Like most ophthalmologists, my partner and I were stagnating a few years ago. Managed care was increasing patient volume while cutting exam fees by 15% to 20%. The federal government was issuing more stringent and time-consuming documentation requirements and imposing severe penalties for inappropriate coding.

Rather than give up or explore alternative sources of revenue � as so many of our colleagues have done � we decided to make some changes.

After streamlining operations at each of our five offices, revising our patient management protocols and revamping our charting process, I alone increased the number of patients I saw daily by 15% to 20% � without needing to add any staff.

Let me explain the challenges we eventually overcame, in hopes of helping you try similar approaches in your practice.

First, every aspect of patient flow had to be evaluated, along with the systems we had in place. Recurrent claim rejections and write-offs couldn�t be tolerated, as this would erode our practice�s viability. Every effort was made to comply with regulations, to code specifically and to appropriately document earned reimbursements for services provided. All of this had to occur at the same time we strove to practice good medicine.

Before implementing any change in the practice, our physicians had to be committed to the process. This sounds simple, but change can�t occur until you�re ready for it.

Motivation in your practice shouldn�t be a problem once each physician realizes that the goals are to:

• increase revenue
• decrease overhead
• decrease audit exposure
• increase access for patients
• maintain high-quality care.

Today, we examine these goals in quarterly meetings, during which the performance of each physician also is reviewed. Internal auditing is performed to identify problem areas. Intensive review of documentation enables us to expose each physician�s weakness and to correct it.

We review rejected claims at quarterly meetings, when we emphasize improved documentation and coding. We also conduct semi-annual reviews on 20 charts from each provider to confirm documentation for the level of service provided.

We�ve implemented an internal compliance plan and continually modify it as weaknesses become apparent. The physicians remain solely responsible for identification of the level of service and ICD-9 codes.

Most practices simply don�t utilize their computer systems to capacity. We recognized this as a problem and focused on our routing slips. (See a sample of the routing slips generated by our computer program on the following page.)

On these slips, the patient�s name, age and the name of the referring doctor lead the list.

This information is important for correct patient identification. The referring physician�s name makes it easier to copy a note or send a letter without searching through the chart.

Meanwhile, our staff uses the "other information" slot to identify potential billing problems. The "next appointment" slot eliminates duplicate appointments for return patients.

Perhaps most helpful are the scrolling lists of previous ICD-9 diagnoses and CPT codes. The most recent five ICD-9 and CPT codes, plus dates of visits, are listed. (These lists are critical to streamlining physician coding.)

The ICD-9 diagnoses are often repeated, unless a new problem is identified. This gives easy access to the majority of codes needed. We also list the codes in order of importance, from one to four. (Our carrier doesn�t recognize more than four codes per encounter.)

Scrolling CPT codes and dates of service have nearly eliminated our errors of using modifiers in the postoperative period or billing inappropriately for services. Matching the dates with the service quickly identifies the need to use modifiers -79 or -24. We eliminate the cost of processing rejections by coding the modifier up front. As the patient leaves, the clerk posts the CPT codes and ICD-9 codes and the service is complete and ready to transmit. The chart is then ready to be filed.

The routing slip is set up so that the physician identifies the level of evaluation and management (E&M) services as level 1 through level 5 for office visits and so that he writes if the patient is established, new or appearing for a consultation. We use eye codes, and most minor office surgeries and laser surgeries are also listed to expedite coding. The use of modifiers -57 and -25 is critical to obtaining appropriate reimbursement. We keep a list of modifiers to remind the physicians.

The physicians are responsible for diagnostic coding (specific diseases, and their order), as this often affects reimbursement. ICD-9 codes may be a 3- 4- or 5-digit code, but must be as specific as possible. Each physician strives for a 5-digit code for each diagnosis, when available.

Besides using the routing slips, we also use a special set of sheets to identify ICD-9 codes. The sheets are kept in each of our exam rooms, the physicians� offices, the front office desk and the technician station.

These sheets have proven invaluable for improving our efficiencies and allowing the physicians to code appropriately. We�ve used them for the past 4 years, with only minor updates. Once you become familiar with the tabulated format, coding couldn�t be easier. The codes are grouped by category and are in numerical order. Within seconds, you can easily identify two or three codes. Various systemic diagnoses are included in the ICD-9 coding sheets we�ve created. We use them when doing pre-operative histories and physicals. We can quickly identify a systemic diagnosis, if laboratory tests are needed pre-operatively (HCFA now requires an ICD-9 code if a test is ordered).

Before we became more efficient, determining the level of service took longer than providing the actual service. We simplified this task by following the HCFA guidelines for level of service.

We extracted information from the guidelines and translated it into a workable, written form with multiple reminders. Each patient receives initial intake sheets for the first visit, followed by periodic updates, as required.

The return encounter form (see above) is placed in the chart at each visit. Pertinent information is recorded, with the prompts provided for the history, examination, assessment and diagnostic/treatment plan. Depending on the type of visit, an E&M code or an eye code is then selected.

As our need to increase our patient volume grew, our ability to document also became more critical, which made using our staff efficiently even more important.

On busy days, our technicians not only scribe information, but educate the patients, work out acceptable schedules for surgery and escort the patients to check out.

We "dictate-examine" the patient, and then explain our findings as our technician records the exam and conversation.

The assessment and plan are recorded as we talk to the patient and while prescriptions are written. We sign the chart, add notes and sign prescriptions. Then we answer patient questions. The technician goes to the next room with the physician, (after escorting the previous patient out) and begins to scribe as the next exam begins.

A key point in making our practice more efficient has been our ability to integrate a full range of services. We have multiple physicians at multiple locations; all are committed to expanding to include optical services and surgical services.

Optical services are provided in all five of our offices. Two locations have independent optometrists, who own and operate the optical services. In one location, the optical service is part of our practice, and in two locations we have joint-ventured with an independent doctor of optometry. (Note that Stark II regulations, possibly restricting dispensing in surgical practices, may affect the structure of our services when the regulations are finalized by the end of 1999.)

We provide some surgical services at local hospitals, but we also use a surgery center near our main office. The surgery center was a joint venture with other ophthalmologists in town and a local community hospital. Surgical center efficiency is significant � helping us achieve a 25%-to-30% reduction in time required for procedures. This gives us more time in the office to provide other services.

Integrating our business functions has been frustrating at times. But with internet lines becoming more available, it�s easier and more cost effective to link offices. Currently, four of our five offices are on-line, and we�re integrating their business functions into one business group. This has significantly lowered our overhead costs. You must consider your own up-front costs before doing this. But we believe it�s worth the cash layout if your volume of services warrants the investment.

Perhaps no method of increasing efficiency is more difficult than that of scheduling physicians. But in a multi-physician, multi-location practice, effective physician schedules are critical. We�d undertaken a team effort to minimize schedule changes, schedule in advance and cross-cover the office.

Each physician schedules a 4-day work week, with one flex day. Once vacations and meetings are scheduled, physicians fill in their fifth day to cover the practice when needed. If an emergency arises, physicians use their flex day to help out.

Each physician tries to keep his or her schedule one year in advance. This decreases the need for the office staff to reschedule appointments. The result is improved office morale and decreased demands on the staff.

You should also keep this in mind: Less rescheduling means better public relations.

Many external forces affect the quality and practice of medicine. The greatest goal for the physicians in our practice has been to maintain high quality and accessible care at an affordable price.

We�ve successfully reduced coding errors, audit risks and overhead costs, while at the same time increased revenues and improved documentation. Office efficiencies and morale are also up � all in a difficult managed care environment.

Every physician who plans to practice beyond the next 5 years must make a commitment to implement change to provide the care that patients need. Changes in a practice require time and investment. It took nearly 2 years to see the full effects of the changes on our bottom line, but in the past 2 to 3 years, we�ve increased gross revenues by 10% to 15%. Here�s to hoping you�ll be able to do the same in your practice � or perhaps even do better. OM

Dr. Powell is the managing physician of a practice in West Virginia, which includes five ophthalmologists and two optometrists. The practice utilizes five office locations and an affiliated surgical facility.

Follow these approaches to catch coding errors when using our patient management system.

• Check the routing slip at each visit, confirming the previous visit and verifying that surgeries and services performed at the previous visit are listed. Missed services and incorrect codes are immediately apparent.
• Always check the name and age of the patient to confirm identity and previous exams.
• Have your staff confirm that ICD-9 codes and CPT services conform to coding directives at check out. If an error is discovered, have the practice place a $2 donation in a "party fund" to be spent at the employees� directive.
• Upon receiving EOBs, identify all coding errors and notify the physicians and staff of the problem.
• Make a manual available to explain Medicare and insurance coding requirements and billing protocols.

Failure to change our practice would have produced devastating effects. Here�s what it would have cost us:

• decreased ability to deal with HMOs
• restricted access to our patients
• a much greater audit risk
• more time to document and code, leavingfewer patient appointment slots
• revenues continuing to plummet, forcing us to offer fewer services and keep less support staff
• business functions becoming more complex
• ultimately not being able to provide services
• for our patients and perhaps feeling the need to
• abandon practicing medicine.