State of the ClinicNortheast

August 6, 2013

My thanks to Lou for presenting this talk. Please complete the required IPHIT

participant form for our HRSA grant. Please complete the evaluation form at the

end or email me any feedback you have about this presentation so we can continue to improve upon it.

Thanks. Jennifer &

The Integrating Public Health Inquiry and Transformation (IPHIT) team

Introductory comments

Review Northeast Clinic demographics, geo-maps and quality metrics

Look at different ways data can be asked and presented

Explore examples of how to data can inform future investigations and interventions

Share the state of clinic finances Provide examples of your own individual

data

Objectives

As you look at this data, formulate your own questions: What else do you want to know? What seems to be missing? What assumptions are we making?

In preparing this presentation, I have inserted black slides followed by my own questions and thoughts as examples of how data can move us to inquiry and, hopefully, ultimately to action.

Goals

In May 2013 12,075 patients were assigned to a PCP at Northeast clinic. From this we have panel-based data.

From 7/1/12 to 6/30/13 (FY13)◦ 7,704 patients were actually seen at Northeast at

least once during this year. From this we have service-based data.

◦ There were 30,650 visits including lab, xray and nurse visits

◦ There were 23,428 visits with NE providers Thus every patient who had >0 provider visits in

FY13 was seen an average of 3 times (23,428/7,704)

Our patients

• Panel: patients assigned to a PCP at NE on May 2013

• Service: patients seen at NE during 7/1/12-6/30/13

• Not NE assigned: patients not assigned to a PCP at NE

Panel

Service

Not NE assigned

This is how it looks:

Panel vs Service vs Visit Data

Which questions are best answered with panel data?

Which questions are best answered with service data?

Which questions are best answered with visit data?

DEMOGRAPHICSThe following slides are based on

panel-based data unless noted

Female (54.7%)Male (45.3%)

Gender distribution

0-5 (5.8%)6-11 (6.6%)12-17 (6.6%)18-34 (27.6%)35-49 (24.8%)50-64 (20.2%)65-79 (6.7%)80+ (1.8%)

Age distribution

Children65+

White NH (61.5%)Black NH (14.9%)Hispanic (4.5%)Asian (6.2%)Native Am (0.4%)Other (12.5%)

Race/ethnicity

English (95.8%)Spanish (0.8%)Hmong (2%)Other (1.4%)

Language preference

Includes lab and xray encounters (30650 encounters) 61% female, 39% male

Less

than

2

2 th

roug

h 4

5 th

roug

h 9

10 th

roug

h 14

15 th

roug

h 19

20 th

roug

h 29

30 th

roug

h 39

40 th

roug

h 49

50 th

roug

h 59

60 th

roug

h 69

70 th

roug

h 79

80 th

roug

h 89

Mor

e th

an 9

00

500

1000

1500

2000

2500

3000

3500

4000Visits by age and gender in FY13

FemaleMale

vis

its

July

12

- J

un

e 1

3

* Includes lab and xray encounters (30650 encounters)

0 through 99% 10

through 196%

20 through 2910%

30 through 5949%

60 and above27%

NE Visits * by age group for FY13

Ten percent of the FMP patient visits must be with patients less than 10 years of age.

Ten percent of the FMP patient visits must be with patients 60 years of age or more

So what is the visit mix for the NE residents?

New RRC requirementsfor resident visits

0 through 915%

10 through 197%

20 through 2912%

30 through 5946%

60 and above20%

NE Visits by age group for FY13(Residents only)

Includes only residents’ visits (6389 visits)

Payor mix

By Panel By Service

Commercial (54.3%)

Medicare 65+ (6.3%)

Medicare under 65 (4.2%)

Medicaid (17.9%)

Uninsured (17.3%)

Commercial (61.3%)

Medicare 65+ (9.6%)

Medicare under 65 (5.9%)

Medicaid (19.1%)

Uninsured (4.1%)

Notice how insurance status affects access/utilization data.

Any Thoughts?As you develop QI and community medicine projects here at Northeast, start by sifting through the data.

Here’s what caught my eye…

◦ Our data shows 14.9% of our patients are black◦ According to the U.S. census bureau, Blacks

make up 5.4% of the population in Dane County 6.5% in WI 13.6% in the U.S. http

://quickfacts.census.gov/qfd/states/55/55025.html

◦ Did you know that we are caring for a relatively large percentage of black patients in our clinic relative to their prevalence in our community?

Example

GEO-MAPPINGWhere are our patients?

Mapping NE patients: To orient you, we have no patients in the lakes

An example of geo-mapping application

We have adopted Lake View Elementary School

We overlaid the census tract data of the Northeast Clinic population ages 5-11 years old with the Lake View Elementary School district map

Then we added data about BMI %ile

This shows most NE obese elementary school-age children don’t live in the Lake View Elementary school district (in light green).

CONDITIONS(Some) Northeast Diagnostic Codes

Condition # Patient

s

% Patient

s

% Female

% Male

Obesity 2628 29.4 60.4 39.6

Hyperlipidemia 1995 16.5 47.5 52.5

Hypertension 1918 15.9 53.2 46.8

Diabetes 661 5.5 52.3 47.7

CAD 222 1.8 36.0 64.0

CHF 78 0.6 64.1 35.9

Chronic Kidney Dis 240 2.0 63.8 36.2

Asthma 1122 9.3 62.7 37.3

Cancer 304 2.5 52.3 47.7

Chronic back pain 1501 12.4 62.2 37.8

Opioid 1268 10.5 61.3 38.7

Gender identity disorder

75 0.6 52.0 48.0

Chronic diseases at Northeast

7/1/12-6/30/13

Condition#

Patients

% Patient

s

% Female

% Male

Depression 2180 18.5 69.6 30.4

Anxiety 1456 12.1 67.3 32.7

Schizophrenia 125 1.0 47.2 52.8

Smoking 1831 17.5 50.8 49.2

Alcohol disorder 520 4.3 35.4 64.6

Substance use disorder

346 2.9 51.4 48.6

And more

7/1/12-6/30/13

Are we interested in the gender mix regarding

these conditions?Maybe. But how about: how are we doing compared to Dane County, WI and the nation?

Condition # Patients

% Patients

Dane county

%

WI %

U.S.%

Obesity 2628 29.4 24 29 25

Smoking 1831 17.5 15 19 13

Alcohol disorder 520 4.3 24 24 7

Diabetes 661 5.5 6 8 8.3

Another look at chronic diseases at Northeast

7/1/12-6/30/13

www.countyhealthrankings.org

??? Christina Lightbourn would likely disagree with this.Remember data is limited by what you input.

What diagnosis code(s) are we using here?

What intrigues you?We have developed some great interventions around diabetes at Northeast, but look at back pain and opiods…

Condition # Patient

s

% Patient

s

% Female

% Male

Obesity 2628 29.4 60.4 39.6

Hyperlipidemia 1995 16.5 47.5 52.5

Hypertension 1918 15.9 53.2 46.8

Diabetes 661 5.5 52.3 47.7

CAD 222 1.8 36.0 64.0

CHF 78 0.6 64.1 35.9

Chronic Kidney Dis 240 2.0 63.8 36.2

Asthma 1122 9.3 62.7 37.3

Cancer 304 2.5 52.3 47.7

Chronic back pain 1501 12.4 62.2 37.8

Opioid 1268 10.5 61.3 38.7

Gender identity disorder

75 0.6 52.0 48.0

Chronic diseases at Northeast

7/1/12-6/30/13

ConditionPanel-Based Service-Based

# Patients

% Patients

# Patients

% Patients

Obesity 2628 29.4 2116 31.8

Hyperlipidemia 1995 16.5 1720 24.3

Hypertension 1918 15.9 1690 23.9

Diabetes 661 5.5 644 9.1

CAD 222 1.8 198 2.8

CHF 78 0.6 74 1.0

Chronic Kidney Dis 240 2.0 231 3.3

Asthma 1122 9.3 887 12.5

Cancer 304 2.5 255 3.6

Chronic back pain 1501 12.4 1187 16.8

Opioid 1268 10.5 1284 18.2

Gender identity disorder

75 0.6 38 0.5

And yet another look: panel vs service data

7/1/12-6/30/13

Our chronic pain champions

Carrie Stoltenberg and Ann O’Connor have founded and led our Chronic Controlled Substance Work Group at Northeast. This group◦ Uses a pain registry◦ Meets regularly and review our top users ◦ Develops QI tools and protocols such as our CCS

contracts

Reflecting upon the data

What the data showsWhat ideas do you

have?

Pain patients are high utilizers of health services.

Almost twice as many women as men have back pain and chronic opioid use

Group visits (e.g. yoga) for chronic pain patients?

A smoother process for refill of chronic controlled substances?

…

QUALITY INDICATORSSome data you can access immediately from your

EPIC dashboard

NE %

UWMF

goal %

Breast CA screening 70.7 >70

Colon CA screening 66.9 >70

% A1c testing 97.9 >67.6

% LDL testing 89.8 >76.7

% A1c control 54.3 >47.7

% LDL control 54.4 >57.5

% BP control 46.9 >48.0

Pneumococcal vaccine 83.7 >75

Examples of clinical metrics that you can find on your dashboard on the clinic level and on a provider level

NE %

UWMF

goal %

SCHEDULING

% Template Filled 67.5 >85

% Slot Utilization 74.3 >85

% No-Show 9.5 <4

PATIENT EXPERIENCE

% appt available when needed 66.9 >77

% Explanations that I understand 89.3 >92.2

Examples of scheduling (access) and Avatar (patient satisfaction) metrics

Looks like we need to work on access issues.

Clinic level data◦Avatar % top box◦Diabetes registry performance◦Immunizations◦Pay for performance

Data Handouts…

Although these metrics are important to track and work on, there are others you could search out.

Keep health disparities in the forefrontIt’s in the data

“Of all the forms on inequality, injustice in health care is the most shocking and

inhumane.” Rev. Martin Luther King, Jr

PHOTO BY UCI DIGITAL COLLECTIONS

An exampleAsthma

UWMF has no quality incentives to encourage the health care community to focus upon asthma parameters

But consider the following slides(and remember about 1 in 6 patients at NE are black):

Asthma

Being non-white in WI with asthma

Adult Asthma Prevalence, 2008

Child Asthma Prevalence, 2008

http://www.cdc.gov/asthma/stateprofiles/Asthma_in_WI.pdf

Whi

te N

H

Blac

k NH

Hispa

nic

Other

NH

Mul

tirac

e NH

0

5

10

15

20

25

WIU.S.

Whi

te N

H

Blac

k NH

Hispa

nic

Other

NH

Mul

tirac

e NH

0

5

10

15

20

25

WIU.S.

White Black Other0

10

20

30

40

50

60

70

WIU.S.

Age-adjusted asthma mortality by race, 2007

http://www.cdc.gov/asthma/stateprofiles/Asthma_in_WI.pdf

Condition # Patient

s

% Patient

s

% Female

% Male

Obesity 2628 29.4 60.4 39.6

Hyperlipidemia 1995 16.5 47.5 52.5

Hypertension 1918 15.9 53.2 46.8

Diabetes 661 5.5 52.3 47.7

CAD 222 1.8 36.0 64.0

CHF 78 0.6 64.1 35.9

Chronic Kidney Dis 240 2.0 63.8 36.2

Asthma 1122 9.3 62.7 37.3

Cancer 304 2.5 52.3 47.7

Chronic back pain 1501 12.4 62.2 37.8

Opioid 1268 10.5 61.3 38.7

Gender identity disorder

75 0.6 52.0 48.0

Chronic diseases at Northeast

7/1/12-6/30/13

At NE, 1122 patients have asthma

White NH (60.1%)

Black NH (24.8%)

Hispanic (4.1%)

Asian (2.9%)

Native Am (0.1%)

Other (7.5%)

White NH

Black NH

Hispanic

Asian

Native Am

Other

0 2 4 6 8 10 12 14 16 18

%

%

The % afflicted with asthma within each racial/ethnic grouping

Where are they? A geo-mapping example: Northeast African American patients

Another layer: African American+ Age (0-17 years) + Asthma

They’re mostly in our backyard.

Is there a future project in the data?

This is an example of the kind of data that you can request of our DFM data warehouse from which could stem future projects◦ Jennifer Edgoose can help you focus your question

to request data from Wen-Jan Tuan, database administrator, at the DFM

FINANCESNext you’ll see data that shows ways

to follow the money

R1s4% R2s

9%

R3s14%

fel-lows

& Reed9%

faculty docs39%

PAs18%

NPs6%

Behav1%

23,428 visits in FY 13

VisitsV

isits

1,700

1,800

1,900

2,000

2,100

2,200

2,300

Month

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Northeast - Visits

Sources: Total Charges, RVUs, Prof essional Charges, wRVUs-Serv ice Prov ider-7207

Fiscal Year 2011 2012 2013

RevenueR

eve

nue

($)

160,000

170,000

180,000

190,000

200,000

210,000

220,000

230,000

240,000

Month

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Northeast - Actual Epic Non-Cap Revenue

Sources: Consolidated DFM - Actual-to-Budget-8027 / ----- DFM Budget

Fiscal Year 2011 2012 2013

Work RVUsW

ork

RV

Us

2,600

2,800

3,000

3,200

3,400

3,600

3,800

4,000

4,200

Month

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Northeast - Work RVUs

Visits exclude clinical staf f , f lu v accine, ancillary . Visits include direct patient care by phy s, PAs/NPs, and f ellows/residents. Sources: Inf ov iew retrospectiv e appointment report-3005B.

Fiscal Year 2011 2012 2013

Relative Value Units for Selected Services, 2008

(HCPCScode) TotalPhysician

WorkPractice Expense

Professional Liability Insurance

Brief Office Visit (99213) 1.9 0.97 1.9 0.05

Intermediate Office Visit (99214) 2.53 1.42 1.06 0.05

Diagnostic Colonoscopy (45378) 5.64 3.69 1.65 0.3

Total Hip Replacement (27130) 37.66 21.61 12.54 3.51

visits per hour

Edgoose Oriel Patterson Rabago SannerSchrage

r Schwab avg

Jul 10 - Dec 10 2.32 2.57 2.49 2.84 2.80 2.72 2.75 2.64

Jan 13 - Jun 13 2.24 2.52 2.21 2.50 2.31 2.60 2.63 2.43change -0.07 -0.05 -0.29 -0.34 -0.48 -0.12 -0.11 -0.21

RVUs per hour

Edgoose Oriel Patterson Rabago SannerSchrage

r Schwab avg

Jul 10 - Dec 10 3.23 4.14 3.21 4.12 4.11 3.84 4.45 3.87

Jan 13 - Jun 13 3.70 4.34 3.39 3.93 4.26 4.11 4.53 4.04change 0.47 0.20 0.18 -0.19 0.15 0.27 0.09 0.17

Does NOT include procedure-only visits

Notice how NE faculty visits per hour have declined while RVU’s per hour have increased

“What do you NEED to address today?” (limited agenda each visit, comprehensive care via a series of visits or at periodic “physicals”)

Now “every visit is about everything”◦ Comprehensive review/action expected at every visit:

Immunizations at every visit Health maintenance at every visit Chronic disease metrics (e.g. Diabetes) reviewed at every visit Complete medication reconciliation

◦ Higher copays – pt’s want to avoid visits◦ Mychart used instead of visits?◦ Patient satisfaction higher with comprehensive care each

time?◦ Higher provider satisfaction with fewer longer more

comprehensive visits?

Is there a shift in approach to managing the visit agenda?

A look at the long-

view (2008 to 2013)

A long-view of charges at NE (2008 to 2013)

see next slide

7/2012-6/2013

Here’s a summary from 2008 to present:Type of Service 2008-2009 2012-2013

Charges $ % Charges $ %

Inpatient Hospital 903,826 12 792,070 8

ED 1328 3220

Home Health 1157 4410

Independent Lab 593,043 8

Office 5,918,666 79 8,726,879 91

Outpatient Hospital 45,195 1 85,879 1

SNF 9,760 25,315

Assisted Living Fac 288

7,472,975 9,638,061

When you make comparisons you see that operations evolve. This is

something we don’t have now.

This shows more care/charges in the office over

time.

Revenue Actual %Rev/%Exp

Budget Variance

Patient fee revenue

4,297,793 58% 4,392,564 (94,771)

Hospital revenue

1,491,431 20% 1,578,269 (86,838)

State revenue 1,538,525 21% 1,538,526 (1)

Other revenue 81,950 1% 117,964 (36,014)

TOTAL REVENUE

7,409,699 100% 7,627,33 (217,624)

Revenue: Northeast May 31,2013

Revenue: Northeast May 31,2013

Actual Revenue Budgeted Revenue

Patient fee revenue (58%)

Hospital revenue (20%)

State revenue (21%)

Other revenue (1%)

Patient fee revenue (58%)Hospital revenue (21%)State revenue (20%)Other revenue (1%)

GHC (including GHC MA) per-member-per-month (PMPM) direct to DFM◦ “converted” to charges/payments for internal

analysis Unity (all) and PPlus (not MA)– PMPM to UW Health

◦ Split between UWH (and Meriter) and UWMF◦ UWMF $ internally allocated by charges

If we bill less then specialists get more… Dean is fee-for-service (FFS) Medicare and Medicaid FFS except GHC-MA

Payer Mix – we get paid differently…

2009/2013 “The work we do” “The money we get” “Money/

Work"

Payor Charges % of chgs Payments % of pays Collection %

GHC 1,228,4661,519,633

1616

891,9891,075,844

2324

7371

Medicaid 1,296,9991,878,035

1719

445,153542,811

1112

3429

Medicare 1,298,2332,185,700

1723

417,127688,925

1115

3232

Physician Plus

1,155,628944,555

1510

507,223342,287

138

4436

Unity 876,3341,475.370

1215

529,038828,358

1418

6056

Workers Comp

38,41237,343

10

35,88531,610

11

9385

All other & self pay

1,578,9031,597,425

2117

1,064,809970,644

2722

6761

TOTAL 7,472,9759,638,061

100100

3,891,2244,480,479

100100

5246

Payor mix: work and pay (comparing 2009 with 2013)

Percent of charges

2009 2013

GHC (16%)

Medicaid (17%

Medi-care

(17%)

Phys Plus

(15%)

Unity (12%)

Workers Comp (1%)

All others/

self pay

(21%)

GHC (16%)

Medicaid (19%)

Medicare (23%)Phys

Plus (10%)

Unity (15%)

All oth-ers/self pay

(17%)

Look at Physician Plus vs Unity over the years

Salaries & Benefits

Actual %Rev/%Exp

Budget Variance

Physician 1,650,510 22% 1,684,353 (33,834)

Resident 821,284 11% 773,960 47,334

PA and NPs 458,490 6% 473,660 (15,170)

Staff 1,696,305 23% 1,861,057 (164,752)

SUB-TOTAL4,626,60

8 62% 4,793,030(166,42

2)

Expenses: Salaries (Northeast May 31,2013)

Non-Personnel Actual

%Rev/%Exp Budget Variance

Facilities 469,053 6% 461,538 7,515

Supplies 389,132 5% 312,895 76,237

Purchased services 111,718 1% 92,213 19,505

Lab 118,968 2% 100,837 18,131

Other operating expenses

950,063 13% 1,044,131 (94,068)

Assessment 755,705 10% 758,857 (3,152)

R&D 41,681 1% 44,627 (2,946)

Sub-total2,836,32

0 38% 2,815,098 21,222

Expenses: Non-Personnel (Northeast May 31,2013)

Expenses: Northeast May 31,2013

Actual Expenses Budgeted Expenses

Physician (22%)

Resident (11%)

PA/NPs (6%)Staff (23%)Facilities

(6%)

Supplies (5%)

Pur-chased services

(1%)

Lab (2%) Other (13%)

Assessment (10%)R&D (1%)

Physician (22%)

Resident (11%)

PA/NPs (6%)Staff (23%)

Facilities (6%)

Supplies (5%)

Pur-chased services

(1%)

Lab (2%) Other (13%)

Assessment (10%)R&D (1%)

Actual Budget Variance

TOTAL REVENUE 7,409,699 7,627,323 (217,624)

TOTAL EXPENSES 7,462,828 7,608,128 (145,200)

NET BALANCE (53,229) 19,195 (72,424)

The final tally: (Northeast May 31,2013)

Clinic % of 99213 %99214-5

Belleville 50.1 46.3

Northeast 40 55.3

Verona 65.3 29

Wingra 55.2 41.6

Fitchburg 26 70.4

Odana Atrium 49.7 44.6

Coding Level for Billing: (data for first 6 months of 2013)

GO NORTHEAST!

While we want to acknowledge the unique individuals who make up each data point, we wanted to share with you a bird eye’s vantage of Northeast.

Our clinic is growing and has room to continue to improve on many different metrics.

We have reviewed Northeast data through◦ Demographics◦ Geo-mapping◦ Chronic conditions◦ Finances

We will provide you with some examples of your own personal data.

In conclusion

Thank youQuestions?

NE Provider specific data-the state of your practice

Document what you do Code what you document Yes… knowing how to code does effect how

you document

Coding of visits

◦ You ARE doing the work (complex management)◦ Reflects your specialty’s value

To your health system and group practice partners To insurers To patients

◦ Effects payment, $ to pay yourself and… Pays for your nurse, receptionist, heat, electricity Higher coding helps pay for services we don’t get paid

for (phone calls, mychart, letters…)◦ Effects “production” expectations – would you

rather have many short visits or fewer longer visits each day? Higher coding justifies a comprehensive care model

Why should you maximize coding?

◦In many group practices (e.g. UW Health) with capitated insurance (e.g. Unity and PPlus) if you code low then the subspecialists get a larger slice of the pie

◦So how much do you want to pay the ***ologists?

The zero sum capitation world

Better to document and code appropriately and then deal with discounting the bill than to undercode.◦ Undercoding is actually fraud in Medicare◦ … as is overcoding

Programs to forgive/discount bills◦ UWMF Community Cares◦ Various prescription drug programs

But what about patients with no insurance or limited coverage?

CODE DESCRIPTIONWork RVU

Total RVU

OFFICE VISIT,NEW PATIENT,EVAL AND MANAGEMENT99202 LEVEL 2 0.93 1.96 99203 LEVEL 3 1.42 2.83 99204 LEVEL 4 2.43 4.39 99205 LEVEL 5 3.17 5.47

OFFICE VISIT,ESTABLISHED PATIENT,EVAL AND MANAGEMENT99213 LEVEL3 0.97 1.90 99214 LEVEL 4 1.50 2.82 99215 LEVEL 5 2.11 3.81

99381 PREVENTIVE MEDICINE , NEW PATIENT,<1 YEAR 1.19 2.45 99382 AGE 1-4 YEARS 1.36 2.69 99383 AGE 5-11 YEARS 1.36 2.69 99384 AGE 12-17 YEARS 1.53 2.93 99385 AGE 18-39 YEARS 1.53 2.93 99386 AGE 40-64 YEARS 1.88 3.42 99387 65 YEARS AND OVER 2.06 3.77

99391 PREVENTIVE MEDICINE ,ESTABLISHED PT,AGE <1 YR 1.02 2.11 99392 AGE 1-4 YEARS 1.19 2.35 99393 AGE 5-11 YEARS 1.19 2.34 99394 AGE 12-17 YEARS 1.36 2.58 99395 AGE 18-39 YEARS 1.36 2.59 99396 AGE 40-64 YEARS 1.53 2.83 99397 AGE 65 AND OVER 1.71 3.19

In summer 2010 I started a series of “revival meetings” at NE and other clinics to more appropriately code visits at a level reflecting our actual work:◦ 99214 vs 99213◦ Preventive visits with carve outs

How are we doing? (data review) Simplified (but accurate) rules for coding

99214 and carve outs

“Level 4 coding revival!”

SannerSchwa

bRabag

o Oriel Schraeger JWN MVDPatterso

nO'Conno

r

Jul 09 - Dec 09 26% 35% 28% 28% 25% 60% 14% 33% 2%

Jan 10 - Jun 10 34% 47% 41% 39% 25% 69% 24% 31% 4%

Jul 10 - Dec 10 60% 64% 58% 48% 39% 66% 42% 16%

Jan 11 - Jun 11 70% 66% 62% 57% 35% 66% 43% 47% 21%

Jul 11 - Dec 11 78% 69% 51% 66% 42% 62% 54% 45% 28%

Jan 12 - Jun 12 78% 69% 55% 65% 63% 61% 48% 47% 39%

Jul 12 - Dec 12 86% 80% 58% 58% 60% 56% 57% 44% 43%

Jan 13 - Jun 13 85% 75% 68% 64% 60% 57% 53% 33% 29%

We got religion… 99214 & 99215 coding as % of all established E&M visits

Aug 2010 rivival!

Jul 09-Dec 09

Jan 10- Jun 10

Jul 10-Dec 10

Jan 11- Jun 11

Jul 11 - Dec 11

Jan 12 - Jun 12

Jul 12 - Dec 12

Jan 13 - Jun 13

0%10%20%30%40%50%60%70%80%90%

% level 4&5 codes for est patient visits

R1s Level 4/5R2s Level 4/5R3s Level 4/5

So did the residents…

And the new recruits…

Jul 09 - Dec

09

Jan 10 - Jun 10

Jul 10 - Dec

10

Jan 11 - Jun 11

Jul 11 - Dec

11

Jan 12 - Jun 12

Jul 12 - Dec

12

Jan 13 - Jun 13

0%10%20%30%40%50%60%70%80%90%

100%

% level 4&5 codes for est patient visits

LemmonReedHayonEdgooseUminski

Coding level 99214 (detailed established office visit) simplified◦ See separate sheet◦ It may change how you structure progess notes,

but not make them longer Rules for carve outs Other “high value” codes

So how do you do this?

Example 1• 66yo male• SUBJECTIVE:• Here with several concerns:• 1) 1 week of nasal congestion green, cough green mucous. 2 days R ear itch but not painful. L jaw ache. Chills but no fever

measured. • 2) DM lab f/u: Taking lantus 10u/d since 12/22/10. FBGs checked 3-4x/week and have been 100s-130s. None <80 in 6 mo. • • ROS: Occas chest pain unchanged in > 1 year. No nausea or diarrhea. No numbness, weakness or tingling all extemeties.• • Pertinent PSFH:: Wife had URI symptoms resolved last week. Stress echo neg in Dec 2010. No hx sinus surgery. Last abx >6 mo

ago.• • • OBJECTIVE:• Nurses note and vital signs reviewed• Head; normocephalic, atraumatic. ENT- both TM normal without fluid or infection, throat normal without erythema or exudate

and frontal sinus tender.• Lungs clear to auscultation. Good air movement bilaterally without rales, wheezes, or rhonchi.• COR: Regular rate and rhythm. S1 and S2 normal, no murmurs, clicks, gallops or rubs.• • Recent labs reviewed.• • ASSESSMENT: • Sinus congestion - possible sinusitis given duration and sinus area tenderness• DM in control. Lipids in control• • PLAN: • zpack• Refilled chronic meds - no change• Return in 4 mo for fasting labs (see orders) with F/U visit with me 1-2 weeks later

Example 2• 75yo male• • SUBJECTIVE:• Here with several issues:• 1) HTN. BPs have been good at home (100-130/60s). • 2) DM. BGs at home checks TID, fastings 93-140s, preprandials 80-170.• 3) Lipids. Taking lovastatin 40 only QOD• • Pertinent PSFH: Lives alone. Retired. Son comes to visit approx 3x/wk, also has a friend who visits. Pt does own grocery

shopping, drives himself. Wakes at 1-2am every day (used to this from lifelong work routine). Known CAD.• • ROS: No CP, diarrhea, nausea, recent fevers. Mild nasal congestion. No dysuria. Stream good. Nocturia x 1 stable. No

lower extremity numbness or pain. No myalgias or weakness.• • OBJECTIVE:• Vital signs and nurse's note reviewed.• Chest: Clear; no wheezes or rales. • Cardiac: Regular rate and rhythm. S1 and S2 normal; no murmurs, clicks, gallops or rubs. • Extremities: 2+edema L, 1+ R • • ASSESSMENT:• DM in good control • LDL near goal (<80) at 88.• HTN in control• • PLAN:• No change meds• He may be getting set up with VA to get a better deal on medication costs• Return to me in 6 mo for fasting labs (see orders) with F/U visit with me 1-2 weeks later

Example 3• 36 yo male• • SUBJECTIVE:• Here with new problem: Dentist noted increasing pigmentation of gingiva over last year and wondered if pt has

hemachromatosis. Patient has noted darkening gingival and buccal mucosal pigment, bilateral symrtric, blotchy distribution, slowly progressing over few years not associated with pain or bleeding. No tooth pain or loosening. Had sores inside lower lip early this mo - now resolved.

• • ROS: No fevers, cough, congestion, sore throat. No nausea/diarrhea. No abdominal pain. Wt stable. Denies

arthralgias, joint swelling, myalgias.• • Pertinent PSFH: No recent foreign travel (last was June 2009 to Mali). No family history arthritis or mouth sores.• • OBJECTIVE:• Vital signs and nurse's note reviewed.• Diffuse variably dark pigmentation buccal mucosa and gingiva. No other skin rash or lesions.• Abdomen: Normal BS. No HSM/masses. Nontender.• • ASSESSMENT:• Hyperpigmented oral mucosa new per pt and dentist. No other signs hemachromatosis or connective tissue disease.• • PLAN:• Check labs (see orders) - letter with results.• If labs normal no further f/u needed at this point.• Due for CPE April

Carve outs and preventive visits If you see a patient for a preventive visit AND

you deal with one or more problems you should bill a “carve out” E&M code

Preventive visits include ”physicals”, WWE, WCC.

A carve out is billed using exactly the same rules as a regular E&M visit◦ E.g. if the patient has 3 stable problems (e.g. DM,

DJD, depression) and you refill meds = 99214 carve out

EPIC example

RBRVS 2010

High value codes…2010

Madison charge

Work RVU

Total RVU

example of a carve out:

99397 AGE 65 AND OVER $ 238 1.71 3.19

99214 LEVEL 4 $ 194 1.50 2.82

3.21 6.01

Internal UW Health "credit for work done" 3.21 RVUs

if insurance ONLY pays for prevention visits then pt gets bill for $ -

if insurance ONLY pays for E&M (illness) visits then pt gets bill for $ 44

Transition Care Management (TCM) codes implemented 1/1/201399495 (moderate complexity): 2.11 4.82

99496 (high complexity):  3.05 6.79

Thus we rarely have a 1:4 staffer:resident ratio

The quick “tag in” interruption is welcomed Tell me what you want me to say… and we

can discuss more later Other visit types need staffer to lay eyes on

pt:◦ R1s in 1st 6 months◦ Procedures◦ Preops billed as consults

Yes… the physician staffer needs to see the patient for a resident to bill a level 4 or 5 (even as part of carve out)

So just do it!

RRC requires 1650 visits over 3 years with minimum 150 in first year

The class that graduated June 2013 (Fox, Schaefer, Marty, Dhanoa) averaged total 1709 visits

Number of visits still matters

visits as R1 visits as R2 visits as R3

class of 2013

295.25 621 792.25

class of 2014

294.25 519.5 NaN

class of 2015

226.75 NaN NaN

50250450650850

NE clinic visits per year

sessions as R1 sessions as R2 sessions as R3

class of 2013

83 103.75 121.25

class of 2014

83 98.75 NaN

class of 2015

74.5 NaN NaN

40

80

120

NE clinic sessions (half-days) per year

visits/session as R1

visits/session as R2

visits/session as R3

class of 2013

3.56241743170623

5.97904851329542

6.53758247661387

class of 2014

3.54872271454434

5.26628525196486

NaN

class of 2015

3.04500058500059

NaN NaN

2.3

3.8

5.3

6.8

NE clinic visits per session

Clinic level data◦ Avatar % top box◦ Diabetes registry performance◦ Immunizations◦ Pay for performance

Individual provider data◦ Clinician profile◦ Opioid registry◦ Diabetes registry◦ Avatar data

Handouts…