Managing Your Practice

Business Lessons I Didn't Learn in Residency


Do you ever wish that your residency years had prepared you better for managing the business side of your practice?

It's critical to learn how to get paid for what we do, yet my experience in residency provided little preparation for doing just that. Here are a few tips I wish I had learned back in residency and that I think are important to pass along to the residents who I teach:

1. Always read your mail. Delegating this task to an office manager means you're out of the loop when it comes to knowing the trends occurring with your explanations of benefits and denials for payment. It's important to know what you are—and are not—getting paid for. Don't assume that if you bill for a service, you'll get paid for it. And don't assume that the amount you bill always covers your own costs. Manufacturers of vaccines and devices can change their charges on a dime, and that can eat into your margin if you're not paying attention. If you can't find the time to read your mail, train someone on your staff to push the information to you.

2. Develop solid relationships with patients. Medicare patients are constantly receiving reminders in the mail to report cases of fraud. Although absolutely no one should ever take advantage of these patients, sometimes they feel they are being taken advantage of due to miscommunication. A Medicare patient of mine recently called to question why I had billed for tobacco cessation, since she believed our discussion about her plans to quit smoking was just part of being a good doctor. I was relieved to be given the opportunity to explain to her that it was a legitimate claim, given that Medicare now reimburses physicians for providing such counseling. Not all your patients are going to like you. The aim is to develop an open relationship so they feel that they can come to you first if they have a question about their bill.

3. Be complete on review of systems. In cases of audit, inadequate review of systems (ROS) is the leading reason for physicians to write checks back to insurance companies. If you're doing the work of a ROS for a higher level of visit, make sure that you're documenting that fact. With any code, you need to at least spell out the pertinent ROS to justify payment.

4. Understand the difference between 99213 and 99214. Over the course of a year, the cumulative difference between billing for a level-3 visit versus a level-4 visit can be huge. Unfortunately, because residents are not allowed to bill above a 99213, they never really become used to doing the expanded documentation required for a 99214. And that's what they stick to once they are in practice, even when they are doing the work of a 99214.5

5. Learn how to code based on time in situations that warrant it. Family physicians in particular manage patients who may not always involve a high level of complexity but who do require a lot of time. The patient who has just been diagnosed with diabetes or the patient with depression, for example, both require considerable counseling time. To get paid for that time, you need to document that you spent at least 50% of the visit counseling and educating these patients on issues related to their diagnosis.

6. Remember consultation codes are a thing of the past. Learn how to add AI modifiers if you are the principal provider or consultant for a Medicare patient. These AI modifiers help explain to Medicare how there can be two codes for the same patient on the same day. They explain who is the principal provider and who is the consultant on the case, and if you don't use them your claim may be denied.

7. Use tobacco cessation counseling codes when appropriate. Codes 99406 and 99407 have been around since 2005, but a lot of physicians still aren't using them. In a patient with a disease or condition affected by tobacco use, these codes allow reimbursement for smoking cessation counseling for two quit attempts per patient during the year, and coverage is for four counseling interactions for each quit attempt. For 99406, the physician must document 3-10 minutes of counseling per interaction; for 99407, more than 10 minutes of counseling must be documented.

8. Use all the codes for diabetic foot exams and care. Physicians can bill for an initial foot exam for loss of protective sensation, or LOPS (G0245), as well as a follow-up exam code for LOPS at subsequent visits. In addition to the LOPS code, the code for routine foot care (G0247) can be used if you address the causes of LOPS, by shaving calluses, for example.

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