1. Stop Losing Money!
How to Improve Billing and Coding in a Family Medicine Residency Practice
Cherrie Rahn Kramer
Robert Pallay, MD
Donna Prill, MD
Bonzo Reddick, MD

2. Memorial Family Medicine Residency Program Savannah, GA

3. Memorial Family Medicine Center 1107 E
Memorial Family Medicine Center 1107 E. 66th Street Savannah, GA TEL: FAX:
Department of Family Medicine Mercer University School of Medicine, Savannah
Family Medicine Residency Program Memorial Health University Medical Center

4. Disclosures
All faculty in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

5. Welcome to Savannah!

6. ACGME Basics
Determines the minimum requirements for accreditation of residency programs
6 core competencies
Patient care
Medical knowledge
Practice-based learning & improvement
Interpersonal & communication skills
Professionalism
Systems-based practice

7. Objectives
Upon completion of this session, participants should be able to: 1. Describe national trends in billing for Evaluation and Management(E&M) office visits in Family Medicine clinics. 2. Describe the revenue that is potentially lost due to undercoding of E&M visits in a Family Medicine practice. 3. Describe how to implement a Family Medicine Residency precepting policy to ensure appropriate billing and coding of E&M office visits.
Upon completion of this session, participants should be able to:

8. The Challenge is…
care provided to patients with complex medical and psychological issues,
while training residents in quality care,
under the constraints of GME regulations,
for reimbursement not under the doctor’s control.

9. The Rules
The Centers for Medicare and Medicaid Services (CMS) require teaching physicians to be physically present during key portions of resident-performed Evaluation and Management (E&M) outpatient visits. Clinical practices within an approved graduate medical education (GME) program may utilize a primary care exception for lower- and mid-level services, which allows the resident physician to see a patient without the presence of a supervising physician.
When it became clear to us that our hospital organization was using productivity measures to determine what resources we were entitled to, we realized that we needed to step up our numbers in some way to justify the costs of improving patient flow.
Does this sound familiar to any of you?

10. The Math- 2014 National numbers
CPT Code Descriptor Payment
New patient office visit, Level $107.65
New patient office visit, Level $165.39
New patient office visit, Level $206.03
Established patient office visit, Level $72.71
Established patient office visit, Level $107.29
Established patient office visit, Level $143.65
Note: Payment for 2014 based on CMS calculated Conversion Factor of $
The Medicare allowable reimbursement for in 2014 was approximately $107 and it was worth 1.5 work RVUs.
Preceptors were supervising 3-4 residents per session, which sometimes led to delays, as residents were waiting to precept, contributing to not only patient flow issues, but also to lost billing when patients were discharged before the attending could see them, resulting in level 3 charges.
What if we could keep this from happening?

11. Reality What do you see happening in your programs?
Preceptors were supervising 3-4 residents per session.
Delays would often occur, due to multifactorial reasons: transportation, late arrivals, more complex issues, inefficient precepting, etc.
What do you see happening in your
programs?
Residents in our program admitted that they occasionally billed patients for lower levels of service so that they did not have to wait for a teaching physician to evaluate the patient.
When we were allowed access to data from other residencies, our percentage of level 4 visits stood out as too low:

12. Factors
When residents were waiting to precept, would they discharge the patient before the attending could see them, resulting in level 3 charges by default?
Some residents in our program admitted that they occasionally billed patients for lower levels of service so that they did not have to wait for a teaching physician to evaluate the patient.
Some residents thought it was a level 3 visit, when in fact it was a level 4.

13. The Review
When we were allowed access to data from other residencies, our percentage of level 4 visits stood out as too low: In July-August 2014, an average of 24% of our E&M’s were billed Other programs were over 50%, some as high as 70%
Residents in our program admitted that they occasionally billed patients for lower levels of service so that they did not have to wait for a teaching physician to evaluate the patient.
When we were allowed access to data from other residencies, our percentage of level 4 visits stood out as too low:

15. Faculty Compensation – Sept 2007
Clinical compensation – 60% with potential 11% bonus
Academic compensation – 40% with potential bonuses for academic achievement.
Reality – faculty average less than $1000/year in bonuses so they play no role in any decisions

16. Faculty Compensation - continued
Faculty - straight salary model contracts –
Emphasis on teaching, improving the program, graduating residents, and getting us off probation.
Within 18 months total turnover in faculty.
INCENTIVE piece to the contract added on 2009
Some bonus based on wRVUs. BUT, for the group as a whole rather than individuals.

17. Faculty Compensation - 2010
By year three we were off probation and well on our way to developing an excellent program!
Subsequent faculty contracts -- base salary and an incentive plan with small – around 0-3% - incentive bonus was based on a group model of wRVUs where we received bonus as 0-3% based on growth over the previous year’s total wRVUs on a percentage basis.
Thus, minimal bonus but still protected from productivity model.

18. Faculty Compensation - 2013
Leadership insists on more “real” clinical productivity.
MGMA Academic practice models used to decide on number of yearly wRVUs although it was still for us as a group.
The outcome of this change was that no one got any incentive bonus for this metric! Nor for an additional bonus set up to make sure charges were submitted in a timely manner.

19. Faculty Compensation - 2014
No significant incentives for two years
No raises at all for faculty for over three years

20. Feedback
What has happened in your programs over the last 5-10 years?

21. Our plan Practice management lectures given
Require teaching physicians to see all patients, regardless of anticipated level of service.
Track our results and tweak issues as they arise.
Teaching physicians were motivated by the concept of improving quality of resident teaching, as well as getting paid for the complex quality care we provide to improve productivity without adding patients or sessions. We could increase our productivity if we:
educated both attendings and residents on the requirements for billing vs 99213;
made an effort for preceptors to see all patients, by adding ourselves back into the schedule as back-up preceptors;
and improved our appropriate billing of complex care, by being available to answer coding questions in real time.

22. Teaching physicians were motivated by the concept of improving quality of resident teaching, as well as getting paid for the complex quality care we provide to improve productivity without adding patients or sessions.
We could increase our productivity if we:
educated both faculty and residents on the requirements for billing vs 99213;
made an effort for faculty to see all patients, by adding ourselves back into the schedule as back-up preceptors;
and improved our appropriate billing of complex care.

23. Our statistics before and after:

24. Excel spreadsheet

25. Our Results- by percentages
You can see the change in November 2014, the month following our education initiative and establishment of our new precepting policy.
The percentage of E&M patients billed at higher levels of service increased from 25% to 44%.
When you compare October 2014 to October 2015 by percentages, we sustained the increase from 28% to 41%.
What could you do for your program with $50,000 a year ?

26. Our Results- by numbers
With one year of data we show:
an increase in total revenue since implementation of $200,000!
If a practice had more commercial payors, the yearly increased revenue could jump by $300,000!!

27. Added educational bonus
Increased teaching opportunities for seemingly simple medical problems (especially dermatologic conditions)
Tinea versicolor
Tinea capitis
Paronychia

28. New Academic Compensation Plan - 2015
Sullivan Carter consultants were hired to help develop a new academic compensation model
This new Academic Compensation plan is different for Primary Care, Specialty Care, and Consultant physicians within the group.

29. New Academic Compensation Plan - 2015
Single base salary for all work – also will be brought into line with market – based salary at the private practice level.
All faculty depending on their year out of residency training will be eligible for either $10,000 or $20,000 per year in incentive bonus based on multipole variables.
However, in order to even qualify for incentive bonus, as a group, we will need to be over 60 %ile for wRVUs FOR ACADEMIC FAMILY PHYSICIANS (probably around 70-80% of practicing FP’s).
AND, each individual faculty must be above 40th %ile.

30. New Academic Compensation Plan
Summary of new model
More fair
Base salary more in line with market dictated salary for FM
No longer academic and clinical pieces
Ability to get yearly raises
Real opportunity to get incentive bonus
BUT:
Must meet minimal standards for participation
Probably won’t keep jobs if too low on productivity
Real clinical productivity standards to meet as an individual and also as a faculty group!

31. Questions or Comments about the Compensation issue or Models – old or new What has been your experience and issues?

32. Discussion
The implementation of this policy resulted in a significant increase in the percentage of E&M visits billed at higher levels of service and a subsequent increase in revenue for the Family Medicine center of $200,000.
During this time frame, we also saw an overall increase in the total number of patients seen.
It appears to be a natural progression from being more productive, which allowed the residents to achieve their goal number of visits, and also increased faculty productivity.

33. Where do we go from here?
We believe this system can be implemented in family medicine residency programs as a way to improve billing and coding education and accuracy, while also increasing learning opportunities for resident physicians. It is clear that without significant refocusing on our goals, we lose some ground. We are continuing practice management lectures and we review our numbers each month. Our next step is to post results on a board to utilize our propensity to compete, and to spend 5 minutes of each monthly resident director’s meeting and executive faculty meeting to remind us of our mission.
It is clear that without significant refocusing on our goals, we lose some ground.
We are continuing practice management lectures and we review our numbers each month.
Our next step is to post results on a board to utilize our propensity to compete, and to spend 5 minutes of each monthly resident director’s meeting and executive faculty meeting to remind us of our mission.

34. References
Department of Health and Human Services: Centers for Medicare & Medicaid Services. Guidelines for teaching physicians, interns, and residents. (last accessed 03/02/15).
Evans DV, Cawse-Lucas J, Ruiz DR, Allcut EA, Andrilla CHA, Norris T. Family medicine resident billing and lost revenue: A regional cross-sectional study. Fam Med 2015; 47(3):

35. Evaluation
Please evaluate this presentation using the conference mobile app! Simply click on the "clipboard" icon on the presentation page.

36. Questions or comments?
Questions or comments?

37. Memorial Family Medicine Center 1107 E
Memorial Family Medicine Center 1107 E. 66th Street Savannah, GA TEL: FAX:
Department of Family Medicine Mercer University School of Medicine, Savannah
Family Medicine Residency Program Memorial Health University Medical Center