2/28/2017 NO DISCLOSURES. K 1/Partner

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1 NO DISCLOSURES LaMon Norton NP Participant will recognize origin & role of Relative Value Unit (RVU) in coding and reimbursement. Participant will be able to link documentation points to coding and RVU generation. Participant will be able to discuss general differences in independent contract and employment agreement models of group affiliation Self employed, with an entity (LLC, LLP) 1099 only May include bonuses Participant will be able to list common features of compensation models. Pro Better tax deductions Easier to claim expenses Some expenses allowed for 1099, that are not for employed Con Omission of paying quarterlies, big risk with IRS Not doing the record keeping to support deductions/expenses K 1/Partner Owner/Partner Distribution of profits (and sometimes tax risk) 1

2 PRO Shared profits from work More profit than other vehicles, because pay no corporation taxes CON May have some risk to pay more taxes More complex tax preparation task Employed/W2 Taxes etc taken care of Employee rules more rigid/hours/ot scheduling Pro Tax obligations deducted for you Reporting taken care of Often includes insurance and other employee like benefits Con Productivity earnings less likely Some deductions/expenses not permitted Subject to employee rules vs availability as you determine Facility fee Room, board, includes nursing Professional fee The professional (medical) component Procedural and cerebral Pre 1992 : paid on charges Post 1992: paid on RBRVU 2

3 Feds created a value for every CPT code CPT Current Procedural Terminology RBRVS Resource Based Relative Value Scale RVU Relative Value Unit Work performed and documented determines the CPT code assigned The higher the patient acuity, the more time clinicians spend with the patient (generally), and the higher the reimbursement level for those services. Government in partnership with provider partners AMA originally created CPT, and supports a committee to address and update ACEP is HIGHLY involved in protecting and advocating for our remuneration Annual review and changes (can be substantial impact to our comp) Work estimated value of the time, effort, expertise, and intensity of the service. About 55% Practice expense estimated value of overhead and other expenses necessary to run the practice. About 42% Professional Liability Insurance (PLI) the estimated value of med mal cost. About 3% Time Mental effort and judgment Technical skill Physical effort Stress Value or cost of overhead (offices etc) to maintain the practice High complexity, high risk, plentiful claims Small percentage contribution ED is extremely disadvantaged here even with the excellent advocacy from ACEP 3

4 Each piece then adjusted in an attempt to compensate for cost of living variances regionally Then the total number is multiplied by a Conversion Factor (which is also annually determined) A few other smaller nuanced factors too Straight salary Salary plus incentive Hourly base plus RVU Hourly base plus per patient incentive Pure production Chemical conversion Carbs, fats, proteins CO2 & H2O OUTCOME: USABLE ENERGY 4

5 We make our money from RVUs! OUTCOME: USABLE CHART = $$$$ Picture worth a thousand words We don t even have words payorsget a series of 5 digit codes to represent your encounter with a patient Empower your coders to get the best possible codes for you Not clinically educated Some are only high school graduates Trained to focus on key words, phrases and impressions NOT CLINICALLY EDUCATED HPI 4 elements ROS 10 systems PFSH one item from each EXAM 8 systems MDM orders, interpretations, conversations and old record review Forgetting the Family and Social Histories Results, interpretations, visualizations Conversations and old record reviews Not listing concerns considered Critical Care time Final Diagnoses 5

6 History Caveat HPI ROS PFSH Exam MDM Procedures Exam with procedures PQRS Critical Care Diagnose$ The level of history obtained within the constraints imposed by the urgency of the patient s clinical condition and/or mental status Must explain why comprehensive history could not be obtained 8 elements 4 elements required for Level 4 or 5 Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms If list a multitude will still only count as one element Not knowing that four elements are necessary Requires down code from 85 to 83!!! Net revenue loss of about $90 per patient for all payers!!!!! 6

7 Don t rely on HPI boxes to fulfill needs for ROS After addressing pertinent systems don t forget to mark all systems negative except as marked Do not just mark the box Don t rely on HPI boxes to fulfill needs for ROS After listing pertinent systems don t forget to mark all systems negative except as marked Requires down code from 85 to 84!!! Net revenue loss of $55 per patient for all payers!!!!! Unless no ROS then loss of about $150 when go to level 81 Best if one item from each Guarantees ability of coder to assign a level five Also allows use of the highest payable observation codes Past history for medical and surgical usually on charts BUT these are not uncommonly forgotten Remember: only need one comment per each Requires down code from 85 to 84 if only one listed If none listed go to 83 Net revenue loss of $55 per patient for all payers with one item and $90 if none listed!!!!! 7

8 For Level 5 need findings from 8 or greater body systems Make sure affected body system documented Systems not body areas Reviewed Data Points Review and/or order of clinical lab tests 1 Review and/or order of x-ray tests 1 Review and/or order of tests in the medicine section of CPT 1 Discussion of test results with performing physician 1 Decision to obtain old records and/or obtain history from someone other than patient Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider Independent visualization of image tracing or specimen itself (not simply review of report) TOTAL 4 or > Must document conversations: Family and friends Medical personnel like EMS, Psych workers Consulting or admitting physicians Test results from another performing physician Document old record review Must document interpretations or visualizations: X rays and Special Studies EKGs Gram stains or wet mounts Requires down code usually from 85 to 84 or lower!!! Net revenue loss of $55 to $90 per patient for all payers!!!!! Involves high complexity of medical decision making to assess, manipulate and support vital system function (s) to prevent further life threatening deterioration. (AMA/CPT 2008) 8

9 Unstable vital signs BP > 230/130 or < 70/40 Pulse Ox < 90% Pulse > 150* or < 40 (adults and > 10 y/o) Respiratory Rate > 20 or < 5 Temperature > 104 degrees or < 95 degrees Shortness of breath or airway compromise Respiratory arrest or failure Pulmonary edema Acute MI or CVA with thrombolytics Accelerated angina Cardiac dysrhythmia if unstable Changing mental status Hemorrhagic CVA Sepsis Coma Immediate need for surgery Trauma or medical Aortic dissection or AAA Perforated viscous GI bleed with unstable vital signs Significant fluid/electrolyte imbalance Diabetic Ketoacidosis Anaphylaxis Many, not all, admissions to ICU or CCU Separately identifiable exam Examples: Head laceration Neurological exam evident Document to high level when order CT Extremity laceration Distal motor, sensory documented and list appropriate nerves reviewed Document interpretations and visualizations of x rays for fracture or FBs I&D Abscess Locations Incision & Drainage Packing Exam of surrounding area and other necessary areas 9

10 Splints Burn codes EKG interpretation X ray interpretation Foley, peripheral IV, NG tube Fecal Disimpaction Fractures and Dislocations Must list exact bones and/or joints involved Document conversations for referral and treatment Fractures and Dislocations DOCUMENT WHAT YOU DID Reduction of angulation and splint Correct subluxation Perform dislocation reduction Evaluate and document your assessment of splint placed by ED staff old records reviewed by me. Note pt had previous incident/episode/admission underwent xyz. Noted clinical finding xx at that time. Defend the pt s acuity with your documentation Reassessments matter. US time contributes to Critical Care Time Images must be saved in order to bill for US procedures are limited or complete ED are usually limited Consider the ROI for Hosp and Pro fee side Hosp may bill for technical component Provider may bill for professional component Faster decision making contributes to faster operational metrics FAST Ocular 0.94 Testicular to r/o torsion

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