Best Practices for Precepting and Teaching Billing and

Best Practices for Precepting and Teaching Billing and Coding Kristy Brown, DO, Maggie Riley, MD Tara Master-Hunter, MD, Joel Heidelbaugh, MD Department of Family Medicine, University of Michigan

Objectives • Review ACGME standards/billing literature • Describe educational interventions – Faculty interventions – Resident interventions – Provide tools for other programs • Review outcomes of our interventions • Discuss successful and unsuccessful attempts made at your programs

ACGME requirements • Management of Health Systems: – Must receive at least 100 hours of management and leadership instruction in both the didactic and practical settings. • The FMC must be considered the primary site for teaching management and leadership skills, and should serve as an example on which residents model future practices. • Each resident must receive reports of individual and practice productivity, financial performance, patient satisfaction and clinical quality. • The management curriculum should include current billing practices, designing and managing a budget…

Background • Family physicians underbill 1/3 of office visits 1 • Pediatric resident billing had a 38% concordance with expert coders 2 • Residents receive inadequate practice management education, including billing – EM, OB/GYN, surgery, pediatrics 3 -6 • 2/3 of family medicine graduates feel unprepared for practice management 7 (1) King MS, et al. J Am Board Fam Pract 2001; 14: 184 -92 (2) Ng M, et al. Pediatrrics 2001; 108(4): 827 -34 (3) Howell J, et al. Acad Emerg Med 2000; 7: 1135 -8 (4) Williford LE, et al. Onstet Gynecol 1999; 94: 476 -9 (5) Fakhry SM, et al. Am J Surgery 2007; 194: 263 -7 (7) Breitweiser D, et al. J Fam Pract 1981; 13: 1063 -4 (6) Andreae MC, et al. Clin Pediatr 2009; 48(9): 939 -44

Background University of Michigan Dept of Family Medicine • Post-grad survey – 54. 5% found practice management training inadequate • Residents billed ½ the number of level 4 visits as attending physicians

Background - What has worked for others? • Templates may improve billing accuracy 8, 9 • Rheumatology - lecture and educational sheet 10 – Increase in level of service billed • EM – lecture, bi-weekly newsletters, casespecific feedback 11 – Increase in RVU’s/resident and amount billed/pt (8) (9) (10) (11) Mulvehill S, et al. J Am Board Fam Pract 2005; 18(6): 464 -9 Sprtel SJ, et al. South Med J 2005; 98(5): 524 -7 Hirsch JM, et al. J Clin Rheumatol 2010; 16(3): 148 -50 Carter KA, et al. Acad Emerg Med 2009; 16(5): 423 -8

Barriers to accurate billing • Time constraints • Concern about possible audit • Resident autonomy • Clinic flow • Perceived lack of importance of appropriate billing LACK OF KNOWLEDGE

Core principles • Education • Feedback • Accountability • Culture Change

Faculty Interventions • Quarterly lectures at faculty meeting – 99213 vs 99214 vs 99215 – 99203 vs 99204 – HME + E/M code, procedure + E/M code – Billing for procedures – Rvu’s per common codes • Feedback on individual billing practices – Provided in relation to peers – Given every 6 months

Resident Interventions • Lectures – Every 1 -3 months as part of professional skills – Emphasized spirit of accurate billing – Interactive: pop quiz, small group coding – Mnemonics (1, 2, 3, 4, 5)

Resident Interventions • Real time evaluation/accountability sheets – Discuss billing at every visit – Tracking system to evaluate behavior change – Improved preceptor documentation accuracy • Billing cheat sheets

Resident Interventions • Preceptor billing feedback – In relation to peers, compared to own clinic • Resident billing feedback – In relation to peers and faculty

Resident Interventions • Family Medical Center Experience Rotation – Weekly 1: 1 sessions reviewing individual billing and documentation • Resident Quality Improvement Project – Virtual paychecks

Core principles • Education • Feedback • Accountability • Culture Change

Results

Results – paired t-test Residents baseline intervention P-value NP level 4 13% 14% 0. 987 RV level 4 29% 43% 0. 002 NP level 4 21% 22% 0. 89 RV level 4 54% 60% 0. 003 Faculty

Conclusions • Departmental culture change – Increased awareness of billing issues/importance • Meeting RRC requirements for practice management • Statistically significant shift in billing patterns

References 1) King MS, Sharp L, Lipsky M. Accuracy of CPT evaluation and management coding by family physicians. J Am Board Fam Pract 2001; 14: 184 -192. 2) Ng M and Lawless ST. What if pediatric residents could bill for their outpatient services? Pediatrics 2001; 108(4): 827834. 3) Howell J, Chisholm C, Clark A, Spillane L. Emergency medicine resident documentation: results of the 1999 American Board of Emergency Medicine in-training examination survey. Acad Emerg Med 2000; 7: 1135 -8. 4) Williford LE, Ling FW, Summitt RL Jr, Stovall TG. Practice Management in obstetrics and gynecology residency curriculum. Obstet Gyenecol 1999; 94: 476 -9. 5) Fakhry SM, Robinson L, Hendershot K, Reines HD. Surgical residents’ knowledge of documentation and coding for professional services: an opportunity for a focused educational offering. Am J Surg 2007; 194: 263 -7. 6) Andreae MC, Dunham K, Freed GL. Inadequate training in billing and coding as perceived by recent pediatric graduates. Clin Pediatr 2009; 48(9): 939 -44. 7) Breitwieser D, Wallace A, Arvidson M. Resident evaluation of current practice management training. J Fam Pract 1981; 13: 1063 -4. 8) Mulvehill S, Schneider G, Cullen CM, Roaten S, Foster B, Porter A. Template-guided versus undirected written medical documentation: a prospective, randomized trial in a family medicine residency clinic. J Am Board Fam Pract. 2005; 18(6): 464 -9. 9) Sprtel SJ, Zlabek JA. Does the use of standardized history and physical forms improve billable income and resident physician awareness of billing codes? South Med J. 2005; 98(5): 524 -7. 10) Hirsh JM, Collier DH, Boyle DJ, Gardner EM. A concise evaluation and management curriculum for physicians in training improved billing at an outpatient academic rheumatology clinic. J Clin Rheumatol 2010; 16(3): 148 -50. 11) Carter KA, Dawson BC, Brewer K, Lawson L. RVU ready? Preparing emergency medicine resident physicians in documentation for an incentive-based work environment. Acad Emerg Med 2009 16(5): 423 -8.