narhc spring institute3. benefits and obstacles in managing for job fulfillment. what is happening...

NARHC Spring InstituteTuesday, March 20, 2018

San Antonio Conference

Breakout SessionsYour choice…

Regency Ballroom East:Washington Update

Bill Finerfrock

Rio Grande:

You are HERE!


Regency Ballroom East:Advanced Billing

Charles James, Jr.

Rio Grande:Leading Through Change While Removing Misery

from Your PracticeJeff Harper

You are HERE!

Leading Through Change While Removing Misery From Your Practice

Jeff HarperPrincipal, Consultant, Coach

InQuiseek, LLC

1

Leading through Change While removing Misery from your

Practice

Jeff Harper

Learning Objectives for Leading through Change

2

1. Healthcare in the Marketplace is driving Change

2. How to Affect Real

Change in Your RHC

3. Benefits and Obstacles in

Managing for Job Fulfillment

What is happening in the healthcare marketplace?

3

Primary Care meets Convenience

4

RHCs were once unique because they were the only game in town

“Oh %&#@!”Change is

difficult but not changing

is fatal!

THE C.A.R.E. MODEL©

5

Courtesy

Accommodate Respect

Excellence

Customer Service Model – C.A.R.E.

© InQuiseek Consulting

Steps to Change

6

But to change attitudes we must lead differently

Therefore we must have team-based leadership

But we must first change the culture

But we first have to change the staff attitudes

To compete with other clinics

We must have a customer service model

Who comes 1st?

7

This is closer to the sign we need

8

Patients come First and everyone else is

second!

To change we have to start acting differently and these two components must act differently…&

they seldom agree with one another

9

You have to appeal to both to see Change

10

IQ strengths:WillfulDeterminedAble to plan

EQ strengths:LoveCompassionLoyaltyGets the job done

IQ weaknesses:OverthinksOveranalyzesProcrastinates

EQ weaknesses:LazySkittishInstant gratification

IQ may ensure 1% to 20% success

EQ may ensure 25%

to 45% success

Use these to Direct the IQ of your staff and yourself

11

Find the Bright Spots

Exceptions to every problem

Overcome decision

paralysis with guidance

We love options but they’ll kill us

Goals or Targets

have to be clear

“Some is not a # and soon is not a date!”

Miss Jenny’s Clinic

401K

Use these to Motivate the EQ of your staff and yourself

12

Find the Feeling

Pain and Pleasure

move people

Always kick-start the change

And break a part the project

Find an identity that will aspire

We all want to be improving

Two things to be successful:

13

A Rural Health Clinic needs to be Smart

A Rural Health Clinic needs to be Healthy

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SMART RHCs are good at these decision sciences*:EHR Integration ComplianceWorkflow DesignTechnology

*we spend most of time here

But those things will not produce these signs of a healthy clinic:

High degree of moraleMinimal politics Less emails and texts stringsLow turnoverHigh degree of productivityCross training that happens naturally

Well…to become Healthy, you must have good Leadership

15

We all have some leadership skills but never enough

What would your Rural Health Clinic look like if the leadership situation improved?

There are four types of Leaders

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Leaders by

Position

Character

Strengths

Strengths and

Character

Contrasting Leadership Models

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Exploitive authoritative Leader

Benevolent authoritative Leader

Consulting Leader

Team-Based Leader

WHY IS TEAM-BASED LEADERSHIP NEEDED?

18

✓ No single person can develop the best solution✓ These changes affect multiple people and/or

departments✓ Buy-in will be required of all stakeholders✓ For these changes you will need an empowered

staff

Empowerment – enabling people to make decisions that affect their work

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Which is more corrupt?Giving power to people orKeeping them powerless?

The Leader

The Team

empowerment

20

Results

Accountability

Commitment

Conflict

Trust

Steps of Team-Building from 5 Dysfunctions of a Team by P. Lencioni

Three Signs of a Miserable Job

21

Anonymity

Irrelevance

Immeasurement

What would your RHC look like w/o these miserable symptoms?...

Misery can’t be contained either at work or at home.

22

Remember People don’t usually choose hospitals but they do choose

Clinics

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AnonymityPeople cannot be

fulfilled in their work if they are not known.

IrrelevanceEveryone needs

to know that their job matters, to someone.

ImmeasurementPeople need to

be able to gauge their own progress and level of contribution for themselves.

Get to know your people. Take time to sit down with each of

them and ask them what's going on in their lives.

They are not just answering the phone, they are giving

people access to vital healthcare!

How miserable would the ballgame be w/o a scoreboard?

People want measurables so that they can get a sense of

accomplishment.

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Jeff HarperInQuiseek, [email protected](318)243-5974

Network Break

SILVERSPONSORS

PREMIERSPONSOR

Refreshments in the Foyer + Regency East with Exhibitors

PLATINUMSPONSOR

GOLD SPONSORS

Hildebrand HealthcareConsulting LLC

http://thie.com/


Regency Ballroom East:PCMH & Other

InnovationsMichael Calhoun

Rio Grande:Top HIPAA Hazards &Social Media Snafus

Margaret C Scavotto

You are HERE!

Top HIPAA Hazards &Social Media Snafus

Margaret ScavottoJD, CHC, President

Management Performance Associates

HIPAA HAZARDS & SOCIAL MEDIA SNAFUSNARHCMARCH 20 , 2018M A R G A R E T S C AV O T T O , J D , C H CM PAS T. L O U I S , M O

E XP E CTT H E

U N E XP E CT E D

SNOOPINGEMPLOYEES WILL BE TEMPTED TO SNOOP MEDICAL RECORDS.

SNOOPING• A nurse snooped the medical records of her

nephew’s girlfriend, and learned she had a baby and gave it up for adoption. This secret was announced at a family funeral.

• Hospital employee snooped patient records for 14 years.

• When Britney Spears was hospitalized in 2008 for psychiatric care, 13 employees and 6 physicians at UCLA medical center looked at her medical records without a reason.

SNOOPING

Who are YOUR celebrities?

SNOOPING

What can you do?• Address snooping in your SRA and policies• Limit access• Terminate access• Review info system activity• Set up alerts• Use access controls• TRAIN

INSIDERS & BURGLARSWHAT COULD SOMEBODY TAKE FROM YOU?

INSIDERS

• An ex-employee stole patient information and patient photos from a Rodeo Drive plastic surgery clinic and put them on social media.

• A mental health tech stole census sheets from a behavioral health facility and sold them for $1,000 each.

INSIDERS

What can you do?• Background checks.• Consider insiders in your HIPAA Security risk

analysis and mitigation plan. • Use the minimum necessary rule. • Terminate access when employees leave.

BURGLARSWhat could a burglar steal from you?

• Burglars stole an unencrypted computer containing PHI for 24,000 patients from a dermatology practice. It was not encrypted.

• Burglars stole paper PHI from an eye doctors’ office – leaving electronic PHI systems untouched.

• Burglars took 13 boxes of paper medical records from an off-site storage facility. The burglar was caught when he tried to sell the patient records.

BURGLARS

What can you do?• Remember there is no such thing as secure

paper PHI. • If you use off-site storage, ask about their

HIPAA security program. Signing a BAA is required – but doesn’t guarantee your records are safe.

MAILWHAT’S IN YOUR ENVELOPE?HIPAA WANTS TO KNOW.

MAIL

What could go wrong?• Aetna used a contractor to complete a mailing.

The contractor used windowed envelopes. Through the window, the following words could be seen: “when filling prescriptions for HIV medications….”

• The Ohio Dept of Mental Health and Addiction Services sent a satisfaction survey to its patients via postcard (rather than sealed envelopes).

MAIL

Email issues• A hospital executive assistant sent an electronic

survey to patients by email. The goal of the survey was to identify ways to improve patient discharge paperwork. Hundreds of patient email addresses were visible in the “To” field of the email.

MINIMUM NECESSARY RULE BREACHESWHEN STAFF NEED TO USE PHI, BUT THEY USE TOO MUCH.

MINIMUM NECESSARY RULE BREACHES• A university student health center employee

discussed the results of a student’s pregnancy test with a female coworker.

• A nurse was fired from a Kentucky hospital after she told a physician and EKG technician to wear gloves for a procedure – because the patient has Hepatitis C.

MINIMUM NECESSARY RULE BREACHES

What can you do?

TRAIN.

AUGMENTED REALITY

PEOPLE USE THEIR PHONES – AND CAMERAS – FOR EVERYTHING.

POKÉMON GO

• Pokemon Go uses the smartphone’s camera phone to superimpose Pokemon characters on real-time photographs.

• Pokemon Go lets the user take a screenshot of the app (e.g., the real-time photograph).

ONLINE REVIEWS THE COMMENTS CONUNDRUM

ONLINE REVIEWS

“I looked very closely at your radiographs and it was obvious that you have cavities and gum disease that your other dentist has overlooked…You can live in a world of denial and simply believe what you want to hear from your other dentist or make an educated and informed decision.”

- [Your dentist]

SOCIAL MEDIAEVERYBODY’S DOING IT

PROTECTED HEALTH INFORMATION

HIPAA protects PHI: information that can identify a patient and relates to the patient’s health condition, treatment, and payment for treatment.

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PHOTOS AND VIDEOSSAY CHEESE!

PHOTOS & VIDEOS

Two paramedics were arrested and face criminal charges after they engaged in a selfie war by text.

“IT WAS JUST A PICTURE OF HER BUTT”

“They just blew everything out of proportion… It was just a picture of her butt. How many people take a picture of people’s butts?... I worked in health care for five years. Everybody takes pictures of residents all the time. I’m not the only one.”

https://www.propublica.org/article/nursing-home-workers-share-explicit-photos-of-residents-on-snapchat

https://www.propublica.org/article/nursing-home-workers-share-explicit-photos-of-residents-on-snapchat

PHOTOS AND VIDEOS

• Doctor posted plastic surgery photos online.

• Hospital employees took photos of a patient with a genital injury.

PROUD PROMOTION

• Entry level clinical staff received a promotion to an administrative role.

• This promotion came with an office.• The staff took a video of his desk and posted it

to Facebook.

SOCIAL MEDIA:

IS IT PHI?

“Sad day at work today ”

30

IS IT PHI?

“Sad day at work treating someone so young today ”

31

IS IT PHI?

“Sad day at work treating an amputee today ”

32

IS IT PHI?

“SAD DAY AT WORK TREATING MY THIRD GRADE TEACHER TODAY ”

33

IS IT PHI?

“SAD DAY AT WORK TREATING MY THIRD GRADE TEACHER AT WALNUT ELEMENTARY TODAY ”

34

IS IT PHI?

SOCIAL MEDIA

What you can do:• Social media policy• Breach notification policy• Train, train, train• Audit

IGNORING BREACHES89% OF HEALTHCARE PROVIDERS HAVE HAD A BREACH

IGNORING BREACHES• Presence Health entered a $475,000 settlement

with the OCR after it missed the 60 day breach notification deadline.

• 10-22-13: Presence discovered breach (paper OR schedules were missing)

• 1-31-14: Presence notified OCR of the breach.

BREACH NOTIFICATION

• Unsecured PHI = not encrypted or destroyed• Within 60 days of discovery• Who:

• The patient• OCR• The media (maybe)

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BREACH NOTIFICATIONWhat can you do? • Breach Notification policy• Breach analysis decision tree• HIPAA attorney on speed dial

BREACH NOTIFICATIONDon’t mess with Texas.• No risk of harm required.• Texas DHHS contractors that provide HHS

services and create, receive, maintain, use or disclose Confidential Information on behalf of HHS programs or clients must notify HHS of breaches of federal data within 60 minutes

YOUR ACTION PLANHOW TO EXPECT THE UNEXPECTED

SECURITY RISK ANALYSIS• Conduct a HIPAA Security risk analysis• Mitigate risks• Update the risk analysis

POLICIES

• Privacy• Security• Breach Notification

Omnibus updates effective September 2013

TRAIN, TRAIN

• New hires• Annual training• Quarterly or monthly reminders• Board, employees, contractors, managers• In-services, written reminders, email, flyers,

video, skits

AUDIT

• Walk throughs• Security Audits• Privacy audits• Breach notification audits• Social media audits

LOOK FOR GUIDANCE• At HCCA’s 2017 Compliance Institute, Iliana

Peters advised that the OCR is developing guidance and FAQ addressing:

• Texting• Social media• Minimum necessary

Margaret Scavotto, JD, CHC

President

314-394-2222 ext. 24

[email protected]

uestions?

(c) 2018 Management Performance AssociatesThis presentation does not constitute legal advice

LUNCH On Your Own

Check out restaurants in the Hyatt or on the RiverwalkSee the App under the “San Antonio” icon for suggestions

Sessions resume at 1:30 p.m.


Regency Ballroom East:Advanced Cost Reports

David James

Rio Grande:How to Document & Select Outpatient Levels of E&M

Services in the RHCJohn Burns

You are HERE!

How to Document & Select Outpatient Levels of E&M Services in the RHC (99201-99215)

John BurnsCPMA, CEMC, CPC, CPC-1VP Audit & Compliance

Assn of Rural & Community HlthProfessional Coding

How To Document and Select Outpatient Levels of Evaluation and Management (E&M) Service in RHC

John F. Burns, CPC, CPC-I, CPMA, CEMCVice President, Audit and Compliance Services

[email protected]

Your Faculty

• John F. Burns, Vice President of Audit and Compliance Services, ARHPC

• 22 years in healthcare coding, billing and compliance• Doctors Management and NAMAS • Modern Conventions in Compliance• Civilian volunteer to US Department of

Defense• Medical Management Institute

LEARNING OBJECTIVES:• Learn and understand the differences between AMA

(CPT®) Documentation Guidelines compared to CMS’

Documentation Guidelines

• Master the process of documenting to meet the various

levels of History, Physical Examination and Medical

Decision Making

• Know when you can and cannot use time as a controlling

factor in E&M code assignment

• Content and references made are based on 2018 CPT®

Professional Edition nomenclature authored by the American

Medical Association (AMA). All right reserved.

Rural Health Clinic Reminders

According to Medicare, “RHC visits are medically necessary face-to-face medical or mental health visits or qualified preventive visits between the patient and a physician, NP, PA, CNM, CP, or CSW during which a qualified RHC service is furnished.” • RHC encounters do not take place in hospital (inpatient or outpatient)

Except for the following, multiple visits with multiple RHC practitioners on the same date are considered a single visit• Separate illness/injury unrelated and subsequent to the initial encounter• A medical visit and a mental health visit furnished on the same date• IPPE with a separate medical or mental health encounter on the same date

Lab tests (except venipuncture) & technical components are paid separately

Evaluation and Management Services (99xxx)

• Represent largest code expenditure to Medicare• E&M coding guidelines were established by Congress in

1995 and revised in 1997• Benchmarks (utilization) can assist with identifying risk• What’s a chief complaint? Is it always required?• How is time defined and can it be used as factor in E&M

code selection?• What are the “key components”• History

• HPI, ROS, PFSH• Physical examination

• 1995 versus 1997, body areas/organ systems vs bullets/elements

• Medical decision making• Risk versus complexity

• Realize the “levels” of each E&M “key component”

CPT® 2018 is a registered trademark of the American Medical Association

(AMA) and the ARHPC claims no rights to nomenclature. For educational

purposes only!

New vs Established Patient Definitions, per CPT®

A new patient is one who has not received any face to faceprofessional service from the physician/qualified healthcare professional

oranother physician/qualified healthcare professional of the exact same specialty/subspecialty who belongs to the same group practice within the past three years

vMedicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician”

v“An interpretation of a diagnostic test, reading an x-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient”

Office or other Outpatient Services

• Report 99201-99205 for “new” patients• Require all 3 KEY COMPONENTS• Remember the 3-year rule

• Report 99212-99215 for “established” patients• 99211 does not qualify for AIR (Medicare)• Require 2 of the 3 KEY COMPONENTS• One of the components should be the MDM process

CPT Preventive Medicine Services

• 99381-99387 (new patients) and 99391-99397 (established patients)

• Medicare does NOT pay an annual physical!• Refer to IPPE (G0402) and AWV (G0438-G0439) HCPCS II codes for these service codes

• Medicare does recognize separate AIR encounter rates for patients who receive the IPPE and a medical and/or mental health visit on the same date of service

• Initial Preventive Physical Examination (IPPE)

• Paid once w/in 12 months of Part B enrollment

• Annual Wellness Visit (AWV)

• Paid for once per year after the 12-month enrollment period has expired

• You may want to consider ABNs for preventive services with “limited” coverage

Preventive Services in the RHC

• Medicare Benefit Policy Language (Chapter 13)• CMS sets the trend but private insurance plans often follow unique policies• Section 40 (“visits”), Section 50 (“services”), 220 (“preventive services”)

• How ‘preventive’ and ‘problem-oriented’ services differ• Essentially, if the patient presents lacking a chief complaint, its preventive,

right?• Properly assigning ICD-10-CM codes is critical

• When can multiple visits be claimed on the same date?• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/FQHCPPS/Downloads/RHC-Preventive-Services.pdf

Problem-Oriented & Preventive Services

• For the sake of argument, a preventive E/M service differs from a problem-oriented E/M service only in that a patient who presents for the former lacks a chief complaint.

• Introductory pages in this section of CPT provide some excellent tables [charts] designed to assist coders assign the accurate ‘levels’ of E&M service• Who are you seeing?

• New, established, initial, subsequent, consultation, etc.• Where are you seeing them?

• Outpatient, inpatient, emergency department, home, RHC, etc• Why are you seeing them?

• Preventive versus ‘problem-oriented’

E&M Documentation Considerations• CPT Guidelines vs. CMS Guidelines• 1995 vs 1997 exam guidelines

• Chief complaints/presenting problems• Preventive vs. Problem-Oriented

• “Complete” reviews of systems (ROS)• Medical decision making vs medical necessity• Are these the same thing?

• Using time to drive level of E&M• When to report modifiers, global period considerations• Modifier -CG reported with medical and/or mental health code that

represents the primary reason for the face-to-face encounter• What about coding ‘wizards’ offered with EHR products?

The Anatomy of an E&M Service Code

• History• Exam• Medical Decision Making

• Nature of Presenting Problem• Counseling• Coordination of Care• Time

“KEY” COMPONENTS

“CONTRIBUTORY” COMPONENTS

History- Subjective

• Chief complaint – clear, concise statement detailing the reason the patient is presenting today, usually in the patient’s own words

• According to CMS guidelines, the CC may be combined with the HPI. But, the HPI MUST be documented by the PROVIDER!!

• HPI (history of present illness)• ROS (review of system)• PFSH (past family social history)

Determining the Level of History

Remember to always start in the highest level of history and work toward the lowest– the element located in the lowest level will determine the overall level of history.It is also possible to have an Extended HPI with the documented status of 3 or more chronic conditions

History Documentation Reminders

• CC, ROS and PFSH may be listed as separate elements of history or included in documentation of the HPI

• ROS and/or PFSH may be recorded by ancillary staff or patient as long as the provider documents confirmation of the information…this is NOT the case with the history of present illness (HPI)

• Providers can use and get credit for ROS and PFSH obtained at another visit as long as it is relevant and can be located within the same record• “Remainder of ROS and PFSH unchanged since 1/30/2018 in this record”

• If the provider is unable to obtain history from the patient or another source, he/she can document the patient’s situation or condition that precludes getting it taking credit for comprehensive history level

Examinations- Objective

• 1995 guidelines (CPT)• Count the number of systems/areas

• Single system exams are not well-defined…

• Often the best option for RHCs

• 1997 DGs benefit Psychiatry/Mental Health

• 1997 guidelines (CMS)• Count the number of “elements” or “bullets” performed

• Most single system specialty exams are defined

• Harder to meet without templates/macros

• Per CMS Guidelines, auditors must consider both 1995 and 1997

Examination Guidelines; whichever suit the provider best

Physical Examination- 1995 GuidelinesEXAMINATION LEVEL / TYPE 1995

PROBLEM FOCUSED 1

EXPANDED PROBLEM FOCUSED 2-7 “limited”

DETAILED *2-7* “extended”

COMPREHENSIVE 8+ Organ Systems

BODY AREAS ORGAN SYSTEMS

• Head, incl. the face• Neck• Chest, incl. breasts and

axillae• Abdomen• Genitalia, groin,

buttocks• Back, including spine• Each extremity

• Constitutional (e.g., vital signs, genappearance)

• Eyes• Ears, nose, mouth and throat• Cardiovascular• Respiratory• Gastrointestinal• Genitourinary• Musculoskeletal• Skin• Neurologic• Psychiatric• Hematologic/lymphatic/immunologic

AMA authors the information above. Some carriers (MACs) [e.g., Novitas, Palmetto, NGS, FCSO, etc] may impose more restrictive guidance

Page 9 2018 CPT

Physical Examination- 1997 GuidelinesEXAMINATION LEVEL / TYPE 1997 (General Multisystem) 1997 (Single Organ System)

PROBLEM FOCUSED 1-5 1-5

EXPANDED PROBLEM FOCUSED 6-11 6-11

DETAILED 12-17 12-17

COMPREHENSIVE 18+ (Document 2 elements from 9 or more areas/systems)

Perform ALL, Document all shaded, document at least 1unshaded

There are not multiple interpretations of the 1997 guidelines. It is simply a matter of counting elements (e.g., bullets) that relate to body areas/systems

Page 9 2018 CPT

**Remember**1997 guidelines are slightly different (and less restrictive) for Eye and Psych exams

Examination Documentation Reminders

• A notation of “abnormal” without elaboration is insufficient documentation.• A brief statement/notation indicating negative or normal

findings is sufficient• Normal or negative findings must be listed by body area

or organ system.• CPT® states the only difference between an Expanded

Problem Focused examination and a Detailed examination is that the first is “limited” and the other is “extended”• You will need to determine which guidelines suit your providers

best and consider local carrier instruction…

A. Number Of Diagnosis or Management OptionsNumber Points Results

Self-limited or minor (stable, improved or worsening) Max = 2 1Est. problem: stable or improved 1Est problem: worsening, failing to change 2New problem: no additional work-up planned Max = 1 3New problem: additional work-up planned 4

Total:

This is a cumulative process based on the the # of problems worked up and evaluated

Medical Decision Making

B: Amount and/or Complexity of Data to Be ReviewedPoints

Review and/or order of clinical lab test 1Review and/or order of tests in the radiology section of CPT 1Review and/or order of tests in the medicine section of CPT 1Discussion of test results with performing physician 1Decision to obtain old records and/or obtaining history from someone other than patient 1

Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider

2Independent visualization, tracing or specimen itself (not simply review of report)

2

Total

C: TABLE OF RISK (element in highest level determines overall risk)Presenting Problems Diagnostic Procedures ordered Management Options Selected

Min

imal

• 1 self-limited or minor problem (eg. Cold, insect bite, tinea corporis

• Lab tests requiring venipuncture• EKG/EEG• Urinalysis• Ultrasound, X-RAYS• KOH prep

• Rest• Gargles• Elastic bandages• Superficial dressings

Low

• 2 or more self-limited or minor problems• 1 stable chronic illness • Acute uncomplicated illness or injury

• Physiologic test not under stress• Non-cardiovascular imaging• Superficial needle biopsies• Clinical lab test requiring arterial puncture• Skin biopsies

• Over-the-counter drugs• Minor surgery w/ no identified risk factors• Physical therapy• Occupational therapy• IV fluids without additives

Mod

erat

e

• 1 or more chronic illnesses w/mild exacerbation, progression or side effects of treatment

• 2 or more stable chronic illnesses• Undiagnosed new problem w/ uncertain

prognosis• Acute illness with systemic symptoms• Acute complicated injury

• Physiologic test under stress• Diagnostic endoscopies w/no identified risk factors• Deep needle or incisional biopsy• Cardiovascular imaging studies w/contrast, no identified

risk factors• Obtain fluid from body cavity

• Minor surgery with identified risk factors• Elective major surgery w/o risk

(open,percutaneous, or endoscopic)• Prescription drug management• Therapeutic nuclear medicine• IV fluids with additives• Closed treatment of fracture or dislocation

w/o manipulation

High

• 1 or more chronic illnesses w/ severe exacerbation, progression, side effects of treatment

• Acute or chronic illnesses or injuries that pose a threat to life or bodily function

• Abrupt change in neurologic status

• Cardiovascular imaging studies w/contrast w/ identified risk factors

• Cardiac eletrophysiological tests• Diagnostic endoscopies w/indentified risk factors• Discography

• Elective major surgery (open, percutaneous or endoscopic) w/risk

• Emergency major surgery (open, percutaneous or endoscopic)

• Parenteral controlled substances• Drug therapy requiring intensive monitoring

for toxicity• Decision not to resuscitate or to de-escalate

care because of poor prognosis

DETERMINING THE FINAL “COMPLEXITY” MEDICAL DECISION MAKING

Final Complexity of Medical Decision Making is determined by 2 of the 3 elements from the table below:

Number of diagnoses or

management options

≤ 1

Minimal

2

Limited

3

Multiple

≥ 4

Extensive

Amount and complexity of

data to be reviewed

≤ 1

Minimal

2

Limited

3

Multiple

≥ 4

Extensive

Risk of complications and/or

morbidity or mortality Minimal Low Moderate High

TYPE OF DECISION MAKINGStraight

Forward

Low

Complexity

Moderate

Complexity

High

Complexity

Per CMS and various MACs, Medical Necessity Determines Payment.“Medical necessity of a service is the overarching criterion for payment. Do not submit a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon

which the service is submitted. Select the code for the service based upon the content of the service. The service furnished and submitted must meet the definition of the code.”

Selecting E&M Service Codes Based on Time

• For visits that involves more than 50 percent counseling or coordination of care, time can determine the level of coding.

• For example, if a 30-minute office visit with an established patient involved more than 15 minutes of counseling and coordination of care, time could be used to support CPT code 99214.

CPT® Code Time Threshold CPT® Code Time Threshold (Unit/Floor)

99201 10 minutes 99221 30 minutes





99211* 5 (*no MD presence*) 99233 35 minutes

99212 10 minutes 99238 < or equal to 30 min.

99213 15 minutes 99239 > 30 minutes






99244 60 minutes 99291,+99292 30-74, +30 minutes

99245 80 minutes OUTPATIENT TIME= FACE TO FACE TIME

INPATIENT TIME= UNIT / FLOOR TIME

John F. Burns, CPC, CPC-I, CEMC, CPMAVice President, Audit and Compliance Services, [email protected]


Regency Ballroom East:Building Your RHC Quality Program

Angie Charlet

Rio Grande:Policy & Procedure Manual

Patty Harper

You are HERE!

Policy & Procedure Manual

Patty HarperRHIA, AHIMA-App ICD-10-CM/PSC Trainer,

CHTS-IM, CHTS-PW, CEOInQuiseek, LLC

Intro Intro

RHC Policies

and Procedures

NARHC Spring Institute March 19-21, 2018 San Antonio, Texas

Patty Harper

Understanding what theregulations say aboutRHC written policies andprocedures

How many are enough?How many are toomany? Why are toomany a bad thing?

Understanding howpolicies are the practicalbackbone ofcompliance?

Understanding how tomanage policiespainlessly

Page 1 of 22

Policies are broad statements or mandates which rarely change.

“We will comply with the Conditions of Certification for RHCs.”

“All providers will maintain current licensure with the state medical board.”

Policies

Policy vs Procedure vs Process vs Plan

Define Define

ProceduresProcedures are the specific steps that are taken to ensure that the policies are maintained.

ProcessesProcesses are even more specific steps within a procedure.

PlanA collection of policies, procedures and processes related to a specific targeted area.

Page 2 of 22

SomeSuggested

Policies and Procedure Categories

What types of policies do you need?

Define Define

Organizational

Physical Plant andEnvironment

Provision ofServices: PatientCare

HR/Employment

Quality/Risk

Financial

Page 3 of 22

→ Policy: Cross Roads RHC will include hand hygiene as part of our infection control plan.

→Procedures: 1)We will train our employees and staff on proper methods of hand hygiene and 2)provide soap/water or alcohol‐based sanitizer in all areas of the clinic.

→Processes: Employees will wash hands before and after entering a pt. room, before and after eating, and before and after toileting.

Page 4 of 22

RegsRegs

42 CFR 491.7

What Do the Regs Say?

Understanding what the

regulations say about RHC written

policies and procedures

§ 491.7 Organizationalstructure.(a) Basic requirements. (1) The clinic or center is under the medical direction of a physician, and has a healthcare staff that meets the requirementsof § 491.8.(2) The organization’s policies and its lines of authority and responsibilities are clearly set forth in writing.

Page 5 of 22

RegsRegs

What do the Regs Say?

42 CFR 491.8(b) Physician responsibilities.(1) The

physician:(ii) In conjunction with the physician’s assistant and/or nurse practitioner

member(s), participates in developing, executing, and periodically reviewing the clinic’s or center’s written policies and the services provided to Federal program patients;

How involved are your medical

director and physicians in

policy development and review?

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RegsRegs


How involved are your NPs

and PAs in policy

development and review?

42 CFR 491.8(1) The physicianassistant and the nurse practitioner members of the clinic’s or center’s staff:

(i) Participate in the development,execution and periodic review of the written policies governing the services the clinic or center furnishes;

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RegsRegs


Is your policy development

a collaborative

process?

§ 491.9 Provision ofservices.

(2) The policies are developed with the advice of a group of professionalpersonnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member is not a member of the clinic or center staff.

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RegsRegs


Our policies dictate how we should

provide services.

42 CFR 491.8

(2) The physician assistant or nurse practitioner performs the following functions, to the extent they are not being performed by a physician:

(i) Provides services in accordance with the clinic’s or center’s policies;

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RegsRegs


Written

Federalcompliance

Statecompliance

§ 491.9 Provision ofservices.

(b) Patient care policies.

(1) The clinic’s or center’s health care services arefurnished in accordance with appropriatewritten policies which are consistent with applicable State law.

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§ 491.9 Provision ofservices.3) The policiesinclude:

Description ofServices Direct services Lab services Services Under

Arrangement Emergency Care Inpatient Care

RegsRegs


What do you do in your clinic?

How do you provide the six required tests?

What services do you contract out?

Emergency Kit, EMS Transfer Policy, Hospitalist Agreement?

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§ 491.9 Provision ofservices.3) The policiesinclude: Guidelines for

MedicalManagement

Medical Records

Patient Referrals

Periodic andAnnual Review

RegsRegs

What do the Regs say?

Clinical protocols?

Content of Medical Record? Retention of Records? ROI?

Chart Review?

Referral Tracking?

Annual Evaluation?

Policy Review?

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RegsRegs


What other policies do you need to make sure you have processes in place for other federal and state laws?

Labor LawsOCROSHAOther HHS/CMS RegsLicensesInspections

§ 491.4 Compliancewith Federal, Stateand local laws.

The rural health clinic and its staff are in compliance with applicable Federal, State and local laws and regulations.

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Enough! You need enough policies to establish and maintain compliance and give operational and managerial guidance.

How Many Policies Do You Need?

How Many? How

Many?

Too Many?

Don’t confuse the need for a written policy or procedure with a minor operational issue that can be handled through improved relationships, better communication or improved processes.

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How Many Policies Do You Need?

How Many? How

Many?

Avoid creating written policies over “people” issues!

Don’t hide behind policies as a passive-aggressive or authoritarian way to address problems.

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Written Policy and Procedures may be maintained in a binder or retrievable on-line.

It is helpful to compile one set of policies and procedures that can serve as your Administrative or Survey Evidence Binder.

In this binder, you would also include any necessary supporting documents which help establish compliance.

POLICY FORMAT

BinderBinder

Well-Organized

Standard Format

Customized to yourRHC

One copy availableto staff

One administrativecopy

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POLICY FORMAT

SAMPLE POLICY HEADER

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POLICY FORMAT

BinderBinder SAMPLE POLICY BODY

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Do’s and Don’ts

POLICY FORMAT

BinderBinder

Train your staff onpolicies and how tofind them.

Maintain policies forregulatory changes;keep former versions.

Organize the policiesfor easy retrieval.

Make sure your actualprocedures areconsistent with thewritten policies.

Have written policies forspecific areas addressedin 42 CFR § 491

Have specific policiesrequired by your state orthe AO standards.

Be careful when“borrowing” policies-Use them as a guide.

Don’t have frivolouspolicies. Add only asneeded.

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You may adopt or adapt a hospital policy as your RHC policy.

“Cross Roads RHC’s policy on PTO is to adhere to the Cross Roads Medical Center Policy #333.”

Place the hospital policy behind your related policy.

Can I just use my hospital’s policies?

What about policies for PBRHCs?

PBRHC PBRHC

Your RHC policies should be specific to rural health clinic regulations and operations. Not all hospital policies will apply to the RHC. Administrative/HR Policies may be universal across a system. Your RHC name should be on the policies.

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Policy Review 491.9

Periodic and Annual Review of Policies

Review

(4) These policies are reviewed atleast annually by the group of professional personnel required under paragraph(b)(2) of this section and reviewed as necessary by the clinic or center.

(2) ...a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member is not a member of the clinic or center staff.

Annual Review is usually done as part of the annual program evaluation per §491.11.

Is this more than just signing an attestation page in the front of the binder?

Periodic Review: Change in regulations Change in operations In response to an event Change in best practices Performance

Improvement Activity

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Patty Harper

Highlight

Patty [email protected]

Page 22 of 22

Network Break

SILVERSPONSORS

PREMIERSPONSOR

Refreshments in the Foyer + Regency East with Exhibitors

PLATINUMSPONSOR

GOLD SPONSORS

Hildebrand HealthcareConsulting LLC

http://thie.com/

BreakoutsYour choice…

Regency Ballroom EMac Discussion:

NovitasKim Robinson

Rio GrandeHow RHCs Fit in a

Regional Health NetworkKatie Jo Raebel & Nick Smith

You are HERE!

How RHCs Fit in a RegionalHealth Network

Katie Jo RaebelCPA, Senior Manager – Wipfli LLP

Nicholas SmithMHA, Director – Wipfli LLP

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What is a Regional Health Network?

Regional Health Network Models

Why Should RHCs be Interested in RHNs?

Tying it All Together

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What Is a Regional Health Network?

“Stakeholders that come together around a core set of goals to improve health and healthcare”

“An alliance of health care organizations working together to effectively strengthen the delivery of health care”

“A collaboration of organizations that work on specific opportunities and needs of the community”

“aligning resources and strategies, achieving economies of scale and efficiency, and increasing value”

The fundamental idea of we are better together

Regional Health Networks

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Regional Health Networks can create efficiencies and transform care by:

• Identifying issues

• Developing solutions

• Implementing plans

• Sharing information

• Reducing costs


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RHNs may be formed around these common criteria:

• Similar patient base

• Geographic area

• Federal designation

• Common issues/goals


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Regional Health Networks Model Examples:

• Hospital Joint Ventures

• Accountable Care Organizations

• Information Networks

• Regional Health Associations

• Independent Hospital/Clinic Networks


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RHN Models for RHCs:

• Regional health systems affiliations

• RHCs Hospital/Health System

• RHCs RHCs

It will all depend on what you are trying to accomplish


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Why are we talking about RHNs?

Why should rural health clinics, both provider-based and independent, be interested in joining a Rural Health Network?


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Information Sharing

• Best Practices

• Benchmarking

• Technical Assistance

• Patient Education

Reasons to Join/Form a Regional Health Network

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Information Sharing and Collaboration

• Quality Improvement

• Practice Management

• Billing

• Clinical Quality Management

• Data Collection/Reporting

• Health Information Exchange

• Financial Reporting


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Market Strength

• What is your market share in primary care and other key specialties? Where is there opportunity for growth in the network or region?


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2017 Population

CDC Primary Care Office Visits

Factor per 100 Population

2017 Market Primary Care

Visits

2017 Clinic Primary

Care Visits

Clinic Market Share

Network RHCsRHC 1 5,936 192.4 11,418 8,542 75%RHC 2 8,772 188.0 16,489 8,294 50%RHC 3 17,046 187.7 32,042 6,705 21%RHC 4 5,857 186.1 11,010 1,257 11%RHC 5 1,768 186.1 3,323 1,455 44%

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Provider Need

• Is there an opportunity for joint recruitment of providers within the network’s region?


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Provider Demand Summary

Primary CareGeneral Surgery

Orthopedics

Overage/ShortageRHC 1 (1.5) 0.1 (0.4)

RHC 2 (5.7) (0.9) (0.6)

RHC 3 (3.0) (1.8) (1.3)

RHC 4 (1.8) (0.6) (0.4)

RHC 5 (1.5) (0.2) (0.1)

Combined Network (13.5) (3.4) (2.9)

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Provider Productivity

• Is your clinic over or under productivity standards? Are those standards affecting your current reimbursement rate? Could organizations share providers to reduce the effect?


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Number Minimum Greater ofof FTE Total Productivity Visits (col. 1 col. 2 or

Personnel Visits Standard (1) x col. 3) col. 4 Positions 1 2 3 4 5

1 Physicians 6.87 16,221 4,200 28,854 2 Physician Assistants 2.16 4,773 2,100 4,536 3 Nurse Practitioners 2,100 - 4 Subtotal (sum of lines 1-3) 9.03 20,994 33,390 33,390 5 Visiting Nurse6 Clinical Psychologist7 Clinical Social Worker8 Total FTEs and Visits (sum of lines 4-7) 9.03 20,994 33,390

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Number Minimum Greater ofof FTE Total Productivity Visits (col. 1 col. 2 or

Personnel Visits Standard (1) x col. 3) col. 4 Positions 1 2 3 4 5

1 Physicians 4.20 16,221 4,200 17,640 2 Physician Assistants 1.50 4,773 2,100 3,150 3 Nurse Practitioners 2,100 - 4 Subtotal (sum of lines 1-3) 5.70 20,994 20,790 20,994 5 Visiting Nurse6 Clinical Psychologist7 Clinical Social Worker8 Total FTEs and Visits (sum of lines 4-7) 5.70 20,994 20,994

Reduced FTEs – Effect on Productivity Standards

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Effect on Cost-Per-Visit Greater of

Actual Visits

or

Productivity

Standard

Visits

Allowable Costs

for Cost-Per-Visit

Calculation RHC Cost-Per-Visit

5,798,460$ Example 1 33,390 173.66$ Example 2 20,994 276.20

• Independent RHC – no effect; cost-per-visit limit

• Provider-based RHC to a hospital with less than 50 beds, $102.54 per visit difference

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Coordination of Care

• Patient coordination

• Referral strategies

• Sharing of nursing staff

• Sharing of medical direction

• Nursing home rounds

• Surgical Services – what should be performed at which location?


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Coordination of Care (continued)

• Specialists/other non-RHC traditional services

• Mental health

• Dental

• Telehealth

• Cardiology, Orthopedics, etc.


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RHC Fact:

Generally most specialists can be included in the RHCas long as services meet RHC encounter definitions and the primary focus of the RHC remains primary

care.


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Financial

• Reimbursement strategies

• Joint Ventures

• i.e – Health Systems collaborating to provide primary care in communities. How can they certify a RHC?

–Will this be a separate tax ID (i.e. – an LLC)?

–Freestanding or Provider-based?

–If provider-based, the provider-based regulations must be met.


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Financial (continued)

• Reduction of expenses

• Shared administrative expenses

• Billing

• Credentialing

• Shared capital costs

• Coordinated consulting

• Shared providers


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Financial (continued)

• Collaborate on Community Health Needs Assessment (CHNA)

• Required by most federally funded healthcare organizations with 501(c)3 status

• Many organizations collaborate on the CHNA by shared geographical area

• Collaboration among hospitals, clinics, public health agencies, and other health care organizations in the community


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How to integrate regional health network planning into your strategic plan as an RHC• What are you trying to accomplish strategically, and how can

a health network strategy align with that?• How will your other strategic goals tie into your RHN goals

(i.e. - strategic and capital planning)?• How can we organize with our competition to share ideas

and become a unified voice?• What funding opportunities may be available for your

network?

Tying it all Together

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What’s next? Ask yourself these questions:• How would a RHN benefit our organization?

• What is our number one challenge that could be addressed through collaboration with a network?

• What type of RHN model could best achieve our desired solutions?

• Make vs. Join?


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Make vs. Join?• Explore networks that already exist that may meet your

needs or to which you could contribute.• Consider forming a network with others that

experience similar challenges (start small!)

Explore Online Resources and Other NetworksRural Information Hub – Rural Health Networks and Coalitions Toolkit: https://www.ruralhealthinfo.org/community-health/networks


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Today’s Presenter:

wipfli.com/healthcare

Katie Jo Raebel, CPA, Senior Manager Health Care [email protected]

Nicholas Smith, MHA, Director Health Care [email protected]

Have a Good Evening!

See you at 8:30 AM tomorrow

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