Ask Me MD: Medical School for the real world
Ask Me MD: Medical School for the real world
Karen Fowler - 2021 E&M Changes and Starting Back after COVID-19
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Karen Fowler, CEO of Trisource Health and a physician practice consultant, discusses the changing practice environment in 2021. Topics discussed include the changes to E&M codes for 2021 as well as some ideas for rethinking practice operations after COVID-19.
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Ask me MD medical school for the real world with the MD Dr. DJ Verret.
D.J. Verret, MD, FACS:Greetings, and thank you for joining us for another edition of Ask Me MD Medical School for the real world. I'm Dr. DJ Verret, and today I'm talking with Karen Fowler, CEO of tri source health, a physician consulting firm about two things. First, we're going to discuss the changes coming to E and M coding in 2021. And second, Karen's going to give us some ideas for things physician should think about as we restart our practices after COVID-19 will talk to Karen right after this.
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D.J. Verret, MD, FACS:Welcome back to Ask Me MD, medical school for the real world. I'm Dr. D.J. Verret. And today we're talking with Karen Fowler, CEO tri source health, about her suggestions to physicians to make 2021 a better year. Karen, thanks for joining us. Thank you. So obviously 20 has been quite the experience for pretty much everybody. physicians have taken a lot of different avenues that I don't think last year we would have thought we'd have to take. And and there's there's some things I think we need to think about going into next year. And there are a lot of changes coming in the e&m coding field. So I'd like to kind of get your take on it. But before that, Karen, can you tell us a little bit about yourself and your background for our listeners?
Karen Fowler:Absolutely. I've got about 35 years of experience in medical practice management, working with both large groups, small groups, rural healthcare environments, as well as integrated delivery networks, focused primarily on the operations and financial activities related to the Medical Group themselves, as well as managed care contracting and pair enrollment.
D.J. Verret, MD, FACS:And with that background, obviously, you work with with all different size practices, but I think some of the insights you have would be applicable across the board. CMS has come out with some changes in e&m coding could could you kind of recap some of those for us that just give us some information that would kind of guide physicians into what to expect next year?
Karen Fowler:Absolutely. Most of the guidelines are specific to Medicare, we will find that many of the payers that are commercial payers will follow these similar guidelines. CMS has basically adopted some e&m changes for 2021. Primarily as it relates to CPT for code levels 9922 through 215, which are the new patient visit codes as well as the established visit codes. Basically, it allows for resending at the plan. Historically, the CMS plan was to implement bundled payment, basically for three levels of codes. And that has now been changed for 2021. So the code clinicians now have the ability to select new and established patient visit codes based on time, or medical decision making. So that's probably the biggest change for 2021. The new guidelines for using time again, will be based on new definitions provided under the medical decision making.
D.J. Verret, MD, FACS:When you when you've kind of taken a look at some of those guidelines. What differences in documentation are we kind of expecting to come down the pike next year
Karen Fowler:Documentation again, you have your historical method of documenting based on the 2015 and 2017 CPT documentation codes. And then you also have the ability now to base that based on time, which will capture many activities that are being done in the practice, that you're not necessarily getting credit for today. And so there are two options that will go into play in 2021.
D.J. Verret, MD, FACS:Now, when you talk about that, you mentioned things that are going on in the practice. I know under the current guidelines, you can only build for time in face to face discussions with the patient. Is that changing under the new guidelines
Karen Fowler:Yes, it is, it does, you know, historically, you could only count your face to face time with the patient. And more than half of that face to face time, you know had to be spent in either cancel counseling or coordination of care. And so the guidelines for 2021 have changed. There are a number of resources that are out there. And in fact, a PC, as well as the AMA, you know, have some additional guidelines and code descriptors. There are some educational programs available and online workshops that would assist in understanding the documentation guidelines. So time spent on reviewing test results, time spent speaking with family members. Additionally, additional time related to EMR documentation, which has not been historically accounted for are several of the new items that are allowed to be included in the time based coding.
D.J. Verret, MD, FACS:So it sounds like this May, it'll be interesting, I think, to see how how it plays out over time, no pun intended, because it sounds like reimbursements are going to kind of shift more towards what you were talking about a kind of a bundled payment and taking into account all of the activities that go into taking care of the patient.
Karen Fowler:Correct. The original bundled payment that was supposed to go in place, of course, has been eliminated. And these changes for 2021 are accounting for those additional time factors. Originally, providers were going to be paid for CPT for code levels 9234 and five, in some cases at the same rate. So that is change. In addition to that the work RVU values 499213 and 214. And two and five, have been revised. And so for providers who may be compensating their internal physicians or advanced practitioners, underneath a work RVU methodology, we are seeing an increase in the work RVU calculations. So Medicare will be accounting for more work activities in the work RVU values that are established by the AMA.
D.J. Verret, MD, FACS:That's I think that's interesting. So if you're a physician that's on a work RVU payment model within a health system, let's say you may actually see a change in your income just because of the change in the work RVU even though you're spending the same time with the patient, would that be accurate?
Karen Fowler:Yes, it would.
D.J. Verret, MD, FACS:Let's kind of shift gears a little bit and talk about some of the things that you've been counseling your practices, in terms of dealing with the the long term repercussions of COVID. Obviously, we've gone through a lot of rapid changes. What are you seeing with your practices that is is changing that you think may actually be permanent and not just temporary while we get over the virus?
Karen Fowler:Well, I think there are a number of factors, one, many of the practices have already come back in and are working to restart their actual practice. I think that there are a number of items that you need to think about. And that is really, really looking at your practice as a startup practice. A few ideas that might be useful to your membership is one is I think you need to look at your financial information, pull together various data elements, such as your staff schedules, your prior provider templates, and take a look at your financial component associated with that. I would suggest that you relook at a performance as well and understand any ramp up activities that may go on and, you know, post true post COVID and what is the new normal inside of your practice? In addition to that, you know, is there really pent up demand and how long will that pent up demand actually stay in play? And will you see a lull in your patient volume, you know, post reopening and again, most practices have reopened in you know, calling county You know, we've had a lot of lift on restrictions for patients And physicians and providing services. I think that factors that need to be reviewed by the practice are. So many of our Collin County residents have lost insurance and have lost jobs. In those case scenarios, they're reluctant to spend money and or come into the practice. We have patients who also are fearful of coming back into the practice of, you know, potentially contracting COVID. And so I think what we need to do is understand staffing solutions. staffing solutions could include things along the lines of creating rotating teams, depending on the size of your practice. And that would be you know, grouping together, you know, your front desk or medical assistance, and your providers who could come in on different days so that if there was an exposure to COVID-19, that you wouldn't shut down the entire practice. Other areas that you might want to look at is for providers who may not be coming into the practice, ensuring that you've got telemedicine set up appropriately, and that you've got the right communication tools, and that you understand on a go forward, what payers are going to cover telemedicine services and how to billing code for those services. In addition to that, there are other just basic housekeeping patient flow activities, ensuring that but that you're protecting both the patients and the staff, making sure that you've got guidelines in place for your practice, making sure that you have appropriate PP for your staff and your patients, requiring your patients to wear masks when entering and exiting the practice. You know, there are many patients who don't want to sit in your waiting room or come into your waiting room, there is an additional burden on your staff to ensure that you know, they're cleaning, the waiting room areas, any any hard surfaces. So looking at opportunities to text, the patient, opportunities to have them wait in the parking lot versus in your waiting room could be an opportunity. Ensuring that you've got and maintain physical distance. So looking at the flow within your clinic, and what your typical check in and check out processes. Eliminating and having touchless check in and check out is also valuable. And there are some software solutions out there that will allow that to occur. Ultimately, telehealth adoption, I think is absolutely important. And I think over the last couple of months, we've seen many of our providers and many of our practices, integrating telehealth into the normal practice operations, you need to make sure again that you've got the appropriate adoption of technology solutions, ensuring the security requirements are there. And then also, you know, determining in your patient scheduling activity, how many visits will be virtual visits versus face to face visits. So that's a change or a shift in the way that, you know, many practices have done business. Understanding, again, the pair requirements, I believe, you know, is an absolute important factor. We're seeing many communications coming from the large payers such as united and Blue Cross Blue Shield, that were originally going to stop paying for certain levels of telehealth visits. And so you know, putting together a master grid and understanding a both the billing requirements as well as what can be done either via the telephone, or via a an electronic means. That's I think, some great information
D.J. Verret, MD, FACS:Kind of back to the top you were talking about putting together just kind of starting your practice from scratch putting together a pro forma, what kind of what kind of specifics, have you seen people changing today versus in 2019? So for instance, adding in the additional cost of PPE. Maybe changing, you'd mentioned your staffing requirements. How How have you seen those performance really changing?
Karen Fowler:I think you've got to start at the top and one is the net revenue side of the house and understanding what the blend between virtual visits and face to face encounters. in understanding the percentages of those telehealth visits are typically reimbursed at a lower level than a face to face encounter. So understanding, you know, volume related to both of those types of visits and the revenue impact associated with that. Thank you also have to look at your accounts receivable. And that's not necessarily a performance factor, but it's a cash flow factor for the practice and understanding, you know, do you have an incremental expenses, again, for cleaning supplies, pp, extended hours, if you chose to extend your hours so that you had the ability to separate out when patients were coming into the practice? Other areas that I think factor into it as well is how are you compensating the physicians and is there a differential and pay for providers to come into the office versus telehealth those are the biggest serious probably on the expense side, you know, physician compensation, you know, additional costs for you know, cleaning, cleaning supplies and time and resources to do that. And then changes in expectations potentially, in your hours.
D.J. Verret, MD, FACS:You mentioned, patients volumes may be down because patients are simply afraid to come to the office. But then the flip side is to to compensate for that you try to do telemedicine or telehealth. And the reimbursement is down for that even though you you have the same fixed cost of operating your building, etc. Have you seen any strategies to help allay the fears of patients who are afraid to come in for a visit,
Karen Fowler:I have an you know, there are a number of organizations practices that are you know, promoting, you know, a safe environment. And a lot of that starts from you know, just your processes and your flows of, you know, how does a patient enter your practice, you know, are patients spaced an hour apart or 30 minutes apart, where you may have had them, you know, 15 minutes apart in, in previous, ensuring that your waiting room, you know, doesn't have a large amount of patients sitting in waiting. So opportunities would be when the patient checked in if you've got the right number of rooms or space, to have the patient self room themselves. So instead of sitting in the waiting room, you know, they would immediately go to an exam room that had already been cleaned. So they're not sitting with other patients in that waiting area. So really looking at your process and flow. And I think also communications, if you've got a web portal or a website, posting that information on your web portal or website, just how you're different or how you're doing business differently, to protect both the patient and your staff members.
D.J. Verret, MD, FACS:That's actually a really good point is not to forget the staff as well. You mentioned one strategy of creating, I guess, kind of teams of staff and having them rotate through so that if there is covid infection, you're not affecting anyone. Have you seen any strategies that that have worked? Well, one of the problems in that regard may be staff not getting their 40 hours of work in? Have you seen strategies where staff can do some things from home and work within the practice to be able to make make payroll be productive to the practice, but also protect everybody from from infection?
Karen Fowler:Absolutely. I think there are a number of activities that occur inside the practice that could be done from home or what is being, you know, looking looked at as hotelling. And that is really working from home. And those could be along the lines of, you know, referrals, authorizations, prescription refills, any activity that doesn't necessarily have a direct face to face patient encounter component associated with it.
D.J. Verret, MD, FACS:It sounds like that kind of goes back to your idea of start thinking of your practice as a de novo practice and really look at not only the financials, but the workflow that's involved as well.
Karen Fowler:Absolutely. I would recommend putting together in conjunction with your office team. Basically a checklist as well as what could we do differently on a go forward basis, a to protect the patients and be to protect the staff with inside the walls of the practice.
D.J. Verret, MD, FACS:It'll be interesting moving forward, because I think some of those, some of those changes we adopt could be long term changes, even when the virus threat is over.
Karen Fowler:Absolutely. You know, as you look out, across, you know, all business activities, you know, real estate size of clinic, numbers of exam rooms, you know, just change and workflow processes, changes in telemedicine, I think will have a significant impact on the ultimate footprint, size of practices in need for real estate as well. I think over the last couple months, we've all found different ways of still achieving and taking care of patients just in a different manner. And not necessarily all on site activities.
D.J. Verret, MD, FACS:We're talking with Karen Fowler, CEO of tri source health, we're gonna take a quick break and when we come back, we're gonna ask Karen her top three.
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D.J. Verret, MD, FACS:Welcome back to ask me MD medical school for the real world. I'm Dr. DJ veranda. Today we're talking with Karen Fowler, CEO of tri source health, about her suggestions to physicians who opened their office after COVID-19. And about the changes coming in Medicare reimbursement for office visits. As we do with all of our interviewees. We're going to ask Karen a top three. And, Karen, if you would tell us what are the top three things you would tell physicians about preparing for 2021.
Karen Fowler:Number one would be ensuring that the providers or physicians have the appropriate training on the new e&m coding. As this is a major shift from historical documentation as well as reimbursement processes. I can't tell you the 2021 CPT for code books are published. So it also suggests that they look into purchasing those as well, too, would be really rethinking the process and looking at your practice as a de novo or a new practice. Looking at the processes, the flows, your staffing level, and the financials associated with changes to your organization. And then three would really be adoption of telemedicine, ensuring that we don't lose sight of the standards of care for patients and that if a patient needs to be seen in the office, that we continue to have ownership of that.
D.J. Verret, MD, FACS:And I think that's an excellent point is that the standard of care is still the standard of care. I know personally, it's it's kind of easy to low yourself into just doing telemedicine and feeling pressure from patients who don't want to come to the office who just want to be seen online or send you send you photos. But but it's really important to remember that the physicians are the ones who know how to deal with something and we shouldn't compromise our quality of care simply because of patient satisfaction.
Karen Fowler:Absolutely. And, you know, just understanding, you know, how you communicate that back with the patient is absolutely critical. People do like to have remote services, but as you said, you know, that is ultimately medical decision, you know, made by the physician or by the provider.
D.J. Verret, MD, FACS:Karen, thanks for some great information. I think it will definitely be interesting to see how things play out but certainly some of these changes are going to be permanent. We'll have to guess time will tell if it's going to be for for better or worse.
Karen Fowler:Your are correct. And I think we've got to continue to evolve you know with COVID or with Without COVID and you know, always look for ways to improve our processes and our practices.
D.J. Verret, MD, FACS:We've been talking with Karen Fowler, CEO of tri source health, about things physicians should start thinking about for 2021 you're listening to ask me MD medical school for the real world. I'm Dr. DJ Verret, until next time, make it an awesome week.
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