Thursday, August 16, 2018

Trends in Compensation Structures for NPs (Nurse Practitioners) and PAs (Physician Assistants)

Now Available on CD - Trends in Compensation Structures for NPs (Nurse Practitioners) and PAs (Physician Assistants)

Setting up compensation structures for NPs and PAs causes a lot of confusion and there are a number of models that healthcare practices employ. If you are setting up compensation plans for the NPs or PAs in your practice, listen to this webinar and let Erin Tolbert help you to do it the right way!

Now is the time to review your practice management business operations and to confirm that the compensation structure you have in place is the most fair, the most efficient, and aids in staff recruitment and retention.
If you have PAs or NPs in your practice, this is the webinar for you.

or (800) 933-3711 or

Thursday, August 9, 2018

Hierarchical Condition Categories (HCCs) by Nicoletti

Excerpt from The Field Guide to Physician Coding, 
4th Edition
By Betsy Nicoletti, MS, CPC

If you find this sample chapter educational, review the book Table of Contents at the link below, order the print or eBook, or order multiple copies for your staff members at discounted rates.  

Every entry for the coding "rule" has a citation "proving" the rule. 

Sample Chapter:
Hierarchical Condition Categories

Definition: HCCs is a risk adjustment model developed by Medicare to pay Medicare Advantage plans. It estimates the expected health care costs for individuals for the next 18 months.

Explanation: In fee-for-service medicine, diagnosis coding establishes medical necessity, and may be the reason for a denial, particularly for diagnostic tests or procedures. Services with national or local coverage policies often have specific diagnosis codes that are required for payment. In risk-based contracts or shared savings programs, payers assess the acuity of a panel of patients, and use that acuity along with age/gender distribution, cost, quality and outcomes, to provide incentive payments or decrease payments at the end of a contract year.

Codes: Selected International Classification of Diseases, 10th Edition (ICD-10) codes.

Coverage: This is the system the Centers for Medicare and Medicaid Services (CMS) uses to adjust payments to Medicare Advantage plans. Some medical groups are part of shared savings programs with Medicare or have risk adjusted contracts with commercial payers. Some private payers use proprietary systems to estimate risk and future payments, and some use HCCs. Using this system in medical practice payment is part of moving from volume-to-value.

Billing and Coding Rules: The risk for an individual is determined by two things: demographics and diagnoses. A 65-year-old living at home has a lower demographic risk score than an 80-year-old living in a long-term care facility, who is dually eligible for Medicare and Medicaid. Demographic factors included in HCC calculations are age/gender, living at home or in an institution, End-Stage Renal Disease (ESRD) patient, and dual eligibility for Medicare and Medicaid. Diagnosis codes assigned on a claim form during a calendar (or contract) year reported on an inpatient claim, outpatient hospital claims, or physician and certain other health professionals’ claims are counted in determining the total risk score. Not all ICD-10 codes have a risk adjustment assigned to them. Those that do are assigned to groups, and groups have a specific weight.

For Medicare patients to Medicare Advantage plans:

Patient demographics + HCC diagnosis codes = Risk adjustment factor × CMS capitation rate
Diagnosis codes ➡ Diagnosis Groups
Diagnosis groups ➡ Condition Categories, and assigned a risk adjustment factor (RAF)

• Related conditions are assigned in one category and only the most serious is counted.
• Conditions in the same group are counted once. For example, morbid obesity and body mass index (BMI) of 42 are in group 22. The risk score associated with these conditions will only be counted once in calculating the RAF. Clinicians shouldn’t assign all diagnoses assessed at the time of the visit that require or affect patient care or treatment.
• A higher ranked condition causes lower ranked conditions in the same category to be ignored. (There are a few exceptions to this.)
• Unrelated conditions in different categories are both counted, and their effect is additive in assigning a score.

Clinicians should follow ICD-10 rules:

1. Use the ICD-10 Clinical Modification (ICD-10-CM) codes that describe the patient’s diagnosis, symptom, complaint, condition, or problem.

2. Use the ICD-10-CM code that is chiefly responsible for the item or service provided.

3. Assign codes to the highest level of specificity.

4. Do not code suspected diagnoses in the outpatient setting. Code only the diagnosis symptom, complaint, condition, or problem reported. Medical records, not claim forms, should reflect that the services were provided for “rule out” purposes.

5. Code a chronic condition as often as applicable to the patient’s treatment.

6. Code all documented conditions, which coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions which no longer exist.)

A clinician should document underlying medical problems that require or affect treatment even if it’s not being treated the problem at this visit. For example, a surgeon sees patient with kidney disease, diabetes, and heart disease, sending the patient for preoperative clearance. The patient’s underlying medical conditions affect the surgeon’s treatment of the patient. The surgeon should report these underlying conditions that affect the patient’s treatment. Do not report problems listed in the problem list or past medical history, which are not treated or which do not affect patient care. Related issues: Individual medical practice claims continue to be paid based on the fee associated with the Current Procedural Terminology (CPT®) or Healthcare Common Procedural Coding System (HCPCS) code. Groups that are part of an accountable care organization or other Medicare shared savings program or that have risk-adjusted commercial contracts will see an adjustment in their fees at the end of the contract year, partially based on the acuity of their patient population.

Key points:

• Follow ICD-10 rules when submitting diagnosis codes on claim form.

• Document those conditions treated, assessed, managed, or reviewed and submit the diagnosis codes for those on a claim form.

• Document those conditions that affect the care of the patient, and submit those on the claim form.

• Do not submit diagnosis codes for conditions that no longer exist. Use “personal history of” codes, when accurate.

See also in The Field Guide for Physician Coding, Chapters on Diagnosis coding, ICD-10-CM

All physicians can increase their revenue and improve their compliance through accurate coding.This book tells you how.” –Betsy Nicoletti, MS, CPC

 or call (800) 933-3711 or send an email to for bulk copy information. 

Thursday, August 2, 2018

8 Steps to Have Those Difficult Conversations

Originally appeared at July 7, 2018.

Although the ability to initiate difficult conversations is part of good leadership, I’ve never met a leader who enjoys it. Whether your conversation is about body odor, rude behavior, dress code, personal conduct or performance issues, difficult conversations are something that most of us avoid. In reality, the primary reason we avoid difficult conversations is that many of us lack the skills we need to handle such situations. As a health care leader, your intention must be about improving performance for the betterment of the practice, period. Anything else is just drama.
I’m going to give you an overview of the steps to use in initiating a difficult performance conversation. This advice comes from years of observing all types and all levels of leaders who have struggled to give valuable performance feedback to their employees until it was too late. If you use this process correctly, 90 percent of the time, employees shape up and get better, or they leave before you have to fire them.
Step 1: Set the right intention
The intention should be twofold: to help the employee and to help your health care practice. Even good leaders have hidden intentions without realizing it. If you have let a problem go on for too long, your hidden intention may be to embarrass the employee, fire her or put her on a difficult rotation. Know your intention before the conversation commences.
Step 2: Articulate the observable behavior
You need the skill to clearly articulate the problem while differentiating between assumptions and observable behaviors. When coaching leaders on this step, I hear a lot of generalizations and assumptions, such as:
  • He has a bad attitude.
  • My colleague doesn’t care about the practice.
  • My employee thinks he can get one over on me.
  • She doesn’t respect her coworkers.
These statements point to your labels, assumptions, and judgments but not necessarily to the facts.
The difference between your perception (your story) and the observable behavior is this:
  • “He has a bad attitude.” Evidenced by frowning, eye-rolling and interrupting.
  • “My colleague doesn’t care about the practice.” Evidenced by consistent tardiness; not volunteering for overtime during the holiday rush.
To get to the observed behavior, see if you can answer these two questions:
1. What is the employee doing that you want him or her to stop?
2. What is the employee not doing that you want him or her to start?
Here is the script: “Karyn does not use eye contact or smile at patients when she greets them, and I want her to start smiling when she greets the patients.”
Step 3: State the business case
There’s a reason you want Karyn to change. That reason is not just because you get irritated when Karyn doesn’t smile. That’s your personal issue. You want her to change because on the last survey you got a low score on patient satisfaction. That’s the business case.
The point I’m making here is that you have to connect the dots about how the observed behavior affects the business results, not your personal life. When you make it clear that your focus is on improving the practice, it’s easier to get alignment from employees, owners, and physicians.
Step 4: Speak to the vision
Now that you know the observable behavior and the business case, you have to be able to ask for what you want. Asking for what you want is difficult because most of us focus on what we don’t want. Many times we say things like, “I don’t want to have to tell you a thousand times,” or “I don’t want to argue.” Asking for what you want is the starting place for speaking the vision.
Instead of saying, “I don’t want to hurt your feelings but…” You say:
“I want our practice to get higher patient satisfaction scores. I want to give you information that will help you to grow. I want you to hear what I have to say and then think about it over the weekend. I want all of us to align with our value of patients first fully, and that includes you smiling at the patients, making eye contact and making them feel welcome. I want you to fully be able to use your gifts and to be happy in your work here.”
Step 5: Diagnose the root cause
Before meeting with your colleague or employee, you may not know for sure how to get to the root of the problem. Even if you know how to articulate the observable behaviors clearly (e.g., the employee misses documentation, frowns, interrupts or fails to ask the patient the correct questions), you still may not know why they do it.
Makayla is making errors with patient records. Makayla may not be aware of how her behaviors affect the team. But let’s say Makayla continues to make errors when documenting patient info, after the conversation to correct has taken place. The errors could be occurring because she was not trained properly. Maybe Makayla is confused because there are too many bosses and she doesn’t know which one takes priority. Maybe Makayla gets overwhelmed, and instead of checking patients in she starts straightening up the reception area because that relieves her stress.
Step 6: Identify resistance
If you’ve ever had a difficult performance conversation and you thought you got through to the employee, but you saw no change, it is either because the employee resists your leadership, or you resist implementing measures of accountability.
You can hear resistance in the following language:
I would but…
I’ve already tried that.
You don’t understand.
Let me tell you what Kim did.
It’s not fair.
But I have seniority.
It’s going to be difficult.
That’s impossible.
My coworkers won’t like it.
Distractions are sidebar conversations intended to get you off topic so that you are no longer in charge of the conversation.
Step 7: Initiate change by removing obstacles
It’s fairly easy to identify obstacles. Where we get hung up is when we fall into distractions and verbal ping-pong. The discussion should go like this:
“If I could reduce the difficulty would you?”
“Yes, it will be difficult. Will you do it anyway?”
“Yes, I may not fully understand. Are you willing to take my direction anyway?”
Until there is a willingness on the part of the employee to change nothing is going to happen. You have to be able to address their resistance, but you also need to look at your own resistance to holding them accountable.
Step 8: accountability
Once you have made an agreement with the employee about what the problem is and what you need the employee to do, the last step is to follow up. Here, you simply put on your calendar a check-in date to discuss his or her progress. The feedback system keeps a focus on improvement while increasing your credibility and trustworthiness.
Marlene Chism is the author of 7 Ways to Stop Drama in Your Healthcare Practice and can be reached at her self-titled site, Marlene Chism.

Thursday, June 21, 2018

Life’s Work: Kareem Abdul-Jabbar. How Does this Translate to a Healthcare Practice?

This was an interesting piece to come across in the venerable Harvard Business Review, a magazine that caters to a business audience. Profiling a sports star is a bit out of the box, but the lessons offered are useful in a number of ways for business leaders. Some of Abdul-Jabbar’s insights apply to managers and “captains of industry” in the C-suite, but many of them apply to workers at any level.

One of the most celebrated basketball stars in history failed in his attempts to become a head coach in the NBA after he retired from playing. But he has successfully changed course and become a successful writer, historian, and filmmaker, specializing in telling the stories of unsung heroes in African-American history. The Harvard Business Review interviewed him about his philosophies and practices that have produced success on and off the basketball court. His life lessons include the following:
  • To really excel, it takes both talent and hard work, but a good work ethic trumps natural talent every time. A talented ball player won’t succeed unless he or she practices long and hard.
  • Abdul-Jabbar had a reputation in the NBA as a focused, but not very personable, player, and it followed him when he was trying to break into coaching. He notes that as he has matured, he has learned to be more sociable and outgoing.
  • He found success as a team captain as a leader by example. He stayed in shape and constantly worked on his fundamentals.
  • He earned a right to be heard by his managers and coaches by approaching them with due respect. They would then listen to his suggestions and criticisms.
  • He is often contrasted with his effervescent teammate Magic Johnson. Abdul-Jabbar learned to enjoy the moment from Johnson, and Johnson learned from Abdul-Jabbar to temper his reaction to each victory (or loss) by focusing on the long haul, a season of 80-plus games.
  • Abdul-Jabbar doesn’t see his career as a writer as a “transition,” but more as leveraging something he has always enjoyed. He was good at English and writing, and in recent years he has cashed in on it on the best-seller lists.

These concepts can prove helpful in managing people and in the environment of any business, including a healthcare practice. Abdul-Jabbar's philosophy that hard work trumps talent every time applies to hiring processes, personal self-discipline, and leading a work team. You may hire a very skilled or knowledgeable staff member, but if he or she doesn’t have a strong work ethic, you’ll be disappointed.

As he talked about himself, Abdul-Jabbar recognized his tight focus and imperfect social skills were both assets and liabilities. His focus helped him lead others by example when he might otherwise not have been an effective encourager. And he found that his personality worked well when teamed with someone very different—he and Johnson balanced each other out in some ways.

If your style is focus and hard work, it provides an example for your staff. If you are more open and sociable, you might be more encouraging and helpful. Just make sure you have some focused workers around, too. As one of the all-time great NBA players, Abdul-Jabbar was never quite able to become a head coach as he had hoped. A great player doesn’t necessarily translate into a great coach. By the same token, a great worker on your staff might not make a good candidate for a supervisory or management position. Keep that in mind when you think you might want to promote one of your star performers.

Thursday, June 14, 2018

Look to Your Employees for Innovative Ideas

Funny thing about the way physicians are trained and socialized in America: They’re taught to be independent thinkers. And while that may make them excellent clinicians, sometimes it can get in the way of creating and cultivating an organization that thinks, learns, and develops new ideas. Successful businesses—the superstars you read about in magazines—are invariably recognized as innovative organizations. Smart organizations tap into the collective brain power of entire business—from the “C” suite to the lowest-grade, common laborer.

We’ve caught glimpses of this principle inside top-performing medical practices, too. When you
walk through the front door of such practices, you’re not greeted by the general chaos that seems to plague many operations. There is a calm efficiency that is downright palpable. Everyone seems to know his or her job, and they’re discharging their duties with poise and confidence. Underlying many of these operations you’ll find dozens—perhaps hundreds—of little ideas and innovations that have made the practice run smoother. And a good deal of the ideas came from the staff workers—not the physicians or the administrator. The practice leaders were smart enough to recognize that the people who actually do these jobs know a great deal about the problems and challenges they face every day.

The leaders have encouraged, recognized, and rewarded innovation from their staff members,
and it pays off in improved operations, higher staff morale, and a culture that consciously looks
for ways to learn and improve.

Innovation and its inspirations aren’t really as mysterious as they seem. The really great performance-enhancing ideas don’t come from the research lab or the executive suite. They come from the people who daily fight the company’s battles—those who serve the customers. Successful corporations that have developed a culture and reputation for innovative ideas have found ways to harness the creative energies and insights of employees across all functions and ranks. These companies have cultivated “innovation communities”—work groups that tackle projects and problems in place of the traditional strategy to engage a team of expensive consultants. These groups provide the opportunity to give new shape and purpose to knowledge already possessed by those employees. Companies establishing successful innovation communities share key characteristics and strategies:

• Creating the space to innovate. They designate time and organize effective meetings and
communication mechanisms.
• Getting a broad variety of viewpoints. They deliberately cross horizontal boundaries to get
input from all management (and non-management) levels, and they cross vertical boundaries
to break down information “silos” and allow knowledge to spread among even unrelated departments.
• Creating conversation between senior management and participants. They require senior
management to pay attention to what participants are saying.
• Pulling, not pushing, participants to join. They recognize that they can’t force anyone to share
the knowledge they have.
• Keeping development costs low by tapping unused talent. Participants usually continue to perform their regular roles even while working on the innovation project.
• Recognizing collateral benefits that sometimes equal or exceed the innovations themselves.
Developing a “learning-organization” culture yields benefits that improve morale and company
• Recognizing that measurement is key. A company can sustain an innovation community
only if it can produce demonstrable value.

Successful companies keep track of how many innovative ideas make it from the communities’
drawing boards to actual implementation—and measure the results.

Thursday, June 7, 2018

Are Performance Reviews Losing Steam?

The annual or semi-annual rite of passage called, “the performance review” has fallen into disfavor among personnel managers in recent years. Dreaded by managers and employees alike, several studies suggest that such evaluations aren’t very effective in improving performance, even as they cause inordinate amounts of stress around the company.

One company dropped its traditional review process for its 450 employees in favor of weekly one-on-one meetings during which supervisors discuss performance goals with each employee. The dialogue invites the employee to evaluate himself or herself using an online app, and the self-analysis serves as a springboard for discussion with the supervisor. Instead of basing pay on an annual review score, employees receive equal raises annually. However, groups within the company receive performance bonuses that include stock options.

Some experts warn that simply doing away with formal reviews creates risk for companies—particularly when they need to dismiss an underperformer. An employer can find itself defending
a wrongful-discharge lawsuit if it can’t show a pattern of poor job performance. But companies that have transitioned away from traditional reviews successfully have maintained some kind of deliberate feedback mechanism. The feedback is usually delivered in a dialogue approach—as opposed to the traditional top-down method. Rather than looking at performance annually or semi-annually, feedback becomes part of an ongoing discussion throughout the year.

Finally, companies happy with their transitions from traditional reviews have removed—or
diminished—the connection between performance feedback and pay raises. Employees demonstrate greater willingness to participate openly and honestly in feedback dialogue when they don’t fret over whether a bad score will affect their paychecks.

Most of the time, we’re offering advice to practice leaders to start doing meaningful performance reviews. Groups of all sizes notoriously neglect giving structured feedback to employees. But nearly everyone hates performance reviews. Managers and doctors don’t like to give them, and staffers don’t like to receive them. Everyone feels uncomfortable. Human resources experts increasingly criticize the typical annual (or semi-annual) performance review plan used by many employers today. Research indicates that companies seldom get the results they seek—and clumsy bosses often don’t handle well the awkwardness associated with delivering employee report cards. But that doesn’t mean you should abandon the concept. Failure to give any honest, actionable feedback is actually worse than stumbling through an annual review process. By “actionable,” we mean criticism or praise that the employee can use to improve or sustain performance. Thoughtful critics of annual reviews are often proponents of more frequent, ongoing dialogue that keeps every well they do their jobs. 
  • Where do they excel? 
  • What needs tweaking? 
  • Where are they missing the boat altogether?

For the manager or owner, this has huge implications. It’s much more than the occasional pat on the back or “attaboy” and “attagirl.” Labor laws and today’s litigious workforce require businesses to maintain thorough documentation that will support management decisions if ever challenged in a Department of Labor complaint or wrongful-discharge lawsuit. If you need to discipline or dismiss an underperformer, you had better be able to show a pattern of unsatisfactory job performance and a record of your failed attempts to correct him or her. 

So if it sounds inviting to you to do away with those annual reviews (those evaluations
you never get around to anyway), be prepared to adopt a new system to provide and record performance feedback. Failing to do that increases your risk exposure. 

Thursday, May 31, 2018

Responding to a Subpoena in the Healthcare Practice

If you’ve ever seen the look on an inexperienced receptionist’s face the first time a process server shows up at your front desk, you already know that your entire staff needs clear-cut policies and procedures about what to do when a subpoena arrives at the office.  Most subpoenas, of course, arrive by certified mail and demand medical records, but however an order comes through the door, each staff member needs to understand his or her role and responsibilities in responding to it. 

When the court orders a witness to appear or a party to provide documentation for legal proceedings (like a trial or deposition), it issues an instrument called a “subpoena.” Governing authorities, like a state medical board, or an attorney general can issue subpoenas as well. Medical practices receive subpoenas frequently to demand copies of medical records—usually in preparation for malpractice and personal-injury lawsuits.

Here are some general guidelines for offices when they receive a subpoena:

Secure and prevent changes in records. Designate a person responsible to ensure that subpoenaed records are pulled from general filing and kept safe from routine destruction or archiving. Create a policy prohibiting alterations of these records.

Create a record log. Note the date when the practice received the subpoena and when a response is due. Determine which subpoenas can be handled as “routine,” and which ones require special handling—such as calling in legal counsel. Determine if you need additional time to produce records (say from archives or remote locations) and ask for an extension (in writing).

Make sure you have no valid objections before releasing records. If, for example, the requestor fails to include a proper written release authorization, do not send records. Under the advice of counsel, there can be other reasons for objections as well. When the request is unreasonably intrusive or expensive to comply with, an attorney may object.

Watch for special circumstances regarding sensitive information. Records containing patient information regarding mental health and certain infectious diseases require special written release under most circumstances. At times a court may allow the provider to redact irrelevant information that could prove detrimental if released.

Produce organized copies. Number each page of a chart to be turned over, and log the exact page numbers included in the package as well as the date you send them. If you need to delete information, make sure the released records show exactly where the deletions were made and the reasons for the deletions. Healthcare providers walk a fine line between the demands of a court order and compliance issues associated with HIPAA and state patient-privacy regulations. Step off that line in either direction, and you could be liable for fines and sanctions from either side.

Although this post provides a good overview that you can use to guide your policies and procedures, it’s up to you to think through each staff member’s role—from receptionist and records clerk to administrator and physicians. Create written procedures that describe exactly what to do. Be as specific as possible, and make sure that proper administrative personnel and affected physicians are notified immediately upon being served. Do not authorize clerical workers to make decisions about legal responses. Their roles should be well supervised—especially when a case calls for extraordinary decisions. And reemphasize the need for confidentiality—not just to protect patient rights, but to protect physicians and the practice.