1. Creating a Culture Change to Improve Billing and Coding Accuracy in a Family Medicine Residency Program Kimberly Legere-Sharples, MD, MMEd Middlesex Family Medicine Residency Program Middletown, CT December 6, 2014

2. Disclosures I have no financial or non-financial disclosures

3. Objectives On Completion of this session, the participants should be able to: –List some of potential barriers to correct billing and coding in outpatient Family Medicine Residency medical practice –Describe the key steps and people needed to make a culture change and bring billing awareness to the forefront –Identify 2-3 strategies for creating a multidisciplinary culture change in your own practice setting and some of the potential benefits of making these changes.

4. Today’s Session Introduction Review of our Journey Small Groups Discussion

5. Audience Participation There will be interspersed questions Please respond via text message Let’s try it!

8. Introduction We are a 4 year FM residency The realities and complexities of our current billing system take time to become familiar with and even longer to master While there is a lot of hope for the future for a better system, most graduates will still have to deal with our current billing and coding system

9. A Dreaded Part of Practice Does not feel related to patient care Poor preparation in medical training Can be uncomfortable Antithesis of the devoted physician

10. Why Do We Care? Prepare residents for future practice Get paid for what you do Avoid fraud Additional income for the residency program

11. Potential Barriers in a Residency Hospital Employed with few/no incentives for residents to improve (lack of personal accountability) Time pressures Documentation requirements A negative perception of the topic Precepting challenges (including varying skill) Patient care/medical knowledge are more important

12. Is There a Problem? One of the former faculty identified the need for improved billing education in 2009

13. 99214s We have specifically focused on 99214 billing Preventive care is clearer A significant number of our visits are follow up and many patients are complicated –Per a 2010 report, established patient E&M codes (99211-99215) constituted about 48% of Medicare payments

14. 2014 Work RVU 992130.97 ($51) 992141.50 ($79) www.cms.org

15. It Boils Down To... We are already doing the work!

16. National Trends Between 2001 and 2010: –Medicare payments for E/M services increased by 48%, from $22.7 billion to $33.5 billion –The number of E/M services billed increased by 13%, from 346 million to 392 million –The average Medicare payment amount per E/M service increased by 31%, from approximately $65 to $85.5 –Combined, physicians increased their billing of the two highest level E/M codes (99214 and 99215) by 17% Coding Trends of Medicare Evaluation and Management Services (OEI-04-10-00180) May 2012

18. Medicare E&M Billing 20012010 992116%4% 9921216%9% 9921354%46% 9921421%36% 99215 3%5%

19. Medicare E&M Billing 20012010 992116%4% 9921216%9% 9921354%46% 9921421%36% 99215 3%5%

20. Shifting the Culture Ran reports to get our numbers Explored attitudes about billing and coding throughout the system Identified opportunities to enhance education

21. Creating a Culture Change Brought it to faculty meeting Introduced to the residents Included front desk and nurses

24. Historic Data It takes time to make a difference

25. Residents (% 99214)

26. Faculty (% 99214)

27. Maintaining Change Introduced as part of orientation Consistently included in precepting Longitudinal inclusion in the scheduled didactics (3/yr) Practice Management Rotation Regular part of chart review Quarterly Report Support Staff education

28. What’s Next? There is clearly a large gap between residents and faculty in average % 99214s of E&M billing that has been stable now for a couple years Should we change? If so, how?

29. Survey Results Faculty: 12 responses Residents: 14 responses

30. What do you think are the biggest barriers to residents billing more 99214's? Not recognizing the visit is a 99214 Too much time to precept Too difficult to have preceptors come in and see patients (for Medicare and Medicaid) Insufficient documentation It is not important to bill 99214s Billing 99213 is easier; it is not worth the extra work to bill 99214s

32. Barriers

33. How do you approach resident billing as a preceptor? Review the scheduled patients for that session with the resident; identifying the patients likely to be 99214s Consistently include a discussion about proper billing with precepting Identify 99214's when the resident is precepting and offer to see the patient/write a note Wait for the resident to identify the opportunity to bill a 99214

34. Approach to Precepting

35. Comments Faculty: –“Residents have to be motivated and allow sufficient time to review schedules ahead of time and plan 99214 precepting. I do this when possible, but in reality only a few are organized enough and arrive with sufficient time to huddle and review their schedule with preceptor.” Residents: –Patients do not want to wait

36. How good are residents at recognizing 99214s? Great- they almost always know which visits are 99214s Good- they recognize most 99214s but miss more than they should if practicing on their own OK- they recognize 99214s when seeing the patients for 3-6 problems, but miss most of the simpler 99214s Fair- miss many 99214s even when covering many issues, but recognize some Poor- almost never identify 99214s

38. How good are residents at recognizing 99214s?

39. Faculty Comments... “varies greatly amongst residents” “As expected, PGY-3 and -4's are better at this than PGY-1 and-2's, but also usually have less time to precept because they have more patients in their schedule”

40. How important is it for residents to accurately identify and bill? Very Important 64.29% (9) Somewhat Important 35.71% (5) No one was neutral or thought that it was unimportant Compared to the Faculty (100% felt that it was “Extremely Important”)

41. Why is it important/unimportant for residents to accurately identify and bill 99214s? Billing accuracy/Avoid Fraud (2) Get paid for our work (5) To prepare for future practice (7) –“Important for after graduation when billing really does matter” Only one identified revenue generation: –“I make significant effort to do as many as I can to generate income for my practice. I can see why other residents may not put time into something that does not benefit them, but I do it because I appreciate the teaching and it is my way to give back”

42. Actual 99214 Billing

43. PGY2

44. PGY3

45. PGY4

47. Faculty

48. 2014 First Quarter

49. How Can We Improve 99214 Billing? Residents: –Making it a part of precepting –Pre-precepting –Positive feedback/recognition –Having preceptors preview schedules –Increased faculty involvement in workflow

50. Faculty Suggestions Preceptors being more proactive, visible, and available Include billing in precepting Pre-precept Raising awareness of the residents of the importance of their revenue/educational benefits Set benchmarks/friendly competition

51. Faculty Suggestions Preceptors being more proactive, visible, and available Include billing in precepting Pre-precept Raising awareness of the residents of the importance of their revenue/educational benefits Set benchmarks/friendly competition

52. Potential Downsides Does it draw unwanted attention for CMS? Does pressure to improve billing encourage fraud? Does it put too much stress on residents/preceptors? Are we spending too much time on a system that is changing?

54. Small Groups How do you handle the challenges of precepting/billing education? Are there downsides to putting too much attention on billing and coding? Should residents have a productivity goal?

55. Small Group Discussion

56. Steps For Change 1.Identify a faculty champion 2.Begin the process of education 3.Get buy-in 4.Keep track of billing 5.Make it fun!

57. Summary Sustainable change requires positive energy, multidisciplinary collaboration, and ongoing attention Residents should be prepared to get paid for the work that they are doing

58. Thank You!

59. Please evaluate this session at: stfm.org/sessionevaluation