Many think of chart audits in the context of making sure the medical record documentation meets the requirements for the codes that are being billed , but just as valuable (if not more), are increasing the standardization of documentation, consistency of data entry, finding training gaps, creation of concrete performance measurements, and assisting with staff reviews and quality improvement activities.

The frequency of a chart audit is decided on by the practice, but it should have a broad sampling of patients that span all providers.  Selecting these patients and looking through their visit record to assess that all the information was included depending on various factors can be incredibly tedious. Did the patient have dilation? If so, what drops were used? Is there a time?  If not dilated, why?  Was the Review of Systems documented?  Were allergy and medications evaluated on that visit?  Reviewing individual patient across all locations, providers, age groups, and primary diagnosis can take days, even with a small sample.

The solution? A Destinations Consulting custom report. Although a complex report, it can easily be run for all patients within a given time period and quickly show missing chart documentation based on defined data points that are specific to your practice:

Our client, Dannielle D. claims this report is a life-saver, “The EHR Verification Report that you created for us has enabled me to perform quality assurance checks for every student on a mobile visit in a fraction of the time.  We are processing over 15,400 exams per year, and with current funding cuts, we have to be as efficient as possible.  In response, we have become paperless to reduce staff tasks related to handling paper, printing, matching and filing, plus required storage space.  Now, the Technician takes about 1/3 the time to complete and reconcile their visit and I am able to perform my quality assurance verification in less than 1 minute per visit, whereas before it required 15-45 minutes per visit depending on the volume.  This was an essential step in enabling the program to become paperless for the coming school year and saving hundreds of hours annually of staff resources dedicated to these tasks.  Thank you so much for creating this valuable resource.”

If this sounds familiar and you could use an extra day or two a month to spend on other tasks, contact Shelly at Shelly@DestinationsConsulting.com for more information.

You know Team Destinations Consulting can problem-solve your Compulink workflow issues by creating magical SQL worklists, customizing screens, or creating buttons to eliminate clicks. You may also know that we can assist you in reviewing MIPS performance and developing a plan to improve your score, but did you also know that Team Destinations Consulting can also assist you with other practice management related tasks?

Whether you know what areas you need help in or just know that you’re not profiting as much as you could be, consulting with our team will help you achieve your goal. We use national benchmarks in addition to reviewing past years data for change to establish a baseline. Once in place, we can assist you each year with reviewing and analyzing the data to set new financial goals for your practice. Key Performance Indicators (KPIs) are a valuable tool for tracking the growth and performance of a practice so that you can make smarter decisions. We have found that the following KPIs are universally important amongst our clients:

• Collected Revenue
• Medical Revenue Collected
• Revenue Collected for Visits/Exams
• Visits/Exams per Year (or Evaluation Period)  
• Revenue per Patient Visit/Exam
• Third Party Payor Revenue 

Each final report you receive from us will include steps you can take to increase revenue, such as restructuring exam schedules, renegotiating or discontinuing contracts with insurance carriers, increasing per patient revenue through increasing special testing rates or capture rate, or restructuring staff schedules and tasks. Comparing metrics against benchmarks identified by professional associations is helpful in measuring how your professionals stack up against their peers as well as within your practice. The practices we work with have seen drastic growth year over year in profitability, with some of our practices seeing as much as a 40% increase in revenue over four years of working with Destinations Consulting. We all know how valuable your time as a manager or practice owner is; why not let someone else do the heavy lifting for you?

Introduction

If you haven’t been thinking about Ransomware, you should. It’s been thinking about you. According to the Symantec Corporation, Ransomware is up 35% over last year. This year, a Florida ophthalmology practice identified a breach of PHI via a third-party company this year affecting as many as 87,000 patients. In March, two hospitals were attacked by malware. Both hospitals recovered quickly without divulging any PHI, but the attack greatly affected their daily operations. Last year, the FBI released a public announcement stating they had received 992 CryptoWall-related complaints between April 2014 and June 2015, with ransoms totaling over $18 million. These attacks aren’t going away or slowing down, they’re increasing each year, and most importantly, they’re evolving.

What is Ransomware?

Ransomware is a type of software that installs itself onto a computer or system of computers with the intent of either encrypting the computer system or stealing information from it. Typically, the program is written and then sold online to one or many organizations on the black market, leaving it totally untraceable. The software is usually installed by clicking a link on a website or email, but hackers have become more sophisticated recently; new forms of Ransomware look specifically for a hole in security patches. Once the Ransomware is installed, it will prompt the user to pay an untraceable ransom to the hacker in BitCoin to receive a key to decrypt the files.

Prevention

The most important tool you have in fighting against this virtual crime is staff education. Your IT company should be able to provide Security Awareness Training for your business, but if they can’t there are other resources available through the Office for Civil Rights and third party companies. Ensure that every person who has access to your computer systems knows what to avoid when opening links in their emails or on websites.

Maintaining current versions of all anti-malware and anti-spam software on ALL devices is critical — this includes tablets, phones, and any equipment that has an internet connection. Convert your mapped drives to UNC; while this may not prevent the attack, it can localize the attack and might be able to keep it from accessing all of your files.

Regularly backup your system, either on a physical drive that’s not connected to your system or in the cloud. Backing up your files is crucial to surviving a malware attack of any kind. In the event of ransomware, with a recent backup a practice can avoid costly delays by restoring their system to the backup, eliminating the need to pay the ransom. The frequency of backing up varies from practice to practice. Can you afford to lose a day, a week, or a month of data?

Have a Plan for When, not If

Working closely with your IT team to develop a plan is the best insurance you can have against a Ransomware attack. It should include, but not be limited to, these things:

• Know who is responsible for heading the response, in-office and at your IT company. Make sure that staff knows who to contact as well.
• Contingency Plan - all offices are required to have one to be HIPPA compliant.
• Disaster Relief Plan - a document outlining the steps to take, not stored in your system. 
• Develop a method to move to paper charts without too much of a disruption of patient care for each department. You need to know which pieces of equipment are connected to the system and which aren’t in the case of an attack, so you know what services you can offer during an exam and which you cannot.
• If and how much you are willing to pay in the case of a ransom?
• How long you can be offline and how to maintain normal business operations without access to your computer system?
• Know when your last backup was and how to access it!
• Know the steps to take if PHI is compromised and how to report a breach.

Resources:

1. FBI- Ransomware Pamphlet
2. FBI- Incidents of Ransomware on the Rise 
3. Compulink Advantage - Converting Mapped Drives to UNC
4. Healthit.gov - Games on Contingency Plans and Security
5. 10 Best Practices for the Small Healthcare Environment

Written by Ashley Shewmaker for Destinations Consulting, 2016

Paying the Price - What Penalties Can You Expect?

 Are you among the more than 440,000 eligible professionals (EP’s) who have received more than$20 billion incentive funds for becoming a Meaningful User of Certified Electronic Health Records Technology? (According to CMS.gov as of March 2015) No? You decided that the incentive money was not enough to take the plunge into the world of Electronic Health Records. Perhaps you have also avoided participating in the Physicians Quality Reporting (PQR) program.  You need to know, your window for pursuing the “carrot” of incentive funds is closed. The dreaded “stick” of penalties is coming down.

You’ve been able to delay the transition to EHR for more than 4 years, now you must decide if it’s worth it to pay the price.  This year you may be experiencing up to 2.5% in penalties (based on your lack of reporting in 2013), if you continue to delay the penalty stacks up to 10% by 2016 (penalty applies to 2018).

The incentives are gone, the penalties begin.  

The grid below describes both the reporting year and the penalty year along with the penalties for each of the programs. The penalties will be from Medicare and the percentage is applied to the allowable amounts submitted by the provider. The penalties really begin to add up for practices choosing to do nothing this year – the penalty will be realized in 2017.

Meaningful Use Penalties

For EP’s choosing not to attest as a Meaningful user of certified EHR technology the penalties will range from 1% to 5% against Medicare payments.

If you decide to participate for the first time in 2015 you will need to attest to Stage 1 for a calendar quarter. By attesting, this year you will avoid penalties for 2017. This will not counteract the penalties you are receiving this year for not attesting in 2013 or the penalties in 2016 for failing to attest in 2014.

There are many great resources available on the AAO and AOA websites for understanding the core and menu set items from an ophthalmic perspective.

For more information see, CMS’s website http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Getting_Started.html

PQRS

Incentive payments for participating in PQRS ended in 2014, choosing not to participate in the Physician Quality Reporting program results in 1.5% to 2% penalties. In 2015 PQRS is a full year program and requires submission of 9 measures from 3 of the 6 clinical quality domains and at least one cross cutting measure. PQRS may be submitted via claims or electronically through a registry such as the American Academy of Ophthalmology’s IRIS.  Submitting PQRS through a registry qualifies for participation in both PQRS and the required eCQM’s needed for Meaningful Use. 

Whereas the CQM and MU program are about performing certain tasks, PQRS is strictly a reporting program. For example, you report that a dilated eye exam was performed on a diabetic patient.

For more information see CMS’s webpage http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/

Perhaps MU and PQRS are not all that mysterious to you. Maybe you are aware of the penalties….even paying them now. Great, it is good you are making an informed decision of which penalties to pay. Do you also understand that starting this year, CMS’s penalties go beyond programs that determine penalties based solely on whether or not you report.

This is where it gets tricky. In 2015, Value Modifiers evaluate both the quality and cost of the services you provide

Value Modifiers

According to CMS.gov “The Value-Based Payment Modifier Program (VM) evaluates the performance of solo practitioners and groups of practitioners, as identified by their Taxpayer Identification Number (TIN), on the quality and cost of care they provide to their Fee-for-Service Medicare beneficiaries.”

The Affordable Care Act mandated CMS to phase in this VM program. The program provides for upward, downward or neutral payment adjustments to providers. The adjustments are calculated based on participation in the PQRS program. In 2015, the VM is being applied to group practices of more than 100 EP’s based on performance in 2013. In 2017 the penalties will apply to practices with soloists and groups of 2 to 9 providers and groups with 10 or more EP’s.

In order to determine the payment adjustments, CMS evaluates two areas; the quality of the service provided and cost of that care provided. Quality is reviewed by participation in PQRS and cost is evaluated by the CMS Physician Fee Schedule. Payment will be affected in one of two ways; by not participating in PQRS or by the assigned Quality Tier made by CMS. For example, soloists and practices with 2 to 9 EP’s who opt not to participate in PQRS this year will automatically receive a 2% VM penalty – this is in addition to the 2% penalty they will receive for not participating in PQRS. Choosing to participate in PQRS for 2015, those same practices may receive no Value Based Modifier penalty or an upward adjustment of up to2% based on the Quality Tier assigned by CMS. For more information, see the CMS website page for the Value Modifier http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html.

For example, there are several measures related to managing glaucoma. CMS will evaluate the quality of service you provide based on the measures you submit. With measure 12 you will document whether or not you performed an optic nerve head evaluation. For PQRS, it’s a matter of indicating whether or not you performed it and the medical reason for not performing it if not performed. The Value Modifier program would rate you higher for performing the evaluation and this would contribute to your quality score.  Whereas the CQM and MU program are about performing certain tasks (“doing”), PQRS is strictly a reporting program. The Value Modifier Program goes a step beyond this to evaluate the quality and cost of what you do.

So what’s the bottom line? What if you continue to do nothing through 2016? In 2018 you could be penalized 10% of your Medicare payments. Unimpressed? Let’s do the math… If you submit 100k in allowables for a provider in a year; in general, you would normally receive payment equal to 80% of that 100k, or $80,000. Instead, that number will be reduced by 10% to $72,000.

Now that you’re armed with more knowledge regarding the potential penalties you can make an informed decision.

By Kimberly Baldwin, MA, LPC

Certification Requirements for Scribes

Many practices utilize scribes for entering data into their medical records software. Doctors often feel the data entry takes too much time and slows them down during the exam. Others feel that the data entry turns them away from their patient and impacts their ability to connect with and focus on what the patient is communicating.

Whatever the reason, scribes are here to stay. If you are a Meaningful User of EHR you will want to be certain you are aware of the limitations to scribe data entry. CMS specifically limits the scope of data entry for CPOE – Computerized Physician Order Entry. CPOE relates to medications, lab and radiology orders.

CPOE is one of the Core Measures for both Stage 1 and 2, however, the guidelines vary by stage for which professionals are authorized by CMS to perform this documentation.

Stage 1

CMS guidelines state, “Any licensed healthcare professionals can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE if they can enter the order per state, local and professional guidelines.” More info available here

According to the American Academy of Ophthalmology’s Stage 1 MU Guidelines document, “Certified ophthalmic assistants and certified ophthalmic technicians are now permitted to enter medication orders for purposes of meaningful use.”

For Stage 1, the provider or a COA, COT will need to be the one(s) to CPOE into the EHR.

Stage 2

According to CMS guidelines found here, “Any licensed healthcare professionals and credentialed medical assistants, can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE if they can originate the order per state, local and professional guidelines. Credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant. ”

Stage 2 expands the pool of staff eligible to enter this critical data into the EHR, to include Certified Scribes. This is great news for Ophthalmologists and Optometrists who employ techs who are not COA’s or COT’s and would like them to be able to enter the medication, lab or radiology orders (Like OCT’s) into the EHR.  

There are two excellent resources for certifying such staff. JCAHPO is now offering an ophthalmic scribe certification.  It will meet the CMS requirements for scribes. The press release may be found here. The exam includes 125 questions focused on History Taking, Ophthalmic Patient Services and Education, Ophthalmic Terminology, Medical Ethics and Legal Issues, and Medical Notes/Records. For less than $100 , staff may be certified for a 3 year period.

The other option to consider is the CMSS (Certified Medical & Surgical Scribe) certification offered by the American College of Medical & Surgical Scribes (www.theACMSS.org).

For more information on MU Stage 2, check out the article written by Darla Shewmaker and Jeff Grant for Ophthalmology Management. (Click Here )

Kimberly Baldwin, MA, LPC

Consultant, Designer, Solutions Expert

I might be addicted to problem solving. There is a high in finding a simple way to break down a problem and expose possible solutions. Here is an interesting case study and the solution we developed. Names and numbers are fictitious.

Problem: We are not meeting our production goals.

Doctor Z: This is so frustrating Darla. I feel like we are doing all of the right things. We establish what I feel are achievable goals for our practice. We educate our staff. There are perks and bonuses associated with reaching the target. Emails are sent out every day letting everyone know our progress.

Darla: Those are all important points. Sounds like you have put a lot of thought into this. Maybe we need go deeper to find the cause. Let’s start with some basic math. What is your average revenue per complete exam?

Doctor Z: We’d like to increase it, but historically we are at $220. These insurance carriers are killing us.

Darla: I hear that every day, but let’s hold off on the insurance discussion. I would like to define which of your appointment types correlate to complete exams. For our purpose we are defining these as appointment types that result in an exam code (92002, 92012, 92004, 92014, 99204, 99214, S codes for well vision).

Doctor Z: Here is our list, now what?

Darla: I want to run your appointment statistic report to see how many of these types of appointments were scheduled.

Doctor Z: I’m surprised as I look at this list. We only had 100 appointments last month. Wow! Look at the no shows! I feel like I am working a lot harder than this.

Darla: What was the monthly goal?

Doctor Z: The goal was $34,000.

Darla: In order to produce $34,000 with your current revenue per exam you’ll need 155 kept exam appointments. That is only one piece of our puzzle. We need to review your appointment templates to see how many complete exam appointments were available.  Well, this is interesting. Your templates show available options of 130, which is significantly higher than the 100 you examined.

Doctor Z: It looks like I didn’t even give my staff a chance. There was no way to hit that goal.

Darla: It appears that way. Were you on vacation last month? I see some days missing?

Doctor Z: I did take a few days off and I didn’t think about the impact of that. 

Here are the steps we took:

1. Reviewed the templates and made sure we were maximizing the number of revenue spots and limiting checks where possible.
2. Added additional appointments to each day to compensate for the high no show rate.
3. Educated the staff about booking patients who were check type appointments in exam slots. Added some additional controls to prevent this as well.
4. Reviewed the appointment confirmation procedures and made changes to minimize no shows.
5. Educated staff on the importance of keeping the schedule full. Started a “same day” list for patients who wanted to be seen sooner.
6. Created a custom report for staff to use daily to track their progress and for management to use at month’s end to measure the effectiveness of the changes. (Click on the link to the left to see more details about this report.)

You’ll be glad to hear this practice is now up 20% over the same month last year. How did that happen? They set achievable daily goals and made the staff aware of the number of complete exams required to hit the goal. They kept the schedule full and they improved their confirmation procedures. It really doesn’t matter if you are booked 3 weeks in the future. What matters is today. The next step is to work on that revenue per complete exam number!

Early last week I was discussing some modifications to a health history screen with a physician. As we were talking I mentioned that our changes would need to be compliant with SNOMED, since SNOMED is required for meaningful use stage 2. The provider asked,” what did you say Darla? Snowman? What in the world is Snowman?”  It HAS been a rough winter here in the Midwest.

As I pulled my sweater around me to get warm, the snowman joke did shine a spot light on the bigger issue. We are 3 months into 2014 and many practices are confused about topics that are affecting their electronic health records and possibly their ability to attest.

What is SNOMED?

SNOMED-CT is an acronym for Systematized Nomenclature of Medicine – Clinical Terminology, SNOMED for short. SNOMED is a number that represents a concept. SNOMED is recognized throughout the US and internationally, and it is available at no cost through the National Library of Medicine.  Using SNOMED enables providers and electronic medical records to communicate in a common language, thus increasing the quality of patient care across many different provider specialties. Today, SNOMED is available in US English, UK English, Spanish, Danish and Swedish. Translations into French, Lithuanian, and several other languages are currently taking place. SNOMED contains more than 311,000 active concepts with unique meanings and formal logic-based definitions organized into hierarchies.

These hierarchies include multiple levels of granularity. The broad coverage of topics included can be illustrated using the following examples (partial list):

Stage 2 meaningful use requires SNOMED in 3 areas:

Problem Lists (Core Measure)

Stage 1 meaningful use allowed providers to codify a patient problem list using ICD-9 terminology. The change for Stage 2 requires SNOMED codes. These are the codes that are embedded in the CDA (clinical document architecture) sent to other providers, IHEs and patients.  Many EHR vendors are utilizing “maps” between ICD-10 and SNOMED. This mapping may enable providers to choose an appropriate ICD-10 code and the EHR will then choose and send the corresponding SNOMED code. 

Smoking Status (Core Measure)

Stage 1 required smoking status as a text. Stage 2 requires one of the following codes:

Family Health History (Menu Set Measure) 

Family health history is new for 2014 and is an available menu set measure. You’ll need to choose 3 from a list of 6 possible menu set measures and this should be one of the easier ones to achieve.  The measure requires more than 20 percent of all unique patients seen by the EP during the EHR reporting period have a structured data entry for one or more first-degree relatives. This structured data must be matched to a SNOMED code or as an alternative the HL-7 pedigree code. 

What Steps Should You Take?

The good news is that your 2014 Certified EHR would have tested these measures and their ability to map and exchange SNOMED codes. Most will provide at a minimum codes that are required for these 3 areas of the patient record. If your system allows for custom templates and you have created templates that include problem list, family history or smoking status, then review these with your vendor to ensure your compliance. Education will be the key to success as it is with so many new concepts. Educate your staff about documentation.  It’s important to stress that systems won’t be able to recognize free text. Important information could be excluded from the patient CDA if not documented appropriately.

Lastly, celebrate Spring!  You deserve some sunshine!

Darla

Learn more about SNOMED:

http://www.ihtsdo.org/snomed-ct/

SNOMED Lookup:

http://www.snomedbrowser.com/

Copyright 2014 Destinations Consulting

My last 17 years were spent at Compulink Business Systems. I led the charge thru certification with CCHIT and the ONC. Most of my time was spent researching government requirements and finding ways to simplify medical record workflow. I have spent thousands of hours talking with you, the doctors and administrators, to understand your needs, wants and desires (nope, these are not the same thing). The fun part was translating this into screens, documents, reports and time saving functionality.

What now? Now is time for implementing some of those creative ideas that have been on the back burner. One of those ideas is this blog.  The content will vary, but the goal is to provide YOU with resources, information, tips, tricks and news that otherwise might not be easy to access. Topics will include security, meaningful use, practice metrics, electronic health records, HIPAA and more.

Why?  I want to GIVE BACK. I understand the struggle that physicians and administrators face in this age of technology and government regulation. My hope is that this resource may give you a few more minutes in your day to enjoy your life and the people you love.

And so it begins….