Taking over a Clinic Theme Song, Over my Head

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Taking over a ClinicTheme Song, Over my Head

• CPT Amanda Cuda
• USAFP 2008

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Goals and Objectives

• Who is the Officer in Charge?
• Some Nuts and Bolts for your toolbox
• Thoughts on Acute Care Clinics
• Resources

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Who is the Officer in Charge?

• Personnel Manager
• Business Manager
• Practice Manager
• Senior Military Officer
• Clinician
• Medical Director
• Facilities Overseer
• Many other potential jobs depending on your
  environment

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Some Nuts and Bolts for your OIC Toolbox

• NSPS
• RVUs
• Coding
• FTEs
• Operational Metrics

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NSPS 101

• National Security Personnel System
• Replaces previous Government Service (GS TAPES)
  system
• Career group, Pay schedule and Pay Bands
  previous GS grade and step

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NSPS 101

• Performance based system
• Ratings five is highest, one is lowest
• Online documentation through My Biz/My Workplace
• http//www.cpms.osd.mil/nsps/nsps101/nsps/index.ht
  m

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What is a RVU?

• Relative Value Unit
• Measurement of the resources required to provide
  a particular service/procedure
• Quantifies work that providers do
• Used by third party payers and HMOsand now by us!

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RVUs

• Attempts to measure provider productivity
• Can be based on per hour work, per clinic
  session, or per FTE
• Guides reimbursement
• RVUs are highly based on documentation and coding
• May be the best way to compare clinics to
  allocate resources

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What Drives the RVU Weight?

• Based on two components
• Evaluation and Management (EM)
• International Classification of Diseases (ICD 9)
• Current Procedural Terminology (CPT)
• Modifiers
• 2008 conversion factor 45.021 RVU

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ADM Diagnosis Level (sample screen)
DOE, J AGE 80y 20-111-11-1111- - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - -
- Appt Dt/Time 16 Jul 2001_at_1330 Type
FU Status Kept MEPRS BAHAIn/Out
patient Outpatient APV No Disposition RELEA
SED W/O LIMITATIONS Work Related No Eval Mgt
Code 99214 Established Detailed Admin Codes
(Opt) Diagnoses (Rank in order of
importance) 1 ASTHMA, ACUTE 2 DEHYDRATION CPT
Code (To associate with Dx enter Dx code) 1
NEBULIZER 2 IV INFUSION
RVUs are obtained from only these two areas
EM and CPT Codes
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Encounter RVU Weights

• New vs. Established makes a difference
• Complexity counts
• Observations are worth recording
• Inpatient visits should be coded

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ADM Diagnosis Level (Sample Screen)
DOE, J AGE 80y 20-111-11-1111- - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - -
- Appt Dt/Time 16 Jul 2001_at_1330 Type
FU Status Kept MEPRS BAHAIn/Out
patient Outpatient APV No Disposition RELEA
SED W/O LIMITATIONS Work Related No Eval Mgt
Code 99214 Established Detailed admin Codes
(Opt) Diagnoses (Rank in order of
importance) 1 ASTHMA, ACUTE 2 DEHYDRATION CPT
Code (To associate with Dx enter Dx code) 1
NEBULIZER 2 IV INFUSION
RVU for 99214 1.42
RVU for 94640
RVU for 90780
What if you did a spirometry test and didnt
code you just lost .17 RVUs
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Limitations of RVUs

• Does not take into consideration the behind the
  scenes work done outside of the appointment
• Reviewing reports/records
• Coordinating care with consultants
• Documentation based
• Poor documentation lower RVUs

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RVU

• Low individual and clinic RVUs are reflective
  of
• Inaccurate workload capture caused by
• Under/misreporting of encounter codes ICD-9/CPT
• Delayed/lost recording into ADM systems
• Incorrect reporting of provider time (EUCAPERS)
• Results in
• Understated productivity for providers
• Missed TPC billing opportunity
• Future understaffing for your hospital

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Coding

• Differences in EM coding
• 3 key factors
• History
• Physical examination
• Decision making
• Other (education/counseling if gt50)

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The Importance of Coding

• The more complete the diagnosis (ICD-9) and the
  more accurate the recording of higher weighted
  procedures (CPT) the higher the RVU.
• Indicates providers are
• Working at a higher skill level (and documenting
  it)
• Seeing sicker patients / identifying more
  medically necessary office procedures, consults,
  referrals
• Establishing good coding profiles with insurance
  companies for private practices after the
  military

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What is a FTE?

• Full Time Equivalent
• Helps reflect RVU data more accurately in most
  MHS
• Variations in clinical environment
• Clinical and non-clinical responsibilities
• Academic medicine
• Inpatient, obstetrics, outpatient care

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Full-Time Equivalents (FTEs)

• A composite of man-hours that equates to one full
  time employee.
• It is a measure of the productive hours that an
  employee works after subtracting out annual
  leave, sick leave, etc.        
• FTE Value for Calculating Productivity
• Clinicians 1 FTE
• PAs/NPs .75 FTE

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Calculating FTE

• Based on an 8 hour work day for productivity
  calculations
• Civilian average of 37 hrs/week(3 for admin)
• For MHS, based on availability for productive
  patient care
• 100 availability 1920 hours/year or 160
  hours/month
• Assume that AD and DOD civilian providers are 80
  available 1536 hours/year or 128 hours/month
• Therefore 1 FTE 1536 hours/year, 128
  hours/month, approx 32 hours/week

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Operational Metrics
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RVU/FTE/day

• pts seen w/ 99213 x RVU value x
• pts seen w/ 99214 x RVU value y
• pts seen w/ 99395 x RVU value z
• Add up total RVUs (xyz)
• Divide total clinic hours reported on EUCAPERS by
  8 (work day) FTE-days
• Divide total RVUs by FTE-days

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DoD/Health Affairs Goal

• 16.0 RVUs per provider FTE per 8 hour day
• 3 patients/hour (99213)2.01 RVU hour x 8hrs x 1
  (168hrs/month) FTE 16.08 RVU per clinician FTE
  per day
• 2 patients/hour (99213) and 1 patient/hour
  (99214) 2.44 RVU hour x 8hrs 19.52 RVU per
  clinician FTE per day
• Increase by seeing more patients or documenting
  more 99214 visits.

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Ambulatory Data Bases

• Family Medicine Productivity
• Visits
• 25 visits per day (AMA, others)
• 92 visits per week (AAFP)
• 125 visits per week (AMA)
• 3995 visits per year
• RVUs (work)
• 17.5 per day
• 2.2 RVU per hour seeing patients
• 3980 Mean Annual Appts
• (25th - 3221 75th - 4568)

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RVU FTE Conclusion

• Meet and exceed MHS Goals
• Improve coding accuracy
• Improve documentation
• Decrease no-shows/cancelled appts
• RVUs are not perfect, but they are one of the
  main metrics we currently implement/track/compare

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Thoughts on Acute Care Clinics

• Something between a Primary Care Clinic and an
  Emergency Room
• High risk environment
• Convenience medicine
• Trend in civilian environment
• If efficient, patients very satisfied
• If not efficient, patients very dissatisfied

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Resources

• AAFP
• FPM www.aafp.org/fpm
• USAFP
• www.usafp.org
• Mentors
• Department head
• DCCS
• Tricare
• www.tricare.osd.mil
• RM/UM

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Final Thoughts

• A ship cant be turned quickly
• Become proficient in EXCEL and ACCESS
• Take care of your people
• Jump up and down when you need to!
• Communicate clearly your expectations and follow
  up
• Balance burn out happens fast
• Per Dr. Fandre This can be a very thankless
  job. When it goes right, you hear nothing when
  it goes sour, you have a parade coming to visit
• Resolved, always to do that, which I shall wish
  I had done when I see others to do it.

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Questions?

• Feedback?

Thank you!
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References

• Easter, Deborah. Utilization Management
  Coordinator, MCXP-RMD-MC. 10Jul2002.
• Johnston, Sarah E., Newton, Warren P.
  Resource-based Relative Value Units A Primer
  for Academic Physicians. Family Medicine, March
  2002.
• Performance Plan Between Deputy Secretary of
  Defense and Assistant Secretary of Defense
  (Health Affairs) FY 2003-2007. 08Aug2002.
• Henley, Douglas E. Coding Better for Better
  Reimbursement. Family Practice Management Jan
  2003.
• CPT Mary Reed
• LTC Telita Crosland
• MAJ Paul Crum
• MAJ Matt Fandre

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Additional Slides to follow

• Courtesy of MAJ Fandre

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How are RVUs Calculated?

• Physician Work RVU
• Time, effort, intensity required on physicians
  part
• Practice Expense RVU
• Direct and indirect expenses to perform
  services/procedures
• Non-physician labor, supplies, equipment,
  utilities
• Malpractice Expense RVU
• Intent is to apply a heavier weight to those
  specialties with higher malpractice costs

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Other factors

• GPCI
• Geographical Practice Cost Index
• Conversion Factor
• Nationally uniform
• Converts RVUs into payment amount

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How does one calculate a payment from RVUs
(civilian market)?

• RVU Physician Work x GPCI for Physician Work
• RVU Practice Expense x GPCI for Practice
  Expense
• RVU Malpractice Expense x GPCI for Malpractice
  Expense
• Total RVUs
• X Conversion Factor
• Payment amount

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In MHS Environment

• No Practice Expense
• No Malpractice Expense
• RVU RVU Physician Work

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Civilian Sector
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In MHS
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99213 vs. 99214

• National average
• 9921350
• 9921430
• 99211/9921218
• 992152