Toth CL

A group of 3 busy orthopedists attended coding education each year and did their best to accurately code and document their services. As a risk-reduction strategy, the group engaged our firm to conduct an audit to determine whether they were documenting their services properly and to provide feedback about how they could improve.

What we found was shocking to the surgeons, but all too common, as we review thousands of orthopedic visit notes every year: The same examination had been documented for all visits, with physicians stating in their notes that the examination was medically necessary. In addition, their documentation supported Current Procedural Terminology (CPT) code 99214 at every visit, with visit frequencies of 2 weeks to 4 months.

The culprit of all this sameness? The practice’s electronic health record (EHR).

“Practices with EHRs often have a large volume of visit notes that look almost identical for a patient who is seen for multiple visits,” explains Mary LeGrand, RN, MA, CCS-P, CPC, KarenZupko & Associates consultant and coding educator. “And that is putting physicians at higher risk of being audited or of not passing an audit.”

According to LeGrand, this is because physicians are using the practice’s EHR to “pull forward” the patient’s previous visit note for the current visit, but failing to customize it for the current visit. The unintended consequence of this workflow efficiency is twofold:

1. It creates documentation that looks strikingly similar to, if not exactly like, the patient’s last billed visit note. This is often referred to as note “cloning.”

2. It creates documentation that includes a lot of unnecessary detail that, even if delivered and documented, doesn’t match the medical necessity of the visit, based on the history of present illness statements.

Both of these things can come back to bite you.

Zero in on the Risk

If your practice has an EHR, it is important that you evaluate whether certain workflow efficiency features are putting the practice at risk. You do not necessarily need to dump the EHR, but you may need to take action to reduce the risk of using these features.

In a pre-EHR practice, physicians began each visit with a blank piece of paper or dictated the entire visit. Then along came EHR vendors who, in an effort to make things easier and more efficient, created visit templates and the ability to “pull forward” the last visit note and use it as a basis for the current visit. The intention was always that physicians would modify it based on the current visit. But the reality is that physicians are busy, editing is time-consuming, and the unintended consequence is cloning.

“If you pull in unnecessary history or exam information from a previous visit that’s not relevant to the current visit, you can get dinged in an audit for not customizing the note to the patient’s specific presenting complaint,” LeGrand explains, “or, for attempting to bill a higher-level code by unintentionally padding the note with irrelevant information. What is documented for ‘reference’ has to be separated from what can be used to select the level of service.”

Your first documentation risk-reduction strategy is to review notes and look for signs of cloning.

LeGrand explains that a practice may be predisposed to cloning simply because of the way the EHR templates and workflow were set up when the system was implemented. “But,” she says, “‘the EHR made me do it’ defense won’t hold water, because it’s still the physician’s responsibility to customize or remove the information from templates and make the note unique to the visit.”

Yes, physician time is precious. But the reality is that the onus is on the physician to integrate EHR features with clinic workflow and to follow documentation rules.

The second documentation risk-reduction strategy is to make sure the level of evaluation and management (E/M) service billed is supported by medical necessity, not only by documentation artifacts that were relevant to the patient in the past but irrelevant to his or her current presenting complaint or condition.

“Medicare won’t pay for services that aren’t supported by medical necessity,” says LeGrand, “and you can’t achieve medical necessity by simply documenting additional E/M elements.”

This has always been the rule, LeGrand says. “But with the increased use of EHRs, and templates that automatically document visit elements and drive visits to a higher level of service, the Centers for Medicare & Medicaid Services [CMS] and private payers have added scrutiny to medical necessity reviews. They want to validate that higher-level visits billed indeed required a higher level of history and/or exam.”

To do this, the Office of the Inspector General (OIG) has supplemented its audit team with registered nurses. “The nurses assist certified coders by determining whether medical necessity has been met,” explains LeGrand.

 Look at a patient who presents with toe pain. You take a detailed family history, conduct a review of systems (ROS), bill a high-level code, and document all the elements to support it. LeGrand explains, “There is no medical necessity to support doing an eye exam for a patient with toe pain in the absence of any other medical history, or performing a ROS to correlate an eye exam with toe pain. So, even if you do it and document it, the higher-level code won’t pass muster in an audit because the information documented is not medically necessary.”

According to LeGrand, the extent of the history and examination should be based on the presenting problem and the patient’s condition. “If an ankle sprain patient returns 2 weeks after the initial evaluation of the injury with a negative medical or surgical history, and the patient has been treated conservatively, it’s probably not necessary to conduct a ROS that includes 10 organ systems,” she says. “If your standard of care is to perform this level of service, no one will fault you for your care delivery; however, if you also choose a level of service based on this system review, without relevance to the presenting problem, and you bill a higher level of service than is supported by the nature of the presenting problem or the plan of care, the documentation probably won’t hold up in an audit where medical necessity is valued into the equation.”

On the other hand, LeGrand adds, if a patient presents to the emergency department after an automobile accident with an open fracture and other injuries, and the surgeon performs a complete ROS, the medical necessity would most likely be supported as the surgeon is preparing the patient for surgery.

Based on LeGrand’s work with practices, this distinction about medical necessity is news to many nonclinical billing staff. “They confuse medical necessity with medical decision-making, an E/M code documentation component, and incorrectly bill for a high-level visit because medical decision-making elements meet the documentation requirements—yet the code is not supported by medical necessity of the presenting problem.”

Talk with your billing team to make sure all staff members understand this critical difference. They must comprehend that the medically necessary level of service is determined by a number of clinical factors, not medical decision-making. Describe some of these clinical factors, which include, but are not limited to, chief complaint, clinical judgment, standards of practice, acute exacerbations/onsets of medical conditions or injuries, and comorbidities.

EHR Dos and Don’ts

LeGrand recommends the following best practices for using EHR documentation features:

 1. DON’T simply cut and paste from a previous note. “This is what leads to verbose notes that have little to do with the patient you are documenting,” she says. “If you don’t cut and paste, you’ll avoid the root cause of this risk.”

2. DON’T pull forward information from previous visit notes that have nothing to do with the nature of the patient’s problem. “We understand that this takes extra time because physicians must review the previous note,” LeGrand says. “So if you don’t have time to review the past note, just don’t pull it forward. Start fresh with a new drop-down menu and select elements pertinent to the current visit. Or, dictate or type a note relevant to the current condition and presenting problems.”

How you choose to work this into your process will vary depending on which EHR system you use. “One surgeon I work with dictates everything because the drop-down menus and templates are cumbersome,” LeGrand says. “Some groups find it faster to use the EHR templates that they have customized. Others find their EHR’s point-and-click features most efficient for customizing quickly.”

3. DO customize your EHR visit templates if the use of templates is critical to your efficiency. “This is the most overlooked step in the EHR implementation process because it takes a fair amount of time to do,” LeGrand says. She suggests avoiding the use of multisystem examination templates created for medicine specialties altogether, and insists, “Don’t assume ‘that is how the vendor built it so we have to use it.’ Customize a template for each of your visit types so you can document in the EHR in the same fashion as when you used a paper system. Doing so will save you loads of documentation time.”

4. DO review your E/M code distribution. Generate a CPT frequency report for each physician and for the practice as a whole. Compare the data with state and national usage in orthopedics as a baseline. The American Academy of Orthopaedic Surgeon’s Code-X tool enables easy comparison of your practice’s E/M code usage with state and national data for orthopedics. Simply generate a CPT frequency report from your practice management system and enter the E/M data. Line graphs are automatically generated, making trends and patterns easy to see (Figure).

“Identify your outliers, pull charts randomly, and review the notes,” recommends LeGrand. “Make sure there is medical necessity for the level of code that’s been billed and that documentation supports it.”

You may be surprised to find you are an outlier on inpatient hospital codes, or your distribution of level-2 or -3 codes varies from your practice, state, or national data. Orthopedic surgeons don’t typically report high volumes of CPT codes 99204, 99205 or 99215, but if your practice does and you are an outlier, best to pay attention before someone else does.

 5. DO select auditors with the right skill sets. Evaluating medical necessity in the note requires a clinical background. “If internal documentation reviews are conducted by the billing team, that’s fine,” LeGrand advises. “Just add a physician assistant or nurse to your internal review team. They can provide clinical oversight and review the note when necessary for medical necessity.”

If you are contracting with external auditors or consultants, verify auditor credentials and skill sets to ensure they can abstract and incorporate medical necessity into the review. “Auditors must be able to do more than count elements,” LeGrand says. “They must have clinical knowledge, and expertise in orthopedics is critical. This knowledge should be used to verify that medical necessity is present in every note.” LeGrand is quick to point out that not every note will be at risk, based on the amount of work performed and documented and the level of service billed. “But medical necessity must always be present.”

The addition of nurses to the OIG’s audit team is a big change and will refine the auditing process by adding more clinical scrutiny. The EHR documentation features are intended to improve efficiency, but only a clinician can determine and document unique visit elements and medical necessity.

Address these intersections of risk by ensuring your documentation meets medical necessity as well as E/M documentation elements. Conduct internal audits bi-annually to verify that E/M usage patterns align with peers and physician documentation is appropriate. And be sure there is clinical expertise on your audit team, whether it is internal or external. CMS now has it, and your practice should too.  ◾

A group of 3 busy orthopedists attended coding education each year and did their best to accurately code and document their services. As a risk-reduction strategy, the group engaged our firm to conduct an audit to determine whether they were documenting their services properly and to provide feedback about how they could improve.

What we found was shocking to the surgeons, but all too common, as we review thousands of orthopedic visit notes every year: The same examination had been documented for all visits, with physicians stating in their notes that the examination was medically necessary. In addition, their documentation supported Current Procedural Terminology (CPT) code 99214 at every visit, with visit frequencies of 2 weeks to 4 months.

The culprit of all this sameness? The practice’s electronic health record (EHR).

“Practices with EHRs often have a large volume of visit notes that look almost identical for a patient who is seen for multiple visits,” explains Mary LeGrand, RN, MA, CCS-P, CPC, KarenZupko & Associates consultant and coding educator. “And that is putting physicians at higher risk of being audited or of not passing an audit.”

According to LeGrand, this is because physicians are using the practice’s EHR to “pull forward” the patient’s previous visit note for the current visit, but failing to customize it for the current visit. The unintended consequence of this workflow efficiency is twofold:

1. It creates documentation that looks strikingly similar to, if not exactly like, the patient’s last billed visit note. This is often referred to as note “cloning.”

2. It creates documentation that includes a lot of unnecessary detail that, even if delivered and documented, doesn’t match the medical necessity of the visit, based on the history of present illness statements.

Both of these things can come back to bite you.

Zero in on the Risk

If your practice has an EHR, it is important that you evaluate whether certain workflow efficiency features are putting the practice at risk. You do not necessarily need to dump the EHR, but you may need to take action to reduce the risk of using these features.

In a pre-EHR practice, physicians began each visit with a blank piece of paper or dictated the entire visit. Then along came EHR vendors who, in an effort to make things easier and more efficient, created visit templates and the ability to “pull forward” the last visit note and use it as a basis for the current visit. The intention was always that physicians would modify it based on the current visit. But the reality is that physicians are busy, editing is time-consuming, and the unintended consequence is cloning.

“If you pull in unnecessary history or exam information from a previous visit that’s not relevant to the current visit, you can get dinged in an audit for not customizing the note to the patient’s specific presenting complaint,” LeGrand explains, “or, for attempting to bill a higher-level code by unintentionally padding the note with irrelevant information. What is documented for ‘reference’ has to be separated from what can be used to select the level of service.”

Your first documentation risk-reduction strategy is to review notes and look for signs of cloning.

LeGrand explains that a practice may be predisposed to cloning simply because of the way the EHR templates and workflow were set up when the system was implemented. “But,” she says, “‘the EHR made me do it’ defense won’t hold water, because it’s still the physician’s responsibility to customize or remove the information from templates and make the note unique to the visit.”

Yes, physician time is precious. But the reality is that the onus is on the physician to integrate EHR features with clinic workflow and to follow documentation rules.

The second documentation risk-reduction strategy is to make sure the level of evaluation and management (E/M) service billed is supported by medical necessity, not only by documentation artifacts that were relevant to the patient in the past but irrelevant to his or her current presenting complaint or condition.

“Medicare won’t pay for services that aren’t supported by medical necessity,” says LeGrand, “and you can’t achieve medical necessity by simply documenting additional E/M elements.”

This has always been the rule, LeGrand says. “But with the increased use of EHRs, and templates that automatically document visit elements and drive visits to a higher level of service, the Centers for Medicare & Medicaid Services [CMS] and private payers have added scrutiny to medical necessity reviews. They want to validate that higher-level visits billed indeed required a higher level of history and/or exam.”

To do this, the Office of the Inspector General (OIG) has supplemented its audit team with registered nurses. “The nurses assist certified coders by determining whether medical necessity has been met,” explains LeGrand.

 Look at a patient who presents with toe pain. You take a detailed family history, conduct a review of systems (ROS), bill a high-level code, and document all the elements to support it. LeGrand explains, “There is no medical necessity to support doing an eye exam for a patient with toe pain in the absence of any other medical history, or performing a ROS to correlate an eye exam with toe pain. So, even if you do it and document it, the higher-level code won’t pass muster in an audit because the information documented is not medically necessary.”

According to LeGrand, the extent of the history and examination should be based on the presenting problem and the patient’s condition. “If an ankle sprain patient returns 2 weeks after the initial evaluation of the injury with a negative medical or surgical history, and the patient has been treated conservatively, it’s probably not necessary to conduct a ROS that includes 10 organ systems,” she says. “If your standard of care is to perform this level of service, no one will fault you for your care delivery; however, if you also choose a level of service based on this system review, without relevance to the presenting problem, and you bill a higher level of service than is supported by the nature of the presenting problem or the plan of care, the documentation probably won’t hold up in an audit where medical necessity is valued into the equation.”

On the other hand, LeGrand adds, if a patient presents to the emergency department after an automobile accident with an open fracture and other injuries, and the surgeon performs a complete ROS, the medical necessity would most likely be supported as the surgeon is preparing the patient for surgery.

Based on LeGrand’s work with practices, this distinction about medical necessity is news to many nonclinical billing staff. “They confuse medical necessity with medical decision-making, an E/M code documentation component, and incorrectly bill for a high-level visit because medical decision-making elements meet the documentation requirements—yet the code is not supported by medical necessity of the presenting problem.”

Talk with your billing team to make sure all staff members understand this critical difference. They must comprehend that the medically necessary level of service is determined by a number of clinical factors, not medical decision-making. Describe some of these clinical factors, which include, but are not limited to, chief complaint, clinical judgment, standards of practice, acute exacerbations/onsets of medical conditions or injuries, and comorbidities.

EHR Dos and Don’ts

LeGrand recommends the following best practices for using EHR documentation features:

 1. DON’T simply cut and paste from a previous note. “This is what leads to verbose notes that have little to do with the patient you are documenting,” she says. “If you don’t cut and paste, you’ll avoid the root cause of this risk.”

2. DON’T pull forward information from previous visit notes that have nothing to do with the nature of the patient’s problem. “We understand that this takes extra time because physicians must review the previous note,” LeGrand says. “So if you don’t have time to review the past note, just don’t pull it forward. Start fresh with a new drop-down menu and select elements pertinent to the current visit. Or, dictate or type a note relevant to the current condition and presenting problems.”

How you choose to work this into your process will vary depending on which EHR system you use. “One surgeon I work with dictates everything because the drop-down menus and templates are cumbersome,” LeGrand says. “Some groups find it faster to use the EHR templates that they have customized. Others find their EHR’s point-and-click features most efficient for customizing quickly.”

3. DO customize your EHR visit templates if the use of templates is critical to your efficiency. “This is the most overlooked step in the EHR implementation process because it takes a fair amount of time to do,” LeGrand says. She suggests avoiding the use of multisystem examination templates created for medicine specialties altogether, and insists, “Don’t assume ‘that is how the vendor built it so we have to use it.’ Customize a template for each of your visit types so you can document in the EHR in the same fashion as when you used a paper system. Doing so will save you loads of documentation time.”

4. DO review your E/M code distribution. Generate a CPT frequency report for each physician and for the practice as a whole. Compare the data with state and national usage in orthopedics as a baseline. The American Academy of Orthopaedic Surgeon’s Code-X tool enables easy comparison of your practice’s E/M code usage with state and national data for orthopedics. Simply generate a CPT frequency report from your practice management system and enter the E/M data. Line graphs are automatically generated, making trends and patterns easy to see (Figure).

“Identify your outliers, pull charts randomly, and review the notes,” recommends LeGrand. “Make sure there is medical necessity for the level of code that’s been billed and that documentation supports it.”

You may be surprised to find you are an outlier on inpatient hospital codes, or your distribution of level-2 or -3 codes varies from your practice, state, or national data. Orthopedic surgeons don’t typically report high volumes of CPT codes 99204, 99205 or 99215, but if your practice does and you are an outlier, best to pay attention before someone else does.

 5. DO select auditors with the right skill sets. Evaluating medical necessity in the note requires a clinical background. “If internal documentation reviews are conducted by the billing team, that’s fine,” LeGrand advises. “Just add a physician assistant or nurse to your internal review team. They can provide clinical oversight and review the note when necessary for medical necessity.”

If you are contracting with external auditors or consultants, verify auditor credentials and skill sets to ensure they can abstract and incorporate medical necessity into the review. “Auditors must be able to do more than count elements,” LeGrand says. “They must have clinical knowledge, and expertise in orthopedics is critical. This knowledge should be used to verify that medical necessity is present in every note.” LeGrand is quick to point out that not every note will be at risk, based on the amount of work performed and documented and the level of service billed. “But medical necessity must always be present.”

The addition of nurses to the OIG’s audit team is a big change and will refine the auditing process by adding more clinical scrutiny. The EHR documentation features are intended to improve efficiency, but only a clinician can determine and document unique visit elements and medical necessity.

Address these intersections of risk by ensuring your documentation meets medical necessity as well as E/M documentation elements. Conduct internal audits bi-annually to verify that E/M usage patterns align with peers and physician documentation is appropriate. And be sure there is clinical expertise on your audit team, whether it is internal or external. CMS now has it, and your practice should too.  ◾

A group of 3 busy orthopedists attended coding education each year and did their best to accurately code and document their services. As a risk-reduction strategy, the group engaged our firm to conduct an audit to determine whether they were documenting their services properly and to provide feedback about how they could improve.

What we found was shocking to the surgeons, but all too common, as we review thousands of orthopedic visit notes every year: The same examination had been documented for all visits, with physicians stating in their notes that the examination was medically necessary. In addition, their documentation supported Current Procedural Terminology (CPT) code 99214 at every visit, with visit frequencies of 2 weeks to 4 months.

The culprit of all this sameness? The practice’s electronic health record (EHR).

“Practices with EHRs often have a large volume of visit notes that look almost identical for a patient who is seen for multiple visits,” explains Mary LeGrand, RN, MA, CCS-P, CPC, KarenZupko & Associates consultant and coding educator. “And that is putting physicians at higher risk of being audited or of not passing an audit.”

According to LeGrand, this is because physicians are using the practice’s EHR to “pull forward” the patient’s previous visit note for the current visit, but failing to customize it for the current visit. The unintended consequence of this workflow efficiency is twofold:

1. It creates documentation that looks strikingly similar to, if not exactly like, the patient’s last billed visit note. This is often referred to as note “cloning.”

2. It creates documentation that includes a lot of unnecessary detail that, even if delivered and documented, doesn’t match the medical necessity of the visit, based on the history of present illness statements.

Both of these things can come back to bite you.

Zero in on the Risk

If your practice has an EHR, it is important that you evaluate whether certain workflow efficiency features are putting the practice at risk. You do not necessarily need to dump the EHR, but you may need to take action to reduce the risk of using these features.

In a pre-EHR practice, physicians began each visit with a blank piece of paper or dictated the entire visit. Then along came EHR vendors who, in an effort to make things easier and more efficient, created visit templates and the ability to “pull forward” the last visit note and use it as a basis for the current visit. The intention was always that physicians would modify it based on the current visit. But the reality is that physicians are busy, editing is time-consuming, and the unintended consequence is cloning.

“If you pull in unnecessary history or exam information from a previous visit that’s not relevant to the current visit, you can get dinged in an audit for not customizing the note to the patient’s specific presenting complaint,” LeGrand explains, “or, for attempting to bill a higher-level code by unintentionally padding the note with irrelevant information. What is documented for ‘reference’ has to be separated from what can be used to select the level of service.”

Your first documentation risk-reduction strategy is to review notes and look for signs of cloning.

LeGrand explains that a practice may be predisposed to cloning simply because of the way the EHR templates and workflow were set up when the system was implemented. “But,” she says, “‘the EHR made me do it’ defense won’t hold water, because it’s still the physician’s responsibility to customize or remove the information from templates and make the note unique to the visit.”

Yes, physician time is precious. But the reality is that the onus is on the physician to integrate EHR features with clinic workflow and to follow documentation rules.

The second documentation risk-reduction strategy is to make sure the level of evaluation and management (E/M) service billed is supported by medical necessity, not only by documentation artifacts that were relevant to the patient in the past but irrelevant to his or her current presenting complaint or condition.

“Medicare won’t pay for services that aren’t supported by medical necessity,” says LeGrand, “and you can’t achieve medical necessity by simply documenting additional E/M elements.”

This has always been the rule, LeGrand says. “But with the increased use of EHRs, and templates that automatically document visit elements and drive visits to a higher level of service, the Centers for Medicare & Medicaid Services [CMS] and private payers have added scrutiny to medical necessity reviews. They want to validate that higher-level visits billed indeed required a higher level of history and/or exam.”

To do this, the Office of the Inspector General (OIG) has supplemented its audit team with registered nurses. “The nurses assist certified coders by determining whether medical necessity has been met,” explains LeGrand.

 Look at a patient who presents with toe pain. You take a detailed family history, conduct a review of systems (ROS), bill a high-level code, and document all the elements to support it. LeGrand explains, “There is no medical necessity to support doing an eye exam for a patient with toe pain in the absence of any other medical history, or performing a ROS to correlate an eye exam with toe pain. So, even if you do it and document it, the higher-level code won’t pass muster in an audit because the information documented is not medically necessary.”

According to LeGrand, the extent of the history and examination should be based on the presenting problem and the patient’s condition. “If an ankle sprain patient returns 2 weeks after the initial evaluation of the injury with a negative medical or surgical history, and the patient has been treated conservatively, it’s probably not necessary to conduct a ROS that includes 10 organ systems,” she says. “If your standard of care is to perform this level of service, no one will fault you for your care delivery; however, if you also choose a level of service based on this system review, without relevance to the presenting problem, and you bill a higher level of service than is supported by the nature of the presenting problem or the plan of care, the documentation probably won’t hold up in an audit where medical necessity is valued into the equation.”

On the other hand, LeGrand adds, if a patient presents to the emergency department after an automobile accident with an open fracture and other injuries, and the surgeon performs a complete ROS, the medical necessity would most likely be supported as the surgeon is preparing the patient for surgery.

Based on LeGrand’s work with practices, this distinction about medical necessity is news to many nonclinical billing staff. “They confuse medical necessity with medical decision-making, an E/M code documentation component, and incorrectly bill for a high-level visit because medical decision-making elements meet the documentation requirements—yet the code is not supported by medical necessity of the presenting problem.”

Talk with your billing team to make sure all staff members understand this critical difference. They must comprehend that the medically necessary level of service is determined by a number of clinical factors, not medical decision-making. Describe some of these clinical factors, which include, but are not limited to, chief complaint, clinical judgment, standards of practice, acute exacerbations/onsets of medical conditions or injuries, and comorbidities.

EHR Dos and Don’ts

LeGrand recommends the following best practices for using EHR documentation features:

 1. DON’T simply cut and paste from a previous note. “This is what leads to verbose notes that have little to do with the patient you are documenting,” she says. “If you don’t cut and paste, you’ll avoid the root cause of this risk.”

2. DON’T pull forward information from previous visit notes that have nothing to do with the nature of the patient’s problem. “We understand that this takes extra time because physicians must review the previous note,” LeGrand says. “So if you don’t have time to review the past note, just don’t pull it forward. Start fresh with a new drop-down menu and select elements pertinent to the current visit. Or, dictate or type a note relevant to the current condition and presenting problems.”

How you choose to work this into your process will vary depending on which EHR system you use. “One surgeon I work with dictates everything because the drop-down menus and templates are cumbersome,” LeGrand says. “Some groups find it faster to use the EHR templates that they have customized. Others find their EHR’s point-and-click features most efficient for customizing quickly.”

3. DO customize your EHR visit templates if the use of templates is critical to your efficiency. “This is the most overlooked step in the EHR implementation process because it takes a fair amount of time to do,” LeGrand says. She suggests avoiding the use of multisystem examination templates created for medicine specialties altogether, and insists, “Don’t assume ‘that is how the vendor built it so we have to use it.’ Customize a template for each of your visit types so you can document in the EHR in the same fashion as when you used a paper system. Doing so will save you loads of documentation time.”

4. DO review your E/M code distribution. Generate a CPT frequency report for each physician and for the practice as a whole. Compare the data with state and national usage in orthopedics as a baseline. The American Academy of Orthopaedic Surgeon’s Code-X tool enables easy comparison of your practice’s E/M code usage with state and national data for orthopedics. Simply generate a CPT frequency report from your practice management system and enter the E/M data. Line graphs are automatically generated, making trends and patterns easy to see (Figure).

“Identify your outliers, pull charts randomly, and review the notes,” recommends LeGrand. “Make sure there is medical necessity for the level of code that’s been billed and that documentation supports it.”

You may be surprised to find you are an outlier on inpatient hospital codes, or your distribution of level-2 or -3 codes varies from your practice, state, or national data. Orthopedic surgeons don’t typically report high volumes of CPT codes 99204, 99205 or 99215, but if your practice does and you are an outlier, best to pay attention before someone else does.

 5. DO select auditors with the right skill sets. Evaluating medical necessity in the note requires a clinical background. “If internal documentation reviews are conducted by the billing team, that’s fine,” LeGrand advises. “Just add a physician assistant or nurse to your internal review team. They can provide clinical oversight and review the note when necessary for medical necessity.”

If you are contracting with external auditors or consultants, verify auditor credentials and skill sets to ensure they can abstract and incorporate medical necessity into the review. “Auditors must be able to do more than count elements,” LeGrand says. “They must have clinical knowledge, and expertise in orthopedics is critical. This knowledge should be used to verify that medical necessity is present in every note.” LeGrand is quick to point out that not every note will be at risk, based on the amount of work performed and documented and the level of service billed. “But medical necessity must always be present.”

The addition of nurses to the OIG’s audit team is a big change and will refine the auditing process by adding more clinical scrutiny. The EHR documentation features are intended to improve efficiency, but only a clinician can determine and document unique visit elements and medical necessity.

Address these intersections of risk by ensuring your documentation meets medical necessity as well as E/M documentation elements. Conduct internal audits bi-annually to verify that E/M usage patterns align with peers and physician documentation is appropriate. And be sure there is clinical expertise on your audit team, whether it is internal or external. CMS now has it, and your practice should too.  ◾

As late as mid-April 2015, a survey of 121 orthopedic practices indicated that 30% had done nothing to start preparing for ICD-10 (International Classification of Diseases, Tenth Revision).¹  That’s scary. And even the practices that had begun to prepare had not completed a number of key tasks (Figure 1).

Certainly, the will-they-or-won’t-they possibility of another congressional delay had many practices sitting on their hands this year. But now that the October 1, 2015, implementation is set in stone, this lack of inertia has many practices woefully behind. If your practice is one of many that hasn’t mapped your common ICD-9 (International Classification of Diseases, Ninth Revision) codes to ICD-10 codes, completed payer testing, or attended training, it’s time for a “full-court press.”

Being unprepared for ICD-10 will cause more than just an increase in claim denials. If your surgery schedule is booked a few months out, your staff will need to pre-authorize cases using ICD-10 as early as August 1—and they won’t be able to do that if you haven’t dictated the clinical terms required to choose an ICD-10 code. Without an understanding of ICD-10, severity of illness coding will suffer, and that will affect your bundled and value-based payments. And, if you don’t provide an adequate diagnosis when sending patients off-site for physical therapy, you’ll soon be getting phone calls from their billing staff demanding more specifics.

The clock is ticking and time is short. Here’s a prioritized list of what needs to get done.

1. Generate an ICD-9 frequency report

Identifying which diagnosis codes are the most frequently used, and therefore drive a significant portion of practice revenue, is an absolute must. The data will help prioritize training and code-mapping activities.

Most practices generate Current Procedural Terminology (CPT) code-frequency reports regularly, but few have ever run an ICD-9 code-frequency report. Call your vendor and ask for assistance, as there are multiple ways to run this report and they vary by practice management system. Sort the data elements and generate the ICD-9 frequency report by:

• Primary diagnosis.
• Unique patient.
• Revenue. (If your practice management system can’t give you diagnosis data by revenue, which enables you to focus on the codes that generate the most revenue, generate it by charges.)

The result should be a report that identifies the 20 to 25 diagnosis codes (or charges, depending on the reports generated) that drive the most revenue for the practice. Use the data to focus and prioritize your training and code-mapping activities.

 2. Schedule training

Forget about “general” ICD-10 training courses. You need orthopedic-specific guidance. That’s because ICD-10 for orthopedics is more complex than for other specialties. Dictating fractures under ICD-10 is not so simple. Selecting an injury code requires confidence in correctly using the seventh character.

“Everyone who uses diagnosis codes must have baseline knowledge: surgeons, billing staff, surgical coordinators, and clinical team,” according to Sarah Wiskerchen, MBA, CPC, consultant and ICD-10 educator with KarenZupko & Associates (KZA). Training must include the practical details of ICD-10, such as assigning laterality, understanding the system architecture, and limiting the use of unspecified codes.

The American Academy of Orthopaedic Surgeons (AAOS) offers a self-paced, online training series that provides details for the top 3 diagnosis codes for each subspecialty. The 10-program course, ICD-10-CM: By the Numbers, is available at www.aaos.org ($299 for members, $399 for nonmembers). If you prefer live instruction, there is one more AAOS-sponsored, regional ICD-10 workshop left before the October 1 deadline, and more may be added. (Details at www.karenzupko.com)

These courses provide highly specific and granular ICD-10 knowledge and incorporate the use of Code-X, an AAOS-developed software tool. They also feature tools for handling the complexities of fractures and injury codes, such as Leo C. Far, an acronym developed by KZA consultant and coding educator Margie Maley, BSN, MS, to make ICD-10 diagnosis coding for fractures easier (Figure 2).

Some subspecialty societies also offer ICD-10 training. The American Society for Surgery of the Hand (www.assh.org), for example, offers a series of webinars and member-developed ICD-9-to-ICD-10 code maps.  

 3. Crosswalk your common codes from ICD-9 to ICD-10

Crosswalking is the process of mapping your most commonly used ICD-9 codes to their equivalent ICD-10 codes. This exercise familiarizes your team with ICD-10 language and terms, and gives a sense of which ICD-9 codes expand to just 1 or 2 ICD-10 codes and which codes expand into 10 or more codes—as some injury codes do (Table).

“Attempting to map the codes before completing ICD-10 training is like trying to write a letter in Greek when you only speak English,” Wiskerchen warns. “So start this process after at least some of your team have grasped the fundamentals of ICD-10.” This is where the data from your ICD-9 frequency report comes in. Use it to prioritize which codes to map first with a goal of mapping your top 25 ICD-9 codes to their ICD-10 equivalents by August 31.

Invest in good tools to support your mapping efforts. Avoid general mapping equivalent (GEM) coding tools, which are free for a good reason—they are incomplete and don’t always lead you to the correct ICD-10 code. Instead, purchase resources from credible sources, such as the American Medical Association (AMA; www.ama-assn.org). The AMA publishes ICD-10-CM 2016: The Complete Official Codebook as well as ICD-10-CM Mappings 2016, which links ICD-9 codes to all valid ICD-10 alternatives. The AMA also offers electronic ICD-10-CM Express Reference Mapping Cards for multiple specialties.

Practice makes perfect and crosswalking from ICD-9 to ICD-10 is one of the best ways for your team to become aware of the nuances in the new coding system. Like learning a new language, “speaking” ICD-10 does not become automatic just because you’ve attended training or completed the coding maps. Training teaches the architecture of the new coding system. Mapping provides a structured way to become familiar with the codes the practice will use most often. Once these 2 primary pieces are understood and assimilated, most physicians find that dictating the necessary new terms becomes quite easy.  

 4. Conduct a gap analysis to identify the ICD-10 terms missing from each provider’s current documentation

Conduct the gap analysis after your team has completed training, and once you’ve at least begun the process of mapping codes from ICD-9 to ICD-10. Here’s how:

• Generate a CPT frequency report.
• Select the top 5 procedures for each physician.
• Pull 2 patients’ notes for each of the top procedures.
• Review the notes and try to select ICD-10 code(s).

If key ICD-10 terms are not included in current documentation, physicians should modify the templates or macros they rely on for dictation.

“This simple exercise makes it obvious which clinical information physicians must add for ICD-10,” Wiskerchen says. For example, if the patient had an arthroscopy, but the note doesn’t specify on which leg, that’s a clear indication that the physician must dictate laterality. “The gap analysis is a great way to coach physicians about the clinical details to document, so staff can bill under ICD-10,” Wiskerchen says.

 5. Contact technology vendors

Given the number of new ICD-10 codes in orthopedics, paper cheat sheets will be obsolete. Instead, you’ll need to rely on pull-down menus and/or search fields in the electronic health record (EHR) and practice management systems.

“Get clarity about how the new features and workflow processes will work in your systems,” suggests Wiskerchen. “Ask questions such as: Which features will be added or changed to accommodate the new codes? Will there be new screens or pick lists for ICD-10, or search fields? How will new screens and features change our current workflow? And schedule any necessary training as soon as possible.”

In addition to software upgrades and training, vendors and clearinghouses offer an array of services to help practices make the transition. Some vendors even provide help coordinating your internal plan with their new product features and training. Contact vendors to find out what they offer.

 6. Use completed code maps to build diagnosis code databases, EHR templates, charge tickets, pick lists, prompters, and other coding tools

“Provide the code crosswalks and results of your documentation gap analysis to the IT [information technology] team so they can get started,” Wiskerchen advises. “And assign a physician or midlevel provider to work with IT so that the tools are clinically accurate.”

 7. Schedule testing with clearinghouses and payers

“Successful testing indicates that your hard work has paid off, and that claims will be processed with few, if any, ICD-10–related hiccups,” Wiskerchen says. Essentially, the testing confirms that your ICD-10 code database, pick lists, vendor features, and other coding fields are working properly. “Testing with a clearinghouse is good. Testing directly with the payer is even better, if you are a direct submitter and it is allowed,” Wiskerchen suggests. Contact your clearinghouse and/or payers for testing opportunities prior to October 1.

 8. Develop a plan for a potential cash flow crunch

So what happens if your best efforts in the 11th hour still aren’t enough to get your practice to the ICD-10 finish line? Prepare for the possibility of increased claim denials and temporary cash flow stalls, and put a plan in place to deal with them.

Start now by cleaning up as much of the accounts receivable as possible, and moving patient collections up front. Ask the billing team for a weekly status update of the largest unpaid balances in the 60-day aging column, and what has been done to appeal or otherwise address them. Analyze denial patterns and trends and fix their causes at the source—some may be ICD-10–related, others may simply be a gap in the reimbursement process that needs improvement.

Use payer cost estimators to calculate patient out-of-pocket cost and to collect unmet deductibles, coinsurance, and noncovered services prior to surgery. The surgeon-developed iPhone app Health Insurance Arithmetic² ($1.99 in the iTunes Store) can help staff do this math on one, simple screen.

Finally, secure a line of credit to guard against a claim denial pile up this fall. A line of credit mitigates financial risk by making cash available quickly, should you need it to cover temporary revenue shortfalls, meet payroll, or pay operational expenses. It’s not too late to meet with your banker and apply for this protection, and the peace of mind may even help you sleep better.

As late as mid-April 2015, a survey of 121 orthopedic practices indicated that 30% had done nothing to start preparing for ICD-10 (International Classification of Diseases, Tenth Revision).¹  That’s scary. And even the practices that had begun to prepare had not completed a number of key tasks (Figure 1).

Certainly, the will-they-or-won’t-they possibility of another congressional delay had many practices sitting on their hands this year. But now that the October 1, 2015, implementation is set in stone, this lack of inertia has many practices woefully behind. If your practice is one of many that hasn’t mapped your common ICD-9 (International Classification of Diseases, Ninth Revision) codes to ICD-10 codes, completed payer testing, or attended training, it’s time for a “full-court press.”

Being unprepared for ICD-10 will cause more than just an increase in claim denials. If your surgery schedule is booked a few months out, your staff will need to pre-authorize cases using ICD-10 as early as August 1—and they won’t be able to do that if you haven’t dictated the clinical terms required to choose an ICD-10 code. Without an understanding of ICD-10, severity of illness coding will suffer, and that will affect your bundled and value-based payments. And, if you don’t provide an adequate diagnosis when sending patients off-site for physical therapy, you’ll soon be getting phone calls from their billing staff demanding more specifics.

The clock is ticking and time is short. Here’s a prioritized list of what needs to get done.

1. Generate an ICD-9 frequency report

Identifying which diagnosis codes are the most frequently used, and therefore drive a significant portion of practice revenue, is an absolute must. The data will help prioritize training and code-mapping activities.

Most practices generate Current Procedural Terminology (CPT) code-frequency reports regularly, but few have ever run an ICD-9 code-frequency report. Call your vendor and ask for assistance, as there are multiple ways to run this report and they vary by practice management system. Sort the data elements and generate the ICD-9 frequency report by:

• Primary diagnosis.
• Unique patient.
• Revenue. (If your practice management system can’t give you diagnosis data by revenue, which enables you to focus on the codes that generate the most revenue, generate it by charges.)

The result should be a report that identifies the 20 to 25 diagnosis codes (or charges, depending on the reports generated) that drive the most revenue for the practice. Use the data to focus and prioritize your training and code-mapping activities.

 2. Schedule training

Forget about “general” ICD-10 training courses. You need orthopedic-specific guidance. That’s because ICD-10 for orthopedics is more complex than for other specialties. Dictating fractures under ICD-10 is not so simple. Selecting an injury code requires confidence in correctly using the seventh character.

“Everyone who uses diagnosis codes must have baseline knowledge: surgeons, billing staff, surgical coordinators, and clinical team,” according to Sarah Wiskerchen, MBA, CPC, consultant and ICD-10 educator with KarenZupko & Associates (KZA). Training must include the practical details of ICD-10, such as assigning laterality, understanding the system architecture, and limiting the use of unspecified codes.

The American Academy of Orthopaedic Surgeons (AAOS) offers a self-paced, online training series that provides details for the top 3 diagnosis codes for each subspecialty. The 10-program course, ICD-10-CM: By the Numbers, is available at www.aaos.org ($299 for members, $399 for nonmembers). If you prefer live instruction, there is one more AAOS-sponsored, regional ICD-10 workshop left before the October 1 deadline, and more may be added. (Details at www.karenzupko.com)

These courses provide highly specific and granular ICD-10 knowledge and incorporate the use of Code-X, an AAOS-developed software tool. They also feature tools for handling the complexities of fractures and injury codes, such as Leo C. Far, an acronym developed by KZA consultant and coding educator Margie Maley, BSN, MS, to make ICD-10 diagnosis coding for fractures easier (Figure 2).

Some subspecialty societies also offer ICD-10 training. The American Society for Surgery of the Hand (www.assh.org), for example, offers a series of webinars and member-developed ICD-9-to-ICD-10 code maps.  

 3. Crosswalk your common codes from ICD-9 to ICD-10

Crosswalking is the process of mapping your most commonly used ICD-9 codes to their equivalent ICD-10 codes. This exercise familiarizes your team with ICD-10 language and terms, and gives a sense of which ICD-9 codes expand to just 1 or 2 ICD-10 codes and which codes expand into 10 or more codes—as some injury codes do (Table).

“Attempting to map the codes before completing ICD-10 training is like trying to write a letter in Greek when you only speak English,” Wiskerchen warns. “So start this process after at least some of your team have grasped the fundamentals of ICD-10.” This is where the data from your ICD-9 frequency report comes in. Use it to prioritize which codes to map first with a goal of mapping your top 25 ICD-9 codes to their ICD-10 equivalents by August 31.

Invest in good tools to support your mapping efforts. Avoid general mapping equivalent (GEM) coding tools, which are free for a good reason—they are incomplete and don’t always lead you to the correct ICD-10 code. Instead, purchase resources from credible sources, such as the American Medical Association (AMA; www.ama-assn.org). The AMA publishes ICD-10-CM 2016: The Complete Official Codebook as well as ICD-10-CM Mappings 2016, which links ICD-9 codes to all valid ICD-10 alternatives. The AMA also offers electronic ICD-10-CM Express Reference Mapping Cards for multiple specialties.

Practice makes perfect and crosswalking from ICD-9 to ICD-10 is one of the best ways for your team to become aware of the nuances in the new coding system. Like learning a new language, “speaking” ICD-10 does not become automatic just because you’ve attended training or completed the coding maps. Training teaches the architecture of the new coding system. Mapping provides a structured way to become familiar with the codes the practice will use most often. Once these 2 primary pieces are understood and assimilated, most physicians find that dictating the necessary new terms becomes quite easy.  

 4. Conduct a gap analysis to identify the ICD-10 terms missing from each provider’s current documentation

Conduct the gap analysis after your team has completed training, and once you’ve at least begun the process of mapping codes from ICD-9 to ICD-10. Here’s how:

• Generate a CPT frequency report.
• Select the top 5 procedures for each physician.
• Pull 2 patients’ notes for each of the top procedures.
• Review the notes and try to select ICD-10 code(s).

If key ICD-10 terms are not included in current documentation, physicians should modify the templates or macros they rely on for dictation.

“This simple exercise makes it obvious which clinical information physicians must add for ICD-10,” Wiskerchen says. For example, if the patient had an arthroscopy, but the note doesn’t specify on which leg, that’s a clear indication that the physician must dictate laterality. “The gap analysis is a great way to coach physicians about the clinical details to document, so staff can bill under ICD-10,” Wiskerchen says.

 5. Contact technology vendors

Given the number of new ICD-10 codes in orthopedics, paper cheat sheets will be obsolete. Instead, you’ll need to rely on pull-down menus and/or search fields in the electronic health record (EHR) and practice management systems.

“Get clarity about how the new features and workflow processes will work in your systems,” suggests Wiskerchen. “Ask questions such as: Which features will be added or changed to accommodate the new codes? Will there be new screens or pick lists for ICD-10, or search fields? How will new screens and features change our current workflow? And schedule any necessary training as soon as possible.”

In addition to software upgrades and training, vendors and clearinghouses offer an array of services to help practices make the transition. Some vendors even provide help coordinating your internal plan with their new product features and training. Contact vendors to find out what they offer.

 6. Use completed code maps to build diagnosis code databases, EHR templates, charge tickets, pick lists, prompters, and other coding tools

“Provide the code crosswalks and results of your documentation gap analysis to the IT [information technology] team so they can get started,” Wiskerchen advises. “And assign a physician or midlevel provider to work with IT so that the tools are clinically accurate.”

 7. Schedule testing with clearinghouses and payers

“Successful testing indicates that your hard work has paid off, and that claims will be processed with few, if any, ICD-10–related hiccups,” Wiskerchen says. Essentially, the testing confirms that your ICD-10 code database, pick lists, vendor features, and other coding fields are working properly. “Testing with a clearinghouse is good. Testing directly with the payer is even better, if you are a direct submitter and it is allowed,” Wiskerchen suggests. Contact your clearinghouse and/or payers for testing opportunities prior to October 1.

 8. Develop a plan for a potential cash flow crunch

So what happens if your best efforts in the 11th hour still aren’t enough to get your practice to the ICD-10 finish line? Prepare for the possibility of increased claim denials and temporary cash flow stalls, and put a plan in place to deal with them.

Start now by cleaning up as much of the accounts receivable as possible, and moving patient collections up front. Ask the billing team for a weekly status update of the largest unpaid balances in the 60-day aging column, and what has been done to appeal or otherwise address them. Analyze denial patterns and trends and fix their causes at the source—some may be ICD-10–related, others may simply be a gap in the reimbursement process that needs improvement.

Use payer cost estimators to calculate patient out-of-pocket cost and to collect unmet deductibles, coinsurance, and noncovered services prior to surgery. The surgeon-developed iPhone app Health Insurance Arithmetic² ($1.99 in the iTunes Store) can help staff do this math on one, simple screen.

Finally, secure a line of credit to guard against a claim denial pile up this fall. A line of credit mitigates financial risk by making cash available quickly, should you need it to cover temporary revenue shortfalls, meet payroll, or pay operational expenses. It’s not too late to meet with your banker and apply for this protection, and the peace of mind may even help you sleep better.

As late as mid-April 2015, a survey of 121 orthopedic practices indicated that 30% had done nothing to start preparing for ICD-10 (International Classification of Diseases, Tenth Revision).¹  That’s scary. And even the practices that had begun to prepare had not completed a number of key tasks (Figure 1).

Certainly, the will-they-or-won’t-they possibility of another congressional delay had many practices sitting on their hands this year. But now that the October 1, 2015, implementation is set in stone, this lack of inertia has many practices woefully behind. If your practice is one of many that hasn’t mapped your common ICD-9 (International Classification of Diseases, Ninth Revision) codes to ICD-10 codes, completed payer testing, or attended training, it’s time for a “full-court press.”

Being unprepared for ICD-10 will cause more than just an increase in claim denials. If your surgery schedule is booked a few months out, your staff will need to pre-authorize cases using ICD-10 as early as August 1—and they won’t be able to do that if you haven’t dictated the clinical terms required to choose an ICD-10 code. Without an understanding of ICD-10, severity of illness coding will suffer, and that will affect your bundled and value-based payments. And, if you don’t provide an adequate diagnosis when sending patients off-site for physical therapy, you’ll soon be getting phone calls from their billing staff demanding more specifics.

The clock is ticking and time is short. Here’s a prioritized list of what needs to get done.

1. Generate an ICD-9 frequency report

Identifying which diagnosis codes are the most frequently used, and therefore drive a significant portion of practice revenue, is an absolute must. The data will help prioritize training and code-mapping activities.

Most practices generate Current Procedural Terminology (CPT) code-frequency reports regularly, but few have ever run an ICD-9 code-frequency report. Call your vendor and ask for assistance, as there are multiple ways to run this report and they vary by practice management system. Sort the data elements and generate the ICD-9 frequency report by:

• Primary diagnosis.
• Unique patient.
• Revenue. (If your practice management system can’t give you diagnosis data by revenue, which enables you to focus on the codes that generate the most revenue, generate it by charges.)

The result should be a report that identifies the 20 to 25 diagnosis codes (or charges, depending on the reports generated) that drive the most revenue for the practice. Use the data to focus and prioritize your training and code-mapping activities.

 2. Schedule training

Forget about “general” ICD-10 training courses. You need orthopedic-specific guidance. That’s because ICD-10 for orthopedics is more complex than for other specialties. Dictating fractures under ICD-10 is not so simple. Selecting an injury code requires confidence in correctly using the seventh character.

“Everyone who uses diagnosis codes must have baseline knowledge: surgeons, billing staff, surgical coordinators, and clinical team,” according to Sarah Wiskerchen, MBA, CPC, consultant and ICD-10 educator with KarenZupko & Associates (KZA). Training must include the practical details of ICD-10, such as assigning laterality, understanding the system architecture, and limiting the use of unspecified codes.

The American Academy of Orthopaedic Surgeons (AAOS) offers a self-paced, online training series that provides details for the top 3 diagnosis codes for each subspecialty. The 10-program course, ICD-10-CM: By the Numbers, is available at www.aaos.org ($299 for members, $399 for nonmembers). If you prefer live instruction, there is one more AAOS-sponsored, regional ICD-10 workshop left before the October 1 deadline, and more may be added. (Details at www.karenzupko.com)

These courses provide highly specific and granular ICD-10 knowledge and incorporate the use of Code-X, an AAOS-developed software tool. They also feature tools for handling the complexities of fractures and injury codes, such as Leo C. Far, an acronym developed by KZA consultant and coding educator Margie Maley, BSN, MS, to make ICD-10 diagnosis coding for fractures easier (Figure 2).

Some subspecialty societies also offer ICD-10 training. The American Society for Surgery of the Hand (www.assh.org), for example, offers a series of webinars and member-developed ICD-9-to-ICD-10 code maps.  

 3. Crosswalk your common codes from ICD-9 to ICD-10

Crosswalking is the process of mapping your most commonly used ICD-9 codes to their equivalent ICD-10 codes. This exercise familiarizes your team with ICD-10 language and terms, and gives a sense of which ICD-9 codes expand to just 1 or 2 ICD-10 codes and which codes expand into 10 or more codes—as some injury codes do (Table).

“Attempting to map the codes before completing ICD-10 training is like trying to write a letter in Greek when you only speak English,” Wiskerchen warns. “So start this process after at least some of your team have grasped the fundamentals of ICD-10.” This is where the data from your ICD-9 frequency report comes in. Use it to prioritize which codes to map first with a goal of mapping your top 25 ICD-9 codes to their ICD-10 equivalents by August 31.

Invest in good tools to support your mapping efforts. Avoid general mapping equivalent (GEM) coding tools, which are free for a good reason—they are incomplete and don’t always lead you to the correct ICD-10 code. Instead, purchase resources from credible sources, such as the American Medical Association (AMA; www.ama-assn.org). The AMA publishes ICD-10-CM 2016: The Complete Official Codebook as well as ICD-10-CM Mappings 2016, which links ICD-9 codes to all valid ICD-10 alternatives. The AMA also offers electronic ICD-10-CM Express Reference Mapping Cards for multiple specialties.

Practice makes perfect and crosswalking from ICD-9 to ICD-10 is one of the best ways for your team to become aware of the nuances in the new coding system. Like learning a new language, “speaking” ICD-10 does not become automatic just because you’ve attended training or completed the coding maps. Training teaches the architecture of the new coding system. Mapping provides a structured way to become familiar with the codes the practice will use most often. Once these 2 primary pieces are understood and assimilated, most physicians find that dictating the necessary new terms becomes quite easy.  

 4. Conduct a gap analysis to identify the ICD-10 terms missing from each provider’s current documentation

Conduct the gap analysis after your team has completed training, and once you’ve at least begun the process of mapping codes from ICD-9 to ICD-10. Here’s how:

• Generate a CPT frequency report.
• Select the top 5 procedures for each physician.
• Pull 2 patients’ notes for each of the top procedures.
• Review the notes and try to select ICD-10 code(s).

If key ICD-10 terms are not included in current documentation, physicians should modify the templates or macros they rely on for dictation.

“This simple exercise makes it obvious which clinical information physicians must add for ICD-10,” Wiskerchen says. For example, if the patient had an arthroscopy, but the note doesn’t specify on which leg, that’s a clear indication that the physician must dictate laterality. “The gap analysis is a great way to coach physicians about the clinical details to document, so staff can bill under ICD-10,” Wiskerchen says.

 5. Contact technology vendors

Given the number of new ICD-10 codes in orthopedics, paper cheat sheets will be obsolete. Instead, you’ll need to rely on pull-down menus and/or search fields in the electronic health record (EHR) and practice management systems.

“Get clarity about how the new features and workflow processes will work in your systems,” suggests Wiskerchen. “Ask questions such as: Which features will be added or changed to accommodate the new codes? Will there be new screens or pick lists for ICD-10, or search fields? How will new screens and features change our current workflow? And schedule any necessary training as soon as possible.”

In addition to software upgrades and training, vendors and clearinghouses offer an array of services to help practices make the transition. Some vendors even provide help coordinating your internal plan with their new product features and training. Contact vendors to find out what they offer.

 6. Use completed code maps to build diagnosis code databases, EHR templates, charge tickets, pick lists, prompters, and other coding tools

“Provide the code crosswalks and results of your documentation gap analysis to the IT [information technology] team so they can get started,” Wiskerchen advises. “And assign a physician or midlevel provider to work with IT so that the tools are clinically accurate.”

 7. Schedule testing with clearinghouses and payers

“Successful testing indicates that your hard work has paid off, and that claims will be processed with few, if any, ICD-10–related hiccups,” Wiskerchen says. Essentially, the testing confirms that your ICD-10 code database, pick lists, vendor features, and other coding fields are working properly. “Testing with a clearinghouse is good. Testing directly with the payer is even better, if you are a direct submitter and it is allowed,” Wiskerchen suggests. Contact your clearinghouse and/or payers for testing opportunities prior to October 1.

 8. Develop a plan for a potential cash flow crunch

So what happens if your best efforts in the 11th hour still aren’t enough to get your practice to the ICD-10 finish line? Prepare for the possibility of increased claim denials and temporary cash flow stalls, and put a plan in place to deal with them.

Start now by cleaning up as much of the accounts receivable as possible, and moving patient collections up front. Ask the billing team for a weekly status update of the largest unpaid balances in the 60-day aging column, and what has been done to appeal or otherwise address them. Analyze denial patterns and trends and fix their causes at the source—some may be ICD-10–related, others may simply be a gap in the reimbursement process that needs improvement.

Use payer cost estimators to calculate patient out-of-pocket cost and to collect unmet deductibles, coinsurance, and noncovered services prior to surgery. The surgeon-developed iPhone app Health Insurance Arithmetic² ($1.99 in the iTunes Store) can help staff do this math on one, simple screen.

Finally, secure a line of credit to guard against a claim denial pile up this fall. A line of credit mitigates financial risk by making cash available quickly, should you need it to cover temporary revenue shortfalls, meet payroll, or pay operational expenses. It’s not too late to meet with your banker and apply for this protection, and the peace of mind may even help you sleep better.

An 8-surgeon group in the Southeast had a history of high patient receivables, the result of a long-held culture of “We’ll submit to your insurance and bill you after insurance pays.”

The billing and collections staff worked in the basement—far away and out of sight of the patients who showed up for their postoperative visits owing big bucks.

In a flash of wisdom, the administrator agreed to move the patient-balance collector into a converted closet near the check-out area, and provided the information, tools, and training that enabled her to speak with patients about their balances when they came in for an appointment. In her first month in this role and location, this employee collected more than her annual salary from patients. 

It Takes a Program

This is one of our favorite client success stories, and it illustrates a key point: point-of-service (POS) collections do not have to be complicated. But the process does have to be deliberate and coordinated. Practices cannot simply update the financial policy and hope the staff members magically begin collecting. If this is your strategy, we promise that it will fail.

Successful POS collecting requires a program approach. And this approach starts at the front-end of the billing cycle, not “after insurance pays.”

POS collections have never been more important. Health insurance exchanges and payers are increasing deductibles and coinsurances. Physicians are opting out of network. Given these realities, POS collections are vital to your cash flow and effective receivables management.

If you are starting practice, you have a perfect opportunity to open with POS collecting in place. A solo surgeon whom we set up in practice did so, and has collected up-front for office services, scans, and surgeries from his first day in practice. Today, the practice’s only outstanding patient receivables are those of patients on payment plans—and these are less than 1% of total accounts receivable.

We also converted the “after insurance pays” philosophy of a surgeon in the South, implementing both POS collections and surgical deposits. In the first month, his patient payments increased by 40%. Another solo orthopedist reported an increased take-home salary of $90,000 in the first year after we helped his staff collect surgery deposits.

Six POS Program Elements

In 30 years of implementing or training staff to implement POS collections, we have come to recognize the following 6 key elements to include in your program approach: Policies + Procedures + Technology + Training + Monitoring + Coaching.

At a high level, here are the actions your practice will need to take:

1. Update the financial policy with 1 written standard for all physicians.

2. Develop granular procedures driven by the policy; these are the “how-tos” that enable the staff to collect successfully.

3. Implement new technologies, such as cost estimators, recurring payments, and online bill pay.

4. Schedule formal training to ensure that staff members know how to ask for money. (Do not assume they are, can, or will without training.)

5. Measure and monitor the outcome of patient collections and staff performance.

6. Provide ongoing coaching and oversight to maintain motivation and skills.

A blueprint for addressing each one of these actions follows.

1. Update the financial policy

The policy is the set of expectations on which to build all procedures and training. Dust off this document, and review it as a group with the practice administrator. First, strike old language that says the patient will be balance-billed, or will only be asked in the office for his visit copay. Next, strive for clarity. “You will be asked to pay your financial responsibility at the time of service,” really says nothing. Instead, the policy should be direct:

If you are recommended for surgery, our staff will calculate your coinsurance and unmet deductible amounts: 50% of this amount will be collected as a surgery deposit, and the remaining 50% is due on or before the day of surgery. Payment plans are available.

For office visits and services, break down the policy by coverage type. We find that a table such as the one shown makes expectations clear.

Finally, strive for 1 standard policy for all providers. If every provider is allowed to create his or her own set of collection policies, the practice is setting staff up for complexity overload, and collections will suffer.

2. Develop granular procedures

Few practices take the time to translate the financial policy into written procedures that can be followed by staff. The policy establishes the rules, but the procedures tell staff what to do to implement those rules. For instance:

Create a “POS Playbook” that contains information such as procedures, cost-quotation worksheets, US Poverty guidelines¹, and financing brochures. As old-school as it sounds, a 3-ring binder is great for this information, and makes information access and updates easy.

3. Implement collection technologies

Modern practices use inexpensive (and often free) tools that increase patient convenience and staff efficiency. Implement at least 2 of these useful technologies and watch your POS collections increase:

Reports from your practice management system (PMS). Use the technology you already have. There are 2 standard reports in your PMS or clearinghouse that give front-desk staff the data to ask patients for money. Eligibility status and past-due balance reports indicate amounts owed, unmet deductibles, and the ineligible patients they can collect from when they come in for their appointment.

Online cost estimators. These free, online tools are offered by payers and provide staff with real-time data about a patient’s unmet deductible and coinsurance. When staff members enter Current Procedural Terminology (CPT) codes and the patient’s benefit information into the online cost estimator, they can access valuable information. Many insurance plans offer cost estimators on their web sites. Others deliver the data through statewide or regional portals, such as Availity (www.availity.com). The accuracy of cost-estimator data can vary by region and depends on the data links with payers. Ask your team to evaluate which estimators are best for you based on your payer mix.

Online bill pay. Everyone appreciates the convenience of paying bills online. Most patient portals offer this feature. If yours does not or you do not have a portal, you can offer PayPal (www.paypal.com) on your practice website, or use a system such as Intuit Health (www.intuithealth.com).

Recurring billing. Recurring billing is how you pay for services, such as Netflix, Pandora, or your gym membership: it is automatically billed to a credit card each month. Offer this option to patients as a payment plan method, and staff will no longer need to send costly statements, post monthly check payments, or follow up when a patient is delinquent. Plus, it guarantees payment every month; patients can no longer say, “I forgot.”

TransFirst (www.transfirstassociation.com) and a-claim (www.a-claim.com) offer recurring billing through a “virtual terminal” that staff logs in to at checkout, or during the preprocedure patient counseling process. Both vendors also offer the option of automatically charging a patient’s credit card after their insurance pays, speeding patient account pay-off and negating the need for statements.

Real-time collections scripts based on payer rules. Patient Access, offered by Availity, combines real-time payer data with financial policies that are entered during set-up to create instant, patient-specific scripts that staff members read to the patient in front of them.

4. Schedule formal training

Just because someone can collect a copay does not mean he or she is comfortable with or capable of asking patients for past-due balances, surgical deposits, or large coinsurances. It is the rare staff person who is a “natural” at asking patients for money in a polished and professional manner.

That’s why training staff how to ask patients for money is vital. A front-office supervisor or manager should conduct several training sessions to cover policies and procedures. Training materials should include talking points and scenarios for collecting for office services and past-due balances, and calculating what patients owe, using technology tools. Use role-playing to ensure staff can explain payment plan options and how to apply for patient financing or financial assistance.

Few practices can skip this part of the POS program and still be successful. If your manager or supervisor is not capable of training, it is worth the investment to hire an outside expert. Without thorough training, staff efforts will be suboptimal or, at worst, fail because the staff members will not know how or what to collect.

5. Measure and monitor the outcome

The Hawthorne effect is a psychological phenomenon that says people perform better and make more positive changes as a result of increased attention.² In other words, staff members will perform better, and collect more, if they know someone is paying attention. Trust us on this one.

Employees respect what management inspects. So even if the implementation of POS collections has been a big success, do not take your eyes off the ball.

Stop by the front desk or surgery coordinator’s office a few times a month and ask how much has been collected. Randomly review daily over-the-counter collections logs. And always put POS collections performance on the monthly partner meeting agenda; review a graph that shows monthly collections at checkout and surgery deposits. Keeping tabs on performance enables the practice to take action quickly when collections drop, and before that decline becomes acute.

6. Provide ongoing coaching and oversight

Most practices train once, then wonder why staff motivation (and collections too) fall off after a while. Like that new couch you bought: it was all you could talk about the week after it was delivered. Now, it is only a comfy place to sit. It is the same with collections efforts. When the newness wears off, staff motivation does too, and training principles can be forgotten. That’s human nature. Conduct role-playing in staff meetings each quarter and discuss best practices for handling patient objections. Encourage peer-to-peer observation and coaching to address knowledge gaps and missed collection opportunities. Ongoing training and coaching will tease out training needs and boost your team’s collection confidence and success.

An 8-surgeon group in the Southeast had a history of high patient receivables, the result of a long-held culture of “We’ll submit to your insurance and bill you after insurance pays.”

The billing and collections staff worked in the basement—far away and out of sight of the patients who showed up for their postoperative visits owing big bucks.

In a flash of wisdom, the administrator agreed to move the patient-balance collector into a converted closet near the check-out area, and provided the information, tools, and training that enabled her to speak with patients about their balances when they came in for an appointment. In her first month in this role and location, this employee collected more than her annual salary from patients. 

It Takes a Program

This is one of our favorite client success stories, and it illustrates a key point: point-of-service (POS) collections do not have to be complicated. But the process does have to be deliberate and coordinated. Practices cannot simply update the financial policy and hope the staff members magically begin collecting. If this is your strategy, we promise that it will fail.

Successful POS collecting requires a program approach. And this approach starts at the front-end of the billing cycle, not “after insurance pays.”

POS collections have never been more important. Health insurance exchanges and payers are increasing deductibles and coinsurances. Physicians are opting out of network. Given these realities, POS collections are vital to your cash flow and effective receivables management.

If you are starting practice, you have a perfect opportunity to open with POS collecting in place. A solo surgeon whom we set up in practice did so, and has collected up-front for office services, scans, and surgeries from his first day in practice. Today, the practice’s only outstanding patient receivables are those of patients on payment plans—and these are less than 1% of total accounts receivable.

We also converted the “after insurance pays” philosophy of a surgeon in the South, implementing both POS collections and surgical deposits. In the first month, his patient payments increased by 40%. Another solo orthopedist reported an increased take-home salary of $90,000 in the first year after we helped his staff collect surgery deposits.

Six POS Program Elements

In 30 years of implementing or training staff to implement POS collections, we have come to recognize the following 6 key elements to include in your program approach: Policies + Procedures + Technology + Training + Monitoring + Coaching.

At a high level, here are the actions your practice will need to take:

1. Update the financial policy with 1 written standard for all physicians.

2. Develop granular procedures driven by the policy; these are the “how-tos” that enable the staff to collect successfully.

3. Implement new technologies, such as cost estimators, recurring payments, and online bill pay.

4. Schedule formal training to ensure that staff members know how to ask for money. (Do not assume they are, can, or will without training.)

5. Measure and monitor the outcome of patient collections and staff performance.

6. Provide ongoing coaching and oversight to maintain motivation and skills.

A blueprint for addressing each one of these actions follows.

1. Update the financial policy

The policy is the set of expectations on which to build all procedures and training. Dust off this document, and review it as a group with the practice administrator. First, strike old language that says the patient will be balance-billed, or will only be asked in the office for his visit copay. Next, strive for clarity. “You will be asked to pay your financial responsibility at the time of service,” really says nothing. Instead, the policy should be direct:

If you are recommended for surgery, our staff will calculate your coinsurance and unmet deductible amounts: 50% of this amount will be collected as a surgery deposit, and the remaining 50% is due on or before the day of surgery. Payment plans are available.

For office visits and services, break down the policy by coverage type. We find that a table such as the one shown makes expectations clear.

Finally, strive for 1 standard policy for all providers. If every provider is allowed to create his or her own set of collection policies, the practice is setting staff up for complexity overload, and collections will suffer.

2. Develop granular procedures

Few practices take the time to translate the financial policy into written procedures that can be followed by staff. The policy establishes the rules, but the procedures tell staff what to do to implement those rules. For instance:

Create a “POS Playbook” that contains information such as procedures, cost-quotation worksheets, US Poverty guidelines¹, and financing brochures. As old-school as it sounds, a 3-ring binder is great for this information, and makes information access and updates easy.

3. Implement collection technologies

Modern practices use inexpensive (and often free) tools that increase patient convenience and staff efficiency. Implement at least 2 of these useful technologies and watch your POS collections increase:

Reports from your practice management system (PMS). Use the technology you already have. There are 2 standard reports in your PMS or clearinghouse that give front-desk staff the data to ask patients for money. Eligibility status and past-due balance reports indicate amounts owed, unmet deductibles, and the ineligible patients they can collect from when they come in for their appointment.

Online cost estimators. These free, online tools are offered by payers and provide staff with real-time data about a patient’s unmet deductible and coinsurance. When staff members enter Current Procedural Terminology (CPT) codes and the patient’s benefit information into the online cost estimator, they can access valuable information. Many insurance plans offer cost estimators on their web sites. Others deliver the data through statewide or regional portals, such as Availity (www.availity.com). The accuracy of cost-estimator data can vary by region and depends on the data links with payers. Ask your team to evaluate which estimators are best for you based on your payer mix.

Online bill pay. Everyone appreciates the convenience of paying bills online. Most patient portals offer this feature. If yours does not or you do not have a portal, you can offer PayPal (www.paypal.com) on your practice website, or use a system such as Intuit Health (www.intuithealth.com).

Recurring billing. Recurring billing is how you pay for services, such as Netflix, Pandora, or your gym membership: it is automatically billed to a credit card each month. Offer this option to patients as a payment plan method, and staff will no longer need to send costly statements, post monthly check payments, or follow up when a patient is delinquent. Plus, it guarantees payment every month; patients can no longer say, “I forgot.”

TransFirst (www.transfirstassociation.com) and a-claim (www.a-claim.com) offer recurring billing through a “virtual terminal” that staff logs in to at checkout, or during the preprocedure patient counseling process. Both vendors also offer the option of automatically charging a patient’s credit card after their insurance pays, speeding patient account pay-off and negating the need for statements.

Real-time collections scripts based on payer rules. Patient Access, offered by Availity, combines real-time payer data with financial policies that are entered during set-up to create instant, patient-specific scripts that staff members read to the patient in front of them.

4. Schedule formal training

Just because someone can collect a copay does not mean he or she is comfortable with or capable of asking patients for past-due balances, surgical deposits, or large coinsurances. It is the rare staff person who is a “natural” at asking patients for money in a polished and professional manner.

That’s why training staff how to ask patients for money is vital. A front-office supervisor or manager should conduct several training sessions to cover policies and procedures. Training materials should include talking points and scenarios for collecting for office services and past-due balances, and calculating what patients owe, using technology tools. Use role-playing to ensure staff can explain payment plan options and how to apply for patient financing or financial assistance.

Few practices can skip this part of the POS program and still be successful. If your manager or supervisor is not capable of training, it is worth the investment to hire an outside expert. Without thorough training, staff efforts will be suboptimal or, at worst, fail because the staff members will not know how or what to collect.

5. Measure and monitor the outcome

The Hawthorne effect is a psychological phenomenon that says people perform better and make more positive changes as a result of increased attention.² In other words, staff members will perform better, and collect more, if they know someone is paying attention. Trust us on this one.

Employees respect what management inspects. So even if the implementation of POS collections has been a big success, do not take your eyes off the ball.

Stop by the front desk or surgery coordinator’s office a few times a month and ask how much has been collected. Randomly review daily over-the-counter collections logs. And always put POS collections performance on the monthly partner meeting agenda; review a graph that shows monthly collections at checkout and surgery deposits. Keeping tabs on performance enables the practice to take action quickly when collections drop, and before that decline becomes acute.

6. Provide ongoing coaching and oversight

Most practices train once, then wonder why staff motivation (and collections too) fall off after a while. Like that new couch you bought: it was all you could talk about the week after it was delivered. Now, it is only a comfy place to sit. It is the same with collections efforts. When the newness wears off, staff motivation does too, and training principles can be forgotten. That’s human nature. Conduct role-playing in staff meetings each quarter and discuss best practices for handling patient objections. Encourage peer-to-peer observation and coaching to address knowledge gaps and missed collection opportunities. Ongoing training and coaching will tease out training needs and boost your team’s collection confidence and success.

An 8-surgeon group in the Southeast had a history of high patient receivables, the result of a long-held culture of “We’ll submit to your insurance and bill you after insurance pays.”

The billing and collections staff worked in the basement—far away and out of sight of the patients who showed up for their postoperative visits owing big bucks.

In a flash of wisdom, the administrator agreed to move the patient-balance collector into a converted closet near the check-out area, and provided the information, tools, and training that enabled her to speak with patients about their balances when they came in for an appointment. In her first month in this role and location, this employee collected more than her annual salary from patients. 

It Takes a Program

This is one of our favorite client success stories, and it illustrates a key point: point-of-service (POS) collections do not have to be complicated. But the process does have to be deliberate and coordinated. Practices cannot simply update the financial policy and hope the staff members magically begin collecting. If this is your strategy, we promise that it will fail.

Successful POS collecting requires a program approach. And this approach starts at the front-end of the billing cycle, not “after insurance pays.”

POS collections have never been more important. Health insurance exchanges and payers are increasing deductibles and coinsurances. Physicians are opting out of network. Given these realities, POS collections are vital to your cash flow and effective receivables management.

If you are starting practice, you have a perfect opportunity to open with POS collecting in place. A solo surgeon whom we set up in practice did so, and has collected up-front for office services, scans, and surgeries from his first day in practice. Today, the practice’s only outstanding patient receivables are those of patients on payment plans—and these are less than 1% of total accounts receivable.

We also converted the “after insurance pays” philosophy of a surgeon in the South, implementing both POS collections and surgical deposits. In the first month, his patient payments increased by 40%. Another solo orthopedist reported an increased take-home salary of $90,000 in the first year after we helped his staff collect surgery deposits.

Six POS Program Elements

In 30 years of implementing or training staff to implement POS collections, we have come to recognize the following 6 key elements to include in your program approach: Policies + Procedures + Technology + Training + Monitoring + Coaching.

At a high level, here are the actions your practice will need to take:

1. Update the financial policy with 1 written standard for all physicians.

2. Develop granular procedures driven by the policy; these are the “how-tos” that enable the staff to collect successfully.

3. Implement new technologies, such as cost estimators, recurring payments, and online bill pay.

4. Schedule formal training to ensure that staff members know how to ask for money. (Do not assume they are, can, or will without training.)

5. Measure and monitor the outcome of patient collections and staff performance.

6. Provide ongoing coaching and oversight to maintain motivation and skills.

A blueprint for addressing each one of these actions follows.

1. Update the financial policy

The policy is the set of expectations on which to build all procedures and training. Dust off this document, and review it as a group with the practice administrator. First, strike old language that says the patient will be balance-billed, or will only be asked in the office for his visit copay. Next, strive for clarity. “You will be asked to pay your financial responsibility at the time of service,” really says nothing. Instead, the policy should be direct:

If you are recommended for surgery, our staff will calculate your coinsurance and unmet deductible amounts: 50% of this amount will be collected as a surgery deposit, and the remaining 50% is due on or before the day of surgery. Payment plans are available.

For office visits and services, break down the policy by coverage type. We find that a table such as the one shown makes expectations clear.

Finally, strive for 1 standard policy for all providers. If every provider is allowed to create his or her own set of collection policies, the practice is setting staff up for complexity overload, and collections will suffer.

2. Develop granular procedures

Few practices take the time to translate the financial policy into written procedures that can be followed by staff. The policy establishes the rules, but the procedures tell staff what to do to implement those rules. For instance:

Create a “POS Playbook” that contains information such as procedures, cost-quotation worksheets, US Poverty guidelines¹, and financing brochures. As old-school as it sounds, a 3-ring binder is great for this information, and makes information access and updates easy.

3. Implement collection technologies

Modern practices use inexpensive (and often free) tools that increase patient convenience and staff efficiency. Implement at least 2 of these useful technologies and watch your POS collections increase:

Reports from your practice management system (PMS). Use the technology you already have. There are 2 standard reports in your PMS or clearinghouse that give front-desk staff the data to ask patients for money. Eligibility status and past-due balance reports indicate amounts owed, unmet deductibles, and the ineligible patients they can collect from when they come in for their appointment.

Online cost estimators. These free, online tools are offered by payers and provide staff with real-time data about a patient’s unmet deductible and coinsurance. When staff members enter Current Procedural Terminology (CPT) codes and the patient’s benefit information into the online cost estimator, they can access valuable information. Many insurance plans offer cost estimators on their web sites. Others deliver the data through statewide or regional portals, such as Availity (www.availity.com). The accuracy of cost-estimator data can vary by region and depends on the data links with payers. Ask your team to evaluate which estimators are best for you based on your payer mix.

Online bill pay. Everyone appreciates the convenience of paying bills online. Most patient portals offer this feature. If yours does not or you do not have a portal, you can offer PayPal (www.paypal.com) on your practice website, or use a system such as Intuit Health (www.intuithealth.com).

Recurring billing. Recurring billing is how you pay for services, such as Netflix, Pandora, or your gym membership: it is automatically billed to a credit card each month. Offer this option to patients as a payment plan method, and staff will no longer need to send costly statements, post monthly check payments, or follow up when a patient is delinquent. Plus, it guarantees payment every month; patients can no longer say, “I forgot.”

TransFirst (www.transfirstassociation.com) and a-claim (www.a-claim.com) offer recurring billing through a “virtual terminal” that staff logs in to at checkout, or during the preprocedure patient counseling process. Both vendors also offer the option of automatically charging a patient’s credit card after their insurance pays, speeding patient account pay-off and negating the need for statements.

Real-time collections scripts based on payer rules. Patient Access, offered by Availity, combines real-time payer data with financial policies that are entered during set-up to create instant, patient-specific scripts that staff members read to the patient in front of them.

4. Schedule formal training

Just because someone can collect a copay does not mean he or she is comfortable with or capable of asking patients for past-due balances, surgical deposits, or large coinsurances. It is the rare staff person who is a “natural” at asking patients for money in a polished and professional manner.

That’s why training staff how to ask patients for money is vital. A front-office supervisor or manager should conduct several training sessions to cover policies and procedures. Training materials should include talking points and scenarios for collecting for office services and past-due balances, and calculating what patients owe, using technology tools. Use role-playing to ensure staff can explain payment plan options and how to apply for patient financing or financial assistance.

Few practices can skip this part of the POS program and still be successful. If your manager or supervisor is not capable of training, it is worth the investment to hire an outside expert. Without thorough training, staff efforts will be suboptimal or, at worst, fail because the staff members will not know how or what to collect.

5. Measure and monitor the outcome

The Hawthorne effect is a psychological phenomenon that says people perform better and make more positive changes as a result of increased attention.² In other words, staff members will perform better, and collect more, if they know someone is paying attention. Trust us on this one.

Employees respect what management inspects. So even if the implementation of POS collections has been a big success, do not take your eyes off the ball.

Stop by the front desk or surgery coordinator’s office a few times a month and ask how much has been collected. Randomly review daily over-the-counter collections logs. And always put POS collections performance on the monthly partner meeting agenda; review a graph that shows monthly collections at checkout and surgery deposits. Keeping tabs on performance enables the practice to take action quickly when collections drop, and before that decline becomes acute.

6. Provide ongoing coaching and oversight

Most practices train once, then wonder why staff motivation (and collections too) fall off after a while. Like that new couch you bought: it was all you could talk about the week after it was delivered. Now, it is only a comfy place to sit. It is the same with collections efforts. When the newness wears off, staff motivation does too, and training principles can be forgotten. That’s human nature. Conduct role-playing in staff meetings each quarter and discuss best practices for handling patient objections. Encourage peer-to-peer observation and coaching to address knowledge gaps and missed collection opportunities. Ongoing training and coaching will tease out training needs and boost your team’s collection confidence and success.