Slide 1 Establishing Personal and Financial

Satisfaction by Enhancing Your Practice: Practice Management Pearls and Strategies

KPMA 2019 Annual Scientific Conference

Ahmad R. Farah, DPMPresident Elect Michigan Podiatric Medical Association

Residency Director Henry Ford Wyandotte Hospital

Slide 2

Professional Life Financial Reward

Success Personal Life

Physician Satisfaction

Slide 3 Professional Life

• Goals

• Patient Satisfaction

• Management of Staff

• Marketing

• Professional Associations

Slide 4 Marketing

Internal

• Your Patients• Reward

• Your Staff• Can make or break and office

• Referral letters / PCP

• Speaking

External

• YP

• Internet

• Facebook

• Twitter

• Blog

• Print

• Media

• Local schools / businesses

Slide 5 Financial Reward

• Treatment Protocols

• Billing and Coding

• Practice Management Financial

Slide 6 Protocols

• Enhance patient care

• Enhance office moral

• Enhance practice bottom line

• Enhance efficiency

• Enhance reproducibility

Slide 7 Protocols

• Step 1: Start with top 3 conditions you treat• Plantar fasciitis• Ankle Sprain• At risk foot care• Fracture• Neuroma

• Step 2: Consider the ideal treatment options• E&M• Diagnostics• Procedures• DME

• Step 3: Consider future care• E&M?

Slide 8 Billing and Coding

• Become an expert in your field

• It it’s going to be, it’s up to me

• Ignorance is expensive

Slide 9

Best Resource

Slide 10 Practice Management

• Software is key

• Determine your practice financial health• What determines if you are financially healthy in your practice?

• Employee MGT

• Accounting software

• Theft

• Compliance issues

• Audits

Slide 11 The Patient Experience

• Initial contact

• Office Impression

• Impression of staff

• Impression of physician

• Convenience of care

• Compliance

• Exit

• Future visits and referral of friends and family

Slide 12 Initial Contact

• Phone• Staff has to speak clear

• Smile before answering

• Enthusiasm to see patient

• Empathy for the condition

• Internet• Presence is out there

• Own your presence

Slide 13

Office Impression

Have you seen your office through the eye of your patient?

This Photo by Unknown Author is licensed under CC BY-NC-ND

Slide 14 What are they seeing?

• Sit in your own waiting room

• Sit in your own exam room

• Have your staff do the same

Slide 15 Thank Your Patients

Dear Patient,

It was a pleasure having you in the office today, thank you for choosing Farah Podiatry Associates for your Podiatric care. I trust your visit with us was to your satisfaction, if not, please let me know. Many times patients think of questions after they leave the office, I encourage you to write these questions down so we can discuss them at your next appointment. I appreciate your confidence in our management of your foot health.

Please visit our website for more practice information and descriptions of common foot ailments. Our website is www.farahpodiatryassociates.com. Like us on facebook for weekly foot condition updates and trends.

Just a reminder that no foot or ankle problem is too small or too big, please call us when you have a problem. We treat everything regarding the foot and ankle, from ingrown toenails to ankle fractures.

"Wishing You Happy Feet!"

Sincerely,

Ahmad R. Farah, DPM

Slide 16 Personal Life

• Home Life

• Leisure

• Preventing Burnout

Slide 17 Home Life

• Take care your significant others

• Intimacy

• Appreciation

• Undivided attention

Slide 18 Leisure

• Take time for yourself

• Find something that makes you happy

• Need a way to decompress

Slide 19 Preventing Burnout

Personal Health

Mental Health

Spiritual health

Entusiasm

Financial rewards

Slide 20 Success

Personal

Career

Family

Financial

Mental

Physical

Spiritual

Slide 21 Treatment Protocols

• Establish quality care

• Increases office efficiency

• Enhances bottom line

Slide 22 E&M Coding

Office or other outpatient visit for the evaluation and management of a new patient

• 99201

• 99202

• 99203

• 99204

• 99205

Slide 23 Which to choose?

99202 99203 99204

Overview An expanded problem focused history; an expanded problem

focused examination; straightforward medical

decision making

A detailed history; a detailed examination;

medical decision making of low complexity.

A comprehensive history; a comprehensive

examination; medical decision making of

moderate complexity.

Time Spent 20 min 30 min 45 min

Severity low to moderate moderate moderate to high

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

Slide 24

E&M Coding

Office or other outpatient visit for the evaluation and management of an established patient

• 99211

• 99212

• 99213

• 99214

• 99215

Slide 25

Which to choose?• Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.

99212 99213 99214

Overview 2 of these 3 key components: a problem focused history; a

problem focused examination; straightforward medical decision

making

A detailed history; a detailed

examination; medical decision

making of low complexity.

A comprehensive history; a

comprehensive examination; medical

decision making of moderate complexity.

Face to Face Time Spent

10 min 20 min 25 min

Presenting Problem

self limited or minor low to moderate severity

moderate to high severity.

Slide 26 LCD L34246

Nailcare

Routine Footcare

At risk foot condition

Class Findings

Debridement of mycotic nails

Onychomycosis

Slide 27 Pathway 1: Routine Footcare

At risk foot

condition

Class finding

Getting paid

Slide 28 Pathway 2: Debridement of Mycotic Nails

Onychomycosis Secondary Diagnosis

Getting paid

Slide 29

What is Routine Foot Care?

• Cutting or removal of corns and calluses;

• Clipping, trimming, or debridement of nails, including debridement of mycotic nails;

• Shaving, paring, cutting or removal of keratoma, tyloma, and heloma;

• Non-definitive simple, palliative treatments like shaving or paring of plantar warts which do not require thermal or chemical cautery and curettage;

• Other hygienic and preventive maintenance care in the realm of self care, such as cleaning and soaking the feet and the use of skin creams to maintain skin tone of both ambulatory and bedridden patients;

• Any services performed in the absence of localized illness, injury, or symptoms involving the foot.

Slide 30 At risk foot conditions

Medicare payment may be made for routine foot care when the patient has a systemic disease, such as metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk (for example, a systemic condition that has resulted in severe circulatory embarrassment or areas of desensitization in the patient’s legs or feet).

1. Diabetes mellitus

2. Arteriosclerosis Obliterans

3. Buerger’s Disease

4. Chronic Thrombophlebitis

5. Peripheral Neuropathies involving the feet

Slide 31 Class Findings

A B C

Non-traumatic amputation of foot or integral skeletal portion thereof

1. Absent posterior tibial pulse 2. Absent dorsalis pedis pulse3. Advanced trophic changes as

evidenced by any three of the following:

• hair growth (decrease or increase)

• nail changes (thickening)• pigmentary changes

(discoloring)• skin texture (thin, shiny)• skin color (rubor or

redness);and

1. Claudication 2. Temperature changes (e.g., cold

feet) 3. Edema 4. Paresthesias (abnormal

spontaneous sensations in the feet)

5. Burning

Slide 32 Routine Care Musts!

Modifiers

• Q7• A class “A” finding

• Q8• 2 class “B” findings

• Q9• 1 class “B” AND 2 class “C” findings

“Reimbursable only if the patient is under the active care of a doctor of medicine or osteopathy (MD or DO) or qualified non-physician practitioner for the treatment and/or evaluation of the complicating disease process during the six (6) month period prior to the rendition of the routine-type service or if the patient had come under a physician’s care shortly after the services were furnished. “

Slide 33 The Codes

Nails

• 11719: Trimming of nondystrophic nails,

• 11720: Debridement of nail(s) by any method(s); one to five

• 11721: Debridement of nail(s) by any method(s); six or more

• G0127: Trimming of dystrophic nails, any number

Calluses

Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus)

• 11055: 1 lesion

• 11056: 2-4 lesions

• 11057: 5+ lesions

Slide 34 To combine or not

1172011719

or G0127

More $

11720 and 11721 are debridement codes : reduce bulk11719 and G0127 are trimming codes, no bulk

11721 STAND ALONEcannot combine with other nail codes

Slide 35 More about 11720/1

Routine Care Route: Systemic disease process

that qualifies personOnychomycosis: nail disease itself

qualifies person for care: No mention of class findings or

systemic disease. Needs secondary diagnosis

Slide 36 Debridement of Nails / Non Routine Footcare

Ambulatory Patient

Onychomycosis

AND

• Marked limitation of ambulation

• Pain

• Secondary Infection resulting from nails

Non-Ambulatory Patient

Onychomycosis

AND

• Pain

• Secondary infection

• Compromises ADL

Slide 37 What about an E&M?

“The global surgery rules will apply to routine foot care procedure codes 11055, 11056, 11057, 11719, 11720, 11721, and G0127. As a result, an E&M service billed on the same day as a routine foot care service is not eligible for reimbursement unless the E&M service is a significant separately identifiable service, indicated by the use of modifier 25, and documented by medical records.”

Slide 38 Modifier 25

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59

Slide 39 Modifier 59

Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

Slide 40 Example

• Diabetic patient with neuropathy, hammertoes, xerosis, and onychmycosis• Initial visit: Label as diabetic foot exam

• Comprehensive visit• Letter back to PCP• Bill E&M• Bill for routine footcare if appropriate

• Subsequent visit• Annual diabetic foot exam - detailed

• E&M• Quarterly as risk foot care

• E&M only if you are actually treating something other than the routine care• i.e. Dermatitis, hammertoe, xerosis, ulcer

• If billing E&M, don’t be scared unless you didn’t do anything above and beyond what is considered for routine care

Slide 41 Other codes to consider

CPT: 99024: Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure

CPT: 99406 Smoking Cessation

• Medicare coverage is for 2 cessation attempts per 12-month period. Each attempt includes a maximum of up to 4 intermediate (99406) or intensive (99407) counseling sessions, Medicare total benefit is 8 sessions yearly.)

• 99406 – Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

• A modifier 25 may be appropriate to append to the primary E/M visit code if the EM visit is unrelated to the tobacco usage.