Point your compass to success with these 11 “need-to-know” tips for making the transition from residency or fellowship to practice.
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AAOS Now

Published 11/1/2014
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Gail S. Chorney, MD; Charles A. Goldfarb, MD

Easing the Transition From Residency into Practice

Eleven things you need to know

Gail S. Chorney, MD, and Charles A. Goldfarb, MD

Residency and fellowship training primarily focus on orthopaedic education. But to succeed, residents and fellows need to learn other aspects of running a practice (such as billing, coding, or compliance issues).

The following 11 “need-to-know” items cover both general tips on running an effective practice and specific tips on coding and billing. Although they apply to any surgeon, they will be most helpful to those about to start or just starting practice.

The second most important person in the practice
As the orthopaedic surgeon, you are the face of your practice; your strengths will determine the growth and success of your practice. Your group’s name or marketing campaign may help attract patients, but your skill and patient interaction talents are vital to keeping them.

But the second most important person in your practice is your nurse (medical assistant). Your nurse represents you when you are not available by phone or in the clinic. In fact, your nurse may have more direct contact with patients than you do. So although your nurse may not build or expand your practice, he or she can certainly undermine it.

You must be able to absolutely trust your nurse to make the right choices, to be highly organized, and to interact well with coworkers, hospital staff, and the operating room (OR) staff. Carefully consider (and don’t delegate) the hiring of this person because he or she will be a vital part of your success.

The three As for practice development
The three keys to practice success are Affability, Availability, and Ability, although some physicians will argue that the three As should simply be Availability, Availability, and Availability. With the changes in health care and the greater emphasis on outcomes, ability may become more significant. This “oldie but goodie” rule remains key to practice development and success.

How the elevator rule applies to social media
Social media is increasingly highlighted as a means to grow a practice and engage patients. But certain rules must be followed to avoid compliance issues. The elevator rule (as stated by blogger Kevin Pho, MD), as it applies to social media, says that to avoid violating patient confidentiality, you should limit your social media comments to what you might state aloud in a crowded elevator. Managing your online presence is vitally important. Your reputation is at stake.

What referring physicians want
Referring physicians want a few simple things. First, and most importantly, they want rapid access for their patients. Same- or next-day access makes everyone happy. Second, they want feedback. The type of desired feedback will vary based on the physician; most are satisfied with a good medical note within 24 hours. A serious problem merits a phone call, but this isn’t necessary most of the time. Finally, referring physicians want excellent and personable care for their patients. The primary physician has chosen you to treat his or her patients; the care you provide will reflect back on the primary physician.

How voice recognition software can change your practice
We waited years before adopting voice recognition software because the programs were not ready for the rigors of a busy orthopaedic practice. Although the software can still be improved, today’s voice recognition is excellent and accurate. Programs perform well out of the box and get better with usage.

Using voice recognition software changes practice. The cost is low compared to line-by-line transcription and the software is easier to use than templates (or combined with templates). It also enables you to generate an accurate and timely note on the day of service, which can then be faxed to the primary or referring physician. Fantastic.

OR nurses talk (and why it matters)
Physicians and surgeons are judged constantly. Patients may consider orthopaedic knowledge and some aspects of technical ability (injections, etc.), but will primarily focus on affability.

An experienced OR nurse will judge surgeons differently; skill, confidence, and level-headed behavior are perhaps most important to them. OR nurses see a range of behaviors, from great skill and composure to tentative approaches, lack of confidence, and errors that lead to sentinel events. In addition, the surgeon’s personality may be magnified in the OR, especially in the high-stress situation.

Residency and fellowship teaches you to be prepared for the OR, from reviewing the anatomy, ensuring the correct OR supplies are available, and planning the surgery. But other things matter as well and affect perception.

First, schedule accurately. If you perform a perfect knee replacement in 120 minutes but scheduled it for 90 minutes, it will appear that the case did not go smoothly. And the rest of the OR day will be a scramble. Delayed cases raise frustration for patients and staff and affect everyone’s satisfaction level. Although some delays may be inevitable, during the first 2 years of practice especially, you should schedule every case for longer than you might expect. Finishing early makes you look more skilled and in more control. And the next time you need to add a case onto the OR schedule, it is more likely that there will be available time.

Second, practice self-control in the OR. Don’t lose your calm; it never helps. The staff will resent an angry, impatient surgeon and may question his or her technical competence and skill.

You should be flattered when OR nurses choose you when in need of care for themselves or their family; their assessment of your skills goes beyond that of the typical patient.

“Doing OK” is not enough; the importance of documentation
The office note is no longer just a quick reminder to yourself about your thoughts on the patient’s visit. The medical record belongs to the patient and should be precise enough to enable any other provider reading the record to know precisely what you were thinking without having to speak directly to you.

Also remember that if it isn’t documented, it wasn’t done. More people will be reading your notes. They will include, but not be limited to, consultants, primary care providers, physical and occupational therapists, and care managers. Even insurance companies are requesting to see documentation for reimbursement or for authorization of prescribed services. Better communication provides for better handoffs and better care.

Not every visit is level 5
If you select ‘level 5’ for every visit’s Evaluation and Management (E&M) code, you will probably get audited. E&M codes have exact criteria for determining which level applies to a new patient visit or a follow-up. It is worth your time to take a coding course to understand how the criteria relate to orthopaedic surgery. The AAOS–Karen Zupko & Associates, Inc. coding courses are excellent.

Central E&M levels are determined by how detailed the history, review of systems, past medical history, social history, and physical examination are, as well as complexity of the decision-making. Asking patients about their general medical condition but neglecting to document the answers in detail won’t support a higher level for E&M coding. It is not sufficient to say that the review of systems was negative. You must demonstrate that you asked specific questions.

Review results
Every risk management and patient safety course includes a section on reviewing and communicating test results to patients. Informing patients about their test results in a timely fashion, with a plan for how to proceed, builds trust.

If you practice in a large institution, you may receive test results automatically. If you are in a smaller practice, you must develop a system to ensure the results will be presented to you or your midlevel providers. Your staff and midlevel providers must also have clear instructions about who will communicate results to patients. Always remember to document your conversation about the results with the patient.

What’s an RVU?
Many compensation formulas use the Relative Value Unit (RVU) as a measure of productivity. An RVU is a value assigned to each Common Procedural Terminology® (CPT®) code by the Centers for Medicare & Medicaid Services (CMS). Based on a formula, Medicare pays the provider a dollar amount per RVU for each procedure.

RVUs are determined by the work performed by the physician, the malpractice risk, and the facility costs. The compensation formula may count only the work RVUs (wRVUs). Using wRVUs as a measure of productivity in cash-based compensation models helps eliminate variables such as payer mix that may be beyond the surgeon’s control. Specialty benchmarks for wRVUs have been published showing differences among geographic regions and types of practice.

Insurance and EOBs
Insurance is very complex, and many patients do not understand what their policy covers. Having a general knowledge of how policies work is helpful so that your communication to patients does not undermine maximum reimbursement.

If you participate with an insurance carrier, you have a contractual obligation to collect the patient responsibility portion of the reimbursement. This portion is increasing, due to copayment requirements, coinsurance, in-network deductibles, and out-of-network deductibles. Patients who hear that “insurance covers” a procedure or visit may believe that they have no financial obligation.

The EOB (explanation of benefits) tells the provider and the patient what the carrier will pay for a service and what the patient must pay. With coinsurance and larger in-network deductibles, the carrier may only be paying a small amount for the insured patient.

These strategies have helped many orthopaedic surgeons succeed; however, each should be considered individually based on factors such as practice type, practice environment, and location. For more tips, don’t miss the free Practice Management Residents’ Course during the AAOS Annual Meeting, Tuesday, March 24, 2015, in Las Vegas.

Gail S. Chorney, MD, and Charles A. Goldfarb, MD, are members of the AAOS Practice Management Committee.