Show me the $$!! Please walk around the room and place one dot on your answer to each question.
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- Domenic Scot Hill
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1 Show me the $$!! Please walk around the room and place one dot on your answer to each question.
2 Disclosures The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of Madigan Army Medical Center or the Department of Defense
3 Productivity 101 MAJ Dawn Sloan, MD CPT Katie Westerfield, DO
4 Objectives Outlined productivity measures Discussed IRIS metrics that impact clinics Reviewed Relative Value Units (RVUs) Integrated techniques to maximize coding
5
6 IRIS PMRM PPR ACE Performance Planning PCE RADaR R&A CART HEDIS PMPM FARM DMHRSi Accuracy? M2 You are here! RVU EASIV MEPRS GFEBS Volume? (Pt Flow / Prov Avail) CarePoint Procedure & Diagnosis codes DMHRSi AHLTA Coding Trends? (Documentation) CHCS SO AP note Specialty Referral CHCS Demand Front Desk 6 RMS
7 IRIS- Integrated Resourcing and Incentive System JOES (APLSS/PSS/SDA) BMI Readiness (service specific) HEDIS based on NCQA Tobacco use ($0.50 per non-smoking adult) PCM continuity (+ $5 / encounter) Relay Health RVUs
8 BMI BLUF: Overweight patients who lose 1% of BMI = $100 to MTF for each 1%
9 HEDIS Healthcare Effectiveness Data and Information Set
10 HEDIS Data 4 Ways: Target by Percentile On IRIS Quality Report Members by Percentile # meeting criteria / enrollees with condition = percent achieved Amount Earned HEDIS Composite Score 1-5 scale (x 9) used by Command to quickly assess
11 Relay Health Take home message: Enroll your patients and teach your staff how to use it!
12 Tricare Online Booking Are you encouraging folks to book their own appointments? $5.00/ appointment
13 RVUs But we re sub-capitated! Why do I care?
14 RVUs Still used to determine Workload Man-power needs Fee-for-Service Determined by CMS Used by civilian providers to get paid Current rate = +$43.68 or -$61.59
15 Where did this coding stuff come from, anyway? Purpose- define documentation needed for Medicare reimbursement Nov 1994 HCFA s first E/M guidelines Developed for implementation Jan 1998
16 Why should I bother? More money for our team: RVU = $ RVU= $ So.$41.93 per visit difference Maybe 5 visits per day, $200+ a day extra per provider (cha-ching!) 15 providers in clinic = $3000+ per day, $15,000+/wk (CHA-CHIIIIIIING!!!!)
17 King for a day Clinic A: Generates $1 million a day Clinic B: Generates $1.5 million a day Who gets more personnel?
18 Are we at risk? Are you confident in your coding skills? Do you trust AHLTA s artificial intelligence to do it for you?
19 What can we do? There is a way: the 90% fix Majority of Family Medicine Clinic visits are s or s KNOW how to code a and you will achieve enlightenment!
20 99214 Meet the Monsters Three areas in the visit, only need to meet standard in TWO for established patient History Physical Exam Medical Decision making
21 History Wimpy Monster HPI- FOUR elements (or three chronic conditions) ROS- Main plus ONE other system Can just say GI/GU/skin noncontributory NKDA/allergies counts as one PMH/SH/FH: just give ONE i.e. 50 py tobacco, PMH noncontributory 4:2:1
22 Physical Exam: Medium Monster TWELVE elements total >1 body area (that means TWO only!) Can I get a little help? I ll spot ya 3: 3 vital signs = 1block General appearance= 1 block A+O x3 = 1 block Keep in mind, only need 2/3, so you don t need to show detailed PE if have other 2! Warning: some count, some don t
23 Physical Exam Bullet Examples Eyes Conjunct/lids, Pupils/Iris, Disks ENT External, TM, hearing, nasal mucosa, lips/teeth/gums, oropharynx Respiratory Auscultation, percussion, palpation, resp effort Cardiovascular Ascultation, palpation, carotids, abd aorta, femoral, pedal, extrem GI/Abdomen Masses/tenderness, liver and spleen, hernia, perineum, hemoccult Musculoskeletal Gait, inspection, ROM, stability, strength/tone
24 Medical Decision making: Most confusing monster Diagnosis and management options, 3 points One point per problem, +1 for co-morbidity affecting One acute systemic illness with beyond minor =2 A undiagnosed problem with 3 ddx=3 Separate list of bullets (i.e. IVF, education, meds, home treatments ) that if exceeds 3 you are a go Amount/complexity of data, 3 points Review/order labs=1 Review/order rad=1 Review/order EKG, phys tx, immuz=1 Review old records, discuss w/m.d.=1 Independent interpretation of EKG, rad result, UA=2 Risk of complications or M+M, moderate Any prescription drugs=moderate (even if just on chart) Undiagnosed problem with uncertain dx=moderate Acute illness with systemic sx=moderate 2 stable chronic conditions=moderate Exacerbation, progression, or side effect of tx on 1 chronic condition =moderate
25
26 Counseling time: 51% or more min, >50% time spent counseling on.x min, >50% time spent counseling.x The note must reflect what was counseled in detail!!
27 Oh, by the way Use the -25 modifier Prev Med + Well child with a URI Well child with a rash Well-woman with knee pain
28 Procedures!!! Get paid for what you re doing! Nurses can add CPT/HCPS codes Create a favorites list Have everyone create favorites list Capture ALL of your codes!!
29 It s the Little Things Vision and Hearing screening Pulse Oximetry EKG IV Fluids Developmental Screenings Depression Screening Immunizations Medicare Wellness visit Tobacco Counseling ($10/ 3 mins) Any other procedures done in clinic
30 One final warning There remains a hidden monster Coding must be based on medical necessity FRAUD Do not do more workup than required just to code a (i.e. 30 min URI visit?)
31 Summary: Master 2 of 3 monsters for History HPI 4, ROS main +1 other, PMH/SH/FH 1 Physical Exam 12 from two systems Medical decision making Dx/Manage options (new prob,1 stable/1worse) Complexity data review (1 for each area, 2 for record review/discuss, 2 for indep interp) Risk complications, M+M (prescrip drugs automatic, undx new problem, exacerbation/progression)
32 Take home points Understand IRIS Learn the Hx and decision making will likely be more valuable than physical exam Only code based on medical necessity. Avoid fraud! But capture all of the work your doing!
33 Questions?
34 Want to Learn More?? The Basic Healthcare Administrative Course Online distance learning 1 week of face-to-face instruction
35 Acknowledgments Thanks to Dr. Ross Colt for the RVU slides. IRIS FY16 User Guide Robert Goodman s Chaos ASPIRE:IRIS 101 series, 2013 Procedure code handout from MAJ David Stanley, PASBA physician champion
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