Vice President of Public Sector Solutions, Orion Health

Gone are the days where fax machines are the leading edge for secure communication in healthcare. And yet, healthcare is the last remaining industry still using fax as the primary way to communicate critical health information.

Healthcare is behind in the adoption of electronic communication solutions, resulting in a fragmented state of communication among professionals long overdue for change. At an ONC Interoperability Forum in August 2018, Seema Varma, the Administrator of the Centers for Medicaid and Medicare Services urged health information technology developers and attendees to 

 by stating, “If I could challenge developers on a mission, it's to help make doctors' offices a fax free zone by 2020.”

Not all healthcare organizations are designed with the same infrastructure nor have access to the same resources. While there is no one size fits all solution, healthcare organizations can take steps to efficiently shift toward electronic data sharing. What types of tools may be accessible to help organizations of any size, structure, or budget shift away from traditional fax-heavy processes and towards a more efficient and interoperable practice?

Direct secure messaging (secure messaging) is a mechanism for the secure exchange of health information within a trusted network. It was launched in 2010 by the Office of the National Coordinator for Health Information Technology (ONC). Unfortunately, many smaller provider organizations have fewer resources to keep up with the healthcare industry's evolving technological standards, but secure messaging is a low-cost, easy-to-use, scalable tool that connects healthcare stakeholders across all systems by providing an encrypted information exchange over the internet. Secure messaging can be used without the need for existing health IT infrastructure, making it an accessible option for organizations of all sizes, structures, and resources to leverage regardless of the type of provider or electronic health system they use.

Secure messaging increases interoperability, reduces errors, and eliminates barriers to care coordination by allowing disparate systems to communicate and exchange sensitive information and patient data while maintaining compliance, patient privacy, and confidentiality. Provider-to-provider communication is crucial for efficient patient careand empowers providers by supplying faster access to richer data from existing sources, at a fraction of the cost. It can help to reduce the risk of privacy breaches from faxes being sent to the wrong number or landing in the wrong hands; reduce communication errors from illegible handwriting or partially received faxes; while also eliminating fax-heavy workflows, helping to ease administrator and physician burnout and increasing productivity and provider job satisfaction.

Secure messaging empowers patients and increases engagement by making data accessible and allowing patients to be in charge of their healthcare. Rather than waiting for a fax to be sent between providers, secure messaging allows for electronic sending and receiving of information in real-time, increasing collaboration and effectiveness of care coordination between organizations, providers, and patients. Access to complete patient information can increase patient safety and allow patients and providers to focus on proactive care, rather than solely on reactive care, leading to better overall health outcomes.

Tools like secure messaging offer high value and flexibility, and can be leveraged by health organizations of all sizes and structures to affordably move towards a more efficient and interoperable landscape while offering the agility to continue to support the organization as it evolves. Now is the time to ‘axe the fax machine,’ move away from cumbersome processes and begin taking advantage of the benefits and efficiencies that secure messaging can provide.

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Diabetes management can be a challenge even in the best of times. Like many chronic conditions, it is about more than a single measurement—in this case, glucose levels. Factors such as weight management and blood pressure control must be monitored regularly since they can have a strong influence on a patient’s health the day of measurement as well as throughout the overall disease progression.

Typically, monitoring occurs through regular testing and visits to the physician’s office. In more advanced cases, people with diabetes may be encouraged to monitor biometric readings such as their weight and blood pressure and call their physician’s office if any reading moves beyond a specific set of parameters.

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Of course, these are anything but the best of times. Clinician concerns about the ability to control spread of the coronavirus and care for the surge of patients who contract it, combined with patient fears of acquiring the virus while in a clinical setting, have pushed diabetes management well into the background for many.

However, that doesn’t mean it’s stopped being a major health threat. In 2017, the latest year for which there are figures, diabetes was listed as the cause of death for 

, and was an underlying factor for more than 270,000. It is also a major contributing factor to quality of life issues such as amputation, blindness, and kidney and heart disease.

Attention was largely diverted away from diabetes management, but that is changing. Now that regulators have some protocols, processes, and understanding in place, healthcare providers and health plans are once again turning their attention to what they can do to get people with diabetes who may have let things slide in the last few months back on track.

One of their most important weapons in this battle is data. There is certainly no lack of data, or data-gathering capabilities, in U.S. healthcare. Between electronic health records (EHRs); formal remote patient monitoring (RPM) programs; and the health data generated by consumer devices such as the Apple Watch, digital scales, and glucose and blood pressure monitoring devices sold at the local Walgreens or CVS, the capacity to keep a close eye on patient health has never been greater.

But that is also part of the problem: so much data is available in so many different forms that understanding the larger picture of what is going on with an individual patient, or a healthcare organization’s diabetic population, is difficult at best. To truly take advantage of all this great data we are accumulating, we need to bring it together in a way that presents a complete picture and gives each healthcare provider access to all the data he or she needs.

That means having a tool that can aggregate data in a variety of forms from a variety of sources, normalize it, and enable the appropriate components to be accessed by the right providers, including primary care physicians, endocrinologists, heart specialists, care management teams, diabetes educators, and others. In some cases, such as when patients begin trending negatively or appear to be disengaging from their plans of care, it will also mean proactively pushing out alerts so the appropriate actions can be taken before patients require more advanced (and costly) interventions.

Real success, however, requires more than just making the data usable. The optimal approach is to create an ecosystem where health IT (HIT) vendors work together in a true spirit of partnership for the greater good. A good model for this ecosystem is what is happening with “smart homes.”

Apple, Amazon, and Google have each created core systems for controlling nearly every function within the home, such as the lights, temperature, locks, garage door, TV, etc. The manufacturers of the devices they can control then take that technology and incorporate into their products. The result is a seamless experience for the consumer, who can now use an app or voice commands to accomplish what they used to have to do manually.

HIT can do the same and more. Imagine if patients were not only uploading biometric readings but also the data from their choice of exercise or movement monitoring apps, sleep monitoring apps, apps that help them record their food intake and alcohol consumption, results from consumer-grade genetic testing, et cetra. Now imagine if all of that data (plus EHR data) was being accumulated in one place. Everything a clinician, care manager, dietician, diabetes educator, or other healthcare professional would ever need to know to deliver optimal care would be available at their fingertips—whether the patient was making regular visits to the office or sheltering at home during the latest lockdown.

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By making this information easily available, healthcare organizations could manage their patients with diabetes (and other conditions) more effectively while ensuring they remain on a positive path. And by creating a user experience that takes patients through the journey of managing their diabetes and makes it easy at every point, we can drive stronger engagement that leads to better health outcomes while minimizing the effort required to achieve it.

Everything needed to build this diabetes management ecosystem is already available. It’s just available in pieces right now.

But with a little vision, and a spirit of collaboration, the healthcare industry can create a world where a global pandemic doesn’t overshadow other health issues such as a diabetes. It merely causes a slight redirect in the way diabetes management is delivered. With the added benefit that HIT organizations that latch onto this concept will find themselves the dominant players in their space.

Anthony Comfort is VP of Product Management at VisiQuate, a leading healthcare analytics company that recently partnered with Ascensia Diabetes Care to further develop its user-friendly and holistic diabetes management platform.

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Brian Eidex is the general manager of pharmacy for Appriss Health, a health IT company providing trusted technology solutions to improve public health.

The U.S Food and Drug Administration (FDA) has recommended that all opioid prescriptions include an advisory to trigger healthcare professionals to discuss and more frequently prescribe naloxone, the opioid antagonist that can rapidly reverse an overdose.

The new advisories are welcome considering that more than 

 have reported increases in opioid-related overdoses, according to the American Medical Association. This upward trend is being fed by the anxiety created by COVID-19 and the resulting social isolation and disruption in care access, even though this spike appears to have begun last year. After several years of stability in opioid-related overdose deaths, 2019 marked a sharp uptick and record year for fatalities – over 

, based on data from the Centers of Disease Control and Prevention (CDC).

Unsurprisingly, the FDA, CDC, and the U.S. Surgeon General have advocated for expanded production of and access to naloxone. In an advisory, the FDA even indicated that it was working with manufacturers to potentially make the drug available 

, after approving the first generic version of naloxone nasal spray in April of last year. Unfortunately, that could take years.

Although naloxone prescriptions have increased significantly in recent years, including an increase of 

between 2017 to 2018, they are still falling short of the public need. In 2018, only one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions, which are classified as 50 or more morphine milligram equivalents (MME). Another study found that 

 of patients in various risk groups, such as those receiving a high-dose opioid prescription or concurrent benzodiazepines, received naloxone along with their opioid medication.

These troubling statistics remain despite naloxone being highly effective and safely administered by non-clinicians. A CDC 

 published in 2015 estimated that between 1996 and 2014, naloxone kits distributed to 152,283 non-clinicians at community-based programs resulted in 26,463 reported overdose reversals. The number of overdoses reversed, and lives saved, likely is significantly higher today than five years ago, due to greater public awareness of the opioid epidemic and naloxone. Still, overdose scenarios have continued to grow, largely due to the massive increase of synthetic opioid consumption, such as fentanyl.

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The lack of access to naloxone in the home poses risks not only to patients, but also their families. In a survey of more than 100,000 children ages 12 to 17, as many as 

 reported obtaining prescription opioids for misuse from a family member or friend, and nearly 8% stole the drugs. Non-intentional consumption of opioids is also a concern. Emergency department (ED) visits involving accidental ingestion of opioid pain relievers by children ages 1 to 5 

 between 2004 and 2011. With naloxone in the home, there is an added layer of protection for family members as well.

How prescribers, pharmacists, and health plans can help

Increasing patient access, public education, and use of naloxone requires a collective effort.

Physicians are the primary resource in co-prescribing the medication along with a high-dose opioid prescription, 

. For the time being, physicians and pharmacists should leverage the regulatory support as an opportunity to expand access by prescribing naloxone for each high-dose prescription and instructing patients and their loved ones on administration. Moreover, pharmacists should feel empowered to prescribe naloxone where state laws allow and collaborate with patients’ physicians if they determine naloxone is warranted, but not ordered.

Pharmacists filling opioid prescriptions should consider the new opioid directives as part of their clinical evaluation for potential counseling and education with patients, and their families, about the need for naloxone and how to administer it. Pharmacists also can play a critical role in the coordination and communication with the physician to help these at-risk patients.

Greater public distribution of naloxone will help first responders, patients, and their families to reverse more overdoses and save more lives. However, naloxone presents a unique challenge. Administration of the lifesaving drug is rarely executed by the patient and often requires the successful intervention of family or friends. Successfully increasing the use of naloxone requires prescribers and pharmacists to consult, educate, and train those who will be near to the patient in case of an overdose. Because the touchpoints with family and friends are often erratic, improved collaboration and coordination between prescribers and pharmacists are vital to this work.

Health plans can bolster efforts to improve naloxone use by reimbursing pharmacists and physicians to educate patients and families about naloxone administration. This simple upfront cost offers staggering potential healthcare cost savings, based on a reported 

$92,400 average cost of care per opioid admission

 in 2015 – a nearly $34,000 increase from 2009.

Patients on lower opioid doses also may warrant a naloxone prescription. As is required in nearly all states and territories, physicians ordering opioid prescriptions should check their state’s prescription drug monitoring program (PDMP) database to review the patient’s controlled-substance prescribing history. Many physicians also benefit from a clinical decision support tool that offers a data-driven “risk” score—based on the patient’s controlled-substance and medical history—indicating the patient’s increased chance of having an overdose event. If a physician chooses to prescribe opioids in such a case, a naloxone co-prescribing would be warranted.

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Progress is evident, but we can, and should, do more

Unlike a vaccine, no single remedy exists for reversing the nation’s opioid epidemic. Rather, reducing opioid use disorder and opioid-related overdoses, while still ensuring those who need opioids use them as intended, requires a collective effort across public and private healthcare professionals, educators, community leaders, first responders and families.

Progress has been made on the prescription opioid front. The U.S. opioid prescription rate fell to the 

 by 2018, and deaths from prescription opioids fell to just over 12,100 in January 2020, which was nearly 3,000 fewer deaths just three years prior, according to the CDC. Unfortunately, the pandemic appears to have erased much of those gains and 

the U.S. has seen an 18% spike in overdoses

. It is imperative that we continue to make additional strides to reduce prescription and other opioid-related fatalities by increasing the availability of naloxone to patients with improved education for family and friends.

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Jason Davis is Vice President of Client Services at

, which provides advisory, analytics, management, billing and collections, and technology solutions to solve financial and practice management challenges faced by hospital-based physician specialties like anesthesia.

Sir Isaac Newton’s first law of motion is often called the 

 Inertia states that an object at rest stays at rest and an object in motion stays in motion at the same speed and in the same direction unless acted upon by an unbalanced force. This law is universal.

For those who are entering the world of medicine, and more specifically anesthesia, it might come as a surprise that there are a host of unbalanced forces that are impacting practices across the country today. In many instances, anesthesia groups may feel a bit like a pinball, actively being bounced by forces that appear to influence both the clinical and business direction of groups.

Certain forces can result in both positive and negative outcomes. As a result of the COVID-19 outbreak, for instance, many anesthesia practices were asked to drastically modify their roles in the patient experience. Operating rooms were limited to only the most critical encounters. 

Anesthesia providers were called to the front lines

 in many locations to intubate patients who had contracted the virus and needed to go on a ventilator. Another outcome, in a broader sense resulting from the COVID-19 pandemic, is the evolution of telemedicine, a concept that had been slow to gain foothold and acceptance. 

Telehealth is now considered a mainstream and acceptable means of treatment and patient care

. Specialty flexibility and telehealth can both be considered positive outcomes resulting from unbalanced forces.

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Additional external forces continue to impact the specialty of anesthesia. Some of these forces include the market implications of state and federal balance billing initiatives, the increasing and expanding forces behind 

From a micro perspective, internal forces also continue to impact the activities of anesthesia practices. Examples include the expansion of services outside operating rooms, the compression of professional service fees for under-compensated markets, ongoing complexities related to quality initiatives and a long list of practice and clinical management responsibilities. 

All of these forces are combined with the pressures of being in the midst of the greatest pandemic the world has seen for at least 100 years. Indeed, the days of remaining “at rest” in the anesthesia world seem a very distant memory.

Physician leadership members are busy and can feel the burden of an unending list of to-do items in the clinical setting. However, for groups motivated to set their own direction in the midst of competing and growing forces, it is critical to establish strong leadership and strategic direction. Creating strategic direction should prioritize driving efficiencies that allow group members to enjoy their work while achieving desired outcomes.

With this in mind, we recommend the following strategies as guiding principles through the COVID-19 pandemic and beyond:

 – Establish what type of entity you wish to become. While forces abound, many groups can still choose to direct their own destiny. It is important to set a clear vision and establish your own force of strategic direction.

 – Group leadership has the ability and opportunity to establish the values of your organization. When these values are clearly articulated and implemented, day-to-day confusion is eliminated in the workforce, and your culture becomes a force that unites and compliments the group’s strategic initiatives.

 – Meeting often as a leadership team is critical to gain alignment and buy-in involving strategic direction and initiatives. Clarity in leadership will energize the entire group. Leaders should prioritize initiatives as short and medium-term goals depending on their importance and complexity.

 Organizational strategy requires some sense of formal structure in order to provide consistency of thought and direction. However, it is critical to allow open communication and free association of ideas within these forums of thought in order to foster the best and brightest ideas. This dialogue should have guidelines of respect and mutual understanding.

 You are surrounded by a group of talented individuals. All members should be invested in the success and strategic direction of the group. By gaining access to opportunities to grow personally, employees gain strength and motivation that are critical for a sense of ownership. By fostering this type of partnership, the team’s energy will complement the vision, values and strategic direction as established.

Practices that have woven these behaviors into the fabric of their culture have maintained a stable and controlled environment during the COVID-19 pandemic. In many instances, groups have actually flourished during such difficult times. For some, hospital and peer relationships have been strengthened through deeper interaction and improved communication. For others, work schedules have been adjusted to accommodate those at higher risk or higher need, providing consideration and overall satisfaction to practice members. Practices have achieved financial recovery thanks to leadership that has successfully navigated its way through the various government assisted programs. 

Regardless of the challenges and decisions facing your group today, you can take control of your own vision and destiny by creating positive forces. May the force be with you as you work together through these confusing times by clearly setting a direction that drives positive inertia and elevates your group to new heights of success. 

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The Best Ways to Show Gratitude to Patients and Staff

Thanksgiving is a special time of year. Families, friends, colleagues, and even strangers go out of their way to gather together to share gratitude, reminisce about positive accomplishments, and feast on the bounties of life.

But why reserve appreciation for one special weekend? Especially since extending expressions of sincere gratitude on a regular basis can go a long way toward enhancing the general tone within professional, domestic, and community environments year-round.

The results of feeling gratitude extend beyond the recipients of thoughtful feedback, though. Expressing spontaneous and genuine words of kindness can have a positive impact on the benefactors of such sentiments, as well.

Here are six simple civility suggestions that will inspire you to genuinely - and generously - share your thankfulness.

a veteran forensic medical investigator turned corporate civility and professionalism consultant, speaker and coach who helps individuals and businesses gain confidence, earn respect, and create courteous corporate cultures.

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, is a traveling physician who is board certified in family practice and lifestyle medicine. He has practiced as a 

 locum tenens physician for the past four years. Zhu is the author of "

Thrive Medicine: How To Cultivate Your Desires and Elevate Your Life

Own a practice? Head a department? You likely know it is essential to bring on the best professional support to make your practice thrive. That means having the best onboarding practices to smooth the transition between the newly hired employee or locum tenens physician and the future high-performing new physician in your facility.

As a locum tenens physician, I have heard horror stories about physicians not getting into their assignments correctly or the facility not running smoothly because of miscommunication. I’ve experienced this myself—there is nothing worse than not being able to onboard properly to a new assignment and starting the first week seeing patients on the wrong foot.

From a locum tenens perspective, a new assignment could represent new opportunities whether it is working at a new facility or city, meeting new people, or potentially a brand-new permanent job. From an employer’s perspective, a new physician could represent an opportunity to fill in a gap of work and possibly open up new relationships with a new potential permanent position that the physician can provide for their practice.

During my four years working as a locums tenens physician, traveling in four different states, and across eight different assignments, I have seen onboarding at its best and worst. I believe there are four key players to making your onboarding the best it can be, whether you are bringing on a new temporary physician or potential permanent provider to a new assignment. The first is the client, who is the employer or private practice owner, the client’s recruiter or HR person, the physician’s personal recruiter (if working with a placement agency), and finally, the physician.

Communication is the number one ingredient between all four parties. There will not be any smooth transition for onboarding, otherwise. I had my own horror story where I ended up moving to a remote city in Northern California for a new assignment. After a week of being on assignment, the medical director of the facility did not even know that I was there, plus I was asked to work and commute between three facilities because they did not have enough patients for me to see. 

Which begs the question: why was I even there to begin with?

 I want to help prevent potential fiascos like this.

For the employer, the most important detail to sort out, first is to establish what is the need for your practice. With that information, you can find out what kind of support you will need and for how long. Then you can go find the best physician for the job. Next, understanding how many patients or how many shifts the physician needs to cover, how much support they are going to need, and what other resources they may require to do the job efficiently while they are there. From my perspective, knowing what kind of support staff, like medical assistants and nurses, would be at my disposal is vital. Also, if procedures are required, knowing what the available resources are that physicians will need is essential to check before they arrive, so they are not scrambling when a procedure needs to be administered.

For the client representatives and the physician’s recruiter, they need to establish all of the above but also housing needs, travel/relocation needs, and vehicle needs for the physician. Also, it is important to make sure they have a proper orientation with the facility and sufficient time for them to familiarize themselves with the electronic medical record of the facility.

However, even before all of this happens, it is crucial to have an interview with the physician to acquire the best initial rapport possible. For the physician it is best to have an interview with the office/practice manager and the medical director of the facility. Take time with this. The interview is important to answer questions between the two parties and also to see if it is a mutual fit during the requested time that is needed for their services. Again, communication is key here.

Lastly, this is an amazing opportunity to create something long-lasting and fulfilling for both parties. Healthcare needs stronger relationships and stronger communication and that comes from establishing great initial rapport with the client (employer) and the physician and everyone else in between. Patients need these relationships to be stronger because they are used every day in the ever-changing and sometime tumultuous nature of healthcare. Let us show them that we are here to serve them and that starts with smooth transitions from onboarding great physicians for accommodating and receptive employers.

, DO, is a traveling physician who is board certified in family practice and lifestyle medicine. He has practiced as a 

As seen from a Locum Tenens perspective. 

Best practices for onboarding physicians 

 I am pleased to bring you this second installment of our Coding Q&A podcast series. 

In this Q&A, we look at two submitted questions from our viewers. The first inquires about problem management credits—specifically, who will retain credit for problem management in new CPT codes in 2021; the second question deals with what notes are required and beneficial in A/P notes for AWVs.

Our first submitted question today concerns upcoming changes to the CPT Manual. Specifically, this individual is asking about ‘problem management’ changes. They wonder: “Is it true that physicians will no longer receive credit for assessing problems when a specialist is involved in their care?” The questioner says that this hardly seems fair…

Ah, no, that's not entirely true. And this provider is certainly not the only one who's wondering about all the upcoming changes to the to the CPT manual and specifically the E&M codes because we haven't seen changes like this and, you know, over 20 years really.

But his question is, “Do we not get credit for Problems are assessed when a specialist is involved in the care?” I think the reason he's probably asking about that is that there is one of the things that the AMA released, that tells you that, you know, unless you have some additional assessment or a care documented, when it comes to listing problems that are managed by others, unless you can show them that you did something, they're really not interested in paying you for this.

And let me just kind of set the context here a little bit. This comes out of the guidance to the E&M guidelines for 2021 that the AMA has released. One of the things that they did was they've redefined what problems are, what problems count, what problems count towards your level of medical decision making. They had made this comment and it was actually a good observation. It's something that people have been wondering about over the years because you'll see a note that says the patient's here for chronic disease follow up or chronic disease management. And they'll give you a little bit of status of a couple of problems in HPI—that pressure, blood pressures or blood sugars, et cetera, et cetera—but when you get down to the assessment and plan, you'll see something about the hypertension, you'll see something about the diabetes with Olympus.

And then you'll see a comment that says, you know, CKD, chronic kidney disease, three, managed by nephrology, or we'll just say CKD3, sees nephrology.

Now, you know, we don't really need that problem in there to get this code to a level four because we've got maybe three problems before it, but if there's only three things listed and the first two are stable issues, and CK3 sees nephrology, we've always wondered whether we were counted that or not because it's more of a comment. than anything else—more of a mention—the physician doesn't really seem to be engaging, you know that problem, he's pretty much saying “Nephrology is taking care of this.”

So, that questions been around for auditors for many, many years. And I think physicians being trained to code based roughly or usually on the number of problems that patients have, you know, would tend to include these things because in their mind, certainly someone with CKD—chronic kidney disease level three—and hypertension, there's an interplay between those two things and they each make the other more complicated. And it's a very real thing to them. But what the AMA is saying is unless you kind of show us that this comorbidity that's out there or this other problem, that you're kind of assigning or giving away to somebody else, unless you can show us that there’s some work that you're doing today that goes along with that, they're not really interested in in counting that.

So what you need to be really careful to do is to kind of again, show your work and say “We did a, a GFR test today or GFR”, give that score in the albumin score, maybe—because I'm sure there's labs that pertain to the CKD—and maybe mention the way that that relates to their hypertension and your choice of medications.

You need to say something in there before you say something as simple as “sees nephrology or will see nephrology next week”, because you're in effect, just kind of giving it away. And you're now kind of on notice that unless you sort of show that work, it's not going to be counted towards your level of medical decision making.

So, in a way, it's a long overdue clarification of something that's always been a little unclear. And I guess it's also kind of noticed to physicians that hey, you know, we were happy to count comorbidities and other things that are going on, as long as you show us how it impacts your level of medical decision making.

So, it's good news in a way, the way that the question was read was kind of like, “What do you mean, I'm not getting credit for that?”

 You know, that's understandable, too. It was just the way I think it was worded that kind of made it sound like that.

I think the guy said it hardly seems fair, you know that that wouldn't count. And it only doesn't count if you really aren't doing much. I mean, you know, we see that a lot with “sees cardiology”, “sees card”, “sees pulmonology”. And if you are kind of just saying that those problems are managed lock, stock, and barrel by somebody else, or being met or addressed by someone else, then you probably shouldn't get credit for it. But if you can show how that impacts your work, then it's all to the good.

You know, it's still going to be, I think all about counting—counting problems, that nature of problems. There's another kind of a one-liner in here that relates to that, where they tell you that, you know, simple referrals to someone else aren't going to be counted either. And that's another case where, you know, all of those situations aren't the same.

If a patient comes into you and the HPI says they're here for a referral to OB for something or other. And then down in the assessment and plan it says, referral provided to OB and there's really no mention of the even the OB issue, that they're not going to count that.

If the patient comes in with a complaint or a problem of bleed or You know, some kind of a symptom, that's OB nature, And you ask questions about it, and you do an exam, and then you get to the assessment and you plan and you say, you know, “we found this and such, we're going to order this in such a lab, but we're also going to refer it to OB to see what they think of it,” that's a completely different animal, because you've worked that one up. You know, you've kind of done what you think you can do? And your answer is I think we better have a specialist look at this, as opposed to somebody who just walks in the door and says, I need a referral to so and so for because my health plan insisted on that.

So, that's another case of the AMA clarifying things where they kind of say referrals won't count. But you have to take into consideration the circumstances because they're not all the same. Some of them are the easy version, and some of them are the after some workup, we've decided that that's the answer.

There's a whole lot of things that are in that release or prerelease, if you will, that the AMA put out that physicians are going to have to get used to, in that assessment and plan because as I said, that the new rules in 2021 are going to be that you can code by medical decision making, or you can code by time. And setting time aside for the moment, you know, the decision-making pieces still going to be about the number and the nature of problems and now they're making it a little bit more clear that they want to know the extent of your involvement.

You know, it's long, not been enough to just name things you know, they've always wanted you to say “stable, continue this inside or worsening or exacerbated or progressing,” But now you in some circumstances, you may need to do a little bit more. And if you don't mind me just kind of going forward with this a little bit only because I know that this is still in the same sort of spirit of what this person is asking. You know, there's new language that physicians are going to have to kind of get used to, I think one of the more important ones.—when I first saw it, it really rang a bell with me—is that the AMA made it very clear that a problem that is not a goal is not considered to be stable.

And what's kind of interesting about that is that, you know, your previous choices to describe problems that weren't stable, the ones that they kind of offered you up in some of the language and CMS shared that same language was, you know, “worsening”, “exacerbated”, “progressing”, “poorly controlled”, “uncontrolled”, that kind of thing. Sometimes physicians set it, sometimes they don't, you know, we always recommend that they do. But there are some problems that they're not really worsening, they're not really uncontrolled, but they aren't where you want them. You know, they're not at goal, not really where you need them to be. And until they came out and said that, you know, that problems not at goal, equal kind of problems that are worsening or exacerbated, or actually what they said was if they're not stable, which pitches them into the other camp of the, you know, poorly controlled, uncontrolled, et cetera, et cetera. So those are going to be counted as you know, two brownie points, if you will, the way that they were that they score those things, as opposed to one.

So that's another kind of set of language or words that, you know, providers are going to have to get used to, but it's an important one because it happens pretty regularly. You know, it's not unstable. But it still requires work. It might require additional medication, it might require changes in medication, and it's just not what the easiest version of describing it might be. So I know that was a lot for that one question, but it all seems kind of related to me.

 The second question we will look at today concerns combination of AWVs and problem vists in the same encounter. This questioner’s staff apparently tells this individual that he or she is not documenting to support both, despite the questioner saying he or she includes problems addressed in the A/P section.

They are at a loss as to what else they need to include. What are your thoughts and/or suggestions?

Okay, you know, once you say the word combination visit, and there's lots of names for this split bill and all that. And I think we've talked about this before. I think we talked about this, maybe even in the last session, but there's many opportunities for things to go sideways here. And I think the last time we talked a little bit about the importance of naming things and making clear that you know the patient is presenting for their annual wellness visit and management of XY&Z etc, etc.

So, this provider kind of says, hey, my office staff is telling me I don't have enough for two codes—here, preventive and Problem Management—but I have a good assessment and plan, which is really where you'll see the problem management port, you know, what else do I need, I think is what he is he or she is saying.

And it's a good question, especially in light of where we're going in 2021, because it kind of gets a little mysterious that it's easy to answer right now today, and I'll answer that. The other piece that you need is the HPI. And part of the reason I say that is that you've always kind of needed two components of a E&M visit to qualify for the code for an established code —history exam, decision making. We know that decision making always needs to be one of them to kind of keep us rooted in medical necessity. But really what goes with chronic disease management or follow-up, which is typically what happens along with an annual wellness visit, they just want that same little HPI that you do on a 99214 that says, you know, hypertension pressures in the 130s, lipids, whatever, diabetes, whatever. It's, it's part of Medicare and other payers’ way of determining medical necessity, that up in the beginning of the note, we're here to do these different things. Here's a little bit of the, I like to think of it as the before and after, you know, before this visit, this is what's going on with these three problems. And then after study and after some discussion and some exam, this is kind of the answer down there in the assessment plan, but that gives Medicare and other payers are very warm and fuzzy feeling that it is what it represents itself as here's a little bit before, here's a little after we've taken a good look at this problem or these problems. And here's what we're going to do about it very much demonstrates the management.

So, I don't know what this person's notes look like. But if their staff is saying there's not enough, and physician is saying that their assessment and plan is good, then really kind of the only thing that can be missing is that little HPI front and very clear documentation that they're here for two things.

The reason that I said that this gets a little murky going forward. I'm really curious about this. Maybe you've been a little worried. Only because I've been in this business for a while. They're not my charges. I'm not going to lose any thing you know, if this doesn't work well, but it just it just hurts my feelings a little bit I guess if we're leading people into uncharted waters, so to speak.

But since the 2021 regulations say that you do whatever history exam you need to do, and they're no longer going to be counting things like HPI and review systems and physical exams, and it's actually actively being touted by CMS “patients before paperwork” and “less documentation” and all of that, that this is exactly the place where physicians might say, “I don't need to write that stuff anymore. You know, I don't need to do that little HPI anymore. All they're looking at is the decision-making piece. coding is based on decision making. So as long as my HPI is, as long as my assessment plan is good, then I'm good to go.”

I think that's a mistake because of what I had mentioned before, the payers need a little bit of context for that those problems that appear in the system assessment and plan, they can't just appear there for the first time.

In the note, if there is no kind of advance warning, I think in prior conversations or articles or questions, you know, we've mentioned that the payers kind of used that HPI like, almost like a table of contents for, you know, what's this visit about. And so if they're not expecting it, if this these things just kind of appear in the assessment and plan, I'm not sure that you've done a good job of documenting the separate and significant nature of that additional code, because remember, the whole scenario here is just that you're billing them for two codes, you've got your hand out twice, I want to be paid for this one, I want to be paid for this one. And the 25 modifier that you put on there when you build two things, says that this is a separate significant and identifiable other service. And so now there's some discussion about well, you don't really need to do the history part anymore, so how much of the separate and significant, you know, went just went out the window.

So that's the part I meant when I said I worry a little bit about this is if people kind of back off or slack off on their documentation too much. Probably the last place you want to do that is the HPI. It's long been the case that the two sections of the chart where physicians need to document you know, specific patient-specific narrative information is in the HPI and the assessment and plan—the EMR can't write that for you, it doesn't know whether something is shooting, stabbing or throbbing, it just doesn't know. It can pull in the past family social history, you can pull in big canned exams, you can pull in big giant can review systems, but it can't write the HPI can't write the assessment and plan.

So I think it's really important and goes back to this question that you remember that that HPI is a little more important than just a piece of the documentation guidelines, it serves as an outline. It serves as the before versus the after that you'll see in the assessment plan. So again, that's, that's kind of my read on that one. Although I don't know what this person's notes look like. It could be dismal. And their staff is right, and they shouldn't build for any of that, you know, but some of it, you just can't tell unless you look at their notes and see what they actually have out there.

But that's the I think the thrust of this question is that, you know, you need to make sure that it's your work is clear, you know, don't abbreviate it.

I said this once years ago, I think in a one of your articles: if you abbreviate your work too much, the payers will find a way to abbreviate your payment. And so, you know, just remember that. Efficiencies great and less keystrokes are great, and it's wonderful let defense have taken away the requirement for a lot of thebig bulky EMR stuff that's contributed to a lot of just junk in the in the note, but don't take away the stuff that is important. And the HPI is going to continue to be important, even if it's not required.

Thank you so much again Bill, your information and insights are always greatly beneficial and appreciated.

And thank you all for listening to this ninth episode of Perspectives, brought to you by Physician’s Practice.

We hope you subscribe where you listen to podcasts, rate us, and let us know what topics you would like to hear more about.

For more practice management insights from the top experts in the field, be sure to visit us at 

, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years. He can be reached at 

Podcasts

Coding expert Bill Dacey, principal of The Dacey Group, answers viewers questions in this second installment of our Coding Q&A podcast series.

Coding Q&A Podcast 2: Problem management credits; A/P notes for AWVs 

 discusses how credit cards can benefit a practice, who in the practice should have access to these cards, and when practices should consider applying.

 How credit cards can benefit a practice, who should have access, and when to apply

Planning for practice credit cards

I start with a note of gratitude to our readers, many of whom have been kind enough to follow this column for a decade and some of whom I’ve had the pleasure of interacting with personally. Special thanks to those of you that have been on the front lines of the COVID-19 crisis this year, your service and sacrifices are certainly among the things all Americans have to be grateful for and that we have hopefully helped support in some small way. – Ike Devji

We’ve covered a variety of risks this year ranging from the most likely and recurring ones like abusive year-end 

. Here are a few more year-end issues to consider

Managing the risks of the office party. Even given current circumstances, many medical offices will still be having holiday parties in some form. This year adds the obvious additional risks of COVID-19 exposure to the long list of predictable and recurring liabilities I have 

 on multiple occasions. Be especially aware of so called “Covid fatigue” and its national prevalence, including among medical professionals, and make sure you plan and manage an event that is safe for them and for you, both 

. While I certainly understand and respect your desire to express your gratitude to staff and partners in very trying times, the usual risks of an office party, combined with the added stress of the season, political tensions and the need for social distancing are leading some employers to think outside the box. Some alternate ideas include gifts, PTO or bonuses in lieu of a party, additional perks or benefits in the office like catered lunches and other pampering touches and even providing additional PPE like air purifiers, which one doctor gave her staff to take home.

8 Things Your Medical Billing Service Should Do

Beware data breach risk when replacing technology.

ID theft and related crimes targeting healthcare organizations are at an all-time high and moving large numbers of employees to remote working conditions has only increased that risk. Given these changes, the number of practices 

replacing obsolete equipment in their offices at year end

 and buying new laptops, phones and tablets for remote workers more appropriately equipped for the “new normal” like telemedicine and Zoom meetings will be a goldmine of equipment that may store 1000s of protected records that hackers may be interested in. Have a disciplined policy and procedure to replace any such equipment and track where and how it was stored and disposed of as well as having heavy limits of data breach and cyber liability insurance in place.

Reevaluate your personal legal planning and

Do you have adult children, parents or other extended family that will be occupying your home or using your cars for an extended period of time due to lockdowns, school closures and other changes that increase your risk? Do you have adequate life insurance in place given the increased Coronavirus related personal safety risks frontline healthcare workers and their families face? Is your legal planning, including both 

 planning in place and adequate for your risks?

Many practice owners leave too much money above a reasonable operating balance in their practices. If your finances allow it, consider “de-risking” some of that excess capital by taking it out of the business and away from its liability to add to your personal savings. Consider increasing your liquidity for any emergencies or opportunities that may arise, you can always loan it back to your practice if required and you may be limited in taking any outsize distribution in the event of a liability at the practice before you do so.

Selling Your Practice: PPP, MAAP, and CARES Act relief fund compliance

Fund qualified plans sooner rather than later.

 If you make recurring fixed contributions to qualified retirement plans late in the year or early next year, considering doing so now to start any vesting period required to avail of statutory creditor protection. For those that make specific dollar amount contributions based on the guidance of their CPA, consider making estimated contributions, even partial ones, now, to avoid any superseding event preventing the funding of your plan.

, JD, has practiced law exclusively in the areas of asset protection, risk management and wealth preservation for the last 16 years. He helps protect a national client base with more than $5 billion in personal assets, including several thousand physicians. He is a contributing author to multiple books for physicians and a frequent medical conference speaker and CME presenter. Learn more at

As we head into the Thanksgiving 2020 holiday, keep these details in mind to help bring a stressful year to a peaceful and predictable close. 

Five year-end asset protection issues

For Those That Have Everything, Give the Gift of Beauty and Nutrition

Find the perfect Christmas gift for everyone on your list this season, no matter your budget. Browse our holiday gift guide for Mom, the guys, teens, and more!
