Save the date: April 17.
It's not official yet - we're confirming a location - but we hope and expect to produce a pediatric coding and practice management seminar in the greater Washington DC area on or around April 17. It will be nearly identical to the one we produced in NYC in August. We hope to get AAP endorsement again and, if everything works out, we may even be able to acquire an educational grant from a generous source that might lower or eliminate the cost for AAP members!
That last item is a bit of a dream still, but it's not off the table.
Anyway, I thought I'd let everyone here be the first to know. As soon as it's official - speakers, location, date, and content - I'll post it all here.
I am feeling a little like the Winooski River, when it freezes over and then dams up, causing the water to overflow the banks and wreak havoc locally.
Last week, Igor and I were looking at the usage of -25 Modified E&M codes as the information about them is a bit of an unspoken subject in our business. I can't find any good, definitive sources so, as usual, we have to create our own.
Two days ago, I posited that the distribution of -25 modified E&M codes should be different from non-modified codes for a simple reason: acute medical issues typically generate their own sick visits and the most common type of modified E&M would be an "Oh, by the way..." Those OBTWs don't often rise to the level of a 99214 or 99215, at least as often as a walk-in would.
That was the thought, anyway. Here are the results, complete with my original estimate of what it would be:
What do we learn? That -25 modified E&M codes actually mimic "normal" E&M codes quite closely. Fewer 99213s, certainly...but more 99214s and 99215s! The opposite of what I predicted. Figures.
So, why were we wrong (I'm trying to spread the blame)? First, we learned that our clients have as many modified E&M codes as non-modified! In other words, even with 22% of our clients not using the codes at all, boatloads of -25 modified codes go out the door of our practices. Why? A faithful reader - who will go unnamed until she asks for credit - offered the following insight:
They are not only when there is an associated well visit
When we do spirometry at these visits, we don't get paid unless we put a -25 on the E/M.
When there is a recheck of illness, Imms won't pay unless there is a -25.
Infant Bili-Weight Check Visits
When We do a transcutaneous bili, we need the -25 on E/M.
Sick visits with opth complaints, migraines, injuries
Visual testing won't pay without the modifier.
Sick visits with hearing, tinnitus
Hearing testing requires us to add the -25 on the E/M.
If the modifier -25 is not used , we would get "bundled" payments from quite a few inscos.
Well, that explains that. Perhaps Igor and I will explore looking only at E&Ms at well visits after all! Harumph.
Physician's Practice magazine has released, both in print and on-line, the results from their annual Fee Schedule survey. On one hand, I continue to applaud PP's effort. On the other hand, their data continues to diverge from ours considerably. In effect, the fortunes of PCC customers continue to rise while those of PP contributors continue to fall. Is it sample size? Are our clients simply doing that much better than the rest of the world? Does PP measure things different (and somewhat oddly)? I suspect it's a combination of all of the above.
Let's see how the numbers compare. There's so much here that I'll have to split it into a few blog entries, I suspect. Let's start with the big piece, the drop in E&M reimbursement. From the article:
Sorry, but the news is no better today. In fact, it’s disturbingly similar: Another sizeable drop in E&M visit reimbursement.
Here is a quick snapshot of their E&M details:
If you want a closer view, you can find their PDF here.
I took the time and made a similar chart for our clients over the last four years. Check it out. It took me a long time to figure out how to lay this out, so applause is welcome :-)
You'll note that we have a distinctly different pattern of behavior over the last four years. While Physician's Practice magazine reports a distinct negative trend in E&M reimbursement, PCC clients are improving.
In the next day or so, I'm going to zoom in specifically on pediatrics and their results. Anyone here seeing different results?
Gosh, a guy makes a couple statements in a blog and now people actually want him to explain the numbers so that they make sense. There's no satisfying the mercurial reader any more. My word isn't good enough?
Actually, my apologies for some confusing data. Let me explain yesterday's post in more detail and, perhaps, add some information. Igor and Susanne Madden pointed out that I accidentally cut off the Y-axis label/Title (d'oh!), which makes it confusing.
I decided to measure the average E&M reimbursement for PCC clients in a different manner than Physician's Practice for a variety of reasons.
...is the average E&M reimbursement here about $100.39 or is it $300? I say it's $100.39, and I think PP lists it as $300.
Therefore, the numbers from yesterday look at overall "average E&M reimbursement" and use 2004 as a base year for measurement. In our data, the Middle Atlantic group has seen their E&M reimbursement improve 16% since 2004 (vs. an estimated 28% decrease in the PP data). I also took some care to make sure that the scale of our graph resembled theirs so that, even though we measure things differently, they approximate a similar message with different results. The bottom line? PP continues to measure a downward trend in E&M reimbursement and we measure an upward one. Which is correct?
I've updated the graph so that the explanatory title is back.
More in a bit.
I was 3/4 of the way through a follow up piece on the Physician's Practice Reimbursement Survey when I realized that some of the data is so goofy that I ought not really say much about it. That is, I can't really reach a conclusion about Pediatric Surgeons averaging $5 for 99212s through 99215s. Is that actually possible? I don't think so.
Instead, you get this comedy from our great weekly, Seven Days. Scroll down to the third article or just read below. John and did not coordinate our outfits the other day, I promise.
From the article:
Viruses are generally to be avoided in the computing world, but they helped launch Physician's Computer Company (PCC). The Winooski firm got its start in 1982, when a local pediatric practice wanted to computerize its student immunization forms. Their medical software provider wouldn't design a program for them; a nurse suggested that her son might be able to do it.
The docs hired 19-year-old John Canning and his friends, Jay Schuster and Ari Shinozaki, to create software that would track immunizations and computerize billing and scheduling. The college students finished the system during the summer of '83. They went back to school and did customer support over the phone from their out-of-state dorm rooms: Canning at Rochester Polytechnic Institute; Schuster at Cornell; and Shinozaki at Princeton.
When other pediatricians began requesting their services, they realized they'd found a market.
Twenty-five years later, PCC is a nationally respected provider of pediatric practice management software. Nearly 200 practices with offices in 40 states use its "Partner" system. PCC now counts 42 full-time employees, including Canning and Schuster, and generates just under $5 million a year in revenue - not bad for a business that started out as a summer project for college students.
Chip Hart, PCC's Pediatric Solutions Manager, explains that the company doesn't have much competition in the pediatric software market. "It's not a pond you would fish in," he says. Pediatricians are poorly paid compared to other medical specialists, he continues. Most medical software companies - such as IDX - target hospitals and doctors who make more money.
Over the years, PCC has evolved to serve the needs of its niche market. In addition to developing software, PCC also sponsors conferences to train pediatricians to manage their practices more efficiently. Most pediatricians, after all, go into medicine to help kids, not to run a business. As medical billing becomes increasingly complex, these docs need skills that aren't taught in medical school, and PCC helps provide them.
The company also does customer support. Hart estimates that PCC fields 1500 support calls a month. The issues range from "the printer paper is jammed," to "our computer system is crashing."
These are serious issues in any workplace, but even more so in offices where doctors are caring for sick kids. "We guarantee support 24/7, 365 days a year," Hart proudly notes. "We're the only people in this business who do that."
Indeed, PCC has won several awards from KLAS, a national firm that evaluates medical software vendors - including one last year for receiving the highest customer rankings of any medical software vendor over the past decade.
These designations are based on customer reviews. The pediatricians who participate in KLAS surveys regularly give PCC very high marks.
New Jersey pediatrician Jill Stoller completed a KLAS research survey in 2006, and offered a comment for a PCC press release announcing its High Scorer award: "I don't think there is any other company out there that comes close to providing the type of software and support PCC does."
If PCC's customers seem happy, so do its employees. Turnover is low. Hart, who attended Burlington High School, has been with the company since he graduated from Middlebury College 18 years ago. "There are four people like me," he says.
Their multiple offices in Winooski's mostly empty Champlain Mill have a funky, creative feel. The main space retains the mill's exposed brick and wooden beams - along with an Aztec temple mural and a Corona parrot, leftovers from the Mexican restaurant that vacated before PCC moved in 10 years ago.
Employees share DVDs through a company rental library, often eat meals together in the office kitchen, and decorate their cubicles with plants, original art, Hello Kitty figures and dog beds for visiting pooches. There's no dress code.
PCC's laid-back corporate culture belies its ambitious plans for the future. The company is about to release new features for its software that will serve both administrative and clinical functions - a big deal for pediatricians seeking to computerize patient chart notes. Hart predicts that the new Electronic Health Record could double the size of the company in the next 18 months.
Canning recalls that, when he first started the company, his parents would ask him, "When are you going to get a real job?" He doesn't get that question much anymore.
It's official. PCC's Spring 2008 Pediatric Coding Conference will be held on April 17 at the Capital Hilton in Washington DC.
And - yes - the seating will be a huge improvement over NYC. Tables, guaranteed viewing, etc., etc., etc.
Thanks again to our amazing speakers, Dr. Lander for helping make this all happen, and the AAP for endorsing the event. Remember: AAP members get a big discount!
Spring 2008 Pediatric Coding Conference
Developed by PCC and Endorsed by the American Academy of Pediatrics
Thursday, April 17, 2008 — Washington, DC
Put your practice ahead of the curve with PCC's 2008 Pediatric Coding Conference, endorsed by the AAP. Pediatric coding experts address key issues during a full day of courses with question and answer sessions designed to improve your coding practices and reimbursement.
The 2008 Pediatric Coding Conference will be held at the Capital Hilton in Washington, DC.
This is an intensive, one-day session focused on important pediatric issues that effect your practice every day. You'll master the coding basics, get answers to your specific questions during Q&A sessions with our pediatric panel, and gain valuable insight on timely topics about immunizations, pay-for-performance programs, physician compensation, and more. Our expert panel of instructors include AAP Fellows Richard Lander, MD; and Richard Tuck, MD.
Register now. Admission to this conference is only $325 for AAP members ($379 for non-members)!
Thursday, April 17, 2008
7:30-Registration and Continental Breakfast
8:00-Welcome and PCC's Free Online Practice Management Tools
9:00-Give Me the Money: How to Decrease your A/R
10:30-Procedure Power Coding
11:15-Pediatric Physicians' Compensation Models
1:30-Vaccine Coding: Preventive Medicine for a Healthy Bottom Line
2:15-Who Wants to Be a Coding Millionaire?
3:15-Break3:45-Thirty Tips in Thirty Minutes
PCC's Free Online Practice Management Tools
Your host, PCC, will provide information about free online pediatric practice management resources. These free resources can help you update your pricing, review your coding curve, select an EHR and more.
Super coding expert Richard Tuck, M.D., covers the essentials of pediatric coding with updates for 2008. Whether you are new to coding or feel like you already know it all, there is something here for everyone.
Give Me the Money--How to Decrease Your A/R
The AAP's SOAPM Chairperson, Richard Lander, M.D., will cover the policies and procedures you need to have in place to collect the money that is due to you. Topics will include everything from preparing for HSAs to how your staff can ask for money at the Time of Service and still keep your patients happy.
Procedure Power Coding
Most pediatric offices leave thousands - tens of thousands! - of dollars on the table every year for work that they have done but failed to code properly. National CPT expert, Richard Tuck, MD, will walk you through providing and coding for procedures to increase your bottom line.
Pediatric Physicians' Compensation Models
Developing a fair compensation model is an ongoing struggle for many pediatric practices. PCC's Chip Hart will walk you through the challenges of many real offices to determine what might work for you. The varied skills, personalities, productivity levels, experience, lifestyle demands, and non-financial contributions of those involved are just some of the factors that contribute to the challenge of physician compensation. Hart will provide an overview of existing models and data from pediatric office across the country and identify patterns of success.
Vaccine Coding: Preventive Medicine for a Healthy Bottom Line
Each passing year makes the process of billing for vaccines more difficult. With the introduction of new vaccines, changes in the coding rules, and many insurance companies adding their own interpretations, Dr. Lander will help you navigate the muddy waters to get properly reimbursed. Stop losing money on one of the most expensive, risky - and necessary! - aspects of running your practice.
Who Wants to Be a Coding Millionaire?
Dr. Tuck provides an entertaining and challenging review of coding highlights to maximize your practice income. Whether you work for a practice that is afraid to use 99214s or have already mastered the subtle details of the -25 modifier, this game show format course is a must attend.
Thirty Tips in Thirty Minutes
Join Dr. Tuck and Dr. Lander in a fast-paced barrage of all the little, but important, tips and tricks that didn't make it into the other topics!
About the Instructors
Richard Lander, MD, FAAP
Dr. Richard Lander is a managing partner in a pediatric private practice in New Jersey and is president and co-founder of Resources in Physician Management Services. He is currently a Clinical Assistant Professor of Pediatrics at UMDNJ. Along with his dedication to the care and well being of children and adolescents, Richard has made it a priority to help to ensure that pediatricians are properly remunerated for their hard work on children's behalf. As the president of the NJ-AAP Chapter, he initiated and remains as co-chair of the Pediatric Council. Richard serves on the national Committee on Child Health Financing and chairs the AAP Section On Administration and Practice Management (SOAPM). He has been a consultant to the AAP Task Forces on Reimbursement, the Task Force on Obesity, and the Task Force on Mental Health. Since 1989, he has been an AAP Regional CPT Trainer and has lectured on coding and practice management for the AAP, private enterprises, and pediatric residency programs. He serves on and contributes to several coding newsletter editorial boards.
Richard Tuck, MD, FAAP
Dr. Richard Tuck is a general pediatrician in a private group practice in Zanesville, Ohio. He is also medical director of Quality Care Partners, a southeastern Ohio PHO. Dr. Tuck is a nationally known expert with extensive knowledge of CPT and ICD coding, as well as payer and reimbursement issues, gained through his personal practice and state/national committee involvement. He serves as the American Academy of Pediatrics’ representative to the AMA RBRVS Review Update Committee (RUC). Dr. Tuck received the Buzzy VanChiere award for his efforts to educate pediatricians on appropriate coding. This education assists physicians in obtaining adequate payment for the work they do and maintains access to care for their patients.
Chip Hart is the Director of PCC's Pediatric Solutions consulting group. Chip's pediatric practice management expertise has helped hundreds of pediatricians increase their financial health. He has conducted many successful negotiations with insurance companies, and worked as a consultant for the American Academy of Pediatrics (AAP) and the AAP Section on Administration and Practice Manangement (SOAPM). As a dynamic and motivating speaker, Chip leads educational seminars and consults for pediatric professionals nationwide. He established the popular "PedTalk" mailing list and moderates this lively forum for pediatric healthcare professionals. Using his varied experiences with pediatric practices for inspiration, he writes regularly about the "Confessions of Pediatric Practice Consultant" (which you can read online at www.chipsblog.pcc.com). Chip has also authored articles on practice management and health care information technology for Pediatric Coding Alert, Beansprout, and Medical Group Management Association.
Location and Accommodations
The conference is held at the Capital Hilton , 1001 16th Street, NW, Washington, DC.
Register now. Admission to this conference is only $325 for AAP members ($379 for non-members)!
I have been critical of the CCHIT certification process before. My position hasn't changed: CCHIT certification is misused and misunderstood by too many people in this business and it is driving up development costs, especially for private practice pediatricians. I don't think this is directly the fault of the organization itself, per se, but it is the practical result. I might have some input on this matter in the future, but for now, I will take a few minutes to examine some of the problems I see with the new child health criteria.
First, needs outside of pediatrics being pushed into our realm. In 2008, EHR vendors will need the following functionality:
The system shall capture patient growth parameters:
including weight, height or length, head circumference;
and vital signs including: blood pressure, temperature,
heart rate, respiratory rate, and severity of pain as
discrete elements of structured data.
That sounds great...until the last item. Severity of pain? Is that really necessary as a requirement for a pediatric office? You can't even begin to measure this subjective vital, as a practical matter, until the children reach a particular age (6? 8?) without using things like the FLACC scale (which, and forgive me if I'm wrong, I've never actually seen in regular use in a private pediatric practice). According to CCHIT itself, this is because of JCAHO requirements.
You'll note that other folks in my shoes have similar questions (look at line 7).
Is it a big deal? No, it's not the end of the world. But now, any EHR vendor who wants to focus on pediatrics is going to be forced to add the "Pain" vital when I don't know a single pediatric office that has asked for it. It will take up important space on the screen, it's another data element to track, and resources are spent on something whose impact on improved or more efficient is minimal, at best.
How about this item:
The system shall synchronize immunization histories with a
public health immunization registry according to applicable
laws and regulations.
Now, note that it says "a" public health immunization registry. So, all PCC would have to do is interface with, say, Vermont's registry, and we'd be certified? Forget that VT serves a handful of pediatricians when compared to NY or TX or CA? Don't get me wrong - CCHIT has its hands tied on this one. The state of immunization registries in this country is an absolute disaster (believe me, PCC interfaces with more of them than anyone). To make this a requirement when there is no standard among them is a mistake. As much as we want to have our registries integrated with EHRs, I think CCHIT should have chosen a standard and pointed to it instead of leaving it helplessly defined.
Finally - for now - I see some big gaps in the understanding of improved pediatric care. Where are the demands for tracking preventive care? Chronic care? Instead of ensuring that the system can indicate that the gender of each patient is unknown (<sarcasm>now THAT feature is long overdue</sarcsasm>), why not have an EHR tell you when a child is overdue for a physical? Or for a recheck? Why not interface with the Bright Futures schedule?
Why will CCHIT require, in 2009, that "The system shall capture the breast milk aliquot identifying data, amount, route, expiration date and date/time of administration" and not have any proper understanding of family mechanics (it only requires custodial information; it has no linking of siblings or families)? Talk about features missing from just about any non-pediatric system now, and we're forcing vendors to track breast milk data?