Handle the toxic people in your life by identifying their type and using these communication strategies and people skills tips! Dealing with toxic people can be incredibly exhausting, especially if you interact or work with them everyday. Unfortunately we cannot fix them, but by using our people skills and new communication techniques we can try to understand them and create better interactions. In this video, the types of difficult people are identified you have in your life and give you actionable strategies on how to not only deal with them but also stop their negativity and toxicity in its tracks.nn
Inadequate coding is one of the biggest mistakes a physician can make. E/M coding is some of the most confusing, so our experts at R.T Welter are sharing their tips to ensure the proper coding. At Welter Healthcare Partners we can help make sure that you stop losing money by using incorrect coding and documentation in your practice. We can make sure that our coding tips will help you boost revenue. For more information and inquires you can contact us at (303) 534-0388.nnThe clock is ticking, and you’re trying to select the right E/M level from a drop-down menu in the EHR. Choose a level that’s too high, and you run the risk of post-payment audits and recoupments. Choose one that’s too low, and you may lose revenue to which you’re entitled. You decide just to trust your instincts and go with a code that feels right so you can move on to the next patient.nnChoosing an E/M code based on a gut feeling is one of the biggest mistakes a physician can make, says Sonal Patel, CPMA, CPC, a healthcare coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, S.C. Payers and auditors use a quantitative scoring process that requires specific elements (i.e., history, exam, and medical decision-making [MDM]—or time spent counseling and coordinating care) for each E/M level.nnIf physicians don’t document these elements adequately—or the elements they document don’t make sense given the patient’s presenting problem (e.g., performing a comprehensive exam for a patient with a sinus infection)—payers and auditors may down-code the service or even conduct a more in-depth audit that could expose additional documentation vulnerabilities, she adds.nnIt’s equally risky to report the same E/M level for all patients with the same diagnoses (e.g., diabetes or congestive heart failure) without first considering medical necessity—a trap into which many physicians fall because they assume all patients with the same diagnoses generally require the same work, says Toni Elhoms, CCS, CPC, director of coding and compliance at Welter Healthcare Partners , a healthcare consulting company in Arvada, Colo. “In reality, every single visit could be a different level based on the documentation and circumstances of the encounter,” she says.nnFocus on quality E/M documentation—and the dollars will follownnKnowing what documentation is required for each E/M level is paramount. For example, the history, exam, and MDM must meet or exceed certain requirements for all new patients. The only exception is when the physician selects the E/M level using time as the controlling factor. In this case, documentation must indicate that the physician spent more than 50 percent of the encounter face-to-face with the patient and/or family providing counseling and/or coordination of care. The physician must also explain the specific services rendered and the reasons for them.nnOnly two of three key components must meet or exceed certain requirements for established patients unless the physician bills based on time. Elhoms provides an E/M scoring guide that includes a visual depiction of documentation requirements for each specific E/M level based on whether the patient is new or established.nnSound confusing? Experts agree that even the most experienced medical coders have difficulty translating physician documentation into an accurate E/M code. They cite several reasons why E/M coding is so difficult for physicians—lack of formal training on E/M guidelines, complex documentation requirements that don’t align with clinical practices, and the subjective nature of the MDM component.nnWe’ve asked our experts to share their best documentation tips to ensure accurate E/M reporting. Here’s what they said.n
History
nWhen billing a level 4 or 5 new patient E/M code (i.e., 99204 or 99205), remember to document one specific item from the past medical history (i.e., illness, operations, injuries, treatments, medications, or allergies), one specific item from the family history (i.e., medical events or hereditary diseases that place the patient at risk), and one item from the social history (e.g., use of tobacco, drugs, or alcohol).nnOriginal article published on medicaleconomics.com
In this code spotlight, Welter Healthcare Partners is providing new information regarding the risk factor reduction services that are used for people without a specific illness. This includes screening, brief intervention, and referral to treatment. Welter who recently teamed up with CDPHE created a two-part webinar series on coding and billing for these codes, and also give information on how school-based health centers can take advantage of their services. nnDoes your practice screen patients for risk factors like smoking, alcohol or drug use? Do you know the correct coding for use patterns? According to section guidelines by the AMA, “…used to report services provided face-to-face by a physician or other qualified health care professional for the purpose of promoting health and preventing illness or injury. They are distinct from evaluation and management (E/M) services that may be reported separately with modifier 25 when performed. Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.”nnThis is especially helpful when we look at codes 99406-99409 and incorporate this into your telemedicine services menu. Welter Healthcare Partners recently teamed up with CDPHE for a two-part webinar series on the coding and billing for these important codes and how school-based health centers can take advantage of the services they support.nn n
The CMS Primary Cares Initiative, being rolled out by officials in the Centers for Medicare & Medicaid Services, spell changes on the horizon for healthcare providers. The initiative is poised to kickstart value-based care, offer five voluntary payment model options, and some significant increases in competition from unlikely places.nnEven as some important questions remain unanswered, the CMS Primary Cares Initiative is generating a lot of excitement. Observers say it opens the door to more competitors for healthcare incumbents.nnThe shift to value-based care has sputtered a bit in the past two years, as hospitals and health systems have waited to see what innovative reforms the Trump administration would push across the healthcare policymaking finish line.nnDespite a litany of attempts—and two years of a Republican-controlled Congress—the administration has neither repealed nor replaced the Affordable Care Act and the value-based payment provisions embedded within it. Even with its individual mandate neutralized and its constitutionality under judicial review, the ACA remains law, and officials in the Centers for Medicare & Medicaid Services are using the ACA’s authority to roll out a potentially transformative undertaking: the CMS Primary Cares Initiative.nnThat initiative, industry stakeholders say, is poised to kickstart value-based care in Medicare and beyond, ushering in a new wave of consumer-centric competition that could help to shake off some healthcare providers’ risk aversion.nn”There was a sense that things were flattening out. It wasn’t going backwards. It wasn’t going down. It just was not progressing as fast as we all had hoped,” says Norman H. Chenven, MD, founding CEO of Austin Regional Clinic in Texas and vice chairman of the Council of Accountable Physician Practices.nn”With this announcement for Medicare—again, with the caveat that the devil is in the details—there is a sense that this is going to be a shot in the arm and we’re going to see some real new energy, innovation, and evolution of the value-based movement,” Chenven tells HealthLeaders.nnThe initiative, which CMS announced last month, has a total of five voluntary payment model options split between two paths. There are two options under the Primary Care First (PCF) path and three options under the Direct Contracting (DC) path. The idea behind all five options is to demonstrate how risk and reward can lead to investment in primary care that ultimately reduces overall healthcare spending and boosts quality outcomes.nnWhile there are still key details we don’t know about how the new models will operate, they appear to present opportunities for healthcare providers that are strategically positioned to make big moves in value-based primary care.nnBut there also seem to be significant threats, including potential competition from some unlikely sources.nnComplete and original article published on healthleadersmedia.com.
Do you have a complicated surgery case need help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected.nn– Click Here to Submit Redacted Surgery Case Study –nn nnnnDATE OF OPERATION: 11/12/2018nnNEUROSURGERY OPERATIVE REPORTnnPREOPERATIVE DIAGNOSIS: Right frontotemporal dural-based tumor with skull base and orbital invasion.nnPOSTOPERATIVE DIAGNOSIS: Right frontotemporal dural-based tumor with skull base and orbital invasion, probable meningioma with atypical features.nnPROCEDURES: Right frontotemporal craniotomy, resection of dural based tumor, suture of bovine pericardial dural graft, Synthes facet bone putty, subtemporal drain, titanium mesh cranioplasty, intraoperative microscope, ICG fluorescence visualization, lateral orbitotomy, and extradural clinoidectomy.nnCO-SURGEONS: Dr. Z, who performed the right frontotemporal craniotomy, resection of dural based tumor, sutured bovine pericardial dural graft, Synthes facet bone putty, subtemporal drain, titanium mesh cranioplasty, intraoperative microscope, and ICG fluorescence visualization.nnCO-SURGEON: L. M., M.D., who performed lateral orbitotomy and extradural clinoidectomy.nnASSISTANT SURGEONS: Dr. M was the assistant surgeon for Dr. Z’s portion of the surgerynnSECOND ASSISTANTS: A. P., MD and C. B., PAnnINDICATIONS: The patient is a 55-year-old left-handed female, with a positive history of left handedness, who presented with a complex past medical history including hypertension and uncontrolled diabetes, with problems of headache, nausea, vomiting, and vertigo. She had a proximally 6 month history of diabetic retinopathy with blood in her eye and was followed closely by her eye doctors for vision changes. She subsequently developed proptotic changes and blurring of the right vision like a film such that her visual acuity was finger counting in the right eye, with the ability to read with retain on the left. Imaging studies were initially performed that demonstrated a complex skull base meningioma with orbital invasion, particularly at the lateral orbital region. She was initially scheduled for surgery, however, because of uncontrolled diabetes, anesthesia colleagues wanted her under better control prior to the procedure. Thus, she was admitted to the medical service for optimization of glucose control and surgery was performed 72 hours later. The patient and her family underwent detailed informed consent, which is documented elsewhere in the electronic health record.nnPROCEDURE DESCRIPTION: Following the attainment of general anesthesia, all performance measures were and had been accomplished including a preoperative time-out, the administration of antibiotics and approved shave and Betadine preparation. The patient’s head was secured in Mayfield-Kees pin fixation and the stealth was registered. The patient’s head was positioned supine with a bump in a vertex down 30 degree facing to the left approach so that the zygoma was at the highest point in the presentation. A modified Yasargil designed flap to include more temporal and frontal lobe exposure was fashioned entirely behind the hairline with the preservation of the anterior hair in a rubber band for cosmesis. After the stealth registration and the designing of the skin incision to the zygoma, a Betadine preparation was performed and local anesthetic was infiltrated in the subcutaneous tissue. The 10 blade knife was utilized to incise the skin and Raney clips were used to secure the drape. The Bovie was used to reflect the pericranium in the anterior portion of the incision and Metzenbaums were used to dissect inferiorly. The fascia was reflected forward using sharp dissection, and the temporalis muscle was reflected inferiorly down to the level of the zygoma with a superb sphenoid wing exposure. The bone flap was designed with the understanding that the tumor in the sphenoid wing region preoperatively was seen to erode through the bone with hyperostosis and direct bony invasion as there was evidence of tumor in contrast-enhanced regions inferior to the temporalis muscle on the outside of the bone. It was also recognized that there was tumor that had transcended the bone of the lateral orbit and was impacting the lateral rectus muscle. Given that, the bone flap was fashioned in a conservative way outside the area of obvious invasion, first using the Codman perforator and the Midas Rex drill. After this, the pineapple bur was used to primarily remove the region of the sphenoid and lateral orbit involved directly with tumor. A specimen of tumor underneath the temporalis and involving the pericranium was removed, and dissection was performed at that level to minimize the amount of observed tumor. With that, multiple specimens were obtained. Hemostasis was obtained by coagulating the dura primarily. The extradural clinoidectomy was performed expertly by Dr. M., who provided his special training in skull base to address the lateral clinoidectomy and the lateral orbitotomy. The dura was gently mobilized and reflected in order to accomplish both of these procedures safely. The dura was then opened until the tumor was identified and a Sonopet was used to remove portions of the tumor. IC-Green was used under the operating microscope to identify the middle cerebral vessels and identify, which vessels were emphasized and which vessels were going directly to the tumor. This technique worked expertly and was useful in safe dissection. The lateral wall of the orbit was removed and the dura was left intact. Some of the superior orbital roof was also reflected. Every aspect of the dura that was clearly involved with tumor was then removed in an en bloc fashion after the tumor had been safely reflected from the sylvian fissure and sylvian vessels. There was a question of brain invasion at the right frontal lobe, which was very limited. Otherwise, there was intact pia over the temporal and frontal lobes abutting the tumor. Once the dura was resected and the bone areas of tumor removed, as well as some of the infratemporal tumor, a bovine pericardial dural graft was then fashioned and secured using 3 mm MRI compatible Synthes screws as well as Tisseel as a tissue glue to prevent drainage through the inlay dural graft. The superior aspects of the graft were closed primarily with running and interrupted 3-0 Nurolon sutures. The bone that was not involved with tumor was replated using Synthes plates and screws, and a mesh was secured over the area of the lateral sphenoid that had been primarily drilled and resected due to involvement with tumor over that. A fast setting bone putty was used for cosmesis with a superb closure and cosmetic result. The wound was irrigated copiously at many stages through the procedure with antibiotic solution including through the dura prior to the placement of the Tisseel. A subgaleal drain was used and remained in place for a prolonged period of time with the tip underneath the temporalis muscle and curvature underneath the galea, so that there were holes picking up any subgaleal fluid and also CSF to serve as a CSF diversion, successfully allowing the dura to close over for a period of several days postoperatively. The alternative would have been to place an external ventricular drain or a lumbar drain; however, this subgaleal drain placed under the temporalis worked superbly as a diversion for CSF to allow excellent healing. The temporalis muscle was secured using 2-0 Vicryl pop-offs. The fascia was secured using 2-0 Vicryl pop- offs. The galea was closed using 2-0 and 3-0 Vicryl interrupted sutures, and the skin was closed with staples with a 3-0 Prolene stitch at the drain exit site, and a Vicryl buddy stitch at the drain exit site. Sterile dressings and a full head wrap were placed. Sponge, needle, and cottonoid counts were correct at the conclusion of the case.nnFINDINGS: The pathology was consistent with meningioma and given the erosion through structures, the final results were consistent with atypical or grade 2 features as expected from the preoperative imaging studies and the findings intraoperatively. The unplug tumor was biopsied and there were also areas of focal probable brain invasion along the right anterior and inferior frontal lobe. There was confirmed involvement of the pericranial aspect of the temporalis muscle with extradural invasion of the lateral orbit and presumed positive bone.nnSPECIMENS: Multiple frozen and permanent section specimens were sent.nESTIMATED BLOOD LOSS: Between 500 and 700 mL.nANESTHESIA: Performed expertly by general endotracheal intubation with Dr. T., Dr. B., and Dr. W.; all contributing to the patient’s care.nnCULTURES: None.nnDRAINS: One 10-French subtemporal subgaleal drain was placed.nnBLOOD REPLACEMENT: Two units of packed cells were placed for intraoperative hematocrit of 24, as I recall.nnThe patient has continued to do well with preserved vision in her right eye and an excellent postoperative resection with no evidence of stroke and no evidence of new deficit.nnDr. Z. was the surgeon for the right frontotemporal craniotomy, resection of dural based tumor, sutured bovine pericardial dural graft, Synthes facet bone putty cranioplasty, subtemporal drain, titanium mesh cranioplasty, intraoperative use of microscope, ICG fluorescent visualization. Dr. M. was the surgeon for the lateral orbitotomy and extradural clinoidectomy. The 2nd surgeon was required due to his particular expertise in training in skull base approaches, which was not otherwise available at our facility.
The clock is ticking, and you’re trying to select the right E/M level from a drop-down menu in the EHR. Choose a level that’s too high, and you run the risk of post-payment audits and recoupments. Choose one that’s too low, and you may lose revenue to which you’re entitled. You decide just to trust your instincts and go with a code that feels right so you can move on to the next patient.nnChoosing an E/M code based on a gut feeling is one of the biggest mistakes a physician can make, says Sonal Patel, CPMA, CPC, a healthcare coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, S.C. Payers and auditors use a quantitative scoring process that requires specific elements (i.e., history, exam, and medical decision-making [MDM]—or time spent counseling and coordinating care) for each E/M level.nnIf physicians don’t document these elements adequately—or the elements they document don’t make sense given the patient’s presenting problem (e.g., performing a comprehensive exam for a patient with a sinus infection)—payers and auditors may down-code the service or even conduct a more in-depth audit that could expose additional documentation vulnerabilities, she adds.nnIt’s equally risky to report the same E/M level for all patients with the same diagnoses (e.g., diabetes or congestive heart failure) without first considering medical necessity—a trap into which many physicians fall because they assume all patients with the same diagnoses generally require the same work, says Toni Elhoms, CCS, CPC, director of coding and compliance at Welter Healthcare Partners , a healthcare consulting company in Arvada, Colo. “In reality, every single visit could be a different level based on the documentation and circumstances of the encounter,” she says.nnFocus on quality E/M documentation—and the dollars will follownnKnowing what documentation is required for each E/M level is paramount. For example, the history, exam, and MDM must meet or exceed certain requirements for all new patients. The only exception is when the physician selects the E/M level using time as the controlling factor. In this case, documentation must indicate that the physician spent more than 50 percent of the encounter face-to-face with the patient and/or family providing counseling and/or coordination of care. The physician must also explain the specific services rendered and the reasons for them.nnOnly two of three key components must meet or exceed certain requirements for established patients unless the physician bills based on time. Elhoms provides an E/M scoring guide that includes a visual depiction of documentation requirements for each specific E/M level based on whether the patient is new or established.nnSound confusing? Experts agree that even the most experienced medical coders have difficulty translating physician documentation into an accurate E/M code. They cite several reasons why E/M coding is so difficult for physicians—lack of formal training on E/M guidelines, complex documentation requirements that don’t align with clinical practices, and the subjective nature of the MDM component.nnWe’ve asked our experts to share their best documentation tips to ensure accurate E/M reporting. Here’s what they said.n
Does your practice screen patients for risk factors like smoking, alcohol or drug use? Do you know the correct coding for use patterns? According to section guidelines by the AMA, “…used to report services provided face-to-face by a physician or other qualified health care professional for the purpose of promoting health and preventing illness or injury. They are distinct from evaluation and management (E/M) services that may be reported separately with modifier 25 when performed. Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.”nnThis is especially helpful when we look at codes 99406-99409 and incorporate this into your telemedicine services menu. Welter Healthcare Partners recently teamed up with CDPHE for a two-part webinar series on the coding and billing for these important codes and how school-based health centers can take advantage of the services they support.nn n
Even as some important questions remain unanswered, the CMS Primary Cares Initiative is generating a lot of excitement. Observers say it opens the door to more competitors for healthcare incumbents.nnThe shift to value-based care has sputtered a bit in the past two years, as hospitals and health systems have waited to see what innovative reforms the Trump administration would push across the healthcare policymaking finish line.nnDespite a litany of attempts—and two years of a Republican-controlled Congress—the administration has neither repealed nor replaced the Affordable Care Act and the value-based payment provisions embedded within it. Even with its individual mandate neutralized and its constitutionality under judicial review, the ACA remains law, and officials in the Centers for Medicare & Medicaid Services are using the ACA’s authority to roll out a potentially transformative undertaking: the CMS Primary Cares Initiative.nnThat initiative, industry stakeholders say, is poised to kickstart value-based care in Medicare and beyond, ushering in a new wave of consumer-centric competition that could help to shake off some healthcare providers’ risk aversion.nn”There was a sense that things were flattening out. It wasn’t going backwards. It wasn’t going down. It just was not progressing as fast as we all had hoped,” says Norman H. Chenven, MD, founding CEO of Austin Regional Clinic in Texas and vice chairman of the 
nn