Is coding your weak spot? Turn to AAFP tutorials

Inaccurate coding can cost family physicians a bundle. To help keep members up-to-date on coding issues, the Academy has released the second in a series of coding tutorials.

The latest tutorial—Outpatient E/M Coding: Selecting a Level of Service—focuses on the documentation and selection of a level of service for outpatient evaluation and management services.

Learn more about how to code based on time, as well as about best coding practices for observation and emergency department services. The tutorial includes case studies that users read before selecting from multiple-choice answers. The program is set up for on-the-spot learning; tutorial participants immediately see the correct answer as well as the explanation for that answer.

The tutorial costs $39.95. An e-mail containing the tutorial as a PDF file will arrive in the user’s inbox within two days of ordering it.

A link to an online post-test and evaluation can be found on the last page of the tutorial. After completing the program, Academy members can log in using their ID number, take the online post-test and complete the evaluation. AAFP Prescribed credit will be reported automatically to the AAFP when the member’s post-test and evaluation are completed.

Physicians who missed the July 2006 launch of this coding initiative—and who want to brush up on coding basics—may want to begin with the first tutorial, Introduction to E/M Services Coding.

Additional modules will be added to the site as content is developed.

WEB LINK
www.aafp.org/online/en/home/practicemgt/codingresources/tutorials.html

Medical Homes Defined

Principles establish basis for health system reform

By Leslie Champlin

The AAFP and three other primary care organizations on March 5 released a definition of the personal medical home that forms the foundation on which health system reform can be built.

The definition, “Joint Principles of the Patient-Centered Medical Home,” was developed by the AAFP, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association.

“The importance of these principles is that all primary care specialists in the country have agreed on what a medical home is,” said AAFP Board Chair Larry Fields, M.D., of Flatwoods, Ky. “The majority of physicians who will be providing a medical home are on record as agreeing to what a medical home actually is. That’s the first step for building a primary care-based health care system that will give us the ability to cover everyone in a cost-efficient, high-quality manner.”

The definition encompasses the physician-patient relationship, the quality of health care, the infrastructure and the payment system that will result in ongoing, comprehensive, cost-efficient and effective health services.

“This is not a gate of any kind,” said Fields of the medical home. “It’s not a hurdle that somebody has to cross to get medical care. It’s a portal to medical care. That’s far different from the way things were in the ’90s.”

American Academy of Pediatrics President Jay Berkelhamer, M.D., agreed. “By its very definition, a medical home is a quality improvement approach that promotes a partnership between the child, the family and the physician care team,” he said in a March 5 news release accompanying the announcement of the principles. “This partnership not only optimizes quality care, but also minimizes patient risk because the medical home forges a safe bond and quality connection between the care delivered and the specific needs of the child and the family.”

According to the principles, key to the personal medical home are:

a physician who has an ongoing relationship with patients, arranges care with other qualified professionals, and leads a team of professionals who take responsibility for the ongoing care of patients;
implementation of evidence-based medicine, continuous quality improvement, information technology, patient participation in care decisions and patient feedback;
improved access, such as open scheduling, expanded hours and new options for communication with patients; and
a payment system that recognizes the medical expertise, administrative requirements and time demands that come with providing a personal medical home.

Vital to the success of personal medical homes is appropriate payment that enables the physician to provide crucial behind-the-scenes services, said Fields. To that end, the principles will undergird communications with large employers, insurance companies, Congress and administration officials.

“It will show them what we mean when we talk about the medical home and how it would work to increase health of employees or government beneficiaries,” said Fields.

The principles call for a system that, in addition to paying for office visits, reflects the value of care management that “falls outside of the face-to-face visit,” such as coordinating internally and with outside practices, ancillary services and community resources. The system also should support adoption and use of health information technology and pay for the doctors’ time and expertise when they monitor patients remotely or communicate with patients via secure e-mail.

The payment system “should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting,” say the principles.

That element, said Ray Stowers, D.O., a member of the American Osteopathic Association Board of Trustees, is key to the success of the medical home.

“There is an investment that must be made in medical homes to keep people out of the hospital,” he said. “Under medical homes, if they’re done correctly, we will see an increase in services in (Medicare) Part B. For example, physicians might provide more breathing treatments to keep a patient out of the hospital. But there should be offsetting decrease in services in Part A.

“Part of that savings has to leave Part A and go to Part B to compensate for management. Unless savings shifted between Part A and Part B, it would be difficult because it would need new money.”

Stowers emphasized the flow of funds between Part A and Part B would not impinge on payment for services provided by hospitals.

“This is not an issue of hospitals getting paid less,” he said. “We’re looking for volume savings. We’re not asking hospitals to get paid less for taking care of diabetic patients when they do go to the hospital. But the volume of hospital stays will go down, and that’s a savings to Part A. If Medicare has x-number fewer hospital stays and it’s saving $1 billion under medical homes, then there should be some flexibility to shift those funds back for rewarding the physician.”

Family medicine residency match remains flat in 2007

The number of family medicine residency positions continues to decline, according to the residency match numbers posted in March. Nationally there were 106 fewer family medicine residency positions offered in 2007 than in 2006. Five fewer medical students chose to enter family medicine residency programs, meaning that the percentage of positions filled increased.

Texas fared slightly better than the rest of the country with eight fewer residency positions offered in 2007 than in 2006 and four fewer filled in the same period.

Despite the level numbers, Samuel Adkins, M.D., residency program director for the Austin Medical Education Program Family Medicine Residency, acknowledges other changes in place that will eventually lead to an increase, including AAFP residency program redesign initiative P4 and other studies. “With the Future of Family Medicine project and P4 initiative, people in the specialty are actively looking to the future,” Adkins says. “Because of this, things will change.”

AAFP President Rick Kellerman, M.D., expresses disappointment with this year’s numbers and supports taking another look at family medicine education. Educators will need to implement innovative practice methods to improve the fill rates for family medicine in the future, starting with the medical schools. “It’s a real concern because our medical schools are, through admissions, curriculum and hidden curriculum, not putting emphasis on primary care when the country’s saying ‘we need more family docs,’” Kellerman says.

More than half of family medicine residency slots, or 57.8 percent, were filled by international medical graduates, a statistic that Adkins sees as a blessing because of international graduates’ ability to diversify a program, and because IMGs tend to practice in areas that need primary care physicians most.

“International graduates are more likely to go to underserved areas in the state, they’re more likely to go take care of people who don’t have access to care, they’re more likely to practice a wider scope of practice,” he says.

Overall, Adkins recognizes that only three or four Texas residencies didn’t fill in the match and says that the numbers in the state aren’t necessarily ominous, but rather indicate “there’s still an interest from the students.”

Adkins says, “we did outstandingly; we should all be very proud that students are recognizing we have good programs in Texas, which is a good indication for the future of health care in Texas.”

Initiative to bring medical home concept to family physician training

Two Texas family medicine residency programs will participate in a national initiative that aims to teach future family physicians how to provide a personal medical home. The John Peter Smith Hospital Family Medicine Residency Program in Fort Worth and the Baylor Family Medicine Residency Program in Houston are two of 14 practices chosen from around the country for the progressive primary care initiative P4, or Preparing the Personal Physician for Practice.

Participating residency programs develop their own ideas to incorporate, and participate in periodic joint meetings among the residency directors to fine-tune the proposed innovations, make adjustments and move forward. For JPS, many of the ideas they’ll implement came directly from residents’ requests for more specific training during a fourth year of residency. Daniel Casey, M.D., program director for the JPS program, says they decided to provide the extra experience throughout the years of residency, not just in the final year.

“We think family medicine is the way to provide care to a general population,” Casey says. “We also think there are training methods we can improve. We’re looking to create the ideal family doctor for the future.”

Data collected from the 6-year project may be used to guide future revisions in requirements, accreditation and content.

TransforMED, AAFP’s practice redesign initiative, will administer P4, allowing the two initiatives to collaborate on training strategies and new approaches to achieve optimal patient care.

“We’re excited that they’re going forth with this type of project and that they’re looking at different ways to improve training,” Casey says. “We’re not resting on our laurels watching all of this pass us by, it is a proactive mood.”