill patients.
A push for improved bedside manner and frustration at the system has lumped customer satisfaction into patient care. The original intent may have been better communication and patient well-being. But in many instances, low patient satisfaction is a result of not receiving the requested antibiotics, imaging, or other warranted diagnostic testing as opposed to poor medical care. The actual root causes of poor patient outcomes rarely show up on a patient satisfaction survey.
Within the very nature of a physician patient relationship there is an undeniable level of inequality. Referring to patients as clients does not remove that imbalance of power. Rather, it only serves to gloss over it. Patients are ill or injured, sometimes gravely. Patients are exposed. Patients are often alone. Patients are vulnerable. Service providers have a commitment to profits first and customers second. Physicians, however, have a responsibility to their patients.
I have a professional dedication to my patients: to care for them, to listen to them, and to give them the best of my medical experience. A physician-patient relationship implies shared decision making using my medical knowledge paired with my patients’ values and needs. When patients become clients, they seem less vulnerable than they are and less in need of compassion or care. Medicine must return to patient care and not merely customer service.
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Chart Labels
Medical and Rx Pads
The word client implies someone with a need that can be satisfied through an agreed upon payment to the provider of the service. To some extent, there is a balance of power. Clients have the ability to choose where to spend their money and can often use that as leverage to gain a desired level of service. Service providers want to attract customers who are likely to spend money. Significant time and money go into advertising and gimmicks that will bring in the right customer. Individuals who cannot or will not spend money are quickly pushed to the side to make way for paying customers. Service providers have a priority on profits. The goal of customer service lies in keeping customers happy so they will spend more money.
Medical care has been pushed more and more into a business model looking to reap profits. The rising costs of healthcare in this country attest to our nation’s inability to curb medical costs. In a business model, when costs go up, the price of services is passed on to the consumer. When the price of a car goes up, customers can buy a cheaper make or model, but healthcare is rarely as flexible. Customers have the ability to take their business elsewhere, but patients often do not. They are limited by insurance coverage or lack thereof. Barriers to care prevent mobility, as does access to reliable and convenient transportation. A client can usually live without a car, but lack of healthcare can—and does—kill patients.
A push for improved bedside manner and frustration at the system has lumped customer satisfaction into patient care. The original intent may have been better communication and patient well-being. But in many instances, low patient satisfaction is a result of not receiving the requested antibiotics, imaging, or other warranted diagnostic testing as opposed to poor medical care. The actual root causes of poor patient outcomes rarely show up on a patient satisfaction survey.
Within the very nature of a physician patient relationship there is an undeniable level of inequality. Referring to patients as clients does not remove that imbalance of power. Rather, it only serves to gloss over it. Patients are ill or injured, sometimes gravely. Patients are exposed. Patients are often alone. Patients are vulnerable. Service providers have a commitment to profits first and customers second. Physicians, however, have a responsibility to their patients.
I have a professional dedication to my patients: to care for them, to listen to them, and to give them the best of my medical experience. A physician-patient relationship implies shared decision making using my medical knowledge paired with my patients’ values and needs. When patients become clients, they seem less vulnerable than they are and less in need of compassion or care. Medicine must return to patient care and not merely customer service.
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Thursday, April 4, 2019
Coding for care on the clock
Q: You have described a 99354 as “a 99214 that just won’t end.” Do you have to have at least 31 minutes, or is it one of those codes where the 16 minute, 50 percent rule, is good enough?
A: You need to have at least 30 minutes of prolonged time, that is, at least 30 minutes beyond the full time normally assigned to the base code. The typical time per CPT for a code 99214 is 25 minutes. A code 99354 means a physician would need to have spent at least 55 minutes with or devoted to the patient.
As for the 50 percent rule, we are actually applying the midpoint rule here. The code description says “one hour of prolonged services is 30-74 minutes” of prolonged time, so we are already at the short end with the 30 minutes.
Q: OK, but as far as documenting this prolonged time, do I need to say, “31 minutes of extended time was spent discussing and reviewing” or should I give the total time of the visit as at least 56 minutes: 25 minutes for a code 99214 and 31 minutes for a code 99354?
A: Both, really. You are billing two codes as above, so try and show them two things. For example, you could write, “Spent a total of 56 minutes today with Beth, initially working her up for xyz, followed by 31 minutes of prolonged service time discussing the natural history of this disease and the best treatment options given the stage of her disease.” That shows the auditor the total time and clearly states that at least 30 minutes was in prolonged services.
Q: Are the 2019 CMS proposed guidelines for E/M just for office visits? I don’t see any discussion about hospital visits.
A: That is correct. The proposed guidance states: “The proposed changes would only apply to office/outpatient visit codes (CPT codes 99201 through 99215), except where we specify
otherwise. We agree with commenters that we should take a stepwise approach to these issues, and therefore, we would limit initial changes to the office/outpatient E/M code set.”
The guidance goes on to say that “We may consider expanding our efforts more broadly to address sections of the E/M code set beyond the office/outpatient codes in future years.”
Please remember: what you have seen so far is only a proposal. Earlier suggestions to go with a one level visit approach were not embraced by the provider community.
Q: We have been asked to see patients who present for routine prothrombin time and international normalized ration (PT/INR) checks and bill for a code 99213 instead of a code 99211. Is that permissible? Can I just use the same note?
A: There is no rule that states a visit of that sort can’t be billed as a 99213, but the way you say it makes it sound as if it may not be medically necessary.
The question might be why you are being asked to do this, although on the face of it, it would appear to be about the billing since that was specifically mentioned. Please get to the bottom of that. If the “nurse visit” approach results in good management of the patient’s anti-coagulation status, then you should likely leave it as it is.
That said, if you are managing the problem that requires anti-coagulation, have some reviews of system (ROS). If you make clear the management, the risk, and the patient visit, then you are well in the ballpark for the standard chronic disease management code 99213. If you document the above, and ideally some mention of the risk of these medicines, then that note should be sufficient.
But don’t just take a supervised 99211 note where you likely only agree and acknowledge the dose and status of the problem and call it a code 99213. If you are going to change the code, make sure you bolster the note to make that higher level of service quite clear.
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A: You need to have at least 30 minutes of prolonged time, that is, at least 30 minutes beyond the full time normally assigned to the base code. The typical time per CPT for a code 99214 is 25 minutes. A code 99354 means a physician would need to have spent at least 55 minutes with or devoted to the patient.
As for the 50 percent rule, we are actually applying the midpoint rule here. The code description says “one hour of prolonged services is 30-74 minutes” of prolonged time, so we are already at the short end with the 30 minutes.
Q: OK, but as far as documenting this prolonged time, do I need to say, “31 minutes of extended time was spent discussing and reviewing” or should I give the total time of the visit as at least 56 minutes: 25 minutes for a code 99214 and 31 minutes for a code 99354?
A: Both, really. You are billing two codes as above, so try and show them two things. For example, you could write, “Spent a total of 56 minutes today with Beth, initially working her up for xyz, followed by 31 minutes of prolonged service time discussing the natural history of this disease and the best treatment options given the stage of her disease.” That shows the auditor the total time and clearly states that at least 30 minutes was in prolonged services.
Q: Are the 2019 CMS proposed guidelines for E/M just for office visits? I don’t see any discussion about hospital visits.
A: That is correct. The proposed guidance states: “The proposed changes would only apply to office/outpatient visit codes (CPT codes 99201 through 99215), except where we specify
otherwise. We agree with commenters that we should take a stepwise approach to these issues, and therefore, we would limit initial changes to the office/outpatient E/M code set.”
The guidance goes on to say that “We may consider expanding our efforts more broadly to address sections of the E/M code set beyond the office/outpatient codes in future years.”
Please remember: what you have seen so far is only a proposal. Earlier suggestions to go with a one level visit approach were not embraced by the provider community.
Q: We have been asked to see patients who present for routine prothrombin time and international normalized ration (PT/INR) checks and bill for a code 99213 instead of a code 99211. Is that permissible? Can I just use the same note?
A: There is no rule that states a visit of that sort can’t be billed as a 99213, but the way you say it makes it sound as if it may not be medically necessary.
The question might be why you are being asked to do this, although on the face of it, it would appear to be about the billing since that was specifically mentioned. Please get to the bottom of that. If the “nurse visit” approach results in good management of the patient’s anti-coagulation status, then you should likely leave it as it is.
That said, if you are managing the problem that requires anti-coagulation, have some reviews of system (ROS). If you make clear the management, the risk, and the patient visit, then you are well in the ballpark for the standard chronic disease management code 99213. If you document the above, and ideally some mention of the risk of these medicines, then that note should be sufficient.
But don’t just take a supervised 99211 note where you likely only agree and acknowledge the dose and status of the problem and call it a code 99213. If you are going to change the code, make sure you bolster the note to make that higher level of service quite clear.
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