What “Clinician-Based” Means To You

A lot of rumors have been spreading about the transition away from the “intern-based” and toward “clinician-based” clinic models. While it’s fun for me to hear some of the rumors, it really does represent a deeper anxiety from you as students who are coming into the clinic system (and especially those who are already interns). 

The bottom line is that the clinician-based model will be better for everyone involved: students, patients, doctors and administrators. Yes, there will probably be a little pain in the transition, but it won’t last forever. So, how will the new clinic setup be different from the current one, and what does each change mean to you?

• Patients assigned to doctors – starting in January, all patients will eventually end up being “assigned” to a particular doctor. That doctor is the primary decision-maker in the patient’s care, and with an ever-revolving door of interns providing care as they move through the system, this will mean better continuity of care for patients. When you take over a patient’s case, you will be doing so in an environment where the doctor knows a lot about the patient, and this will mean an easier transition for you. 
• Students assigned to doctors – as it stands, the type of supervision we have over your work is not ideal. This new system will mean that the majority of your work is supervised by one doctor. That means that doctor will be very aware of your strengths and your weaknesses, and more importantly, will be able to work on them with you. By building on your strengths and identifying weaknesses to work on, setting goals, etc, you will have a better clinic experience and should walk the graduation stage more confident and with a better skill set. 

In pragmatic terms, you will work either at Brookside or Overland Park, and you’ll schedule your patients in the time slots available with the doctor you’ve been assigned. Doctors have been paired up, so if you need to schedule in a time your primary doc isn’t available, you’ll schedule with the secondary doctor. That way you still have all day, every day, available to see patients, but you won’t have 20 different people supervising your work in a very disjointed and discombobulated way. Instead, you’ll still gain input and insight from the same 1-2 doctors for most of your work.

Finally, it means a lot more supervision over your work. Before you start moaning and groaning, that doesn’t necessarily mean a bad thing. Supervision when you are a newbie is good. At this point in your career, you don’t even know what you don’t know! We’re here to make sure you learn some things and walk out of school with some good habits, so greater supervision will make you more accountable and will enhance the quality of your work, guaranteed. You are going to be the biggest beneficiary to this new system, so take a deep breath, relax, and enjoy the process.

Learn Documentation & Coding the Easy Way

One of the biggest responsibilities in health care practice is documentation, coding and billing. Documentation means all recording of patient care, billing, etc. It includes your daily patient encounters that build into the patient’s permanent record (file) in your office, and this documentation is used to justify the procedures you are doing and the bills you send to the patient and/or insurance companies.

The requirements for documentation are always changing, and the need for good documentation are imperative in a practice, as poor documentation can get a practice in a lot of financial and legal trouble. It is important for a doctor to know the ins and outs of documentation and coding so they can train their staff properly and keep excellent records.

Coding the art of applying ICD-9 diagnosis codes and CPT® procedure codes to the patient’s case. Insurance companies use a language of coding in which each diagnosis has a code and each procedure has its own code. Based on this coding, the insurance company can tell if the treatment is appropriate for the diagnosis, modifies case limits based on the complexity of the diagnosis, etc.

In essence, good documentation gives a solid support to your coding, and good coding gets you paid. What’s not to like?!

There are several ways to learn how to do good documentation and coding. Seminars, books, trial and error… in the past I’ve discussed an essential book (ChiroCode Deskbook) that every office needs. Seminars can vary depending on who is teaching them. Some give very good information whereas others essentially teach you how to get yourself in a lot of trouble really quickly. Today, my email box showed me another option, which is perfect for students.

Renowned documentation expert Kathy Mills Chang (she presented at Cleveland’s Homecoming this year) has a 12 hour DVD/computer course available. Doctors can get CEU credit for this course, but as a student you can learn everything you need to know about documentation at your own pace from their leisure of your home computer. You can find out more about the course by following this link.

The course cover 6 hours of establishing medical necessity through case history, exam, tests and measures, goals, diagnosis and treatment plans, etc. Essentially how to effectively communicate what you know is wrong with your patient to the insurance carrier. Another 3 hours of the course is for Medicare Compliance, which is a vital topic to understand. The final 3 hours of the course have to do with practical principles for coding and billing, in other words, how to use the codes in day to day practice and get paid for what you are doing.

The course is for Apple or PC computers and costs $295, which is a steal for this type of content. You can’t put a price on good documentation and it is a huge benefit to you and your practice to know this information before you start practicing rather than after, when it is too late!

We Mean Business

I just saw an online episode of A&E’s TV show, We Mean Business featuring Cleveland Chiropractic College – LA graduate Dr. Lou Woelfel. The show is a typical “makeover” type show, but because it features a chiropractor, in particular a graduate of our college, it is very relevant for students who are close to graduating and planning their own practice strategies. It takes about 20 minutes to watch the three segments, so take a few minutes to have a look.

What I found interesting was Dr. Woelfel’s emotional attachment to the way the place looked. This is very common in all small businesses, where the business is an extension of the person who started it. When starting a business you have to rely on others’ opinions and be receptive to them.

Dr. Woelfel’s decision to join a practice management consultant group for $25,000/year when his business was struggling was a huge mistake. You could see that his consultants were clearly not doing anything for him for the money! The place looked awful and the business was poor. What was that money supposed to be paying his consultants for, exactly???

The show focused too much on how the place looked, but it is still important. His biggest mistake was using his mother’s mortgage as collateral for a business loan. Never, EVER compromise your home for a business. Businesses can open and close all the time, but you can’t go homeless trying to start a business.

Every student needs to see this and focus on the first segment, not the makeover.

Numbers

When you’re a student, life is all about numbers… what percentage on the last test? How many days left until finals? How many physicals have I done? How many adjustments do I need before I can check out? Etc.

In many ways, practicing is about numbers, too, but a lot of students find difficulty in transitioning from unimportant numbers to more important numbers. For example, I was looking at chiropractic videos on YouTube today and I saw a video by a guy who graduated a couple years ahead of me in school. His video had his name, with “1500 Visits per Month” below it.

Well, OK.

So what?

Is 1500 visits per month an important number? To a student, it SURE is, and, evidently, to a lot of chiropractors it is. But is it REALLY? I recently saw an ad for a chiropractic speaker whose achievement was seeing 50 new patients in one month after opening his office.

Well, OK.

So what?

(Are you sensing a theme?) Let’s look at the so-called importance of these numbers. Is seeing 1500 patient visits in a month an achievement? It sure is. Is having 50 new patients in a month something big? I think so. But in terms of what numbers MEAN, do they mean much? Not really. 

For example… did the doctor who saw 50 new patients in one month give away a bunch of free services? Was he running a We’re-New-In-Town-Here’s-A-Special-Deal-To-Come-See-Us special? Maybe the exam and x-rays were free? Did he and his staff put 30-50 hours in that month to see 50 new patients without charging them anything? Anyone can bring a lot of new patients through the door when they are giving their time and services away.

Maybe the doctor charged for his services, but is running an ad campaign on radio, print and television that cost him $10,000 that month. Let’s say he charges an average of $120 for a new patient visit. Did his ad yield a return on the investment? Not initially, but it might over time.

See why there is more to the numbers than the numbers?

Let’s look at Dr. 1500. 1,500 patient visits in a month is a LOT. He is a member of a certain practice management group, and that group isn’t big on chit chat and wasting time with things like taking a history, so he isn’t spending that much time with each patient, but seeing that number of patients is a huge amount of work. It takes training, discipline, the right office setup, a management company and coach, and a staff.

What is he charging per patient visit? Maybe he is charging $10. Maybe he is not charging anything and just takes what insurance pays (illegal, by the way). Maybe he is putting families on care plans and is only averaging $8/visit once it’s all said and done… we don’t know. Maybe he has enormous overhead and it costs him what he makes from the first 1,000 patients just to pay his expenses for the month. Maybe all of the above…

I’ve seen very busy practices have very rough financial times because of poor business practices, namely bad collections policies and high overhead. 1,500 visits doesn’t look so good when you’re only making a few thousand dollars a month in profit doing it. That’s hard work for little money.

Be smart and start learning about how businesses run. Get out of this mindset that more visits and more new patients equates to better practices and more profit. Those numbers, outside of the context of the practices overall business expenses, are completely meaningless. Don’t be duped by the numbers, but rather put your stock in the quality of the doctor producing the numbers and the overall health and fitness of the practice.

Know the Insurance Game

I was just talking to a doctor and heard yet another new disturbing trend in the insurance industry, which is why as students you really need must learn how to handle billing and insurance properly.

The doctor had a patient come to him and receive care. Bills were submitted to the insurance company, and paid. Months later, the doctor received a letter stating that a mistake had been made and that the patient had not been covered by a policy at the time, requesting a refund of everything they paid toward that patient’s care. The doctor refused to pay the money back, as it was the mistake of the insurance company who told him the patient was covered when he verified the patient’s policy information (!).

Since then, the insurance company has been taking a portion of the payments from other patients’ reimbursements who are covered and receiving services in that office. In other words, the insurance company is essentially garnishing the checks of the doctor until the “refund” they wanted is paid off. 

The only way to handle such behavior is to contact the state insurance commissioner and file a formal complaint, as well as contacting the state chiropractic association so they can alert other members of the problem and, if there are enough infractions, start a class action lawsuit against the offending (and offensive!) insurance company that is stealing your money.

Unfortunately, a huge difficulty in dealing with health insurance companies is that they are not obligated to tell you factual information when you verify benefits, and they have an automated message that comes on before any call is received that says, “Our information may or may not be accurate.” You must be very careful in dealing with these companies. I was always pretty lucky, but times are changing.

On a side note, the patient was upside down on a house he bought subprime (stupid) and so is penniless and is another one of the people caught up in the “housing crunch” (another word for people who couldn’t budget money properly), so the doctor can’t get the patient to hold up their end of the responsibility for THEIR insurance policy. As usual, the health care provider is left paying for the patient’s inability to uphold financial obligations.

New Evaluations for Students

By now you’re aware of the new evaluation slips being used in the clinic. We’ve adopted these for a dew reasons. First, as the college switches to a campus-wide computer management system we found out that there is no way to do “pass/fail” grading, so all courses, like the clinic courses, that were pass/fail must now be graded. More importantly, however, students have mentioned for some time that you want more feedback from clinicians, so these new evaluation forms kill two birds with one stone, contributing toward your grade as well as giving you the feedback you asked for!

The grading form takes a little more supervision from the clinician than the Palm Pilot evaluations, which you still need to continue doing. My best piece of advice is to make sure you get your evaluations done sooner than later. As the trimester goes on, we get busier, and toward the end of the trimester things are busy enough that we often cannot do evaluations to keep up with the pace. So, get started on them now or else you’ll likely run into trouble later.

The Importance of Staying in Touch

I realized recently why things are always so slow to start up after the trimester break. It really hit home today when a patient complained that he had called his new intern 3-4 times in a few days’ time, leaving messages every time, and the intern never bothered to call back.

I am the first to know that we all have personal lives, but your commitment as an intern, and soon as a doctor, is to take care of people. That doesn’t always happen at a time that is convenient for you, and you are often asked to make sacrifices to take care of others. This is the reality of being a doctor of any type. Calling a patient back is hardly a sacrifice… this is a person who wants to come into the clinic weekly, and his intern is too busy or too preoccupied to return a phone call? In the real world this is a patient who would be switching to another practice.

Anyway, I started thinking about the trimester break. Senior interns start checking out of clinic a couple weeks before finals. Junior interns are still worrying about finals, and so they think “Well, I’ll call this patient next week…” Well, think again. Finals goes on for a couple weeks, then there is the trimester break. I’m sure a lot of interns take “one last vacation” or veg out a little. Coupled with the reduced clinic schedule, all of a sudden we have a recipe for disaster…. Senior interns start turning patients over to junior interns a week or two before finals, the juniors are studying and worried about finals and then check out mentally for the break, thinking “I’ll get that patient in soon when school starts back up…” and lo and behold, 4-5 weeks have gone by without any communication with these patients.

Not only is this inconsiderate of these patients, who need and want your care, but it is very poor patient management. Like I already mentioned, in the “real world” every single one of these patients would have thrown the towel in with you and found a new doctor to take care of them. I had close to 25 chiropractic offices in the town of 38,000 I practiced in. It would be effortless to find a new doctor who could see a patient the same day. You better believe I stayed in good communication with patients!

Put good habits into place now. Call your patients and schedule them as soon as they are transferred to you. Schedule time for a patient transfer evaluation and fill it out properly by spending some time with the patient’s file. This is what you will be doing everyday for the rest of your career if you plan on practicing, so you should get comfortable with this now, as well as juggling exams, personal life, finances, etc. Life doesn’t get any less hectic in practice.

How to Use Soft-Tissue Procedure Codes

We visited this topic in another post, concerning the use of the internal clinic code 19-NC, but this is a more in-depth look at how and when to properly use soft tissue codes. This area gets a lot of chiropractors into trouble in practice, so start implementing this information in the clinic and you’ll be ready to continue good habits out into your own practice! Using the various codes available for soft-tissue work seems pretty straightforward, but I suspect that doctors and students are not given the best information at practice-building or technique seminars concerning how to use these codes.

 

Massage - 97124

Massage – 97124:

The massage code is separate and distinct from the other manual therapy and adjusting procedures you would be performing on a given day. Massage is used for soft-tissue work that is totally passive in nature, requiring no movement or work from the patient. The goal of massage is to relax tissues and promote circulation. Massage may be used to reduce edema or swelling, calm a muscle spasm, restore muscle function and improve joint range of motion. The procedures included in the 97124 massage code are effleurage, petrissage, percussion, superficial (Swedish) massage, pressure point (acupressure, trigger point, Nimmo, etc) work that is passive (as opposed to something like ART or Strain Counterstrain, as we’ll see in a moment) and the use of tools to accomplish the same thing, such as a “Thumper,” G5 massager, etc. Massage is generally given to a large area of the body and crosses multiple types of tissue in a general way (i.e. not making much of a distinction between muscle, tendon, ligament, etc. In some cases Graston or other instrument-assisted soft-tissue techniques may be considered a 97124 code, but usually it falls under another code described below. Of course, massage requires a doctor or therapist to be in constant contact with the patient.

Trigger Points - 97124

This code is billed in 15-minutes units. One unit of massage would be appropriate for 8-22 minutes of application. Two units would be used for 23-37 minutes of application, etc.

Manual Therapy – 97140:

This code encompasses a wide variety of services commonly performed by chiropractors, including manual traction, non-chiropractic manipulation (mobilization, for example), myofascial release, joint mobilization and lymphatic drainage. Techniques such as Strain Counterstrain, ART (MFR), muscle energy techniques and Graston would be most appropriately billed using this code.

As important distinction between manual therapy and massage is the specificity. Manual therapy is generally specific to a single tissue or muscle/joint. Massage, on the other hand, is more general in nature without much distinction to specific tissue types in the delivery of the therapy. For example, massage may be given to the entire back, whereas Graston would be isolated to the right upper trapezius.

 

Graston Technique - 97140

The intent of manual therapy is generally to work on fibrotic tissue and adhesions. The goal is to restore function to the target tissue. Manual therapy may be passive (from the patient’s perspective), such as in the case of most Graston techniques, or active, as in Strain Counterstrain or ART. Notes should always specify the specific area and time that was treated, as well as the technique used and any outcomes (improved ROM, improved tissue pliability, muscle function, etc). 

 

 

Neuromuscular Re-Education (97112):

This is an often misunderstood and improperly used code. It is used when re-training a body part to perform a task it was previously able to do. Physical and occupational therapists typically use this code for post-surgery, stroke or injury patients. It involves exercises that retrain the body part to do what it is commonly needed to do (standing, walking, flexing, extending, grip, etc). Balance, coordination, proprioception and posture may be a factor of this code, too. Chiropractors rarely engage in true neuromuscular re-education activities. Some types of postural rehabilitation and the use of wobble boards, for example, would be allowable under 97112, but the soft-tissue techniques mentioned above are never to be used with this code, contrary to what seminars may tell you!

Taking Time To Celebrate

This is for those students who are graduating in a few days… remember to celebrate your achievement! Not just partying, etc, but really take time to reflect on where you have been in the past few years… 7-8 years of college, moving, working hard, ups and downs… A lot of people go, go, go, but forget to pause and pat themselves on the back for their achievement.

Celebrate, but don't light yourself on fire!

Now, the REAL work and learning begin! lol Seriously, it does, but seriously, take a little time to do something for yourself and your family, loved ones, friends, etc. You deserve it, and so do they for putting up with you! Remember throughout life to stop and smell the roses from time to time… take stock of where you’ve been and what you’ve done, celebrate it, and move on toward creating and meeting new goals. Most importantly, do worthwhile things well and with pride and you’ll be a success!

The Art of the Patient Transfer Evaluation

OK, well, maybe “art” is pushing it a little bit, but since we introduced the Patient Transfer Evaluation a year ago, the “art” of doing it properly (and getting the most out of it) has been lost, so this article is timely if nothing else.

The purpose of the Patient Transfer Evaluation (PTE) is twofold: to familiarize yourself with the case of a patient who has just been transferred to you from another intern, and to evaluate the patient’s progress. Unfortunately, interns always wait to do the entire PTE when the patient is in the room, but in fact, about 1/2 or more of the PTE is supposed to be done before the patient’s visit. Most of the PTE is you going through the file looking at the information… past complaints, positive examination findings, current progress, etc. 

A PTE should take no longer than a “blue soap” note, when done properly. The part that is done when the patient is in the room is simply the updated evaluation procedures. When done properly, the PTE should only add a handful of minutes to your regular visit, and you get CMR credit (once you do the CMR, of course) from it. 

Start spending more time with transferred patients’ files so you can learn about their problems, what is working (or isn’t working) in their care, and can pick up right where the past intern left off, or move in a new direction as may be necessary. It makes you look a lot more professional to the patient, you’ll save time, and your care of the patient will be much better.