Thursday, May 16, 2013

Relationships Are a Critical Part of Building Medical Homes


The small Nebraska town where I practice family medicine has a population of about 2,000. Although my practice is only 30 minutes west of Lincoln -- the state's capital and second-largest city -- solo and small family practices are common in the rural areas to my north, south and west.
As my colleagues in these small practices ponder the patient-centered medical home (PCMH), I know that it can seem overwhelming to implement. The bodies that recognize or certify PCMH practices have numerous confusing requirements that have more to do with processes than patient care. So when I talk to family physicians who have concerns about the PCMH, I suggest they read the original articles on the subject by Barbara Starfield, M.D., M.P.H.
Instead of a large number of boxes to check, Starfield thought there were three simple things at the core of becoming a medical home.
The first is to be comprehensive in your approach to health care. It is comprehensiveness that separates us from our subspecialty colleagues who focus on a single organ system or a single disease entity. It is comprehensiveness that separates us from midlevel providers who say they can deliver care as well or better than family physicians. Ordering more tests and referring to subspecialists is not comprehensive care. Family medicine is.
The second critical factor is disease management. We all know there are certain diagnoses that predispose patients to increased morbidity and mortality. The Academy has clinical recommendationsand resources to help your practice with chronic disease management protocols that fit your practice. You also can develop disease registries to be more proactive with these patients. By doing so, we can reduce morbidity and mortality and ultimately reduce costs to our health care system.
Finally, relationships and continuity of care are important. Knowing our patients and their families facilitates caring for them. This can reduce duplication of tests and improve compliance to treatment plans by understanding each patient's culture and concerns. I recently had this brought home to me by one of my long-time patients.
Oliver was a 92-year-old, retired minister who had contracted pneumonia and required hospitalization. I have cared for his family for years. In fact, I delivered two of his grandsons.
Oliver was not responding to treatment, so as I examined him, I talked to his family -- including those grandsons -- about other interventions we could try to improve his situation. As I talked, his son, David, got out of his chair, came to me and placed his hand on my arm. He said, "Dr. Wergin, you know my dad loves you, and we all love you. You are as much a part of our family as anyone in this room. We wanted to let you know that my father does not fear death and is ready for what's to come. In fact, we are all ready for what's to come, but we're worried about you. You don't seem to be ready."
I looked at David and told him I understood. I went to the nurse's station and wrote a prescription for morphine and other comfort measures. I continued to round on him and talk to him each day. There was no new hospice nurse or shift-working hospitalist. Instead, it was just me and Oliver's family. That's family medicine.
Oliver passed away a few days later. It was a quiet death, and his family members were with him.
Medicine is always changing, and we have to be prepared. It is important to develop a plan to meet PCMH requirements if you want to be recognized or certified as a PCMH practice. We know that our strict fee-for-service model, which has not served us well, is coming to an end. To be reimbursed in a new model of payment, we must show we deliver what we promise. Don't be discouraged, and remember that patient-centered care is based on these three things: comprehensiveness, disease management and relationships.
How do you build relationships with your patients?
Robert Wergin, M.D., is a member of the AAFP Board of Directors.

U.S. sets $1 billion healthcare innovation initiative

Related Topics

U.S. President Barack Obama speaks at a Democratic Party fundraiser at the Waldorf Astoria hotel in New York, May 13, 2013. REUTERS/Jason Reed
WASHINGTON | Wed May 15, 2013 3:27pm EDT
(Reuters) - The Obama administration on Wednesday announced a $1 billion initiative to fund innovations in federal healthcare programs aimed at cutting costs while improving the health results.
The Department of Health and Human Services said the money will be used to award and evaluate projects that test new payment and delivery models for federal programs including Medicare, Medicaid and the Children's Health Insurance Program.
The announcement marks the second round of innovation initiatives for the administration under President Barack Obama's 2010 Patient Protection and Affordable Care Act.
The government is looking for models that can quickly cut costs in outpatient or post-acute settings, improve care for people with special needs, transform healthcare providers' financial and clinical models or improve health conditions by clinical category, geographic area or socioeconomic class.
The application period runs from June 14 to August 15.
(Reporting by David Morgan; Editing by Gerald E. McCormick and Vicki Allen)

NYU launches ICD-10 medical coding certificate program

 Author Name Jennifer Bresnick   |   Date May 15, 2013
ICD-10 represents more than just a disruption in a physician’s note taking habits, or a couple of new letters and numbers for coders to tap in to their billing claims.  It’s a fundamental overhaul in the way that diagnoses and procedures are documented, and it will require specialized knowledge and a level of proficiency many ICD-9 coders will initially struggle to master.  Enter New York University and its brand new Certificate in Medical Coding, offered through the School of Continuing and Professional Studies (NYU-SCPS).  It’s one of the first major programs from an academic institution to be built upon an ICD-10 foundation, offering students the anatomical and medical expertise necessary to tackle the new system.
“We believe that as demands in the health information management industry increase, coding professionals will be required to have certifications or a credential to demonstrate they have met a minimum professional standard,” says Denisse Jimenez, program administrator at NYU-SCPS . “Many programs are still providing ICD-9 training which will be obsolete by 2014. Our program addresses the changes that are occurring in the health information management field and recognizes the expanded skill sets that will be required by medical coding professionals.”
To keep up with mounting financial pressures resulting from ICD-10, EHR adoption, meaningful use, and a number of other health IT initiatives all hitting the industry at once, providers are changing the way they hire and retain staff.  A recent survey indicates that a quarter of practices are cutting staff, including medical coders, just to stay in the black.  But coders with ICD-10 proficiency are only going to become more and more valuable as the implementation date creeps up and providers realize the impact of the transition on productivity and timely payments.
“A huge component of ICD-10 transition planning is employee retention,” explains Bonnie Cassidy, MPA, RHIA, FAHIMA, FHIMSS.  “You’re going to be dealing with a very competitive market of supply and demand.  Those who embrace it and get trained, and become experts in ICD-10, are going to be a real commodity.”  AHIMA and other organizations also provide training and education for physicians and coders alike, and constantly urge professionals not to delay education in anticipation of another pushback of the compliance deadline.
NYU’s certificate includes nine required courses ranging from instruction in anatomy and physiology to pathophysiology and pharmacology.  The program is designed for both new students as well as experienced coders seeking a foundation in ICD-10 before the October 1, 2014 transition date.  More information about the certificate program is available on NYU’s website.

MS-DRG shifts in ICD-10-PCS

In a perfect world, inpatient facilities would receive the same payments for diseases and procedures after the switch to ICD-10-PCS. We know that won’t happen, that facilities will see some shift in MS-DRG assignment and as a result, different reimbursement.
question marksWhy will certain conditions track to different MS-DRGs? In part, code assignment to MS-DRGs will change because the coding guidelines are changing. Specificity is increasing in many cases and decreasing in a few.
ICD-10-CM also changes the meaning of some of the diagnosis descriptions by including more combination codes and is also changing the CC/MCC designations for some codes.
Don’t forget about coding errors. Coders may be incorrectly assigning an ICD-9-CM code now, which could lead to incorrect MS-DRG assignment. In ICD-10-PCS, coders may also assign an incorrect code by choosing the wrong root operation. That could also lead to a change in the MS-DRG.
Hospitals should begin looking at their top MS-DRGs and determining whether the documentation is sufficient to code in ICD-10. Then code the case in ICD-10 and see which MS-DRG it ends up in. Is it the same MS-DRG, a higher paying MS-DRG, or a lower paying one?
Then try and determine why the MS-DRG changed. Maybe you have more specific information. You could be picking up a CC or MCC you aren’t currently reporting. Are you correctly sequencing the codes?
Once you figure out what will happen with your top MS-DRGs, you’ll have a better understanding of the financial impact of ICD-10 and also have a starting point for physician education.

Entry Information

Michelle A. LeppertAbout the Author: Michelle A. Leppert, CPC, is a senior managing editor specializing in outpatient coding for, which provides coders, coding supervisors, and health information management (HIM) directors with educational resources to test their coding knowledge, employ correct coding guidelines, and stay abreast of CMS transmittals.
In addition, she writes and edits the HCPro Inc. publications, Briefings on APCs andAPCs Weekly Monitor. Email her at

A drop in the bucket…

Every year, the Centers for Medicare and Medicaid Services (CMS) conducts a recovery audit. In a recent report, Medicare collected over $797 million in Medicare overpayments in 2011. Where do these overpayments come from?
  • Inpatient: $677m
  • Durable Medical Equipment & Other: $35m
  • Physician: $33m
  • Outpatient: $17m
  • Skilled Nursing Facilities: $0.2m
Recovery Audit Contractors returned $488 million in improper payments to the Medicare Trust Fund in 2011. Although this may seem like a large amount of money, Medicare spending in 2010 was $524 billion. Thus, the recovered funds amount to less than two tenths of a percentage of total Medicare spending.

Figures from the FY2010 audit are displayed below. These figures do not, however, include payments returned to the trust fund.