northeast august 6, 2013. my thanks to lou for presenting this talk. please complete the required...
TRANSCRIPT
State of the ClinicNortheast
August 6, 2013
My thanks to Lou for presenting this talk. Please complete the required IPHIT
participant form for our HRSA grant. Please complete the evaluation form at the
end or email me any feedback you have about this presentation so we can continue to improve upon it.
Thanks. Jennifer &
The Integrating Public Health Inquiry and Transformation (IPHIT) team
Introductory comments
Review Northeast Clinic demographics, geo-maps and quality metrics
Look at different ways data can be asked and presented
Explore examples of how to data can inform future investigations and interventions
Share the state of clinic finances Provide examples of your own individual
data
Objectives
As you look at this data, formulate your own questions: What else do you want to know? What seems to be missing? What assumptions are we making?
In preparing this presentation, I have inserted black slides followed by my own questions and thoughts as examples of how data can move us to inquiry and, hopefully, ultimately to action.
Goals
In May 2013 12,075 patients were assigned to a PCP at Northeast clinic. From this we have panel-based data.
From 7/1/12 to 6/30/13 (FY13)◦ 7,704 patients were actually seen at Northeast at
least once during this year. From this we have service-based data.
◦ There were 30,650 visits including lab, xray and nurse visits
◦ There were 23,428 visits with NE providers Thus every patient who had >0 provider visits in
FY13 was seen an average of 3 times (23,428/7,704)
Our patients
• Panel: patients assigned to a PCP at NE on May 2013
• Service: patients seen at NE during 7/1/12-6/30/13
• Not NE assigned: patients not assigned to a PCP at NE
Panel
Service
Not NE assigned
This is how it looks:
Panel vs Service vs Visit Data
Which questions are best answered with panel data?
Which questions are best answered with service data?
Which questions are best answered with visit data?
DEMOGRAPHICSThe following slides are based on
panel-based data unless noted
Female (54.7%)Male (45.3%)
Gender distribution
0-5 (5.8%)6-11 (6.6%)12-17 (6.6%)18-34 (27.6%)35-49 (24.8%)50-64 (20.2%)65-79 (6.7%)80+ (1.8%)
Age distribution
Children65+
White NH (61.5%)Black NH (14.9%)Hispanic (4.5%)Asian (6.2%)Native Am (0.4%)Other (12.5%)
Race/ethnicity
English (95.8%)Spanish (0.8%)Hmong (2%)Other (1.4%)
Language preference
Includes lab and xray encounters (30650 encounters) 61% female, 39% male
Less
than
2
2 th
roug
h 4
5 th
roug
h 9
10 th
roug
h 14
15 th
roug
h 19
20 th
roug
h 29
30 th
roug
h 39
40 th
roug
h 49
50 th
roug
h 59
60 th
roug
h 69
70 th
roug
h 79
80 th
roug
h 89
Mor
e th
an 9
00
500
1000
1500
2000
2500
3000
3500
4000Visits by age and gender in FY13
FemaleMale
vis
its
July
12
- J
un
e 1
3
* Includes lab and xray encounters (30650 encounters)
0 through 99% 10
through 196%
20 through 2910%
30 through 5949%
60 and above27%
NE Visits * by age group for FY13
Ten percent of the FMP patient visits must be with patients less than 10 years of age.
Ten percent of the FMP patient visits must be with patients 60 years of age or more
So what is the visit mix for the NE residents?
New RRC requirementsfor resident visits
0 through 915%
10 through 197%
20 through 2912%
30 through 5946%
60 and above20%
NE Visits by age group for FY13(Residents only)
Includes only residents’ visits (6389 visits)
Payor mix
By Panel By Service
Commercial (54.3%)
Medicare 65+ (6.3%)
Medicare under 65 (4.2%)
Medicaid (17.9%)
Uninsured (17.3%)
Commercial (61.3%)
Medicare 65+ (9.6%)
Medicare under 65 (5.9%)
Medicaid (19.1%)
Uninsured (4.1%)
Notice how insurance status affects access/utilization data.
Any Thoughts?As you develop QI and community medicine projects here at Northeast, start by sifting through the data.
Here’s what caught my eye…
◦ Our data shows 14.9% of our patients are black◦ According to the U.S. census bureau, Blacks
make up 5.4% of the population in Dane County 6.5% in WI 13.6% in the U.S. http
://quickfacts.census.gov/qfd/states/55/55025.html
◦ Did you know that we are caring for a relatively large percentage of black patients in our clinic relative to their prevalence in our community?
Example
GEO-MAPPINGWhere are our patients?
Mapping NE patients: To orient you, we have no patients in the lakes
An example of geo-mapping application
We have adopted Lake View Elementary School
We overlaid the census tract data of the Northeast Clinic population ages 5-11 years old with the Lake View Elementary School district map
Then we added data about BMI %ile
This shows most NE obese elementary school-age children don’t live in the Lake View Elementary school district (in light green).
CONDITIONS(Some) Northeast Diagnostic Codes
Condition # Patient
s
% Patient
s
% Female
% Male
Obesity 2628 29.4 60.4 39.6
Hyperlipidemia 1995 16.5 47.5 52.5
Hypertension 1918 15.9 53.2 46.8
Diabetes 661 5.5 52.3 47.7
CAD 222 1.8 36.0 64.0
CHF 78 0.6 64.1 35.9
Chronic Kidney Dis 240 2.0 63.8 36.2
Asthma 1122 9.3 62.7 37.3
Cancer 304 2.5 52.3 47.7
Chronic back pain 1501 12.4 62.2 37.8
Opioid 1268 10.5 61.3 38.7
Gender identity disorder
75 0.6 52.0 48.0
Chronic diseases at Northeast
7/1/12-6/30/13
Condition#
Patients
% Patient
s
% Female
% Male
Depression 2180 18.5 69.6 30.4
Anxiety 1456 12.1 67.3 32.7
Schizophrenia 125 1.0 47.2 52.8
Smoking 1831 17.5 50.8 49.2
Alcohol disorder 520 4.3 35.4 64.6
Substance use disorder
346 2.9 51.4 48.6
And more
7/1/12-6/30/13
Are we interested in the gender mix regarding
these conditions?Maybe. But how about: how are we doing compared to Dane County, WI and the nation?
Condition # Patients
% Patients
Dane county
%
WI %
U.S.%
Obesity 2628 29.4 24 29 25
Smoking 1831 17.5 15 19 13
Alcohol disorder 520 4.3 24 24 7
Diabetes 661 5.5 6 8 8.3
Another look at chronic diseases at Northeast
7/1/12-6/30/13
www.countyhealthrankings.org
??? Christina Lightbourn would likely disagree with this.Remember data is limited by what you input.
What diagnosis code(s) are we using here?
What intrigues you?We have developed some great interventions around diabetes at Northeast, but look at back pain and opiods…
Condition # Patient
s
% Patient
s
% Female
% Male
Obesity 2628 29.4 60.4 39.6
Hyperlipidemia 1995 16.5 47.5 52.5
Hypertension 1918 15.9 53.2 46.8
Diabetes 661 5.5 52.3 47.7
CAD 222 1.8 36.0 64.0
CHF 78 0.6 64.1 35.9
Chronic Kidney Dis 240 2.0 63.8 36.2
Asthma 1122 9.3 62.7 37.3
Cancer 304 2.5 52.3 47.7
Chronic back pain 1501 12.4 62.2 37.8
Opioid 1268 10.5 61.3 38.7
Gender identity disorder
75 0.6 52.0 48.0
Chronic diseases at Northeast
7/1/12-6/30/13
ConditionPanel-Based Service-Based
# Patients
% Patients
# Patients
% Patients
Obesity 2628 29.4 2116 31.8
Hyperlipidemia 1995 16.5 1720 24.3
Hypertension 1918 15.9 1690 23.9
Diabetes 661 5.5 644 9.1
CAD 222 1.8 198 2.8
CHF 78 0.6 74 1.0
Chronic Kidney Dis 240 2.0 231 3.3
Asthma 1122 9.3 887 12.5
Cancer 304 2.5 255 3.6
Chronic back pain 1501 12.4 1187 16.8
Opioid 1268 10.5 1284 18.2
Gender identity disorder
75 0.6 38 0.5
And yet another look: panel vs service data
7/1/12-6/30/13
Our chronic pain champions
Carrie Stoltenberg and Ann O’Connor have founded and led our Chronic Controlled Substance Work Group at Northeast. This group◦ Uses a pain registry◦ Meets regularly and review our top users ◦ Develops QI tools and protocols such as our CCS
contracts
Reflecting upon the data
What the data showsWhat ideas do you
have?
Pain patients are high utilizers of health services.
Almost twice as many women as men have back pain and chronic opioid use
Group visits (e.g. yoga) for chronic pain patients?
A smoother process for refill of chronic controlled substances?
…
QUALITY INDICATORSSome data you can access immediately from your
EPIC dashboard
NE %
UWMF
goal %
Breast CA screening 70.7 >70
Colon CA screening 66.9 >70
% A1c testing 97.9 >67.6
% LDL testing 89.8 >76.7
% A1c control 54.3 >47.7
% LDL control 54.4 >57.5
% BP control 46.9 >48.0
Pneumococcal vaccine 83.7 >75
Examples of clinical metrics that you can find on your dashboard on the clinic level and on a provider level
NE %
UWMF
goal %
SCHEDULING
% Template Filled 67.5 >85
% Slot Utilization 74.3 >85
% No-Show 9.5 <4
PATIENT EXPERIENCE
% appt available when needed 66.9 >77
% Explanations that I understand 89.3 >92.2
Examples of scheduling (access) and Avatar (patient satisfaction) metrics
Looks like we need to work on access issues.
Clinic level data◦Avatar % top box◦Diabetes registry performance◦Immunizations◦Pay for performance
Data Handouts…
Although these metrics are important to track and work on, there are others you could search out.
Keep health disparities in the forefrontIt’s in the data
“Of all the forms on inequality, injustice in health care is the most shocking and
inhumane.” Rev. Martin Luther King, Jr
PHOTO BY UCI DIGITAL COLLECTIONS
An exampleAsthma
UWMF has no quality incentives to encourage the health care community to focus upon asthma parameters
But consider the following slides(and remember about 1 in 6 patients at NE are black):
Asthma
Being non-white in WI with asthma
Adult Asthma Prevalence, 2008
Child Asthma Prevalence, 2008
http://www.cdc.gov/asthma/stateprofiles/Asthma_in_WI.pdf
Whi
te N
H
Blac
k NH
Hispa
nic
Other
NH
Mul
tirac
e NH
0
5
10
15
20
25
WIU.S.
Whi
te N
H
Blac
k NH
Hispa
nic
Other
NH
Mul
tirac
e NH
0
5
10
15
20
25
WIU.S.
White Black Other0
10
20
30
40
50
60
70
WIU.S.
Age-adjusted asthma mortality by race, 2007
http://www.cdc.gov/asthma/stateprofiles/Asthma_in_WI.pdf
Condition # Patient
s
% Patient
s
% Female
% Male
Obesity 2628 29.4 60.4 39.6
Hyperlipidemia 1995 16.5 47.5 52.5
Hypertension 1918 15.9 53.2 46.8
Diabetes 661 5.5 52.3 47.7
CAD 222 1.8 36.0 64.0
CHF 78 0.6 64.1 35.9
Chronic Kidney Dis 240 2.0 63.8 36.2
Asthma 1122 9.3 62.7 37.3
Cancer 304 2.5 52.3 47.7
Chronic back pain 1501 12.4 62.2 37.8
Opioid 1268 10.5 61.3 38.7
Gender identity disorder
75 0.6 52.0 48.0
Chronic diseases at Northeast
7/1/12-6/30/13
At NE, 1122 patients have asthma
White NH (60.1%)
Black NH (24.8%)
Hispanic (4.1%)
Asian (2.9%)
Native Am (0.1%)
Other (7.5%)
White NH
Black NH
Hispanic
Asian
Native Am
Other
0 2 4 6 8 10 12 14 16 18
%
%
The % afflicted with asthma within each racial/ethnic grouping
Where are they? A geo-mapping example: Northeast African American patients
Another layer: African American+ Age (0-17 years) + Asthma
They’re mostly in our backyard.
Is there a future project in the data?
This is an example of the kind of data that you can request of our DFM data warehouse from which could stem future projects◦ Jennifer Edgoose can help you focus your question
to request data from Wen-Jan Tuan, database administrator, at the DFM
FINANCESNext you’ll see data that shows ways
to follow the money
R1s4% R2s
9%
R3s14%
fel-lows
& Reed9%
faculty docs39%
PAs18%
NPs6%
Behav1%
23,428 visits in FY 13
VisitsV
isits
1,700
1,800
1,900
2,000
2,100
2,200
2,300
Month
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Northeast - Visits
Sources: Total Charges, RVUs, Prof essional Charges, wRVUs-Serv ice Prov ider-7207
Fiscal Year 2011 2012 2013
RevenueR
eve
nue
($)
160,000
170,000
180,000
190,000
200,000
210,000
220,000
230,000
240,000
Month
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Northeast - Actual Epic Non-Cap Revenue
Sources: Consolidated DFM - Actual-to-Budget-8027 / ----- DFM Budget
Fiscal Year 2011 2012 2013
Work RVUsW
ork
RV
Us
2,600
2,800
3,000
3,200
3,400
3,600
3,800
4,000
4,200
Month
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Northeast - Work RVUs
Visits exclude clinical staf f , f lu v accine, ancillary . Visits include direct patient care by phy s, PAs/NPs, and f ellows/residents. Sources: Inf ov iew retrospectiv e appointment report-3005B.
Fiscal Year 2011 2012 2013
Relative Value Units for Selected Services, 2008
(HCPCScode) TotalPhysician
WorkPractice Expense
Professional Liability Insurance
Brief Office Visit (99213) 1.9 0.97 1.9 0.05
Intermediate Office Visit (99214) 2.53 1.42 1.06 0.05
Diagnostic Colonoscopy (45378) 5.64 3.69 1.65 0.3
Total Hip Replacement (27130) 37.66 21.61 12.54 3.51
visits per hour
Edgoose Oriel Patterson Rabago SannerSchrage
r Schwab avg
Jul 10 - Dec 10 2.32 2.57 2.49 2.84 2.80 2.72 2.75 2.64
Jan 13 - Jun 13 2.24 2.52 2.21 2.50 2.31 2.60 2.63 2.43change -0.07 -0.05 -0.29 -0.34 -0.48 -0.12 -0.11 -0.21
RVUs per hour
Edgoose Oriel Patterson Rabago SannerSchrage
r Schwab avg
Jul 10 - Dec 10 3.23 4.14 3.21 4.12 4.11 3.84 4.45 3.87
Jan 13 - Jun 13 3.70 4.34 3.39 3.93 4.26 4.11 4.53 4.04change 0.47 0.20 0.18 -0.19 0.15 0.27 0.09 0.17
Does NOT include procedure-only visits
Notice how NE faculty visits per hour have declined while RVU’s per hour have increased
“What do you NEED to address today?” (limited agenda each visit, comprehensive care via a series of visits or at periodic “physicals”)
Now “every visit is about everything”◦ Comprehensive review/action expected at every visit:
Immunizations at every visit Health maintenance at every visit Chronic disease metrics (e.g. Diabetes) reviewed at every visit Complete medication reconciliation
◦ Higher copays – pt’s want to avoid visits◦ Mychart used instead of visits?◦ Patient satisfaction higher with comprehensive care each
time?◦ Higher provider satisfaction with fewer longer more
comprehensive visits?
Is there a shift in approach to managing the visit agenda?
A look at the long-
view (2008 to 2013)
A long-view of charges at NE (2008 to 2013)
see next slide
7/2012-6/2013
Here’s a summary from 2008 to present:Type of Service 2008-2009 2012-2013
Charges $ % Charges $ %
Inpatient Hospital 903,826 12 792,070 8
ED 1328 3220
Home Health 1157 4410
Independent Lab 593,043 8
Office 5,918,666 79 8,726,879 91
Outpatient Hospital 45,195 1 85,879 1
SNF 9,760 25,315
Assisted Living Fac 288
7,472,975 9,638,061
When you make comparisons you see that operations evolve. This is
something we don’t have now.
This shows more care/charges in the office over
time.
Revenue Actual %Rev/%Exp
Budget Variance
Patient fee revenue
4,297,793 58% 4,392,564 (94,771)
Hospital revenue
1,491,431 20% 1,578,269 (86,838)
State revenue 1,538,525 21% 1,538,526 (1)
Other revenue 81,950 1% 117,964 (36,014)
TOTAL REVENUE
7,409,699 100% 7,627,33 (217,624)
Revenue: Northeast May 31,2013
Revenue: Northeast May 31,2013
Actual Revenue Budgeted Revenue
Patient fee revenue (58%)
Hospital revenue (20%)
State revenue (21%)
Other revenue (1%)
Patient fee revenue (58%)Hospital revenue (21%)State revenue (20%)Other revenue (1%)
GHC (including GHC MA) per-member-per-month (PMPM) direct to DFM◦ “converted” to charges/payments for internal
analysis Unity (all) and PPlus (not MA)– PMPM to UW Health
◦ Split between UWH (and Meriter) and UWMF◦ UWMF $ internally allocated by charges
If we bill less then specialists get more… Dean is fee-for-service (FFS) Medicare and Medicaid FFS except GHC-MA
Payer Mix – we get paid differently…
2009/2013 “The work we do” “The money we get” “Money/
Work"
Payor Charges % of chgs Payments % of pays Collection %
GHC 1,228,4661,519,633
1616
891,9891,075,844
2324
7371
Medicaid 1,296,9991,878,035
1719
445,153542,811
1112
3429
Medicare 1,298,2332,185,700
1723
417,127688,925
1115
3232
Physician Plus
1,155,628944,555
1510
507,223342,287
138
4436
Unity 876,3341,475.370
1215
529,038828,358
1418
6056
Workers Comp
38,41237,343
10
35,88531,610
11
9385
All other & self pay
1,578,9031,597,425
2117
1,064,809970,644
2722
6761
TOTAL 7,472,9759,638,061
100100
3,891,2244,480,479
100100
5246
Payor mix: work and pay (comparing 2009 with 2013)
Percent of charges
2009 2013
GHC (16%)
Medicaid (17%
Medi-care
(17%)
Phys Plus
(15%)
Unity (12%)
Workers Comp (1%)
All others/
self pay
(21%)
GHC (16%)
Medicaid (19%)
Medicare (23%)Phys
Plus (10%)
Unity (15%)
All oth-ers/self pay
(17%)
Look at Physician Plus vs Unity over the years
Salaries & Benefits
Actual %Rev/%Exp
Budget Variance
Physician 1,650,510 22% 1,684,353 (33,834)
Resident 821,284 11% 773,960 47,334
PA and NPs 458,490 6% 473,660 (15,170)
Staff 1,696,305 23% 1,861,057 (164,752)
SUB-TOTAL4,626,60
8 62% 4,793,030(166,42
2)
Expenses: Salaries (Northeast May 31,2013)
Non-Personnel Actual
%Rev/%Exp Budget Variance
Facilities 469,053 6% 461,538 7,515
Supplies 389,132 5% 312,895 76,237
Purchased services 111,718 1% 92,213 19,505
Lab 118,968 2% 100,837 18,131
Other operating expenses
950,063 13% 1,044,131 (94,068)
Assessment 755,705 10% 758,857 (3,152)
R&D 41,681 1% 44,627 (2,946)
Sub-total2,836,32
0 38% 2,815,098 21,222
Expenses: Non-Personnel (Northeast May 31,2013)
Expenses: Northeast May 31,2013
Actual Expenses Budgeted Expenses
Physician (22%)
Resident (11%)
PA/NPs (6%)Staff (23%)Facilities
(6%)
Supplies (5%)
Pur-chased services
(1%)
Lab (2%) Other (13%)
Assessment (10%)R&D (1%)
Physician (22%)
Resident (11%)
PA/NPs (6%)Staff (23%)
Facilities (6%)
Supplies (5%)
Pur-chased services
(1%)
Lab (2%) Other (13%)
Assessment (10%)R&D (1%)
Actual Budget Variance
TOTAL REVENUE 7,409,699 7,627,323 (217,624)
TOTAL EXPENSES 7,462,828 7,608,128 (145,200)
NET BALANCE (53,229) 19,195 (72,424)
The final tally: (Northeast May 31,2013)
Clinic % of 99213 %99214-5
Belleville 50.1 46.3
Northeast 40 55.3
Verona 65.3 29
Wingra 55.2 41.6
Fitchburg 26 70.4
Odana Atrium 49.7 44.6
Coding Level for Billing: (data for first 6 months of 2013)
GO NORTHEAST!
While we want to acknowledge the unique individuals who make up each data point, we wanted to share with you a bird eye’s vantage of Northeast.
Our clinic is growing and has room to continue to improve on many different metrics.
We have reviewed Northeast data through◦ Demographics◦ Geo-mapping◦ Chronic conditions◦ Finances
We will provide you with some examples of your own personal data.
In conclusion
Thank youQuestions?
NE Provider specific data-the state of your practice
Document what you do Code what you document Yes… knowing how to code does effect how
you document
Coding of visits
◦ You ARE doing the work (complex management)◦ Reflects your specialty’s value
To your health system and group practice partners To insurers To patients
◦ Effects payment, $ to pay yourself and… Pays for your nurse, receptionist, heat, electricity Higher coding helps pay for services we don’t get paid
for (phone calls, mychart, letters…)◦ Effects “production” expectations – would you
rather have many short visits or fewer longer visits each day? Higher coding justifies a comprehensive care model
Why should you maximize coding?
◦In many group practices (e.g. UW Health) with capitated insurance (e.g. Unity and PPlus) if you code low then the subspecialists get a larger slice of the pie
◦So how much do you want to pay the ***ologists?
The zero sum capitation world
Better to document and code appropriately and then deal with discounting the bill than to undercode.◦ Undercoding is actually fraud in Medicare◦ … as is overcoding
Programs to forgive/discount bills◦ UWMF Community Cares◦ Various prescription drug programs
But what about patients with no insurance or limited coverage?
CODE DESCRIPTIONWork RVU
Total RVU
OFFICE VISIT,NEW PATIENT,EVAL AND MANAGEMENT99202 LEVEL 2 0.93 1.96 99203 LEVEL 3 1.42 2.83 99204 LEVEL 4 2.43 4.39 99205 LEVEL 5 3.17 5.47
OFFICE VISIT,ESTABLISHED PATIENT,EVAL AND MANAGEMENT99213 LEVEL3 0.97 1.90 99214 LEVEL 4 1.50 2.82 99215 LEVEL 5 2.11 3.81
99381 PREVENTIVE MEDICINE , NEW PATIENT,<1 YEAR 1.19 2.45 99382 AGE 1-4 YEARS 1.36 2.69 99383 AGE 5-11 YEARS 1.36 2.69 99384 AGE 12-17 YEARS 1.53 2.93 99385 AGE 18-39 YEARS 1.53 2.93 99386 AGE 40-64 YEARS 1.88 3.42 99387 65 YEARS AND OVER 2.06 3.77
99391 PREVENTIVE MEDICINE ,ESTABLISHED PT,AGE <1 YR 1.02 2.11 99392 AGE 1-4 YEARS 1.19 2.35 99393 AGE 5-11 YEARS 1.19 2.34 99394 AGE 12-17 YEARS 1.36 2.58 99395 AGE 18-39 YEARS 1.36 2.59 99396 AGE 40-64 YEARS 1.53 2.83 99397 AGE 65 AND OVER 1.71 3.19
In summer 2010 I started a series of “revival meetings” at NE and other clinics to more appropriately code visits at a level reflecting our actual work:◦ 99214 vs 99213◦ Preventive visits with carve outs
How are we doing? (data review) Simplified (but accurate) rules for coding
99214 and carve outs
“Level 4 coding revival!”
SannerSchwa
bRabag
o Oriel Schraeger JWN MVDPatterso
nO'Conno
r
Jul 09 - Dec 09 26% 35% 28% 28% 25% 60% 14% 33% 2%
Jan 10 - Jun 10 34% 47% 41% 39% 25% 69% 24% 31% 4%
Jul 10 - Dec 10 60% 64% 58% 48% 39% 66% 42% 16%
Jan 11 - Jun 11 70% 66% 62% 57% 35% 66% 43% 47% 21%
Jul 11 - Dec 11 78% 69% 51% 66% 42% 62% 54% 45% 28%
Jan 12 - Jun 12 78% 69% 55% 65% 63% 61% 48% 47% 39%
Jul 12 - Dec 12 86% 80% 58% 58% 60% 56% 57% 44% 43%
Jan 13 - Jun 13 85% 75% 68% 64% 60% 57% 53% 33% 29%
We got religion… 99214 & 99215 coding as % of all established E&M visits
Aug 2010 rivival!
Jul 09-Dec 09
Jan 10- Jun 10
Jul 10-Dec 10
Jan 11- Jun 11
Jul 11 - Dec 11
Jan 12 - Jun 12
Jul 12 - Dec 12
Jan 13 - Jun 13
0%10%20%30%40%50%60%70%80%90%
% level 4&5 codes for est patient visits
R1s Level 4/5R2s Level 4/5R3s Level 4/5
So did the residents…
And the new recruits…
Jul 09 - Dec
09
Jan 10 - Jun 10
Jul 10 - Dec
10
Jan 11 - Jun 11
Jul 11 - Dec
11
Jan 12 - Jun 12
Jul 12 - Dec
12
Jan 13 - Jun 13
0%10%20%30%40%50%60%70%80%90%
100%
% level 4&5 codes for est patient visits
LemmonReedHayonEdgooseUminski
Coding level 99214 (detailed established office visit) simplified◦ See separate sheet◦ It may change how you structure progess notes,
but not make them longer Rules for carve outs Other “high value” codes
So how do you do this?
Example 1• 66yo male• SUBJECTIVE:• Here with several concerns:• 1) 1 week of nasal congestion green, cough green mucous. 2 days R ear itch but not painful. L jaw ache. Chills but no fever
measured. • 2) DM lab f/u: Taking lantus 10u/d since 12/22/10. FBGs checked 3-4x/week and have been 100s-130s. None <80 in 6 mo. • • ROS: Occas chest pain unchanged in > 1 year. No nausea or diarrhea. No numbness, weakness or tingling all extemeties.• • Pertinent PSFH:: Wife had URI symptoms resolved last week. Stress echo neg in Dec 2010. No hx sinus surgery. Last abx >6 mo
ago.• • • OBJECTIVE:• Nurses note and vital signs reviewed• Head; normocephalic, atraumatic. ENT- both TM normal without fluid or infection, throat normal without erythema or exudate
and frontal sinus tender.• Lungs clear to auscultation. Good air movement bilaterally without rales, wheezes, or rhonchi.• COR: Regular rate and rhythm. S1 and S2 normal, no murmurs, clicks, gallops or rubs.• • Recent labs reviewed.• • ASSESSMENT: • Sinus congestion - possible sinusitis given duration and sinus area tenderness• DM in control. Lipids in control• • PLAN: • zpack• Refilled chronic meds - no change• Return in 4 mo for fasting labs (see orders) with F/U visit with me 1-2 weeks later
Example 2• 75yo male• • SUBJECTIVE:• Here with several issues:• 1) HTN. BPs have been good at home (100-130/60s). • 2) DM. BGs at home checks TID, fastings 93-140s, preprandials 80-170.• 3) Lipids. Taking lovastatin 40 only QOD• • Pertinent PSFH: Lives alone. Retired. Son comes to visit approx 3x/wk, also has a friend who visits. Pt does own grocery
shopping, drives himself. Wakes at 1-2am every day (used to this from lifelong work routine). Known CAD.• • ROS: No CP, diarrhea, nausea, recent fevers. Mild nasal congestion. No dysuria. Stream good. Nocturia x 1 stable. No
lower extremity numbness or pain. No myalgias or weakness.• • OBJECTIVE:• Vital signs and nurse's note reviewed.• Chest: Clear; no wheezes or rales. • Cardiac: Regular rate and rhythm. S1 and S2 normal; no murmurs, clicks, gallops or rubs. • Extremities: 2+edema L, 1+ R • • ASSESSMENT:• DM in good control • LDL near goal (<80) at 88.• HTN in control• • PLAN:• No change meds• He may be getting set up with VA to get a better deal on medication costs• Return to me in 6 mo for fasting labs (see orders) with F/U visit with me 1-2 weeks later
Example 3• 36 yo male• • SUBJECTIVE:• Here with new problem: Dentist noted increasing pigmentation of gingiva over last year and wondered if pt has
hemachromatosis. Patient has noted darkening gingival and buccal mucosal pigment, bilateral symrtric, blotchy distribution, slowly progressing over few years not associated with pain or bleeding. No tooth pain or loosening. Had sores inside lower lip early this mo - now resolved.
• • ROS: No fevers, cough, congestion, sore throat. No nausea/diarrhea. No abdominal pain. Wt stable. Denies
arthralgias, joint swelling, myalgias.• • Pertinent PSFH: No recent foreign travel (last was June 2009 to Mali). No family history arthritis or mouth sores.• • OBJECTIVE:• Vital signs and nurse's note reviewed.• Diffuse variably dark pigmentation buccal mucosa and gingiva. No other skin rash or lesions.• Abdomen: Normal BS. No HSM/masses. Nontender.• • ASSESSMENT:• Hyperpigmented oral mucosa new per pt and dentist. No other signs hemachromatosis or connective tissue disease.• • PLAN:• Check labs (see orders) - letter with results.• If labs normal no further f/u needed at this point.• Due for CPE April
Carve outs and preventive visits If you see a patient for a preventive visit AND
you deal with one or more problems you should bill a “carve out” E&M code
Preventive visits include ”physicals”, WWE, WCC.
A carve out is billed using exactly the same rules as a regular E&M visit◦ E.g. if the patient has 3 stable problems (e.g. DM,
DJD, depression) and you refill meds = 99214 carve out
EPIC example
RBRVS 2010
High value codes…2010
Madison charge
Work RVU
Total RVU
example of a carve out:
99397 AGE 65 AND OVER $ 238 1.71 3.19
99214 LEVEL 4 $ 194 1.50 2.82
3.21 6.01
Internal UW Health "credit for work done" 3.21 RVUs
if insurance ONLY pays for prevention visits then pt gets bill for $ -
if insurance ONLY pays for E&M (illness) visits then pt gets bill for $ 44
Transition Care Management (TCM) codes implemented 1/1/201399495 (moderate complexity): 2.11 4.82
99496 (high complexity): 3.05 6.79
Thus we rarely have a 1:4 staffer:resident ratio
The quick “tag in” interruption is welcomed Tell me what you want me to say… and we
can discuss more later Other visit types need staffer to lay eyes on
pt:◦ R1s in 1st 6 months◦ Procedures◦ Preops billed as consults
Yes… the physician staffer needs to see the patient for a resident to bill a level 4 or 5 (even as part of carve out)
So just do it!
RRC requires 1650 visits over 3 years with minimum 150 in first year
The class that graduated June 2013 (Fox, Schaefer, Marty, Dhanoa) averaged total 1709 visits
Number of visits still matters
visits as R1 visits as R2 visits as R3
class of 2013
295.25 621 792.25
class of 2014
294.25 519.5 NaN
class of 2015
226.75 NaN NaN
50250450650850
NE clinic visits per year
sessions as R1 sessions as R2 sessions as R3
class of 2013
83 103.75 121.25
class of 2014
83 98.75 NaN
class of 2015
74.5 NaN NaN
40
80
120
NE clinic sessions (half-days) per year
visits/session as R1
visits/session as R2
visits/session as R3
class of 2013
3.56241743170623
5.97904851329542
6.53758247661387
class of 2014
3.54872271454434
5.26628525196486
NaN
class of 2015
3.04500058500059
NaN NaN
2.3
3.8
5.3
6.8
NE clinic visits per session
Clinic level data◦ Avatar % top box◦ Diabetes registry performance◦ Immunizations◦ Pay for performance
Individual provider data◦ Clinician profile◦ Opioid registry◦ Diabetes registry◦ Avatar data
Handouts…