Thursday, August 30, 2018

Get and Stay on Track with MIPS 2018

Now available!
Our 60-minute timely webinar recording on MIPS with Joy Rios. PDF handout, audio recording and a terrific Q&A session with Joy Rios.
Call (800) 933-3711 or

Need multiple copies?  Send an email to for discounted pricing.

Thursday, August 23, 2018

Happy 35th Birthday to The Journal of Medical Practice Management

In celebration of The Journal of Medical Practice Management's 35th birthday, I post the visionary "Letter from the Editor," by Marcel Frenkel, MD, MBA, from the inaugural issue of JMPM.  In many ways, this letter could be written today. The mission of JMPM is still the same. Thank you too to our authors and subscribers!
Nancy Collins
President & Publisher

"A Journal for a Time of Change"
from July 1985, Vol. 1, No. 1

It is now commonplace to state that the healthcare system of the United States is in the midst of a major change. This restructuring will greatly alter the substance, character, and style of the practice of medicine. The concept of this publication grew out of the desire to present in one journal a comprehensive approach to these changes, directed specifically to the practicing physician.

Rather than the gradual and evolutional developments which have characterized past progress, a great many organizational changes are underway. Differing systems of medical practice are now in place with competition emerging among these modes. The financing of medical care and the internal structure of the organizations of delivery present a bewildering complexity. Government regulation, fiscal constraints, local factors, and demographic trends all influence the fabric and future of medical practice.

The individual is now confronted with perplexing vistas. In past and simpler times, completion of a training program brought a modicum of assurance of the attainment of professional goals. The practitioner, individually or as member of a grouping, may now find difficulty in gauging the future and his or her new role in the new scheme of medicine. It now becomes imperative to develop an awareness of business methods socioeconomic trends in order to chart a sensible course for one's professional career.

Philosophically, the Journal is not wedded to any theory of healthcare structuring but wishes to provide an authoritative background to help physicians reach important decisions in the conduct of their affairs. This nation is large and varied, its population being diverse and requiring differing answers to its medical needs. During the transition phase that we foresee in the next decade, a variety of patterns of healthcare delivery will likely coexist and provide means for experimentation. This will allow the emergence or retention of practice patterns which are most useful in terms of economy and patient acceptance. Once can visualize the existence of fee for service alongside preferred provider organization (PPO) mechanisms and health maintenance organization (HMO) participation, all in one practice. As a private practitioner as well as an academician, I view the maintenance of a viable private sector of individual practitioners as a valid counterpoint to the emerging corporate groupings. It will provide patients with an alternate system with its own characteristics. Additionally it would allow both the individual and the corporate sectors to react to each other, refine their methods, and evolve in competition to provide better, more equitable, and economical care.

In spite of the rhetoric, it is important to remember that the art and science of healing remain the province of physicians who can also exert considerable influence on the course of events. Therein lies an opportunity. Informed physicians can help mold the future of the healthcare system in general and their own fate in particular, by participating in a dialogue within their own communities and assuming a leadership role. In instances where communications between medical leaders and the business and consumer sectors have been active, physicians have been able to maintain their traditional and pivotal role.

The purpose of “The Journal of Medical Practice Management” is to present, principally, to the medical practitioner, but also to the health administrator and others interested in this extraordinarily large system of healthcare, an overview of events and trends affecting medical practice. While there has been a proliferation of journals related to health policy, practice, and specialty issues, reading such publications with varying emphases requires the expenditure of considerable time and money. Few are directed to the practicing physician in an analytical way. Assembled in this journal, we propose to offer scholarly analyses and practical items to aid in the conduct and progress of medical practices. These will include articles on techniques of office management, computer technology, the marketing of medical services, reviews on developments in legislation, and government regulation. We will follow legal, legislative, and litigation trends affecting practitioners and also survey the constant changes in taxation that bear on practice management. Each issue will review an important facet of healthcare policy and also describe some some the varied modes of healthcare delivery, organizational structure, and the dynamics within healthcare groupings. Continuing article will consider medical education and manpower issues because of their great importance on the supply side of the medical economics equation. While our society cannot be compared with any other political entity, there is much written that we can learn from patterns of health care in nations which have already altered their systems. A regular “Letter from Abroad” will help familiarize the reader with developments throughout the world.

In addition to analyses of important issues, we will offer shorter reviews of current topics, all written by experts in their respective disciplines. These will include:
  • a review of the Washington scene
  • computers in review
  • a taxation update
  • abstracts of important medico legal decisions
  • a survey of the HMO and PPO industry
  • selected healthcare statistics
  • abstracts of the relevant literature.
Other features will profile the structure and financing of individual for-profit healthcare systems, followed by reviews of not-for-profit organizations.

Together with the regular Journal reviews, the Editorial Board hopes the continuing analyses will provide a comprehensive and practical approach to the varied factors which bear on medical practice.

Marcel Frenkel, MD, MBA
Founder and Editor
July, 1985
(800) 933-3711

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.