A PKF North America publication with contributions from:
Practice
Strategies
A Newsletter for Healthcare Professionals
Summer
Spring 2015
Documentation
Early Warning Overload
Can
Medical
Scribe
Improve
Your Efficiency?
Signsa of
Practice
Financial
Problems
IT
hrough training and experience,
t was meant to be a time-saver, but
medical practitioners are well
Electronic Health Records (EHRs)
versed in the distinct warning signs
have created some unintended conof various health conditions — the
sequences. Physicians are finding
telltale signs that health problems
themselves overloaded with docuare afoot. However, the clear signs
mentation and clerical responsibiliof financial problems in the practice
ties — and pulled away from actual
often go undetected.
patient
care. are a few key warning
Following
In
the
end, providers
are finding
that
signs of potential
problems
in practice
they
make
for
very
expensive
typists.
finances that you should keep an eye
As
result, many are increasingly
outafor:
turning to medical scribes — trained
medical information managers who
• A drop
in receivables
— A signififollow
a physician
throughout
the
cant
drop
in
accounts
receivable
can
workday and chart patient encounsignal
a
drop
in
production.
It
could
ters. In fact, a 2014 Technology Survey
simply be abybump
in thePractice
road —
a
conducted
Physicians
magphysician
returning
from
a
two-week
azine noted that one out of every five
vacation wouldn’t
expected
to have
practices
surveyedbe
that
was using
an
much in the way of charges in AR.
EHR is also using a scribe.
Or, it could be a signal of something
In addition to making patient vismore worrisome, like a loss of referits run more efficiently, scribes can
rals, for example.
sometimes even add to the bottom
line. A 2013 report published in CliniAction: Prepare
monthly Research
summary
coEconomics
and aOutcomes
accounts
receivable
report
showing
comevaluated four cardiologists in an
parisons
over
several
months
as
well
outpatient clinic over 65 clinical as
year-to-year.
hours
and found that they were able
to see 81 additional patients when
using
scribes.
• Lagging
collections — A steady
increase in receivables over 90 days
Thinking
Medically
(Instead
old may signal
a problem with
collecof
Clerically)
tions.
A high percentage of AR in the
By
handling
management
tasks
90-day
bucketdata
could
be due to anything
for
physicians,
medical
scribes freeto
from
delayed claim
submissions
physicians
medically
instead
dirty claimstoorthink
a host
of other issues
of
clerically.
This allows providers to:
that
require attention.
• Increase patient contact time
• Give more thought to
complex cases
• Better manage
patient flow
• Increase productivity
to see more patients
In practice, here’s how
a hypothetical scribe/
physician/patient interaction might look:
Action: Create a detailed accounts receivDr. B.
with report as well
ableAs
report
—speaks
a basic aging
the
established
patient
in
as aging
by insurance
company
and, sepaExam
note-taking
rately, 1,
forhis
patient
receivables and insur“shadow”
taps into a laptop, updating
ance receivables.
the patient’s electronic chart. Dr. B.
loses
eye contact
with his—patient
• A jump
in adjustments
Substantial
only
to attend
to a normal
lingering
wound.
variations
to your
adjustment
His
down
important
ratescribe
can besets
a sign
of the
anything
from
points
in the medical
record,
embezzlement
to changes
in noting
billing
the
lab tests
and medications
patterns
or payer
mix. Or, it may just
ordered.
Next, data
the scribe
be a recurring
entryprints
error. out a
copy of the summary sheet as well as
wound-care
instructions
for thecycles
Action: Depending
on your billing
patient
to take home.
Then, as
B.
and productivity,
adjustments
canDr.
follow
writes
and
chargesup
by the
twoprescription,
to eight weeks.checks
To accomsigns
chart
and says
goodbye
to
modatethe
for this,
compare
the current
month’s
his
patient,to
the
scribeand
is collections
off to Exam
2
adjustments
charges
from
for
the next
encounter.
the prior
month
or even the month before.
• A surge
overheadFeel?
— Even with a
How
Doin
Patients
firmmost
handmeasures,
on cost control,
a practice’s
On
patients
seem to
overhead
will concept.
inevitably
rise in
like
the scribe
It frees
upstep
with the
consumer
price
index.
Yet a
their
doctors
to focus
more
exclu-
2
Patient
Portals
and
Are You
Ready
Stage 2forMeaningful
ICD-10? Use
sharp and sudden increase in medical
supply costs, for example, demands
investigation. When running the
numbers, it’s important to remember
sively
onother
them.part
Yet,of
thethe
idea
has its
that the
overhead
detractors.
sayYour
that overhead
having
equation isCritics
revenue.
medical
scribes
inbe
theinflated
exam room
percentages
may
if reveintrudes
the doctor-patient relanues are on
declining.
tionship. The presence of another
person
the sure
exam
room,
they say,
Action: in
Make
you
understand
the
may
cause
less forthaverages
forpatients
your areatoofbe
practice
or specoming
about
medical
concerns
cialty, and
then their
compare
costs from
month
—
whichand
could
impact
to month
yearultimately
to year. Better:
Monitor
their
diagnosis
and
treatment.
practice
expenses by
category
— staff, facilthesupplies
workflow
side, physicians’
ity,On
office
and medical
supplies.
verification and authentication of the
• Unexpected
late charges
and
penscribed
documentation
adds
another
alties
—
A
medical
practice
that
step to the patient exam process.can’t
In
pay its bills
within 30 days
may
be
addition,
inexperienced
scribes
may
suffering
from
serious
cash
flow
issues.
make errors as they learn the medical
Getting dinged
with
late charges
and
terminology
and
technology,
further
penalties
is
compelling
proof.
slowing down the overall workflow.
Continued on page 3
3
Q&A: Avoiding
Requirements
for
Incident-to
SignatureOverbilling
Scribes
4
Set Your
ICD-10
What
Are the
Feds
Priorities
Watching
Out For?
Countdown to ICD-10
Is Your Practice Ready for Launch?
Y
es, ICD-10 is really going to happen. The launch is set for Oct. 1,
2015, and if you’re not ready for
implementation, the alarm bells
should be going off.
Ideally, you will have everything
in place by early September, giving
you and your team time for testing
and trial runs. However, if you have
not taken all the necessary steps,
you’ll need to prioritize your activities in the limited time before Oct. 1.
Consider these five mission-critical steps for ICD-10 readiness:
1. Make sure all (data) systems are
go. Specifically, ensure that your data
systems are updated for ICD-10 capability. This means your vendor has
delivered the most recent version and
current user materials to guide you,
and your staff has updated systems
appropriately. Likewise, all systems
involved in documentation, coding
and billing should be updated.
Action: Verify with your EHR
vendor that all software products
and applications are ICD-10 compliant. Note that vendor resources are
being stretched very thin with the
nationwide rollout, so keep in touch
with your vendor and get these
updates scheduled.
2. Master the codes that matter.
You don’t need to master them all but
you do need to master the codes for
the top conditions you treat. Consult
the ICD-10 code set to determine
what and how you will need to document. For example, when coding for
diabetes with the new code set, you’ll
need to document the manifestation
of the disease as well as insulin use
and presence of coma.
The key is specificity. In fact, some
experts are saying that the five most
important words you can master
under the new system are: “mild,
moderate, severe, chronic and acute.”
Action: Select charts that correspond to your practice’s most fre-
2
Practice Strategies Summer 2015
quent diagnosis codes. Then review
each medical record and see if there
is sufficient documentation to support appropriate ICD-10 codes. If
clinical information is missing, make
a list and begin addressing the lapses
in those areas.
3. Root out unspecified diagnosis
codes. A good way to tell if you’re
going to have trouble with ICD-10 is
to see how much trouble you’re having with ICD-9. Hint: If you currently
have a substantial number of claims
denied as “not medically necessary”
or have pre-authorizations for diagnostic tests denied because there is
“no covered indication,” you’re probably suffering from diagnosis-code
issues. The problem is only going to
get worse in ICD-10.
Action: Run a report to find the
frequency of unspecified codes
(codes ending in .9). If you find a high
percentage, start using specific ICD-9
diagnosis codes now to ease the
transition to the more detailed and
descriptive ICD-10 system.
4. Revise forms and templates.
Evaluate how the transition to ICD-10
will affect your EHR or paper records.
Revise forms and electronic screens,
including those for:
• Pre-admission/Pre-certification
• Authorization
• Super Bills/Patient Encounters
• Orders
• Quality Reporting
• Referrals
• Inpatient and Outpatient Scheduling
• Public Health Reporting
Action: Look for all forms and
tools that document diagnosis code
information.
5. Conduct a test launch. The
Workgroup for Electronic Data Interchange (WEDI) suggests identifying
the payers that process the highest
percentage of your claims and testing
ICD-10 readiness with them. Here,
your clearinghouse or billing service
may be able to provide assistance.
Note also that some payers are creating their own web-based, self-service
testing opportunities. And, if you
haven’t already, contact Medicare
Administrative Contractors (MACs)
and the Centers for Medicare & Medicaid Services (CMS) to register for
ICD-10 testing during the remaining
testing period.
Action: After you have completed
ICD-10 testing, work with your payers
to understand any errors that may
have occurred and develop strategies
to prevent payment snags once ICD10 implementation is in full swing.
Prepare for Blast-off!
As you complete implementation
plans and prepare for go-live in October, don’t forget to establish a financial reserve that will see you though
the inevitable payment delays.
If an outright cash reserve is
unfeasible, experts recommend that
practices establish a credit line that
can cover at least three to six months
of operating expenses. n
Questions? Contact our office for guidance on managing ICD-10 conversion in
your practice.
Medical Scribes and Practice Efficiency
Continued from page 1
To be sure, a medical scribe isn’t
right for every practice. But most doctors report that their scribes make
them more productive and their
patients happy. In fact, a 2013 study
by the National Library of Medicine
indicates that scribes improve both
productivity and patient care.
Staffing company — Companies
such as ScribeAmerica and PhysAssist
can help with recruiting and staffing.
They provide trained, vetted scribes
to hospitals and medical practices at
a cost in the $20-$25/hour range, according to staffing provider eScribe.
Who’s a Candidate?
If you choose to hire a medical scribe,
follow these three best practices for a
greater chance of success:
Need some help running the numbers? Our
experts can help you determine the ROI on
hiring a scribe for your practice.
1. Establish clear goals. Set specific
goals such as increased revenue,
enhanced patient satisfaction, improved timeliness of documentation,
etc. Practice management consultants
typically recommend using objective
metrics, such as relative value units
per hour or shift, number of patients
seen per hour, clinical versus administrative time, average charge per
billable visit, and patient satisfaction
survey results.
Scribe Signature
Requirements
2. Stay engaged. Although using a
scribe will free you from many clerical duties, you’ll still need to be
involved with patient information.
Your review and authentication of
the scribe’s documentation ensures
that your patients’ records are accurate and complete. Consider implementing a performance improvement
process to ensure
that the scribe is not
acting outside of his
or her job description, authentication
is occurring as
required, and no
orders are being
acted on before they
are authenticated.
• The practitioner must authenticate
the entry by signing, dating and
recording the time. Here, a physician
signature stamp is not permitted —
the physician must actually sign or
authenticate through the clinical
information system.
The answer depends on whether you
are looking for a note-taker or something more.
Nonclinical staff person — If what
you have in mind is just plain scribing, you might train a current staff
member to take on the role. Or, consider looking outside the practice for
a pre-med student or medical/nursing student. If you hire from outside
the practice, figure on a starting salary roughly comparable to that of an
entry- or mid-level office worker in
your area.
MA or CMA — On the other hand,
if you’d like your medical scribe to do
more than just document — for example, provide patient education — a
Medical Assistant might be a good
choice. In certain specialty practices,
Certified Medical Assistants who
have completed extra education and
training may be the best choice.
Follow Some Best Practices
3. Follow up.
Evaluate the effectiveness of using a
scribe by measuring
the practice’s overall improvement in
efficiency and productivity — and
making adjustments as needed.
In the end, bringing on a medical
scribe may be the answer for providers struggling to balance the demands
of documentation and coding with
the very real desire to interact meaningfully with their patients. n
According to The Joint Commission,
a medical scribe is an unlicensed person hired to enter information into
the Electronic Health Record or chart
at the direction of a physician or
practitioner. Specific signature
requirements for scribes include the
following:
• Authentication cannot be delegated
to another practitioner, and the
authentication must take place before
the physician and scribe leave the
patient care area.
• The role and signature of the
scribe must be clearly identifiable
and distinguishable from that of the
practitioner or other staff. Example:
“Scribed for Dr. X by Jane Scribe”
with the date and time of the entry.
• If the scribe is allowed to enter
orders into the medical record, those
orders cannot be acted on until
authenticated by the practitioner who
provided the orders scribed. n
3
Summer 2015 Practice Strategies
A PKF North America publication with contributions from:
www.muellerprost.com
MISSOURI
MISSOURI
CALIFORNIA
St. Louis (main office)
St. Charles
Irvine
7733 Forsyth Blvd., Suite 1200
2460 Executive Drive
2010 Main Street, Suite 340
St. Louis, MO 63105
St. Charles, MO 63303
Irvine, CA 92614
tel: 314.862.2070
tel: 636.441.5800
tel: 800.649.4838
fax: 314.862.1549
fax: 636.922.3139
fax: 562.624.9818
ICD-10:Things
Master
What
Three
the
FedsMatters
Are Watching
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comesyear,
to tackling
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the Department
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ICD-10 implementation
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pation in federal health care programs.
According
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agency’s
Master
what you
can
master.2015
Rather
Work
Plan, these
few of the
areas
than focusing
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all a155,000
codes,
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agency
will
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focus on mastering the codes relevant
the
current
fiscal(e.g.,
yearmake
and beyond:
to your
specialty
a short list
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Coding
Errors
of the codes you have to be good
at). —
Medicare Part B claims for services
performed
ASCs and hospital
outBone up onin
documentation.
ICD-10
patient
departments
are
being
reviewed
requires a much higher level of
to ensure that physicians are properly
specificity. Sit down with your billing
coding the place of service. In the
staff to talk through documentation
past, OIG reviews determined that
issues. In particular, work with your
• Plea
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tter
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to understand
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some
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t hey ’l for
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ed to do cplaces
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more
Defense: Ensure that your system
specifically.
for identifying the place of service for
billing
purposes is accurate.
Run a documentation
readiness assess2.
Utilization
of
Sleep-testing
ment. Pull a few charts and haveProbillcedures
Due to high
utilization
of
ing staff—evaluate
whether
current
certain
sleep-testing
procedures
—
documentation
would
support codespecially
CPT codes
95810
and
ing with ICD-10.
If not,
determine
95811
— the OIG is
checking for
what additional
information
would
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testing.
The
agency will
be needed to make it ICD-10
ready.
be looking to see if any additional
tests
being ordered
when the
reTrainare
everyone
who matters.
Anyone
sults
an initialthe
testsystem
are stillshould
clinic- be
who of
“touches”
ally
pertinent.
trained in the new coding procedures.
Defense: Make sure you are not
For instance, a medical assistant who
duplicating testing when ordering or
fills out lab forms will need to list patients’
performing sleep studies.
diagnoses using the proper codes.
Make
it manageable.
with
prac3. Imaging
ServicesEven
— The
OIG
is
monitoring
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B payments
tice management
andPart
EHR
vendors
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imaging
to “determine
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of the heavy
lifting, pracwhether
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investthe
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Cash up.toPayment
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almost
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as improperly
rates
for imaging
equipmentcoded
reflect
claims work
their way through the
industry
practices.
system.
Avoid
a cash-flow
crunch by
The OIG
Work
Plan is a valuable
establishing
a
financial
reserve
that
resource for identifying compliance
will
see
you
though
th
ree
to
six
risk areas. You can download a copy

months
of
payment
delays.
of the 2015 Work Plan on the OIG
website (http://oig.hhs.gov) in the
Contact our office for guidance on managing
Reports and Publications archive. n
ICD-10 conversion in your practice.
This publication is distributed with the understanding that the author, publisher, and distributor are not rendering legal, accounting, tax, or other
professional advice or opinions on specific facts or matters and, accordingly, assume no liability whatsoever in connection with its use. The information
in this publication is not intended or written to be used, and cannot be used, by a taxpayer for the purpose of (i) avoiding penalties that may be imposed
under the Internal Revenue Code or applicable state or local tax law provisions or (ii) promoting, marketing, or recommending to another party any
transaction or matter addressed in this publication. © 2015
4
Summer
Spring 2015 Practice Strategies
le This Ne
cyc
w
Re