What is the proper Ecode – Oh, that’s an E-code? – for a diabetic with ketoacidosis due to malfunction of insulin pump, pump failed to deliver insulin causing ketoacidosis.

Diabetic with Ketoacidosis VIDEO

There’s a bunch of research, but she said E-code. I didn’t put in E-code. I’ll have to think about that. I can probably come up with it from memory.

So, diabetic with ketoacidosis due to failure of insulin pump. Now, what you have to think about when you’re doing something where when you’re coding for something, when you’re coding and something goes wrong, think complication. The terminology that you’re going to use to look up the codes is Complication. There’s a whole great section in the index under Complication.  So, when you look under Complication and then you look up “insulin” and then it will say insulin pump, you’re going to find 996.57 -medical complication due to insulin pump. Select this code to report the mechanical failure of an insulin pump – a device used by diabetics that injects insulin to the blood stream in intervals to regulate blood sugar levels.

If you’re familiar with a diabetic sliding scale, if you’re heard that term before; and what that is, if you’re looking at a prescription for insulin, it will usually say, maybe 10 cc’s. They’ve take it in the afternoon and the evening but every morning they take 5 cc’s, and that’s because you want more insulin as you’re more active; and when you wake up in the morning you haven’t been active so you don’t need as much insulin. But, let’s say a person has all kinds of things going on with their blood sugar so their insulin goes up and down, up and down, and they use a sliding scale. So, they check their sugar before they eat their lunch. If it’s 175 to 200, they use x amount of insulin. If it’s 200 to 250, they use x amount of insulin. They have this like 10-point little grid, you’d say, of how much insulin to go per what their blood sugar is.

Now, this is really obnoxious to do for some insulin users because they are constantly having to check their blood sugar. You may have to do that like 10 times a day. But what the insulin pump does is it actually checks your blood sugar for you. You stick it in your side. It’s got a little thing that looks like a cell phone or music thing. You don’t even hardly know it’s there and it actually delivers the insulin as it’s supposed to as you need it for your blood sugar. But, if that goes wrong, gets clogged, stops working, you are in big trouble and you usually don’t know it, so you can go into ketoacidosis.

So, what is ketoacidosis? 250.10 is the code for diabetes with ketoacidosis. Meaning that ketoacidosis is something that you have constantly, like a manifestation, but this is a manifestation. This means you’re in bad shape. So, type II or unspecified, not stated as uncontrolled, all the things they are associated with. Now, they throw in that you can use V58.67 because that’s long-term insulin use. So, usually code that as well.

So, what is ketoacidosis? It’s a really bad thing for diabetics. It’s going to cause all kinds of problems. What it means is it produces high levels of blood acids called ketones in the body. The diabetic ketoacidosis develops when your body is unable to produce enough insulin, thus you would be taking insulin. If your pump is not working and you don’t know it, you don’t check your sugar, the insulin normally plays a key role in helping regulate your sugar, your glucose – a major source of energy for your muscles and other tissues enter your cells. Without enough insulin, your body begins to break down fat as an alternate fuel. So, in other words, it literally is going to start breaking, feeding off of fat to produce enough insulin for your body to survive, which is not a good thing because that’s not what the fat was intended to do. And as a result, it’s going to make a buildup of toxic acids in the blood stream.

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This is SuperCoder.com, if you go to CodingCertification.Org/supercoder  that will talk you to their page with different pricing information. But this is a very good encoder, one of my favorites. I like SuperCoder and FindACode, and there’s a third where I’m going to be doing a review of my three favorites so people can see how I use them.

We met them at a conference, did we not, for the first time? Yes, she’s a great gal.

Yup. Jenny came over. And I love Super Coder; they had a great booth there.

Down on the bottom, it’s talking about these two codes. This is what she’s talking about this statement here. Let me show you in the answer sheet how we work this out. On the bottom of the page where I just showed you, the scenario describes both impedance and pH test being performed in one session. “If you think coding it is as easy as billing 91038 and 91034, you’re wrong.” – So she’s quoting the article. “Dodge a potential audit by looking into another important factor CCI Edits…” It goes on to talk about these two codes. She is confused by the articles.

National Correct Coding Initiative - VIDEO

What I want to do is show you I do CCI Edit kind of research for myself to see if there’s a bundling issue and how I chose which code to report. So, I‘m going to grab these two codes and I’m going to back to my SuperCoder. Up on the top when you pay for this, you’ll get things like CCI Edit Checker. You just go in and in this box, you put in your codes and you need to separate them by a comma instead of the word “and” and you just click on “validate”.

So, here’s the two codes, 91038 and 91034. We’ve got this red big flag. So this is telling me, “Nah-ah, I’m not going to get away with coding both.” So, I’m going to read what the box says and it says, “The 91038 is a column two code for 91034. These codes cannot be billed together in any circumstance. Code 91038 is bundled into 91034. Code 91038 cannot be billed with 91034.”

Basically what I do is I look at the RVUs. This one is worth 14.50 RVUs. This one is worth 5.93. So, depending on where you live and whatever, this gets multiplied times a conversion factor to come up with the dollar amount. The higher the RVU, the more money the code is worth. I normally, when I have between two codes, we’ll go with the higher code, the 91038 because it’s worth 14.50 RVUs.

That’s what you’re looking for. If your documentation sounds like it supports both, and you pop up both of those codes into your CCI Edit Checker and it comes up as you can’t bill both of them together, then bill the more comprehensive one. So, the smaller or lesser RVU one is the one that’s bundled into it.

Let me go back to the rest of my answer. So this is what she was struggling with. I just kind of comparing the two codes here to see visually what they share in common, so in green, I did that. They both say gastroesophageal reflux test with nasal catheter. They both say recording analysis and interpretation. The 038 code, the higher RVU one is called an esophageal function test and it’s little, apparently more involved that talk about greater than one hour, etc.

So, if your documentation supports greater than one hour etc., then go with the 91038 and do not report the 91034. Or else you would be violating the CCI Edit.

This sentence here should be reversed. Check out the CCI Edit’s table and you’ll see 91034 described as the more extensive code. It actually should say 91038 is the more extensive code. So I can see why that would have tripped someone up. So focus on the RVU values and you just need to ask yourself: Does my documentation support the higher RVU one? If that’s the case, then go ahead and report that and forego the lesser RVU one.

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Now, it looks like there’s tons of stuff going on here. If you were to look at that, I’m sure you’re kind of thinking, “Oh my Lord where do I start?” So, what we’re going to do. We’re going to start with left heart cath (93458) – oh this is what she did. This is actually what she was thinking. She was going to use 93458 with a modifier-26. But she was confused. “I read the CPT book several times. I went online to find the answer and I had no luck. I’m confused. Does this code include everything that was done or am I missing other codes that this procedure was done? Please help.” I think her name is Magda.

Left Heart Cath and Aortography – VIDEO

This is common. You don’t think that you’re the only one out there that has problems with this. She did everything right. She went to the CPT book. She looked at it. She went online. She did her other resources and she still isn’t positive. That’s I think something that coders have to remember – they’re really researchers, actually. I’ve had several people say, “Do we get to use our book?” Yes. You get to use your book for everything because that’s what a coder does.

This is the report that the doctor gave her which is actually a duplicate of what was above. So, I’m not going to repeat that. The thing here, complication – none; there is no complication. So, we get to move aside from that. Don’t think of that. Estimated blood loss 20 ml… local approach for the right femoral artery… I’m not going to read all of that because we’re going to go over it. You guys can access this again later, but this is all the description of what she was reading to come up with her codes.

Go ahead and keep going down a little bit more. We had ejection fraction, that’s important. There’s our conclusion.

Here’s the meat of what you need to know. It’s actually so much simpler when you look at that, say this was a board exam question. This would throw you for a loop, but in the answer, you’re going to break down 93458.

Catheter placement in coronary artery(s) – you notice it says “s “  – for coronary angiography including the intraprocedural injection(s).

See? That’s included – for coronary angiography, imaging, supervision and interpretation. That’s all included.

So, with left catheterization including the intraprocedural injection(s) for left ventriculography when performed.

So, yes, it includes the three main pieces to the cardiac cath: the catheter placement in the coronary vessel, the catheter placement in the heart, and the dye injection and the pictures or the imaging that were taken.

Anyways, if you want to go into more detail or anything, you’d had to see the rest of the upper part, I guess.

But, that’s what they’ll also do, mind you guys, if you’re taking a board exam. They’re going to want to know can you determine if all of those questions… or everything that was done to that patient, are you going to need one code or you’re going to need multiple codes? See, if you go in and you look at that, you break that upper part, you break down what the description of that code was, everything was there. You can do that with a highlighter as well… but you can use a piece of paper to make sure.

That really is an excellent question. I’m glad, you asked that Magda.

All right, thank you.

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Yeah, in our Physician-Based Coding Course Chapter 1 covers these topics and you’ll also find it in the AAPC CPC Study Guide. They have on the AAPC website – we’ll just go there first to show you what I’m looking at. When you go under Certification and then CPC and you scroll down… actually the first tab here. It tells you the areas, the topics that they test you on. We’ll there’s one here Practice Management, that’s kind of a generic catch-all category. There’re about 9 to 10 questions out of the 150 questions on it. Those are some of the things that she mentioned in her question that will be on it.

So, I basically went through Chapter 1 of the textbook which is the AAPC’s textbook for Physician-Based Coding. They have Types of Payers, so they feel it’s important for you to understand the difference between government payers like Medicare and Medicaid and private payers. It goes into talking about the Medical Record and what does an E/M note look like? They discuss the SOAP format – Subjective, Objective, Assessment, Plan. Then they talk about Operative Report documentation. So, anything on these general topics for CPC Exam could be in that section on the board exam.

CPC Exam and Other Stuff – VIDEO

Medical Necessity – Basically, Medical Necessity equals your diagnostic coding which makes Alicia very happy. It makes diagnostic coding important to support the procedure that was done which ties in with your local carrier decisions that Medicare puts out there so you can know for any given procedure what diagnoses codes support that procedure where Medicare would consider paying for it. So, they want you to have some familiarity with that.

Advance Beneficiary Notice (ABN) – That’s something that you have a patient sign if you know or suspect that a service is not going to be covered because maybe they don’t have one of those diagnoses on the list. By the way, those diagnoses on the list are not a shopping list for us to use as coders to say, “OK, we will use this one.” You’re supposed to be coding with the physician documented their diagnosis is. Then, if that is not on the approved list, that’s when you have a patient fill out an Advance Beneficiary Notice (ABN).

Then we’ve got HIPAA, The Health Insurance Portability and Accountability Act. It talks about national standards/code sets that everyone is supposed to be using. It also has a portion about privacy and security. So, anyone who’s going to the doctor, they’ll say, “Oh you need to sign this form for HIPAA.”

Then the HITECH Act. I’m going through this quickly because my end advice… OK, Compliance and the OIG – the Office of the Inspector General. My advice for all of these is just do a Google search, quite honestly. You don’t need to know for the board exam any of these in-depth, but you should be familiar with them so they don’t seem like complete Greek.

So, in this webinar, all of these would probably take several hours to go through and do a lecture on. If you take the course and you’ll get the lecture there, but I would just do a Google search. A lot of this information you’ll find in the CMS website. And do some research that way.

I just did a webinar yesterday about “How to Be Your Own Consultant Using Research Tools Online.” I’m going to get a recording of that and be offering that to our group as well for CEUs, and so look for that. And I show you how you can use things to start… just pretty much how Alicia and I go and research the answers to these questions we give you. Nine times out of ten we start with the Google search or we go to our encoder and we just start pulling pieces of information together and we synthesize it and then present it to you. That webinar will teach you how to do it for yourself, and you can use that to go and explore these topics to prepare for those ten questions on the exam or just for general knowledge.

By the way, a lot of these overlap with the CPC-H credential, with the Physician Practice Management credential; so it does benefit us all to understand these concepts. Now, if you join our discussion forum CodingCertification.Org/forum or our email list which is a Yahoo group’s email list. This kind of stuff comes up all the time. People start taking about HIPAA and they talk about compliance. That’s how I learned back in 1999 when I got my credential. I started an email list called CRNL which we recently changed the name to CCOL because it’s still my list. And they talk about the stuff all the time, like what is that? So, I Google it and I go, “Oh, now I know what that is.” And if someone was stuck on something and they ask a question, I’d watch how others with more experience answered it. That’s really the best way to learn. So, get on our forum and our email list and you will be educated whether you want to be or not.

Then, she’d also asked about RVUs. I don’t recall that being on the exam. If anyone has recently taken the exam, if you want to put in the chat whether or not you remember a question on RVUs; I mean, we can’t talk about specific questions but I really don’t remember them asking about that. But, I did cover it on the other slide with the NCCI Edit. It’s a relative value unit. It’s basically a way to compare one CPT code to another to know the weight of it.

Alicia, you’re up.

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Alicia: Because it’s one of those simple ones and yet… I can tell you, you don’t talk about test questions. You’re not allowed to talk about test questions when you walk out. But I do recall a question about this on the exam. The person had said “My 3-year old is prone to ear infections. I work in an allergy office that she goes to regularly and I was looking at her chart to get dates of ear infections for her ENT appointment she had on Monday. Anyway… question is what is the difference between 381.01 Otitis Media Acute and Otitis Media Allergic? I noticed the documentation was fairly similar and (I can’t find the paper now) but two of the three times she was given an antibiotic, yet each time it had one of these two diagnoses. Also, the last visit the doctor/PA told me that she didn’t have an ear infection; that the ears were red, yet the diagnosis was Otitis Media Acute and no antibiotic.”

Otitis Media vs Allergic Reaction- VIDEO

She’s ultimately confused about the details about otitis media and the adjectives that go along with it. So, what is otitis media? There is a link which I kind of copied the information here. There are three kinds of ear infections, which are called: 1) acute otitis media – acute means sudden onset, 2) otitis media with effusion, which means that there is pressure built up behind the ear, and 3) otitis externa which is swimmer’s ear, which I know some of you have heard that. That is just meaning that the ear canal is irritated.

Now, with all of those you can have some other things. One of the key words besides acute and chronic – and most of you will know what that is – but you have to pay attention to that, they are different codes. If I’m writing a test question, you bet I’m going to throw one of those in there because it lets me know if you’re paying attention to the details. You’ve got to pay attention to the adjectives. That’s what they’re wanting to know on the CPC exam. One word can make a lot of difference.

In acute serous otitis media, the infection of the middle ear is accompanied by a build-up of fluid, usually due to inflammation of the Eustachian tube preventing drainage. Scroll down to the ear real quick, Laureen, that we’ve got. Here you’ve got the ear canal. You’ve got the eardrum right there, that little pink circle there. Now, then, in the middle ear, that can have pressure. Fluid can build up in there and all that can have swelling and stuff. The eardrum will bulge ultimately. And if it’s bulging, then they know it’s with effusion. If you’d ever had a chance to see inside of the ear – and I advise you to go on YouTube and you can see all kinds of pictures.

But that’s how they would diagnose otitis media with effusion. Now, when they say serous, what they’re saying is, ultimately, is there any pus? Is there any drainage, serous fluid, that’s what that means. There’s something oozing out of your eardrum around the eardrum. So, they’ll look in the ear; if it is just irritated, the ear canal is just irritated- it’s inflamed, it’s itchy. Think of “itis” there’s irritation there. That is a lot of times due to an allergic reaction. It doesn’t have to be because it’s infected. If the eardrum is bulging, then you have effusion. If you have all three of those things and on top of that fluid coming out of the ear, that’s also when you would need an antibiotic. A lot of times, they will not give an antibiotic for just irritation, but they will give it for fluid, the bulging eardrum and they’ll give it for… Because a lot of times, your eardrum will go ahead and perforate and they don’t know what’s behind the eardrum. Is it pus, is it just pressure? What’s back there, they can’t see it. Your eardrum is actually kind of clear and if it’s white and foggy, they know there’s something back there.
Then, the build-up of the fluid… and the drainage. So, acute allergic serous otitis media – that means sudden onset. It was brought on because of an allergic reaction. There’s fluid or something coming out of the ear that’s made it inflamed, 381.04.

Now, your doctor may not write all of that. You may have to go in and see… he’ll write acute or chronic because that’s just a given. But he may not write allergic. If he doesn’t say allergic, you can’t say it’s allergic. If he indicates that it’s allergic reaction or the patient has allergies or something, then you can probably draw the line and use that 04. If it doesn’t say “due to an allergic reaction,” of any kind, you can’t use that code.

381.10 is a completely different scenario. Chronic – that means this has been going on for a long time, maybe they’ve had it either for a long time or they get them repeatedly. Serous – so you have fluid draining, there’s stuff coming out of the ear whether it’s pus or fluid or something. And inflammation – simple or unspecified. Now, this is probably one of the more common codes that are used specially with a child that keeps getting an ear infection. They don’t know. Have we just not been able to get it cleared up? We’ve got fluid, we’ve got inflammation and he didn’t say whether it’s simple or unspecified so this kind of – if there’s fluid, this is going to be a catch-all one.

Now, when you go in to 381… are you able to bring up that page or is that too much work to bring up the manual?
Laureen: Which one?

Alicia: The manual, the 381 in the ICD-9.

Laureen: I can do SuperCoder.

Alicia: OK, I’m not sure if it looks the same as the manual, but I bet it does.

Laureen: Which one?

Alicia: You want to just pay attention to those fine tune words, those adjectives.

There you go. Put in 381 and let it give the details of all of them. That’s what’s so great about this; you can… if you know where you’re at, it will give you. There are more than just those ones I mentioned. See? You’ve got acute nonsuppurative – that means there’s no fluid, there’s nothing coming out of the ear. There’s no pus, there’s no drainage. Then, it’s zero. One – Chronic and there’s fluid. Mucoid is just another word for mucus. Other and unspecified – nothing coming out of the ear. Now, all of these are going to use another digit, mind you.
But, see all of your options there? You have to be very careful, and this is one that you’ll often see on test questions especially mock ones because it’s so easy to trick somebody at. They say, “Ops, otitis media. Okay, 381.01, got it!” and not paying attention to the details. I keep saying that, it will get you on the test. Pay attention to details. Don’t go too fast.
This is where you want to bubble and highlight. Right, Laureen?

Laureen: Yup! Although I tend to do that on my CPT manual, but absolutely you can do it in your ICD manual. Alright, thank you, good one.

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Highlight: What did she use to help her staff of coders get certified? Hmmm… let me guess

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Coding Certification Review- Tera Russo Video

OK. Here comes the answer sheet…Assistants at surgery modifiers. I found, I think it was from 2009, article on the AAPC about this assistants at surgery modifiers. Basically, you’re going to have modifier-80. I’ll show you the choices first: 81 minimum assistant, 82 assistant at a teaching facility, and AS – this was the one that she was talking about which by the way, it took me a while to figure out her question because she didn’t have AS capitalized. I kept going, “I use modifier as, but I’m…” I finally figured it out. So, do us a favor when writing questions, capitalize when it’s important.

Medical Coding – Modifier for Assistant-RNFA Surgery VIDEO

Let’s review what this is telling us. So Modifier-80 is the typical modifier you think of for assistant surgeons. You have a primary surgeon billing a procedure and then you have someone that’s assisting that primary surgeon. They both use the same CPT code. But the assistant puts an 80 on their code. The private payers will typically pay 20% to 25% and Medicare pays like 16%. Medicare has on their website the CMS website, a Medicare physician fees scheduled database, something like that. They’ve got columns for every single HCPCS code, meaning HCPCS level I which is your CPT codes and HCPCS Level II which is the HCPCS Level II manual.

Next to all of these, they will let you know a whole bunch of things about the code, but there is one about assistant at surgery. You’ll also find it in your encoders like SuperCoder or Find-A-Code; all of those will take that Medicare CMS, that table and put it into just more user friendly format. So, not all surgery codes warrant having an assistant. It doesn’t mean that you can’t have an assistant help, but it doesn’t mean that they will pay for it. So, it’s all about medical necessity. When you get on the CMS site, you’ll read things like, they do studies to see how often assistants are needed for particular procedure. If it’s not that often, then they will, in the future years, probably not allow it. So, that’s 80.

Now, here’s a little blip about Medicare and modifier-80, they restrict the use of it to the primary procedure. So, if the physician, the primary surgeon did more than one procedure, they’re only… for Medicare letting the assistant bill one of them – the primary one with modifier-80 and they get 16% of the fees schedule.

There’s this other Minimum Assistant At Surgery. Medicare doesn’t recognize this, but some private payers do. They put 81 on. It’s kind of like a pecking order. I’ve always explained it in my modifier lecture that they’re kind of like your openers and your closers; they don’t stay for the whole thing.

Modifier-82 is exactly the same as 81, except that’s used in teaching facilities because the idea is in teaching facilities they’re supposed to be using residents. Residents are doctors, but they are doctors that you can’t bill for yet. So, teaching facilities get paid more and therefore with the expectation that the residents are assisting.

If in your facility, there are no trained residents to assist for that surgery, then they will let a non-resident physician be an assistant and they have to use a modifier-82 because it puts onus on them to say, “We’ve got documentation that none of the residents that we currently had on staff were qualified.” Not that they were busy, not that they were doing rounds, or getting a Coke down the hallway, that they were not qualified to assist and therefore a nonresident physician came in to assist. I used to say a real physician, but that’s not very nice because residents are definitely real physicians. They’re just newer and they can’t be billedl for yet. So that’s how modifier-82 works.

Modifier AS-Assistant at Surgery – These are for your PA (your physician assistant), NP (nurse practitioners, or clinical nurse specialist). They can also be assistants at surgery and they are identified by putting an AS after their surgery code. This modifier may only be submitted with surgery codes and additional documentation is required. This is the documentation, according to this article, that they’re looking for a statement that no qualified resident was available.

A statement indicated that exceptional medical circumstances exist. A statement indicated the primary surgeon has an across-the-board policy of never involving residents in the preoperative, operative, or postoperative care of his/her patients. Actually, I think that’s more for the 82.

There are some limitations with this, but this is a good article and let me click on the link so you can see it in context. It’s the news that AAPC.com, oh, it’s 2008.

While it’s doing that, just to go back to the question, when I looked at what people were saying in other discussion boards, they’re kind of like you really can’t bill for two assistants except in rare circumstances like some very complicated cardiothoracic procedures is it allowed. Oftentimes, you have to send in, in documentation.

So what I suspect is going on here for you Stephanie is that they just aren’t considering the second one medically necessary, so I would bill the ones that would give you the most return. So, if you have a non-AS physician, then I would use the regular 80 code before the AS. So, hopefully, that helps with that one.

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The Many Roles Of A Physician Practice Manager

Depending on the size of the practice, a PPM may assume many roles, such as functioning as an accounting manager. If reporting to a large governing organization, responsibilities may be more wide spread but the ability to communicate to Chief Financial Officers and Controllers is an important factor to consider; thus, the understanding of all financial processes is still a mandatory part of the PPM’s job description.
In some medical practices, the PPM may focus on the more day to day operations, using strategic methods to improve patient flow as well as cash flow. However, the understanding of billing and collections would be a significant aspect of the job.

Often times, a physician practice manager monitors all billing processes, review accounts receivable reports and query the billing department for additional information on reimbursements and payer concerns. Payroll, bookkeeping, and preparation of other practice reports may be reported to the practice owner or a business administrator, such as the practice’s CPA.

Beyond basic fundamentals of accounting, a PPM has the responsibility to keep the owner of the practice up-to-date with changes in health care reform and quality improvement. He or she should also schedule educational training on a regular basis in all areas that help the business financially.

There are basic accounting measures that PPMs should know such as the income statement, balance sheet and cash flow statements which can be presented monthly, quarterly, or as needed. A simple software such as Quicken or QuickBooks can be set up to display all revenue categories such as office service reimbursements, honorarium income, revenue from research or activities outside the office such as interpreting EKGs for a hospital. Expenses would be similar to any business classifications with additional expenses such as malpractice insurance, professional license fees, and medical supplies. Payroll would include all staff salaries, including the physician’s, plus medical and dental coverage, taxes, and contributions to a retirement plan.

There are two types of accounting methods: cash accounting and accrual accounting.

Cash Accounting is simple to understand. When any revenue is received, it is recorded when the money is collected. When an expense is paid out, it is recorded at that time. This simple form of accounting excludes the accounts receivable or payable accounts, accrued expenses or deferred costs, etc. It is a clean method of record keeping. The balance sheet, prepared in a clean cash basis has two items to record: cash as the asset and the owner’s equity.

Accrual Accounting provides a more precise calculation of when patient services are rendered opposed to when reimbursements are received. In other words, focus is on the production numbers prior to payment from the payers. Expenses are recorded when they are incurred and pending for payment.

Activity Based Accounting is a complex method of calculating the variety of tasks a staff person performs in a specific amount of time for each activity. This method of accounting is not used often and would work best within a radiology department.

An Income Statement is a valuable report that demonstrates a practice’s financial condition and is a reliable tool to form a good budget. Income statements can be used for annual projections and modifications based on income and expenses.

Budgeting for a practice is a process which is based on the prior year’s expenses with adjustments to represent any changes that have taken place or will take place based on production or expenses. It is important to figure out what you want as a percentage of total revenue when measured against variable expenses which can fluctuate based on production. Fixed expenses such as rent are easy to calculate into a budget. Creating a budget is time consuming but worth the effort if you want your practice to grow. Be consistent with comparing figures to see if you reach your goals.

A Balance Sheet is a quick view of the medical practice’s financial condition. It will include assets, liabilities, and stockholder’s equity. NOTE: TOTAL ASSETS MUST EQUAL THE SUM OF LIABILITIES AND EQUITY AT ALL TIMES. The balance sheet is a great tool to track trends in accounts payable and receivable.

A Statement of Cash Flow is basically a report that shows how your cash was used during a specific period of time. There are three parts of a cash flow report: (1) cash from production (2) cash from investments and (3) cash from financing. It is vital for a PPM to manage the cash flow of the practice because it reflects the monies available to maintain business operations.

It is vital to be able to account for all money coming in and going out of the practice. Financial controls are necessary and should be dispersed amongst staff in order to discourage mishandling of money or temptations to steal. Internal and external controls should be set up as standard operating procedures and regular audits should take place to let personnel know their tasks are being monitored.

Lastly, a PPM should be able to identify and understand the makeup of a practice. If a physician is a sole proprietor, he has no liability protection and involves minimal paperwork for taxes. A “C” Corporation is a more formal set up and is taxed twice – first at the corporate level and then again at the physician level. An “S” Corporation is similar to a “C” Corporation but has a limited amount of shareholders. Profits can flow to a doctor’s personal tax return and not get a double tax when the business is an “S” Corporation. The Limited Liability Corporation (LLC) offers liability protection of a corporation but is taxed like a sole proprietor. An unlimited number of members can make up an LLC and there are fewer restrictions on ownership of the practice.

Accounting requires organization and planning as well as an understanding of the type of practice being managed. By managing a medical practice properly, financial rewards will be achieved.

Related Physician Practice Manager Medical Practice Accounting

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The Health and Human Services Office of the Inspector General (OIG) is the largest inspector general’s office in the Federal Government with over 1700 employees dedicated to preventing healthcare fraud, waste, and abuse against the Social Security Administration’s (SSA) programs. Medicare and Medicaid are two examples of such programs. The OIG conducts comprehensive audits and investigations continuously as a preventive measure against crimes of fraud and abuse.

Information on OIG Work Plans, as well as audit reports, can be accessed by the public at http://oig/hhs.gov/. The evidence posted to this website names the abusers and the crimes committed, as well as punishment and fines. It is serious business and not to be taken lightly. Physician Practice Managers should follow the OIG website for compliance assistance on a regular basis. Governmental regulations are posted to help a medical practice. Should an investigation take place, the physician as well as all staff, managers and outside vendors will be questioned for their part in the crime.

There are specific risk areas for medical practice managers that should be monitored regularly to prevent errors or fraudulent behavior:
• Coding and billing
• Reasonable and necessary services
• Documentation
• Improper incentives, kickbacks and self-referrals

The OIG offers several formats for executing compliance plans. The plan can be accessed at http://oig.hhs.gov/authorities/docs/physician.pdf and offers compliance programs for individual physicians as well as large groups.

Healthcare Compliance For Medical Practice Managers

It is imperative to learn the requirements of an OIG Compliance Program. Key points of the program include:
• Leading internal monitoring and auditing of billing and coding procedures as well as the practice’s compliance with federal and state coding and billing regulations
• Implementing compliance and practice standards
• Designating a compliance officer or contact(s) to monitor compliance
• Responding quickly and appropriately to identified violations
• Developing open lines of communication
• Enforcing disciplinary standards through well publicized guidelines

The OIG guidelines are still voluntary for individual providers and small groups. In 2010, however, the Affordable Care Act made compliancy plans mandatory with a pending implementation date.
A well designed compliance program will optimize proper payment of claims as well as faster turnaround of money. Patient privacy will also be protected.
No one wants to be audited by the Centers of Medicare and Medicaid or the OIG, so utilizing a compliance program reduces the chances of experiencing a not-so-pleasant investigation.
By being aware of rule breakers such as self-referrals and anti-kickback statutes, the Physician Practice Manager (PPM) is allowing the medical practice to operate as an ethical business. If anti-kickback rules are not adhered to, penalties will be enforced and may include a fine of up to $25,000, imprisonment of up to five years, and exclusion from participating in federal health care programs for up to one year. Civil Monetary Penalties are $50,000 per violation. Plain and simple – this is serious business and these types of crimes are considered felonies.
Awareness of office performance is critical and guidance is readily available via the Web through the OIG. A practice manager or physician can customize a compliance plan best suited for their practice’s needs with a little research.

The first step in developing a plan would be to audit every function of the office and form a baseline to work from. Benchmarking is essential in tracking your improvements and tweaking your weak areas. Maintain all paperwork in the event of an audit. No longer does the industry use the phrase “if you get audited”; they say “when you get audited”. Be prepared.
Follow the guidelines of HIPAA and Privacy Rules which protect an individual’s protected health information (PHI). PHI is permitted in specific circumstances and in some instances can only be given out if approved by the patient or by a patient representative in writing. During an investigative action by Health and Human Services, PHI is made available without patient permission.
Occupational Safety and Health Administration (OSHA) also falls under compliance regulations. Important concerns in a medical practice are blood borne pathogens, radiation, chemicals, and biohazardous waste. Employers must provide a place that is free from recognized hazards which could result in physical harm or death. There are guidelines online to assist an employer with complying with health standards as well.

There are many coding and billing issues that can trigger an audit and the fault can point to the practitioner or the biller/coder. Do not think bad behavior goes unnoticed. Red flags are linked to problems concerning a negligent medical practice and it is just a matter of time before an investigation takes place.

Audit Triggers:
• Using one level of E/M services consistently
• Using higher levels of E/M service that are not justified
• Ordering excessive tests
• Unbundling of procedures
• Waiving co-payments, co-insurance, and deductibles without financial hardship
• Changing codes to get paid or to appease an irate patient
• Coding based on reimbursement and not medical necessity
• A provider’s specialty profile (utilization pattern – bell curve) that does not meet industry standards
Documentation Principles:
• Documentation should be complete and legible
• Each patient encounter should include (1) reason for visit (2) relevant history, physical examination findings (3) prior diagnostic test results (4) assessment (5) clinical impression or diagnosis (6) medical plan of care
• Date and legible identity of the observer

With technology taking over paper, safeguards must be in place to protect electronic protected health information. A few precautions would be to control access to information based on a person’s role in the office. No computer screen should remain open with personal information available for anyone to view. An automatic logoff should be put in place if the computer has been unattended for a short period of time. Logins and passwords should be used to authenticate admittance into the medical records as well. Lastly, transmission security should be at a high level and monitored regularly. By establishing appropriate safeguards, health care providers will avoid civil and criminal penalties that are associated with compromising a patient’s privacy rights.

The OIG releases a work plan every year outlining potential problem areas with claim submissions and focuses on specific areas to examine. You can review the work plan by visiting http://oig.hhs.gov/reports-and-publications/workplan/index.asp.

Health Care Compliance is a very serious matter. By initiating steps to maintain compliancy, you can be assured that a medical practice managers efforts will be rewarded.

More Related Healthcare Compliance for Medical Practice Managers

http://oig.hhs.gov/

http://oig.hhs.gov/authorities/docs/physician.pdf

http://oig.hhs.gov/reports-and-publications/workplan/index.asp