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Your Top Questions Answered
Shortened Patient Visits; Post-op Modifiers; Preventing Theft
SHORTENING PATIENT VISITS
Q: We are a geriatric, internal medicine clinic practice, and we are considering moving from a 20-minute appointment schedule to a 15-minute appointment schedule. What insights can you offer?
A: I certainly think 15 minutes is doable. Many in internal medicine (though not necessarily geriatrics) set a 10-minute schedule, though heaven knows it's tight. You obviously don't want to hurt patient safety.
You may want to create three appointment types - allowing longer time slots for new patients and those coming in for preventive exams and establishing shorter time slots for those coming in for quick follow-up visits.
Keep in mind that it will not do to change patient schedules in your books just to have your physicians continue to practice at the same 20-minute pace they were before. You'll just produce long waits and lots of staff frustration rather than heightened productivity.
If you want to shorten your appointment times, you'll also have to change some of your workflow practices to make the short times doable. For example, physicians can be more efficient if support staff is really supporting them - that is, if exam rooms are always fully stocked, if nurses do a thorough intake and handle all follow up, and if someone is previewing patient charts to ensure everything that is needed is there. Your physicians will need to "stay in the paint," or the exam rooms, at all times - no more escorting patients or leaving exam rooms to look for a missing piece of equipment.
If you have an in-office lab, make sure you don't create a backlog of orders for your phlebotomist as a result of the increased patient flow. Measure the actual cycle time for your patients - from time in to time out - not just the time spent waiting for physicians.
For example, I routinely visit my primary-care practice, and I see the physician fairly quickly. But then it's back to the crowded waiting room for 30 minutes to wait for a blood draw.
You also might want to get permission to sit in on some exams with your physicians and time them - can patient exams really be completed faster? How? Base any changes on reality; not just your desire to see more patients.
It may be that in a longer session physicians can actually generate more RVUs and more revenue than they would by seeing additional patients each day. You'll want to keep a very close eye on outcomes, by RVU and revenue, to see if any scheduling changes are having the effect you want. You can always change back next month.
It is important to share all the numbers you track with your physicians so they can immediately see the results of working faster and more efficiently.
You might also consider whether it would be more effective to extend your office's work day rather than cramming more visits into the same amount of time.
Finally, I'm a huge fan of the "fourth virtual appointment." What this means is that your schedule is set up so that a physician performs three 15-minute patient sessions. During the fourth "session" of the hour, rather than seeing another patient, the physician completes documentation on the first three patients and returns any phone calls. That means that even if a physician is technically working longer (say, seeing patients up to 5 pm), she still gets to leave the practice shortly after her last patient leaves - there is no documentation backlog or waiting messages for her to return at the end of the day.
MEDICAL RECORDS TRAINING
Q: I need to train a new medical records clerk. Are there any courses or companies you can recommend?
A: Medical records technician courses are available through adult education services, Regional Occupation Programs (ROP), and private colleges and schools. Try the DeVry/Phoenix Universities and other similar institutions in your area. There also are online educational opportunities, such as those available at http://allied.brightoncollege.edu.
POST-OP MODIFIERS
Q: What modifier can I use for an E&M visit by a nonsurgical physician during the postoperative period? I have two different cases. One patient is from out-of-state, and the surgery was in the other state. I also have a patient who had surgery and during the post-op period had a bad cold/flu. I know these cases are rare, but they do happen.
A: As you are a different physician, the global should not apply and you should not need a modifier. The related modifiers are all for the same physician providing a service. For example, -79 is for an unrelated procedure or service by the same physician during the postoperative period, while -24 is for an unrelated E&M service by the same physician during a postoperative period.
There is modifier -55, which is for postoperative care only; when one physician does the surgery and another does just the post-op, that physician would append -55 to their services.
CMS PILOT PROGRAM
Q: Can I get more information about the G codes CMS wants for its pay performance pilot?
A: You can get all the information you need about Medicare's pilot program to reimburse for better quality at www.cms.hhs.gov/PVRP/.
STOPPING THEFT
Q: What procedures should I have in place in to minimize likelihood of staff theft or embezzlement?
A: Outpatient medicine is largely a cash business, and it has the highest embezzlement rate of any service industry. Some tips to guard against theft include prioritizing money; if it's everywhere and treated with indifference, it's easy to take.
Another standard way to prevent embezzlement is to separate duties. The goal is to make it hard for any one person to have enough power to both steal and cover up the theft. It's a good rule to follow when it comes to cash transactions. For example, have one person collect cash payments, and have another record the charges and payments received. That way, one staff member acts as a moral guard for the other.
You may also want to use control logs. At the end of each day - or at the end of your morning and afternoon clinics - have everyone batch out; that is, account for every cent added or taken. This isn't about catching staff; it's about creating an environment in which crime doesn't occur.
Most practice management systems can run a "missing charge ticket" report; make sure all patient visits have been accounted for by the end of each day. However, make sure you also void no-shows and cancellations in your system; if you don't, these will show up as missing charge tickets. You want this report to be blank each time you run it by having all tickets accounted for.
Lock up your cash. It's surprising how many practices leave cash or checks lying around. Often, checks are attached to an encounter form and aren't deposited in the bank for days or weeks after being received.
Also exchange real cash for "pretend" cash at posting, so real money is deposited promptly. Put your money in the bank quickly. Don't leave $6,000 worth of checks sitting in a drawer until someone gets around to processing them.
Put the practice's bank account in the physician's name. Easy as it is to trust your manager or someone else to handle all the banking for you, that leaves you with no way to track what is put in - and, more important, removed from, your account. Restrict signature authority on the checkbook.
Finally, conduct an annual audit and bond your billing employees.
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