1. Practice Management Peter Bidey, D.O. February 20, 2016
Instructor, Family Medicine
Medical Director, Family PCOM
PCOM

2. Outline The Man The Measures The Money The Madness
I feel like it is a rap song
Or, OSHA requirements
HR Concerns
QI/Patinet Safety/Performance improvement
Billing and Coding
Docmenetation/HER
HIPAA

3. Occupational Safety & Health Administration (OSHA)
Blood borne pathogens
Everyone must comply
Must use “Safer Devices”
Must have training and documentation
Aware of proper disinfectants
HIV and HBV specific
There is no number to employees that you must provide these standards too. Even if there is one or 10 or 100 employees everyone must have the protection
The good thing is there is no exact device you need to use. You have to use what is on the market and controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace." Employers who have employees exposed to contaminated sharps must consider and implement appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure.
You want to have a manual of what to do. Also need to have a policy for needle sticks.

4. Occupational Safety & Health Administration (OSHA)
Airborne hazards
Employer’s role
Employee’s role
Mask myths
Masks and respirators provide the same protection
They can be reused
You can write on your respirator
Everyone can wear a respirator
You can’t have facial hair and wear a respirator
Everyone’s favorite, use the N-95 masks
The employer must provide engineering control, work practice control, and administrative control. When this is not enough You must you a personal protective equipment. There must be training from the employer, as well as respiratory protection plan documented.
Your role is to use the mask, use it properly, and alert if need for refitting (change in weight, change in dental work, facial surgery, or facial scarring around seal.)
Masks provide only against large droplet protection and do not provide any protection againist small airborne particles. Respitator N95 masks cannot be used for gaseous chemicals. Most cannot be reused (N-95) unless have filters that can be replaced and cleaned.
Writing on your resporiator will cause it to faulter. You can only write on strap.
If you have heart lungs or pyscological disease you may not be able to wear a respirator
You can have facial hair but it needs to be trimmed so that it is not interfering with the seal of the particular mask.

5. Laboratory Reporting Know your state CDC reportable diseases
CDC reportable diseases
Find out which ones we do or do not need to report

6. Human Resources Hiring Things you can ask: Things you can’t ask:
Ask open-ended and scenario driven questions
General knowledge, conflict management, motivation, work ethic, problem solving strategies, response to office politics, gossip, & computer confidence
Things you can’t ask:
Age, religion, national origin, martial status, children, and medical issues.
Ask if you can contact previous employers
Look at specific questions. Write a question about what you can ask at an interiview. Background checks?

7. Human Resources Firing Communicate Expectations Termination
Written, orientated, and regularly checked
Termination
Who?
Where?
When?
How?
Address the Details
Pitfalls
People can fail for multiple reasons. From the start of their employment you want their expectations job description in writing. You want to properly orient and train and regularly check in on the person. Want to have this all done, so in case you do need to fire someone you are protected
If they are poor performing and termination is the plan planning is key.
Don’t be alone. Have another member as well as another witness of managerial status
Meeting in a private meeting room that does not allow others to see into the room. People can become embarrassed, hostile, or emotional
Meet on the day of termination. Furthermore, despite what people think, Friday may not be the best option. Try to meet at a non disruptive time with the fewest amount of employees present.
What to say depends on whether it is for cause or not for cause. Be firm but compassionate, and avoid debate. Document the proceedings incase a suit I alter brought.
Cause means there is a specific reason, not for cause states there is no specific reason (at-will employees). Not for cause will be entitled to unemployment benefits and you do not need to give a reason therefore. If for cause you can oppose an application for unemployment. You want to make the employee aware of this at this time. They can still file, but you can contest.
Details:
Last paycheck, epersonal items, getting home, rference, and practice assets.
Pitfalls: (Consult your attorney)
Complaints about anti discrimination laws, complaints about safety or working conditions, took recent leave for jury duty, filed for bankruptcy protection, requested an accommodations under fmla or disability act.

8. Family Medical Leave Act (FMLA)
Who is covered?
Works for a covered employer
Has worked for the employer for at least 12 months
At least 1,250 hours of service for the employer during a 12 months period preceding leave
Works at a location where the employer has at lease 50 employees within 75 miles
Covered employers
Private sectors employer with 50 or more employees in 20 or more work weeks in a current or preceding calendar year.
Public agency regardless of number of employees
Public or prate elementary or secondary school regardless of employees

9. Family Medical Leave Act (FMLA)
What it allows?
Eligible employees may take up to 12 work weeks of leave in a 12-month period for:
Birth, or placement for adoption, or foster care
Care for spouse, son, daughter, or parent who is seriously ill
If the employee has a health condition that makes the employee unable to preform essential functions
For any qualifying exigency arising out of the fact that a spouse, son, daughter, or parent is a military member on covered active duty or call to covered active duty status
26 work weeks of leave for care of a covered service member with a serious injury or illness when the employee is the spouse, son, daughter, parent, or next of kin of the service member
Intermittent leave allowed
This is unpaid, job-protected leave for specified family and medical reasons

10. Quality Improvement Basics
Establish a culture of quality in your practice
Determine and prioritize potential areas of improvement
Collect and analyze data
Communicate your results
Commit to ongoing evaluation
Some examples of methods are model for improvement (Plan-Do-Study-Act) PDSA Cycles - This uses total quality management and rapid cycle implement allows you to test interventions on a small scale. Lean Six Sigma- combines QI models lean and six sigma. The results is a framework that provides a mean for assessing value of potentials QI efforts and approach to executing QI projects referred to a DMAIC – Define, Measure, Analyze, Improve, and control.

11. QI Lingo/Patient Safety
Adverse Event- results in unintended harm to the patient by an act of commission, or omission rather than by the underlying disease or condition of the patient.
Composite Measure- a combination of two or more individual measures in a single measure that results in a single score
Incident- A patient safety event that reached the patient, whether or not the patient was harmed
We want to talk like we know what we are talking about

12. QI Lingo/Patient Safety
Mandatory Reporting- legal requirement for physicians and other professional providing health services to report suspected incidents or abuse or neglect
Near miss- an event or a situation that did not produce patient harm, but only because intervening factors, such as patient health or timely intervention
Preventable (event)- Described an event that could have been anticipated and prepared for, but that occurs because of an error or other system failure
Sentinel event- an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof
This means a loss of limb or function. The phrase the risk thereof includes process variation for which a recurrence would carry a significant change of a serious adverse outcome. They are deemed sentinel because they signal the need for immediate investigation and response.
This is different than a serious event in that a serious event is death or loss of body part, disability or loss of bodily function lasting more than seven days or still present at time of discharge or when referring to other than an adverse even, a non-trivial event.

13. QI Math Specificity-SpIN Sensitivity-SnOUT Positive Predictive Value
Specificity=true negatives/(true negative + false positives)
Sensitivity-SnOUT
Sensitivity= true positives/(true positive + false negative)
Positive Predictive Value
PV+= true positive/(true positive + false positive)
Negative Predictive Value
PV-= true negatives/(true negatives +false negatives)
Want to be able to understand what to do with the numbers
Specificity - measures the proportion of negatives that are correctly identified as such (e.g., the percentage of healthy people who are correctly identified as not having the condition)
Sensitivity - measures the proportion of positives that are correctly identified as such (e.g., the percentage of sick people who are correctly identified as having the condition).
Predictive value for a positive result (PV+):
PV+ asks " If the test result is positive what is the probability that the patient actually has the disease?"
PV+= true positive/(true positive + false positive)
Predictive value for a negative result (PV-):

PV- aks " If f the test result is negative what is the probability that the patient does not have disease?"
PV-= true negatives/(true negatives +false negatives)

14. Billing and Coding CPT Codes 99201-99205 for NEW patients
for established patients
for NEW preventive patients visit
for established preventive patient visit
G Medicare Annual Wellness Initial
G0439 – Medicare Annual Wellness Subsequent
CPT-Common Procedural Terminology
Where are we using them:
Home Healthcare
• Hospice Agencies
• Outpt Hospital Departments – Amb Surg, ED, Outpt Lab, Outpt Radiology
• Physicians who are employees (VA, etc.)
• Physicians who see pts in – Office
– Clinic – Patient homes

15. Billing and Coding Basics
History
Physical

16. Billing and Coding Basics
Medical Decision Making

17. Billing and Coding MC Chronic Care Management (CCM) - 99490
Requires an agreement
There is a co-pay
Requires 2 or more chronic conditions expected to last 12 months and place patient at significant risk of functional decline
Require at last 20 minutes of clinical staff time directed by physician or qualified health care professional per month
Comprehensive care plan established, implemented, revised, or monitored
8-20 dallors per month. No always covered by co-insurance.
This focus on 24/7 access, continutiy of care, chonic condition mt, patient centered, mangement of transitions, coordiation of home and commity care, better communication and electronic capture and sharing of care.

18. Billing and Coding Transitional Care Management (TCM) – 99495
Communication with patient or caretaker within 2 business days from discharge
Medical decision making of at least moderate complexity during the service period
Face-to-face encounter within 14 calendar days of discharge
There is also a which must be seen within 7 days as well as need a high complexity illness.
Communication can be phone, portal, ect.
It pays more, has more RVUs for things you are usually doing.
Also, if readmitted the face to face encounter converts to a regular visit which you would be paid. You can bill for other visits, but need to hold the bill till end of 30 days period.

19. Billing and Coding OMT Bill regular office visit with -25 modifier
Place allopathic diagnosis
Place osteopathic-somatic dysfunction diagnosis
Level of OMT performed
98925 – 1-2 body regions
98926 – 3-4 body regions
98927 – 5-6 body regions
98928 – 7-8 body regions
98929 – 9-10 body regions

20. Billing ICD-9 ICD-10 739.0 Head region 739.1 Cervical region
739.2 Thoracic region
739.3 Lumbar region
739.4 Sacral region
739.5 Pelvic region
739.6 Lower extremities
739.7 Upper extremities
739.8 Rib cage
739.9 Abdomen and other
M99.00 Segmental and somatic dysfunction of head region
M99.01 Segmental and somatic dysfunction of cervical region
M99.02 Segmental and somatic dysfunction of thoracic region
M99.03 Segmental and somatic dysfunction of lumbar region
M99.04 Segmental and somatic dysfunction of sacral region
M99.05 Segmental and somatic dysfunction of pelvic region
M99.06 Segmental and somatic dysfunction of lower extremity
M99.07 Segmental and somatic dysfunction of upper extremity
M99.08 Segmental and somatic dysfunction of rib cage
M99.09 Segmental and somatic dysfunction of abdomen and other regions

21. Documentation/EHR You should do it. You should do it well.
It will protect you.
Seriously however, it is just good care.
Each EMR is different and has its pros and cons. You want to thoroughly research them, see their capabilities, ability for portals and lab/radiology transfers, and patient access. You want to know exactly what you are getting before you spend a lot of money that may not benefit you.
Furthermore, it does help to use EHRs, excluding their pitfalls that have been discussed but can be used to attest for meaningful use, which unfortunately by the time you are practicing will be gone, however especially for calculating QI initiatives, ect.
Ex: gathering data, retrieving data on DM, BMI, ect. espically for going medical home ect.

22. HIPPA
Who does it apply to. You have just had some exclusions done. I do not want to be repetitive however a key issue deal with the business associate aggrement

23. HIPPA Business Associates (BA)
Who is a BA….more complex then you think
Entities that access, use, or disclose patient Personal Health Information (PHI) on your behalf
Anyone you have direct control over is not a BA, but rather considered “workforce”
Examples: electronic prescribing gateways, health informatin organizations, document storage agencies, EHR vendors (if they provide personal health records to patients on your behalf), attoneys, call services
If they are BAs you need an agreement
The best way to understand this is too ask yourself do they perform a service on our behalf that has them accessing, using, and/or disclosing our patinets’ PHI (personal health inforamtion). If yes, then they most likely are and you need an agrrement
However, here is the murkiness. If you send someone to radiology that doesn’t mean you are their BA and just them sending you the results does not me that the radiology practice is your BA. Here everyone is using the PHI for their own personal purposes and disclosure is done by one covered entity to another for treatment purposes. However, if your practice was doing billing for the diagnostic tests performed by the radiology group, then the radiology group is your practices BA.
Therefore, your staff are not BAs but an independent contractor over whom you exercise no control like your attorney or call service are BAs and need an agreement.
The covered entity must have a written business associate contract or other arrangement with the business associate that establishes specifically what the business associate has been engaged to do and requires the business associate to comply with the Rules’ requirements to protect the privacy and security of protected health information. In addition to these contractual obligations, business associates are directly liable for compliance with certain provisions of the HIPAA Rules.

24. HIPPA HIPPA Office Compliance-Checklist
Have your Notice of Privacy Practices posted in a visible location. Make sure new patients sign that they’ve received it
Inventory all mobile devices and make sure they are both password protected, secure, and encrypted for texts and s
Use a virtual private network (VPN) to access our HER remotely
Make sure you fax cover sheet has a HIPAA disclaimer and never fax without a cover page
Ensure that passwords are changed at least every 6 months
Mostly due to the HITECH Act
HIPPA Office Compliance TO DOs
Have your Notice of Privacy Practices posted in a visible location. Make sure new patients sign that they’ve received it.
Inventory all mobile devices and make sure they are both password protected, secure, and encrypted for texts and s.
Use a virtual private network (VPN) to access our HER remotely
Make sure you fax cover sheet has a HIPAA disclaimer and never fax without a cover page.
Ensure that passwords are changed at least every 6 months

25. Questions?