The Financial Aspects of Proper Case Management · The Financial Aspects of Proper Case Management Dr Dianne M Baynes RN DC MCSP CPPM Change Is In The Air! •Healthcare is one of

www.KMCUniversity.com 4/17/2015

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The Financial Aspects of Proper Case Management

Dr Dianne M Baynes RN DC MCSP CPPM

Change Is In The Air!

• Healthcare is one of the most regulated industries today

• Healthcare is changing at a phenomenal rate over the last 50 years

• But . . . how often have you assessed your practice and looked at how you ‘do business’?

Who Is in Charge Here?

• Do you know what drives the cash flow of your practice? • Number of other DCs in

my town?

• Marketing activities?

• The season of the year?

• Your team members?

• Luck?

What Decisions Have You Made Already?

• What are the services you offer to your community?

• What are the products you offer in your practice?

• When did you last think about your products and services?

This Weekend = Wear Your Owner Hat! Key Business Skills

• Keeping stats

• Understanding your numbers

• Looking at overhead

• Sizing up your ROI

• Handling your human capital

• Maximizing your support team

• Managing your time


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Understanding the Numbers

• Any business is assessed by the numbers

• How are you doing?

• Balance Sheet

• Profit & Loss

• This will help you understand where you are on the map

Keeping Stats

• Your place on the map can be quickly determined by looking at a few simple numbers that show the health of your practice

• 4 cardinal numbers

• NP, OV, Services and Collections

Keeping Stats

• 4 cardinal numbers

• NP, OV, Services and Collections

• These numbers can be combined to tell even more about what is going on in your office.

• PVA, OVA, CCA, and Collection Percentage

PVA

• Patient Visit Average is calculated by dividing the office visits for a period of time by the NP for the same period of time

• What is ideal?

• What do your numbers tell you?

OVA/COVA/CVA

• Office Visit Average is calculated by dividing the office visits for a period of time into the services for the same period of time

• Your Collected Visit Average is calculated using the collections for the same period of time

CA/CCA

• Case Average is calculated by dividing the NP for a period of time into the services for the same period of time

• With the Collected Case Average using the collections for the same period of time

• What is ideal?



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Collection Percentage

• Collection Percentage is calculated by dividing your services by your Collections

• What is ideal?

• Are you working with managed care or are you out of network?


Looking at Overhead

• You have to look at both sides of the equation

• What comes in to your practice is critical to watch and measure

• Many doctors never look at what is going out the door, making their job harder!

Looking at Overhead

• When was the last time you went over your overhead?

• It is important to look at everything. Do you have a water cooler? Do you have a tea and coffee service? Do you create NP welcome bags?

Money Out the Door

• What about the money you thought was yours –the money you collected?

• Third-party payers are doing more recoupment audits, taking money back for poor documentation

• Master your documentation!

Sizing Up Your ROI

• What are the Cash Profit Centers you have in your office?

• How do your measure the amount of revenue you are generating?

• Do you know your ‘net’ your ‘gross’ or both?

• Do you have that breakdown for each item?

Sizing Up Your ROI

• What is the difference in the ROI of the various profit centers in your practice?

• What about your nutrition?

• What about your orthotics, etc.?


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Handling Your Human Capitol

• Economist Theodore Schultz invented the term in the 1960s to reflect the value of our human capacities

• The concept of human capital recognizes that not all labor is equal and that the quality of employees can be improved by investing in them

Maximizing Your Support Team

• What can you do to maximize you team members?

• Team training

• Team meetings

• Open communication policies

• Clear policies and expectations

Handling Your Human Capital

• People who produce good results – feel good about themselves!

• Use the magic of the One Minute Manager

• Get the book:

Ken Blanchard & Spencer Johnson

One Minute Manager

• One Minute Goals –• Agree in advance, 250 words or less, identify behaviors, review

daily for congruence – less than a minute

• One Minute Praising –• Tell them you will be giving feedback, tell them specifically

what they did right, share your feelings, moment of silence to feel it, encourage additional positive behavior, non-verbal encouragement through touch of support, like a hand shake or shoulder pat

One Minute Manager

• One Minute Reprimand –• Tell them you will be giving feedback, reprimand immediately,

tell them specifically what they did wrong, share your feelings, moment of silence to feel it

• Encourage additional positive behavior, non-verbal encouragement like a hand shake or shoulder pat, say you value them, reaffirm them - not their bad behavior, reprimand is over when it is over


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Behavior and Consequence

• When managing humans – it is best to monitor behavior, because it can be observed and measured

• Behaviors must yield consequences• Positive

• Negative

Reset Goals vs Reprimand

• Unmet goal:

• If someone CAN’T DO something = go back to goal setting

(Training Problem)

• If someone WON’T DO something = reprimand (Attitude Problem)

Managing your Time

• It all comes down to time: do you master it –or does it master you?

• Administrative needs and other important business functions

• Time management is often commitment management

Analysis and Implementation

Symptoms and Cause Let’s Analyze!


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E/M Code Usage And Another…

And Another…

Money Lost!


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Money Found!

+$33.86

+$15.82

Leaving Money on the Table!

Let’s Brainstorm!

Rules of the Game

• Medical Review Policies have an influence on your bottom line, they are the rules of the insurance game

• Use Medical Review Policy to maximize reimbursement, compliance, and proper treatment planning


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Medicare Guidelines Medical Review Policies

Aetna BCBS

Coding for Dollars

• Know the language of reimbursement – it is critical to your success

• Look at your office activities each day and ask yourself . . .

• Is there a code for that?

Your Clinical Decisions

• We don’t advocate making clinical recommendations based on financial motives

• Every clinical decision has a financial outcome

• Your clinical decisions must be evidence-based, not financially based

Patient Values &

Expectations

Best External Evidence

Individual Clinical

Expertise

Think Outside the Box


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Purpose of Coding

• Coding is meant to be a description of the work you’re doing with the patient

• Also a language used to communicate with insurers

• Use to describe what you do rather than finding a code and then deciding how to use it

Code Accurately

• Accurate coding is important because each service provided by the doctor is represented by a specific code (a number)

• That number goes on your claim form and is read by a computer

• Therefore, you must be sure to provide the computer with the right numbers

Codes Supported by Documentation

• Use codes that are supported by your documentation

• Select appropriate codes, utilizing your coding resources

• Know the documentation specifics for each code

Evaluation and Management Coding

• Overview

• Most commonly used codes

• NP E/M codes

• Established pt. E/M codes

• Key components

• 1995 vs. 1997 guidelines

Evaluation and Management Coding—New Patients

• New patient E/M codes

• Key components

• Three out of three components must meet or exceed to code it

• Perhaps the most undervalued code in your arsenal

History

Exam

Clinical

Decision

Making

INPUT OUTPUT

E/M Visit


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#1 Documentation of History

• Each type of history that we will select will contain some of all of these subcomponents:• Chief complaint (CC)

• History of present illness (HPI)

• Review of systems (ROS)

• Past, family, and/or social history (PFSH)

Selection of Type of History

E/M Coding Key Component #2: Examination

• Examination is the quantifiable portion of the E/M service

• Tests and measurements will be documented

• Four levels of E/M must be considered

• Problem-focused, expanded PF, detailed, comprehensive

E/M Coding Key Component #3: Clinical Decision-Making

• Three subcomponents determine the level of CDM

• This is the “thinking” part of the E/M code

• Think of this as the “doctoring” part of the service

#3 Documentation of Complexity of Clinical Decision-Making



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Clinical Decision-Making Matrix

Number of

Diagnoses or

Management

Options

Amount and/or

Complexity of

Data to be

Reviewed

Risk of

Complications

and/or Morbidity

or Mortality

Type of

Decision

Making

Minimal Minimal or None MinimalStraight-

Forward

Limited Limited LowLow Complexity

Multiple Moderate ModerateModerate

Complexity

Extensive Extensive HighHigh

Complexity

Time: The Wild Card!

• Counseling and coordination of care

• Greater than 50% of the encounter is face-to-face

• Document well

• Follow the guidelines for time in E/M Coding rules


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CMT Codes

• 98940-3: the basic building blocks and best description of the DC’s work

• Most comprehensive physician code to describe chiropractic services

• Basic service around which everything else is built

5 Spinal Regions

• 98940 – 1-2 Regions

• 98941 – 3-4 Regions

• 98942 – 5 Regions

• Common Ratios• 98940 – 40-60%

• 98941 – 40-60%

• 98942 – 10% or less

Extra Spinal Manipulation – 98943

• Regions:

– Head

– Upper extremities (shoulder to fingers)

– Lower extremities (hip to toes)

– Anterior ribs

– Abdomen

Put on Your Auditor Hat

• What is expected/typical

• 98940: 40-60%

• 98941: 40-60%

• 98942: 1-10%

• We often see offices that stick out!

• How would your office look?

Supervised Modalities

• 97010-97028 do not require one-on-one contact by the provider

• Billed only once per encounter

• Code 97012 Mechanical Traction

• Code 97014 Electrical Stimulation


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Coding Oddities• 97014 is not billed for

Electrical Stimulation in certain cases

• G0283 is used instead

• Presently, United Health Care and Medicare are the only ones requiring this

Constant Attendance Modalities

• 97032-97039 require direct one-on-one patient contact by provider

• These are timed codes

• Code 97032 manual electrical stimulation

• Code 97035 ultrasound

Therapeutic Procedures Coding: Active Care

• Therapeutic Procedures are time-based codes

• The patient is active in the encounter

• Require direct one-on-one patient contact by provider of the service

Example of Third-Party Reimbursement

97110 Therapeutic Exercises

• Develop one functional parameter: strength, endurance, range of motion, or flexibility

• Treadmill for endurance

• Isokinetic exercise for ROM

• Lumbar stabilization exercises for flexibility

• Stability ball to stretch or strengthen

97112 NeuromuscularRe-education

• Used to describe those activities that affect proprioception

• Balance

• Coordination

• Kinesthetic sense

• Posture


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97530 Therapeutic Activities

• Used when multiple parameters are trained, including balance, strength, and range of motion

• Must be related to a functional activity with direct functional improvement expected

• Use Outcomes Assessment Tools.

Opportunities

What’s Possible

• Average of 150 PV per week

• Average reimbursement for 97110 = $35/unit

• 40% of office visits per week participate in active care rehab = 60 OV/week

• 60 OV X $35 = $2100.00 per week income

• 4.2 weeks per month = $8820.00 per month income

• 52 weeks per year = $109,200.00 per annum

97150 Group Therapy• When supervising more than

one individual, for a service that requires direct supervision, use code 97150 for each patient

• For example, if NMR is performed in a group setting, use code 97150 — do not use 97112 and 97150 at the same time

• Billed once per session

• Constant Attendance - Not On-on-One

S Codes

“Non-Medicare, temporary national codes. These S codes are used by the Health Insurance Association of America and the Blue Cross Blue Shield Association to report drugs, services, and supplies for which there are no national codes but for which codes are needed by the private sector to implement policies, programs, or claims processing. They are for meeting these particular needs of the private sector.”

HCPCS


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Low-Level Laser Therapy• CPT 97039 - an unlisted modality; specify type and

time if in constant attendance

• HCPCS S8948 -application of a modality to one or more areas; low-level laser; each 15 minutes

Decompression Therapy

• HCPCS S9090 - Vertebral Axial Decompression, per session

• CPT 97012 - Application of a modality to one or more areas, traction, mechanical

• Medicare - CPT 97799 -Unlisted physical medicine/rehabilitation services or procedures

Is This 97140 or 97124? Which Should I Use?

• The service may LOOK very similar, but the difference is clarified in the documentation

• Treatment plan must reflect the specific service along with projected outcomes and goals

• Based on their definitions, the INTENT of the service is clearly different between the two codes

97140 - Manual Therapy Techniques

• The AMA CPT 2013 edition describes 97140 as “manual therapy techniques (eg. mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes”

• It has also been described as manual trigger point therapy and myofascial release

• It is used to treat restricted motion of soft tissues in the extremities, neck, and trunk

When to Use 97140• To effect changes in soft

tissues, articular structures, and neural or vascular systems

• To address a loss of joint motion, strength, or mobility

• Must be part of an active treatment plan directed at a specific outcome

• Daily routine visit documentation should include progress toward those stated goals


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97124 – Massage Therapy

• The AMA CPT 2013 edition describes 97124 as “therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage, and /or tapotement (stroking, compression, percussion)”

• Massage might be used to improve muscle function, stiffness, edema, muscle spasms, or reduced joint motion

When to Use 97124

• To increase circulation and promote tissue relaxation to the muscles

• When treatment is prescribed for the friction-based, relaxation type massage that may be less specific than 97140

Who Can Perform These Services

• Dependent upon state law or provider contract provision

• Should verify each patient’s plan to determine specific requirements

• Would be different guidelines if a cash service

One-on-One means “One-on-One”

• One-on-one attendance is defined as “maintaining visual, verbal, and/or manual contact with the patient during the provision of the service.” One-on-one attendance is achieved when the provider is attending to one patient individually for each minute counted toward the required minutes in order to bill the CPT code for that particular therapy service.

Timed Treatment Codes

• Timed codes are counted per 15 minutes

• Up to 15 minutes is not a full unit under the CPT guidelines

• Some carriers may have you use the Medicare standard of 8 minutes for the 1st unit

• Check with each carrier and document appropriately

• Use of the -52 modifier could negate the service

Timed Treatment Codes

• For a single timed code being billed in a visit:• 8 up to 23 min = 1

• 23 up to 38 min = 2

• 38 up to 53 min = 3

• 53 up to 68 min = 4

• And so on

• For multiple timed codes billed on the same visit, use this standard, but count TOTAL time spent on each timed code


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Opportunities Code Usage – How Do I Look?

• Coding matters to your bottom line

• Do you look at coding from both a clinical and a business perspective?

"How can I serve this patient today?"

Understanding Day 1.5

• An often overlooked process in a chiropractic practice is formally defining the patient findings, including what we plan to do to remedy the issues with which the patient presents

Mastery Comes from Preparation

• Prepare for success by making sure you are ready to address the patient’s issues completely and in writing

• Once you are clear, it is simple to explain the findings to your patient


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Set Your Physical Space

• Success depends upon preparation

• Where will you formally complete the patient evaluation by writing up your findings in preparation for the Report of Findings?

• Define your space!

Manage Your Time

• If you do not set aside time each day, or each shift to complete your written Report of Findings, you will inevitably run behind

• Running behind can set up resistance to NP –the LAST thing you want to encourage!

Lay Out Your Findings

• It is important for you to step back and review all your findings

• Remember, history drives exam, together with the OATs they drive decisions about diagnostics

• All findings drive your diagnosis and treatment choices

Our First Name Is “Doctor”

• We are responsible for the welfare of our patients

• Our primary job is to effectively document and manage the patient’s episodic cases

• Our goal is to resolve their functional deficits.

Episodes of Care


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You Need Clarity FIRST

• Your patients must understand that their active treatment has a beginning, middle, and end, from the onset of care

• If you are not clear on the definition of an episode of care, you will not explain this clearly

Let Them Know What to Expect

• Teach your patient to be observant about their functional performance

• Let them know that will help you document their progress clearly and easily for their Insurance company

Define the Problem

• Our job is to identify the diagnosis with the most specificity possible

• The diagnosis will drive the treatment plan and treatment goals

• The more clear your description of the problem the better

Diagnosis Hierarchy

• Position 1 – Nerve

• Position 2 –Bone/Joint/Disc

• Position 3 & 4–Muscle/Disc/Other

• Position 3 & 4–Extremity/Catch-all/Other

You’ve Already Decided

• You have likely already decided what you think is the best recipe

• Make it easy to re-create when it is time to create a written treatment plan

• Create your written standards for care

Case Management Means Control

• Get clear about how you will manage your patients; do it in writing

• What are your preferred treatment options?

• What chiropractic treatment and chiropractic evaluation process?

• What are your support treatments or therapies?


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Meet the Requirements

• Frequency and duration

• Treatment goals for each region/treatment to include long term goal

• An evaluation of treatment effectiveness measurement

• Date of the plan

CCGPP Prognostic Factors• Older age

• History of prior episodes

• Severity of initial episode of injury

• Number of exacerbations

• Duration of current episode longer than 1 month

• Psycho-social factors

CCGPP Prognostic Factors

• Pre-existing pathology

• Nature of employment

• Waiting more than 7 days to seek treatment

• Congenital anomalies

• Patient compliance

Codify it Now

• The first step is to codify your preferences:• mild through severe

conditions,

• include length of treatment

• number of visits

• and which modalities and procedures may be utilized.

26 Adjustments8 Ext Adjustments5 Ultrasound4 EMS23 Therapeutic Exercise3 Re-exams


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Reverse Protocols

• Adjustments

• Modalities (list)

• Procedures (list)

• Cervical pillow

• Ice pack

• Biofreeze

• Nutrition pain pack

• Home traction unit

• Rehab equipment

• Cervical collar

• Tens unit

• Etc.

Reverse Protocols

• Adjustments

• Modalities (list)• Procedures (list)

• Cervical pillow

• Ice pack

• Biofreeze• Nutrition pain pack

• Home traction unit

• Rehab equipment• Cervical collar

• Tens unit

Recap and Review

• Have a place and a plan

• Review your materials and define your: • Diagnoses• Medical Review Policy• Treatment Protocols• Written Rehab Standards

• Set up a tissue-specific solution

• Have measurable functional goals

Is All Care Medically Necessary?

Clinically Appropriate Care

• Enhances life

• Relieves symptoms

• Wellness care

• Supportive care

• Maintenance care

Medically Necessary Care

• Yields a significant improvement in clinical findings and patient functionality


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Big Brother Is Watching

Set Up to Fail?

• In the world of compliance, DCs who routinely adjust the full spine are challenged

• Because documentation and coding must match exactly

• Coding 98942, because all five regions have been adjusted, may be asking for trouble

Set Up to Fail?

• But what if you actually did adjust all five?

• And what if your documentation simply can’t reflect Medical Necessity in all five regions?

• It leaves you – and your inconsistencies – living in the gray zone of high risk!

• How can this be clarified?

Technique-Driven• How should providers who practice

with techniques like Thompson, Activator, and Chiropractic Biophysics (CBP) document and code for maximum compliance?

Philosophically Driven

• Whether you are subluxation-based chiropractor or simply believe that every patient requires a full-spine adjustment, you need clarity

• Proper coding and case management for these technique-specific and philosophically driven coding conundrums need to be defined by you for your office


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You Define Your Intentions

• Clarify your motivations so you can describe your situation and your intentions

• Create and implement a policy in order to describe why it could appear that your documentation doesn’t match your coding

• Outline in writing – in advance of any requests for records – to help to keep you and your practice safe

PolicySubluxations and Compensations

PolicyDifferentiate Subluxations and

Compensations

PolicyIdentify Subluxations and Compensations

Policies and SOPs

• Policy: This is how we do things here, and why we do them

• Procedure: Standard Operating Procedure (SOP)—it’s how we implement the policy we’ve decided upon

How This Looks on Paper


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Code This as 98940 Code This as 98941

Code This as 98942 Put Your Policy to Work for You

• House your Policy with your other compliance policies and your SOP with your other SOPs

• When records are requested and you send in your documentation and coding, you need to send in a copy of your Policy

• In order to protect your practice and your license include the specifics of your SOP about how you differentiate subluxationsfrom compensations

ROF Communication Form


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Cash Practice

Clinical Report of Findings

• Master a Report of Findings that properly sets up your team for success in the Financial Report of Findings

• Be succinct

• Be orderly

• Get agreements

You’re in the RIGHT Place!

I Have a Problem!

Clinical ROF

Clinical ROF

Exam

Clinical ROF


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Clinical ROF

I Have a Problem!

Missed Appointments

24 hours

Clinical ROF

Clinical ROF

How much does this cost?

Will it fit in my Family Budget?

Clinical ROF

Passing the Baton

• Private agreement become public

• Recap your agreements in front of your patient and your teammate

• Reinforcing what your patient has agreed to helps your patient remember

Clinical ROF


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How Do You Measure Up?

• Evaluate your Clinical Report of Findings process• Are there activities you

could add to your present process?

• Are you getting true commitments?

• What might you do differently?

I’m Not a Sales Person!

• When you hear ROF/FROF do your palms sweat?

• Do you feel anxious or demeaned?

• Now is the time to evaluate your beliefs!

Clinical ROF Scripting

• Keep your explanation of their specific problem and a description of subluxation to a minimum at this time

• We want the patient to know they are in the right place

• We will expand on their education during a different phase of the Doctor-Patient relationship called the Healthy Lifestyle Workshop

• Right now our focus is on being brief, assuring them they are in the right place, and getting their “4 Yeses” to start your relationship with strength

There’s Hope! Yes #1

• Mary, it’s good to see you again. I am going to go over what we found yesterday with your evaluation process. In a short answer, we found the cause of your health concerns and it is treatable. I expect good results and we can treat it right here in our office. Are you ready to get started getting well? Great! Let me explain a few things most folks want to know at this time.

• Net Result: I’m in the right place, I’m ready to start!

Healing Takes Time

• My recommendations are based on my experience, and on cases similar to yours. Based on that, it will take approximately 20 to 30 visits over the next three to four months to correct your condition. It will NOT take that long for your pain to subside. The first thing you will experience is decreased pain. But it will take several months to correct your condition.

• Net Result: This will take some time, but the pain will go away fast.

Care Will Decrease

• Initially, your care will be more frequent. As you improve, we will graduate you to less and less frequent visits. Your care will begin three times weekly. As your body gives us the go‐ahead, we will graduate you to twice weekly and eventually to once weekly.

• Net Result: My time commitment will get smaller soon, I can do this!


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Triangulate Your Relationship

• We will do periodic examinations to determine the progress you've been making and your response to care. These periodic exams will help determine how quickly we graduate you from care. Ultimately, your body will tell us when you are complete with your care plan.

• So, initially you'll be seen three times weekly for (4) weeks and we’ll do a re‐evaluation at that time for your body to let us know how well you are responding.

• Net Result: No tug-of-war with the doctor, my body is in charge here.

No Missed Appointments! Yes #2

• We will schedule your appointments at a time that’s convenient for you, around your work schedule. Okay? It’s important for you to keep your appointments. It is crucial that you follow your prescription of care, because it will save you time and money. You will get the best and fastest results. We know life happens. If you're unable to make a scheduled appointment, please call as soon as you can. Additionally, I expect you to make up your appointment the same day, or at least within 24 hours. Will you do that?

• Net Result: Kept appointments

Healthy Lifestyle Workshop

• Another important appointment you need to be aware of is our Healthy Lifestyle Workshop. We have it each Tuesday and your attendance is required because there is mandatory one-time attendance for each new member of our practice. You will learn how to work with us to speed your healing, saving you time and money.

• Net Result: High perceived value of care, with improved patient education and better time management

Successful Scheduling! Yes #3

• That is why your attendance is required. Would this Tuesday or next Tuesday work for you? (Hold their gaze and sit silently until they answer.)

• You will need to bring a guest, who will you bring with you?

• Great, please write your name and daytime phone number here and your guest’s name and daytime phone number here. (Have them sign up for class before proceeding.)

• Net Result: HLW attendance with guest

FROF is set up for Success & Yes #4!

• If you’re like most of my patients, what you’re thinking about right now is “how much is this going to cost, and how can I fit it into my budget?” That is exactly what we are going to address next. Sallie has contacted your insurance company and will explain what she learned and make sure your financial responsibility fits into your family budget to ensure you can complete your prescription of care as we described. Do you have any questions before I get her? Let me get Sallie for you now.

• Net Result: All objections are managed BEFORE finances are reviewed


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The Financial Aspects of Proper Case Management · The Financial Aspects of Proper Case Management Dr Dianne M Baynes RN DC MCSP CPPM Change Is In The Air! •Healthcare is one of

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