Jumping into Primary Jumping into Primary CareCare

Kimmer Collison-RisKimmer Collison-Ris

MSN, ARNP, WOCNMSN, ARNP, WOCN

Taking on a New RoleTaking on a New Role

Find a mentor matchFind a mentor match Understanding the learning Understanding the learning

curvecurve Know what you knowKnow what you know Study-study-studyStudy-study-study Simplify your home lifeSimplify your home life Build routines into your weekBuild routines into your week Build in a day of restBuild in a day of rest

Preparing for the visitPreparing for the visit

Work with your MAWork with your MA Know what your RN’s doKnow what your RN’s do Delegate when you canDelegate when you can Know your patient roomsKnow your patient rooms Know your daily scheduleKnow your daily schedule Know how long procedures takeKnow how long procedures take Know how to billKnow how to bill Chart as you goChart as you go Plan on 15 min for a visitPlan on 15 min for a visit Keep your visit straight forwardKeep your visit straight forward Know when to referKnow when to refer

Types of Patient visitsTypes of Patient visits

1 problem (approx 15 min)1 problem (approx 15 min) Assess each system above & downAssess each system above & down Know when to include another Know when to include another

systemsystem Culture, peak flow, treat as you goCulture, peak flow, treat as you go Chart as you goChart as you go Account for time spentAccount for time spent Plan f/u visit for other issuesPlan f/u visit for other issues

ProceduresProcedures

Plan ahead & schedule apptPlan ahead & schedule appt Can only do on same visit if new Can only do on same visit if new

patientpatient Can’t do w/office visit on same Can’t do w/office visit on same

day day Plan (30-40 min)Plan (30-40 min) Know what you can do in officeKnow what you can do in office Know when to refer!!!Know when to refer!!!

Being preparedBeing prepared

Know your daily scheduleKnow your daily schedule Know your “go to resource”Know your “go to resource” Carry a couple reference booksCarry a couple reference books Carry paperwork w/youCarry paperwork w/you Know recent labs/studies performedKnow recent labs/studies performed Do cultures/dips/sats/screensDo cultures/dips/sats/screens Plan next f/u visitPlan next f/u visit Enlist MA or Nurse assistanceEnlist MA or Nurse assistance Know where local resources areKnow where local resources are

Mid-Level CareMid-Level Care

Different than student roleDifferent than student role Can feel overwhelmingCan feel overwhelming Designed for PE’s, wcc’s, episodic Designed for PE’s, wcc’s, episodic

care, chronic care, & urgent carecare, chronic care, & urgent care Increases patient access to careIncreases patient access to care Frees MD’s for complex careFrees MD’s for complex care Temptation to work out of scopeTemptation to work out of scope Need to “tag-team” with MDNeed to “tag-team” with MD Know roles/scope of MA’s, Nurses, & Know roles/scope of MA’s, Nurses, &

Office staffOffice staff

New ExperienceNew Experience

Interpreting odd Lab dataInterpreting odd Lab data Interpreting odd diagnostic testsInterpreting odd diagnostic tests Keeping visits simple/shortKeeping visits simple/short Charting in “real time”Charting in “real time” Constant flow of patientsConstant flow of patients Temptation to skip breaksTemptation to skip breaks Temptation to “do it all”Temptation to “do it all” Temptation to do proceduresTemptation to do procedures Temptation to work out of role/scopeTemptation to work out of role/scope

Know Practice ExpectationsKnow Practice Expectations

How many patients dailyHow many patients daily Charting expectationsCharting expectations Patient follow up expectationsPatient follow up expectations Know practice reimbursementKnow practice reimbursement Know practice philosophy of careKnow practice philosophy of care Know role of practice managerKnow role of practice manager Who is your boss?Who is your boss? Know practice medical director roleKnow practice medical director role Know when to interrupt someoneKnow when to interrupt someone Know practice expectation of staffKnow practice expectation of staff

General Family PracticeGeneral Family Practice Philosophy of carePhilosophy of care Make up of Pediatrics/Adults/GeriatricsMake up of Pediatrics/Adults/Geriatrics Charting Requirements for reimbursementCharting Requirements for reimbursement Coding Requirements for reimbursementCoding Requirements for reimbursement ““Leaky Boat” to a practiceLeaky Boat” to a practice

High % of HMO, Medicade, Medicare, chronic wound High % of HMO, Medicade, Medicare, chronic wound carecare

Money MakersMoney Makers Labs, proceduresLabs, procedures CosmeticCosmetic

% of Practice Patients% of Practice Patients MedicadeMedicade MedicareMedicare HMO’sHMO’s Private PayPrivate Pay InsurersInsurers

Surgical PracticeSurgical Practice Know pt mixKnow pt mix Know insurers/reimbursement foKnow insurers/reimbursement fo

ConsultationsConsultations ProceduresProcedures

Your role frees up SurgeonsYour role frees up Surgeons Surgical assist is reimbursableSurgical assist is reimbursable Cosmetic procedures make $Cosmetic procedures make $ Know your scope of practiceKnow your scope of practice Know practice philosophyKnow practice philosophy Know expected work & on call hoursKnow expected work & on call hours

Specialty PracticeSpecialty Practice

Know patient mixKnow patient mix Know philosophy of careKnow philosophy of care Know your expected roleKnow your expected role Know how you benefit practiceKnow how you benefit practice How do you bring in moneyHow do you bring in money Know reimbursement differencesKnow reimbursement differences ConsultationConsultation Stream-lined care, specializedStream-lined care, specialized Usually affords more timeUsually affords more time Know money-pitsKnow money-pits Know money makersKnow money makers

Becoming a Smart ProviderBecoming a Smart Provider Fill out your own paperworkFill out your own paperwork Know your numbersKnow your numbers Know Coding/billing/reimbursement processKnow Coding/billing/reimbursement process Consider becoming a P.S.Consider becoming a P.S. Carry your own Malpractice InsuranceCarry your own Malpractice Insurance Get an accountant (file quarterly)Get an accountant (file quarterly) Know your tax write-offsKnow your tax write-offs Get quickbooks and record receipts dailyGet quickbooks and record receipts daily Employee, Consultant, Sub-Contractor Employee, Consultant, Sub-Contractor

(Locums)(Locums) Signing up w/insurersSigning up w/insurers

Medicare (know probs & pitfalls)Medicare (know probs & pitfalls) Regence, Premera, UniformRegence, Premera, Uniform HMO’s expectationsHMO’s expectations MedicadeMedicade

Charting the basicsCharting the basics Write out chief complaint cc:Write out chief complaint cc: State new or “pt is new to me”State new or “pt is new to me” Write out timing, duration, location, severity, worsening Write out timing, duration, location, severity, worsening

sxsx Include pertinent (+) and (-)Include pertinent (+) and (-) ROS (at least 2)ROS (at least 2) Exam (1 system up, 1 system down, others as Exam (1 system up, 1 system down, others as

indicated)indicated) Assessment: Dx &/or diff. dxAssessment: Dx &/or diff. dx Determine stability, acute, chronic, worseningDetermine stability, acute, chronic, worsening Plan of care: address all pointsPlan of care: address all points If referring use “consultation”If referring use “consultation” Describe when f/u will occurDescribe when f/u will occur Include labs reviewed/discussed/MD specialists Include labs reviewed/discussed/MD specialists

conferred withconferred with Include rx meds orderedInclude rx meds ordered

Medical Medical Coding/ReimbursementCoding/ReimbursementRemember that carrying out care is different Remember that carrying out care is different

than what you learned in schoolthan what you learned in schoolNeed to know the basics to include in charting Need to know the basics to include in charting

to meet coding criteriato meet coding criteriaAlways include amt of time spent Always include amt of time spent

assessing/counseling if poss to help visit assessing/counseling if poss to help visit code code

Know difference between new, estab, Know difference between new, estab, consultation, well visit, and timed visitconsultation, well visit, and timed visit

Write out detail diagnosis codes or add Write out detail diagnosis codes or add descriptorsdescriptors

If poss use more than 1 dx to help justify your If poss use more than 1 dx to help justify your codecode

Coding/ReimbursementCoding/Reimbursement You need to know as much as medical coder You need to know as much as medical coder

(your totally responsible)(your totally responsible) Know procedures need body identification and Know procedures need body identification and

code and have return time requirementscode and have return time requirements Know office visits (OV) and procedures Know office visits (OV) and procedures

generally can’t be billed on same day unless generally can’t be billed on same day unless new and require code “25”new and require code “25”

Know code modifiersKnow code modifiers Reimbursement classes from medical billers Reimbursement classes from medical billers

vary per practice settingvary per practice setting Can’t bill for visit same day as other specialist Can’t bill for visit same day as other specialist

visit for Medicare pts as is considered visit for Medicare pts as is considered “duplication of services”“duplication of services”

Medicade coding is differentMedicade coding is different

How to get paid/reimbursedHow to get paid/reimbursed Know Credentialing ProcessKnow Credentialing Process Know Cash reimbursement rulesKnow Cash reimbursement rules Can’t charge non-insured less than Can’t charge non-insured less than

reimbursed for by insurers or considered reimbursed for by insurers or considered fraudfraud

Can’t pay someone’s co pay or licensure can Can’t pay someone’s co pay or licensure can be revokedbe revoked

Know HMO rules before signing upKnow HMO rules before signing up Know how your practice is paidKnow how your practice is paid Can’t “forgive” debt unless funding is set upCan’t “forgive” debt unless funding is set up If private practice, find reliable subcontracted If private practice, find reliable subcontracted

medical biller and call their referencesmedical biller and call their references Match charting to coding on fee slipMatch charting to coding on fee slip

Organizing your timeOrganizing your time First: look at daily scheduleFirst: look at daily schedule Review abn labs, pass normals to MA to call ptReview abn labs, pass normals to MA to call pt Have MA room pt as arrivesHave MA room pt as arrives Don’t double bookDon’t double book Keep visits to around 15 minKeep visits to around 15 min Clean as you go in roomClean as you go in room Clarify needs to MAClarify needs to MA Ask for teaching help from RNAsk for teaching help from RN Send pt for necessary tests, sched f/u Send pt for necessary tests, sched f/u

afterwardsafterwards In pt visit: Pick 1 or 2 probs onlyIn pt visit: Pick 1 or 2 probs only Carry resource books w/youCarry resource books w/you Keep interruptions to minimumKeep interruptions to minimum Get your lunch, leave the facility-re energiesGet your lunch, leave the facility-re energies Get help if need second opinionGet help if need second opinion

Keeping an office visit on trackKeeping an office visit on track After “hello” _____________After “hello” _____________ What can I do for you today? (cc) have them What can I do for you today? (cc) have them

pick top 2pick top 2 Let them they can set up add’l appt for other Let them they can set up add’l appt for other

issuesissues Explain you want to ask specific questionsExplain you want to ask specific questions Chart as you go your observations and what Chart as you go your observations and what

they saythey say Assess system up and down of cc:Assess system up and down of cc: If you find other things may need sep. apptIf you find other things may need sep. appt Exam & ask clarifying questionsExam & ask clarifying questions Explain observations as you goExplain observations as you go Discuss poss tx/tests as you goDiscuss poss tx/tests as you go Teach & Type-stating when to call/seek careTeach & Type-stating when to call/seek care State visit finished end w/giving rx/apptState visit finished end w/giving rx/appt

Plan for Patient EncountersPlan for Patient Encounters

Know visit: components, worrisome findings, Know visit: components, worrisome findings, gen tx/meds, tests to order, pt education, f/u gen tx/meds, tests to order, pt education, f/u

Practice visit types:Practice visit types: New born examNew born exam Jaundice/poor feeding NB examJaundice/poor feeding NB exam Well childWell child Well adultWell adult Sick childSick child Sick adultSick adult Initial, f/u, & emergency OB visitInitial, f/u, & emergency OB visit Postpartum f/u visitPostpartum f/u visit Chronically ill adultChronically ill adult Urgent care type visitsUrgent care type visits Emergency type visitsEmergency type visits

Balancing Work/Home LifeBalancing Work/Home Life Your family is your lifeYour family is your life Don’t sacrifice your spouse/S.O.Don’t sacrifice your spouse/S.O. Don’t sacrifice your kids-set time aside Don’t sacrifice your kids-set time aside Learn to say “no”Learn to say “no” Incorporate daily/weekly routinesIncorporate daily/weekly routines Know you can’t “do it all”Know you can’t “do it all” Make time to studyMake time to study Make time to exerciseMake time to exercise Plan out meals aheadPlan out meals ahead Keep work out of family timeKeep work out of family time Don’t talk to patients at homeDon’t talk to patients at home Date your spouse/S.O.Date your spouse/S.O. Plan out vacation/away timePlan out vacation/away time

Building your C.V.Building your C.V.

-Work history-Work history-Specialty focus-Specialty focus-Professional Membership/Affiliations-Professional Membership/Affiliations-Professional Lectures given-Professional Lectures given-Professional Publications written-Professional Publications written-Continuing Education -Continuing Education -Professional Education-Professional Education-Preferred Provider w/list of insurers-Preferred Provider w/list of insurers-Community Involvement-Community Involvement

NetworkingNetworking Look beyond your instructor/schoolLook beyond your instructor/school Visit your colleagues/classmatesVisit your colleagues/classmates Join a professional organizationJoin a professional organization Lecture at a universityLecture at a university Lecture within the communityLecture within the community Host/participate in health eventsHost/participate in health events Write a local health newsletterWrite a local health newsletter Participate in conferencesParticipate in conferences Participate in a studyParticipate in a study Specialize in a field of interestSpecialize in a field of interest Join a study group/peer review groupJoin a study group/peer review group