Many health care businesses have an employee handbook, or employee policy handout, but fail to update them on a regular basis. Here are some items you should be sure to include:

Do you have a social media policy? You can prohibit the use of social media in the work area on business time and on company computers.

If your state has an at-will employment law, you should also have a statement that the handbook cannot be considered a contract and that you have the right to make changes in an employee’s status whenever you feel necessary.

Do you have a huge list of things employees might do that would result in disciplinary action? You might want to review that process and delete the list. You might instead have a statement about honesty, ethics, respect and the attributes you expect from them.

Do you have a policy that says harassment should be reported to the manager or supervisor? Just keep in mind that the manager/supervisor could be the person harassing the employee. You might want the employee to have the option of reporting to any manager. They need a way to report that does not affect their job in any way.

Have you reviewed your benefits to make sure they comply with federal and state laws?

Does your handbook explain specifically how these will be calculated? Whether you choose vacation and sick leave in your business or PTO, you need to document how they will be calculated and when the employee will be eligible for these benefits.

Carol Gibbons, RN, B.S.N., NHA, is a health care business consultant. Send your legal questions to medec@mjhlifesciences.com.

Articles

If you don't have these six items in your handbook, you are putting your practice at risk.

What you must have in your employee handbook

Especially in uncertain tunes, it is crucial for physicians to build a plan that protects their financial future.

Creating a solid retirement plan can build peace of mind as you navigate the challenges of practicing medicine today. So what should you be doing?

® sat down with Joel Greenwald, M.D., CFP, president of Greenwald Wealth Management in St. Louis Park, Minnesota, to discuss important tips for physician retirement planning. This interview has been edited for length and clarity.

Medical Economics®: Why do many doctors seem to have trouble saving for retirement?

 I would say that is multifactorial. First off, I don’t think that difficulty saving for retirement is limited to physicians. There are certainly plenty of other highly paid folks who don’t do a good job of saving for retirement. Spending money is fun. You know, having a big beautiful house is fun. Driving a fancy car is more fun than a run-of-the-mill car. Eating out is a big expense that we see. And the even bigger one is travel, travel to Europe, travel to Asia. So spending a lot and not being a good saver is just, I think, part of our culture.

Maybe something that’s unique to physicians is the pent-up demand after all the years of training. You know, the four years of medical school, at least three years of residency, possibly more fellowship. Doctors come out with the desire to keep up with their peers who maybe didn’t go to medical school. Or after making $55,000 a year in training, now they go up to a salary that’s four, five, six times or more than they were making as a resident. They want what’s due to them.

Part of it for physicians, and Americans in general, is we don’t do a good job in this country of providing financial education. And it doesn’t get any better in medical school or in residency or fellowship. Doctors just don’t learn this stuff.

Another thing that plays into it is that medicine is a helping profession. For some reason, the idea of helping people and thinking that money is important seem to be contrary ideas. And so a lot of physicians say to themselves, “I went into this to help people. And I’m going to ignore the money side.” It doesn’t mean that they need to be greedy, but certainly one should understand what’s going on with their money.

I would say another thing that plays into this, and, again, it’s not unique to physicians, is family of origin. We see people who grew up without a lot of money; they can take one of two paths forward. One is that they’re good about saving, maybe they don’t even spend enough. On the other hand, some people make up for the fact that they had deprivation when they were growing up.

Maybe the last thing is that saving money takes hard work. And the hard work that it takes is understanding where your money goes. A lot of doctors just don’t bother to take the time to understand where their spending is going. And they figure it’ll take care of itself or they’ll just continue to make a nice income. So they think there will never be a day of reckoning. And obviously, the day of reckoning is the day that they decide maybe they want to cut back. Maybe they don’t want to practice anymore. Maybe they’re not able to practice anymore. If they haven’t been doing the savings, that’s going to come back to hurt them.

ME: What percentage of their work income should doctors aim to replace when they retire?

: What we look at is how much a physician wants to be able to spend in retirement. And I would break this into two different cohorts. The first cohort is young and mid-career physicians. It’s very hard for those folks to get a handle on how much they want to be able to spend in retirement. If you were to ask a 40- or 45-year-old doctor, “How much do you want to be able to spend in retirement?” they don’t have a clue, nor really should they. That’s why at our firm, we use the 20% of gross income rule. As long as our clients are saving 20% of their gross income, we’re confident they will be on track to retire.

I’ve been doing this for more than 20 years. So I’ve had a chance to see how some of this stuff turns out, you know, the doctors who saved 25, 30, 35%, they’re in great shape. They can cut back when they want, they can retire when they want. The ones who were saving 10% don’t get to retire.

As far as the replacing income idea, sometimes we’re asked, “What number do I have to accumulate and then I can be done working?” And that obviously varies for everybody. We have clients who spend $4,000 a month in retirement, and they’re perfectly happy. And when we point out to them, “You could afford to spend a lot more than that,” they say, “No, we’re doing all the things we want to do, we’re enjoying life, spending more money would not bring us greater joy.” We have other clients who spend $20,000 a month.

Once people get closer to retirement, then it’s possible to run accurate retirement projections, because they have a good sense of what their baseline spending is. On top of that baseline spending, we break out health care as a separate expense, because we want to inflate that faster than regular inflation. We usually set aside a vacation bucket that runs until age 80. In our experience, a lot of our clients have pent-up desires to travel, and then at age 80 that gets cut back.

SoI guess it varies based on where they are in their life cycle. For younger doctors, saving 20% is good. If they’re behind on their retirement savings, then it should be more than 20%. And for those closer to retirement, we can run a real robust financial plan to tell them where they are.

ME: What are some of the savings plans that are available

: Most doctors are going to be familiar with the 401(k) or the 403(b) plans that they have at work. For those under age 50, they can put away $19,500 a year. And for those 50 and older, they can put in $25,000, All doctors, in my opinion should be maxing out their retirement savings vehicle.

One thing that we’ve been seeing is more and more retirement plans are allowing after-tax contributions to the 401(k) or 403(b).Traditionally, it was only pretax money you could put in, but now you can put in after-tax money. For younger physicians, who are under 40, we have them do after-tax Roth contributions to the 401(k). So no tax advantage now. But on the back end, they don’t have to pay any tax.

talking about retirement at a younger age?

: No. I know we all read about burnout and discontent. I don’t see people trying to get out early. What I will say is, I sometimes will have a client say to me, I need to be done at 60, and the numbers just don’t work in their case. What is very common in those cases is they work full time until 60. And then they cut back to 80% or 60% of an full-time equivalent. They try to workin the areas of their practice that they like better, and get rid of the parts they don’t like.

Doing that for three or five or seven years is incredibly powerful in that they’re happier. And they’re continuing to build their nest egg.

I have a client who has been working with me pretty much since I started in this practice. And at age 50 she went to half time, and now at 60 she just recently retired. And she told me the best thing she ever did was going to half time because she’s been able to do all the things that she wanted to do. I can tell you, my clients who go even to 90% of full time, they are so much happier. Their lives are much more their own.

Physician retirement planning tips

Despite recent pressures on physician profit margins, a physician’s income remains relatively high compared with that of the general public. Without the proper tax planning strategies in place, a physician could face some costly surprises.

In 2020, a physician filing a joint tax return with taxable income exceeding $414,701 is taxed at the 35% federal tax bracket, which goes to 37% if taxable income exceeds $622,051. The physician would also be subject to Social Security, Medicare and state income taxes, as well.

For most working physicians, the majority of their income will come from their paycheck or practice revenue. In retirement, though, physicians will likely rely on multiple different sources to generate income including investment income, IRAs, social security, and possibly even pension plans. Each type of income incurs different tax liabilities and will affect your “take-home” amount in different ways.

For example, contributions made to traditional retirement plans with pre-tax dollars during your working years will be taxed upon withdrawal in retirement as ordinary income, but Roth IRA contributions made with post-tax dollars will not be taxed when withdrawn. A portion of your social security benefit is taxed based on your overall income (from 0%-85% of the benefit), which means physicians’ benefits will likely be heavily taxed.

Understanding how your retirement income will be generated will give you an overall plan for how to withdraw the funds with the least amount of tax liability chipping away at your resources. It will also allow you and your financial adviser to plan ahead — working to avoid becoming “tax deferred” rich and owing a huge chunk of change each year in retirement.

When selling a security, the tax rate on the gain in a taxable account is determined by the length of time you have owned the security. Since selling securities may be part of your draw-down plan for generating retirement income, you’ll need to know at which rate your securities will be taxed. Long-term capital gains are taxed up to 15%-20% depending on income, and short-term capital gains are taxed as ordinary income, which could be as high as 37% depending on your marginal tax bracket. A security qualifies for long-term gains when it has been held for over a year.

Sometimes, it may be advisable to take tax losses to offset capital gains elsewhere. This is known as “tax loss harvesting” and involves the selling of certain investments that show a loss in order to offset the high capital gains rates on other securities being sold or taxed that year.

Be aware of the “wash sale rule,” which prohibits individuals from claiming a loss if the same or substantially similar security is purchased within 30 days of the sale.

Other tax-minimizing strategies are related to the practice retirement plan, and thanks to provisions of the 2019 SECURE Act, can now be implemented both in the accumulation and decumulation phases so long as the physician is earning wages from noninvestment income.Physicians should maximize their annual contributions to their retirement plans to:

variegate their retirement income between tax-free, tax-deferred, and tax-advantaged accounts;

and lower their taxable income during their working years.

In 2020, physicians under 50 can contribute $19,500 each year to their 401k accounts while physicians over 50 can put aside that same amount plus an additional $6,500 each year, which makes them able to contribute a total of $26,000 to a 401k annually. Pairing a 401k with a profit-sharing plan can further increase the annual contribution to $57,000 for those under 50 and $63,500 for those over 50.

Any amount that is contributed to a 401k is made with pre-tax dollars.

In previous years, physicians could only continue contributing to their IRAs until age 70½ when they were forced to begin taking Required Minimum Contributions (RMDs). However, the 2019 SECURE Act both extended the RMD age to 72 and eliminated the curtail on making contributions.

One caveat: the physician can only continue to make contributions past this date if he or she shows earned income not generated from investment accounts. This change will especially benefit those individuals who continue to work past age 72 in some fashion and allow a tax deduction for contributed funds.

Julianne F. Andrews, MBA, CFP, AIF, is a principal and co-founder of Atlanta Financial Associates. Send your financial questions to medec@mjhlifesciences.com

Why tax planning matters for your retirement

Physicians who have spent most of their working life building a practice often have no clue how much their business is worth. This lack of knowledge can affect retirement planning, create financial delays when applying for loans and allow inefficiencies to erode the overall value of the practice.

“I believe doctors should have this information so they know what their business as an asset is worth,” says Vincent M. Brinly, the CEO and director of valuation services at the Practice Valuation Group. “More often than not, it’s their most important asset; they need to know how to make it better, if possible.”

Knowing the value allows doctors to protect their investment with different forms of insurance that accurately reflect the total worth of their practice. Another advantage to having an accurate valuation done is to better connect a retirement plan that relies on the proceeds from a practice sale to the reality of the market.

“What someone thinks a practice is worth and what they can sell it for (are) sometimes different—and sometimes that difference can be a wide chasm,” says Brinly. “That’s why getting it valued by somebody who doesn’t have the blood, sweat and tears invested in it and is looking at it pragmatically from a third-party perspective is important.”

Experts agree that the most important decision is who to hire to perform the valuation. Although there are several industry designations (see sidebar) to help identify people with the right training, it is important to ask a lot of questions before hiring a professional.

“Make sure they are health care specific, because business valuation can range from valuing restaurants to retail and all kinds of other industries,” says Valora Gurganious, MBA, CHBA, a partner and senior management consultant at Doctors Management, a practice management consulting company. “You absolutely want to select a valuation analyst with expertise in health care, because there are so many intangible goodwill and other categories of value that the individual has to be trained (in) specifically on how to assess that value.”

Ask how many medical practices they have valued, what specialties they were, and in which regions of the country they were located, Gurganious suggests.

“The most catastrophic mistake a doctor can make is finding someone that doesn’t specialize in medicine,” says Brinly.

Once the doctor has chosen an expert, the valuation process proceeds in a similar manner as a doctor approaching a new patient. First, the valuation analyst will take a case history, with the doctor describing the practice and his or her goals. Next comes the physical examination of the financial records. This would typically include the last five years of tax returns, a copy of the income statements, accounts receivable broken down by provider and a breakdown between Medicare and private payer.

“They’ll also want to know what the accounts payable looks like, including any liabilities the practice has in place, (such as) any loans, notes (and) contractual agreements plus any hospital or health plan affiliations,” says Gurganious. “Clearly, they’ll be valuing the tangible assets of the practice, which would include furniture, fixtures (and) equipment—both medical and business—including how it’s been depreciated and if there is any residual value.”

Brinly says that the analyst will review where existing and new patients are coming from, and examine all the contracts with doctors and nonphysician providers.

“They’ll take all that information and compare the practice to benchmarks to see how they compare to their peers in certain metrics,” says Brinly. “We come to a decision on what’s going right with the practice, what’s going wrong and how that affects value.”

The entire process from start to finish usually takes about four to six weeks. Typically, there is a site visit, which may include additional interviews with key employees, such as a practice manager or other physicians. When the process is complete, the analyst will provide a report that explains how the final valuation number was reached, and what can be done to increase the value.

Valuation costs can be a percentage of the valuation, hourly charges for time spent calculating it, a fixed fee or some combination of these. Brinly advises making sure costs and budgets are clear before the process starts.

The reason the valuation is being conducted can change the time and scope of the process. For instance, if a small practice is being sold to another physician because the current owner is retiring, the commitment of the remaining employees is important, as is a transition plan to introduce patients to the new owner.

“The owner may provide some kind of incentive to stay once the practice is sold,” says Gurganious. “Maybe (the employees are) offered a bonus at the end of 12 months after the transition of ownership — anything to keep the stability so the new owner has confidence that the practice will look the same or better than before. They don’t want to worry about half the talent walking out the door.”

Likewise, with patients, transition time can add value for the buyer of a smaller practice where the goodwill relationship between doctor and patient is the main asset. “There has to be a proper transition plan set up where the doctor selling is going to introduce the buying doctor to ensure patients continue to flow to the practice,” says Brinly. “If you don’t, then there’s really not much value and that unfortunately plays out when doctors haven’t prepared. The timing of the valuation is very important.”

If retirement is the selling doctor’s goal, the earlier the valuation the better, as it allows time to fix inefficiencies and to sell before the value declines. “I’ve had many doctors come to me and say they are ready to get out and hang up the stethoscope, but they are down to two half-days a week,” says Brinly. “There’s just not a lot to sell there. (They have) to plan out when it’s time and when they want to get out.”

For practices receiving an offer of a buyout from a hospital, an asset-only valuation may be performed, which looks solely at the tangible assets and not the doctor’s goodwill with patients, says Randy R. Bauman, the CEO at Delta Health Care, which advises both hospitals and physicians on sales transactions. Although having your own valuation done to compare it with the hospital’s offer may make sense, for smaller practices, the cost of the valuation may exceed any impact on the selling price.

“Physicians should remember that the hospital’s valuation isn’t subject to negotiation,” says Bauman. “They are limited to the value determined by their independent appraiser. Valuations can be updated to correct errors in the data provided (by) the appraiser, reflect additional information, reflect changes in quantities and other pertinent information, but a negotiation between two competing valuations is not going to happen.”

For physicians going through a divorce proceeding, separate valuations may be performed with one expert representing each side. However, according to Gurganious, it is common to have both sides agree on which expert to use with the stipulation that both sides will accept the findings.

If a physician plans on selling the practice, maximizing its value becomes paramount. A valuation report will indicate which areas need the most help, but there are steps a practice can take to increase its value now.

Gurganious recommends taking at least a year to start implementing plans that will increase profits. “You are always going to be more attractive if the cash that the practice kicks off is higher, so any ways that expenses can be reduced or new service lines added, that should be done,” she says.

Aesthetic lines that can be run by nonphysicians can be an attractive addition to a practice buyer, as is subleasing unused space.

Make sure the structure of the practice is set up so that the practice can run without the physician doing everything. “If they’ve got a strong management team, a strong clinical team, and everyone operates like a well-oiled machine, that is highly valuable to someone acquiring the practice because they can come in on day one and just fit right in and begin to make money,” says Gurganious.

And don’t forget about the obvious items that can make a bad first impression on both patients and buyers: walls that need painted, outdated flooring, a poorly designed website and equipment in need of repair. “Nobody wants to buy something that’s rundown,” says Gurganious. “Take that year and get the house in order, and from a fiscal standpoint, driving revenue is key, as is reducing expenses as much as possible.”

Experts say physicians need to be prepared for a valuation that may be lower than what they personally think it’s worth, especially those doctors running smaller practices.

“I think it’s understandable, because they have put in all of those decades’ worth of work,” says Brinly. “They started it from nothing, or they bought it from another doctor who was retiring and spent the next 30 years building on that.”

“I remind my physician clients that, in general, whatever value they have created through their hard work, they have taken home in compensation and profits over the years,” says Bauman.

By creating goals and timelines, physicians have more time to get the best return for their hard work.

“A practice has more value when you plan ahead,” says Brinly. “Selling the practice in the declining phase of its life cycle is not going to net you as much value as selling it in the growth or mature phase. The more you plan and get the valuation done early, the more time that you can make course corrections to increase that value.”

How much is your practice really worth?

If resuming clinical operations during a pandemic were as simple as flipping a switch and welcoming patients back, health care providers across the country would be in a very different situation. COVID-19 has completely upended clinical operations, requiring a “new normal” going forward.

As you develop a plan for successfully resuming operations, you’ll need to answer many fundamental questions. How will I keep patients safe? How will I protect my staff? How many staff do I need? How can we leverage data to be nimbler and more responsive? Centers for Medicare & Medicaid Services and the American Medical Association have published helpful guides on restarting nonemergency clinical care.

The reopening experiences of a high-volume outpatient clinic can provide several valuable lessons. This clinic focused on three principal areas of importance: safely serving patients, ensuring staff safety and resuming operations.

Patient safety was the top priority. The clinic quickly established a robust pre-screening process to keep individuals who may have been exposed to or were experiencing symptoms of COVID-19 away from the outpatient setting, and triaged them to a COVID-19 screening center. The pre-screening also incorporated scripting that allowed the clinic’s staff to communicate to patients any changes that had been implemented to keep them safe.

Initially this pre-screening process was entirely manual and involved the time of countless staff members. The clinic’s goal was to transition as much of this screening to digital as possible. A two-phased plan was developed to bring patient pre-screening online. After just six weeks, more than half of the clinic’s patient pre-screening was being done electronically. This enabled staff to do additional work with patients in the clinic and spend more time on the phone with patients who reported positive symptoms during the pre-screening process.

Understanding the importance of rapid communication to patients, the team quickly revamped an existing website and repurposed it to provide critical updates for patients. This included information on visitor restrictions, changed hours of operation and facility changes to maintain social distancing, as well as the clinic’s enhanced cleaning protocols.

Most critical in terms of patient safety were the changes the clinic made to scheduling, which ensured patient appointments did not overlap and that there would be ample time between appointments to clean equipment and shared spaces. The clinic’s prior scheduling templates were modified and reduced by 30%, subsequently extending the clinic’s hours to accommodate a volume comparable to pre-COVID-19.

Ramping up clinical capacity also meant thinking differently about keeping staff safe while also providing care. The same safety measures for patients were also applied to staff, such as requiring wearing of masks and social distancing. For clinic staff, physical distancing proved the most challenging, as staff had previously worked in close proximity. To counteract this, the clinic began staggering staff schedules and placed limits, based on office square footage, on the number of staff members.

The clinic also established an all-staff screening program for exposure to COVID-19 and symptoms of COVID-19, similar to the one used for patients. The clinic is investigating the feasibility of t testing for all of its frontline workers.

While patient and staff safety were the clinic’s priorities, there was still a need to provide clinical care and resume revenue-generating activities. After severely minimizing its clinical activity to only the most urgent of patient cases, the department faced a significant backlog of outpatient appointments that had been canceled. The combination of rescheduled appointments and new volume could not fit within the newly reduced capacity. The clinic began using patient visit data to determine appropriate staffing levels and created dashboards to project volumes and hours of operation to match demand and revenue requirements.

With daily operational changes in the clinic a new norm, daily huddles enabled staff members to assess what was working well and what needed to be changed. These daily huddles allowed staff members to respond more swiftly to quickly changing operational dynamics.

Liz Aron is a consultant with Freed Associates, a California-based health care management consulting firm. Send your practice management questions to medec@mjhlifesciences.com.

COVID-19 has completely upended clinical operations, requiring a “new normal” going forward.

Learn from a medical practice that reopened during COVID-19

As the COVID-19 pandemic and shutdown kept people at home to avoid getting sick, especially those with chronic health conditions, experts recommended remote patient monitoring (RPM) as a solution to continuity of care. With forethought and the right technology on board, RPM can be a good complement to telehealth, allowing physicians to receive data about their patients’ in real time.

The most commonly used RPM devices track essential vital signs such as blood pressure, heart rate, blood glucose levels, oxygen saturation and temperature. There are also RPM devices for nervous system signals, weight, patient activityand sleep.

“As we gain more experience with RPM, we’ll figure out even more clinical conditions that it can help us with,” says Richard L. Seidman, M.D., MPH, chief medical officer of L.A. Care Health Plan.

In fact, his practice has been using RPM in a prenatal pilot to reduce the number of times pregnant women visit their doctor’s offices in person. Women in this pilot take their blood pressure and weigh themselves daily at home, then transmit that information to their doctors.

Physicians at the leading edge of RPM have adopted remote spirometry for to monitor patients with chronic obstructive pulmonary disease (COPD) and asthma, a population at high risk for COVID-19.

A big benefit RPM is that many systems don’t need to rely upon patient reporting their data. This is especially helpful for patients with conditions such as diabetes, which are subject to many incremental changes between physician visits. With RPM, crucial data can be transmitted to the doctor instantly, such as medication adherence and A1c.

RPM cannot replacein-person clinical visit, but it’s an essential tool alongside taking a good history, says Abe Malkin, M.D., MBA, founder and medical director of Concierge MD LA, a concierge practice.

“In primary care, once you have a really good history, you can almost make your determination. You use the physical exam to confirm that diagnosis. So [RPM] is sufficient to make diagnoses with a high level of comfort,” Malkin says. “It won’t replace in-person visits, but as we get more comfortable with it, it will give better access to care.”

Seidman adds that RPM is a great complement to telehealth, which is quickly becoming the standard for seeing patients during the COVID-19 pandemic.

For physicians who wish to begin adopting RPM or increase its usage in their practice, “the first thing is to define the highest yield monitoring that you think you need to do as part of your practice,” says Joel Klein, M.D., senior vice president and chief information officer at the University of Maryland Medical System in Baltimore. “Really define what problem you’re trying to solve.”

For physicians who have a large chronic care population, it may be wise to start with just one, he says.

Let’s say a physician chooses monitoring blood glucose. It’s important to use an RPM technology that allows a physician to see the big picture of the data, Klein says. “You need the ability to get insights from it.”

With insights, however, comes responsibility, Klein says. This RPM may show danger signals such as a patient who is hypoxic or with a dangerous blood sugar level. “What are you going to do with that information?” he asks. Physicians need to think about their obligation and how to set the patient up for success.

In order to access the RPM data, most physicians will need a telehealth platform that interfaces with their EHR. A physician’s vendor can help find the best platform to sync with the EHR, Malkin says.

Identifying the patient populations a physician will treat with RPM also is critical to narrowing the software or platform choice. “I would start with taking patients who feel their symptoms lend more to a telehealth exam,” Malkin says.

Additionally, Malkin suggests physicians look for RPM technology that is easy for patients to use at home, whether it be a blood pressure cuff, glucose monitor, pulse oximeter or another device.

RPM may offer an increased revenue stream for physicians whose income is negatively affected by COVID-19. Medicare waivers have made it possible for physicians to bill for services done remotelywithout having to bring patients in.

Additionally, many of the platforms may help physicians defray costs early on by taking a higher cut of the revenue, but eventually physicians can increase their revenue.

Physicians may not be aware of how many aspects of RPM are reimbursable, as well, says Adam Powell, Ph.D., president of Payer+Provider Syndicate, a Boston-based health care consulting firm.

Initial setup of the device and patient education: 99453.

An additional code that can be billed each 30 days for supplying the device: 99454.

20 minutes or more of clinical staff, physician or other qualified health professional time in a calendar month requiring interactive communication with the patient or caregiver: 99457.

Collection and interpretation of physiological data digitally stored and transmitted to the patient and/or caregiver, to the physician or qualified health professional: 99091.

With forethought and the right technology on board, remote patient monitoring can be a good complement to telehealth, allowing physicians to receive data about their patients’ in real time.

Benefits to remote patient monitoring 

In the medical billing and coding field, getting paid requires accurate documentation and selecting the correct codes. In our Coding Case Studies, we will explore the correct coding for a specific condition based on a hypothetical clinical scenario. This scenario involves a patient presenting with symptoms of chronic obstructive pulmonary disease (COPD); see if you can choose the correct codes.

 over the last week. The problem has been gradually worsening. The cough is nonproductive. Associated symptoms include rhinorrhea, a sore throat, shortness of breath and wheezing. Pertinent negatives include no chest pain, chills, fever, headaches or myalgias. Symptoms are aggravated by lying down. Patient has tried a beta-agonist inhaler for the symptoms. The treatment provided no relief. There is no history of pneumonia.

Patient denies any history of lung problems. Had this same issue in September treated with Medrol Dosepak (methylprednisolone) and azithromycin.

In October, the same issue was treated with Medrol Dosepak and Augmentin (amoxicillin and clavulanate). Wife states that patient has had moderate relief with past treatment but breathing problem has not completely gone away.

Constitutional: Positive for fatigue. Negative for chills and fever

HENT: Positive for congestion, rhinorrhea and sore throat. Negative for sinus pressure, sinus pain and trouble swallowing

Respiratory: Positive for cough, chest tightness, shortness of breath and wheezing

Cardiovascular: Negative for chest pain and leg swelling

Gastrointestinal: Negative for nausea and vomiting

Musculoskeletal: Negative for arthralgias and myalgias

Neurological: Negative for dizziness, light-headedness and headaches

Psychiatric/Behavioral: Negative for confusion

Constitutional: Patient is oriented to person, place and time.

Pulmonary/Chest: Accessory muscle usage present. He has wheezes in the right upper field and the left upper field. He has rhonchi in the right middle field, the right lower field, the left middle field and the left lower field.

Neurological: He is alert and oriented to person, place and time.

Psychiatric: He has a normal mood and affect. His behavior
is normal.


DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL nebulizer solution; 3 mL doxycycline hyclate 100-mg tablet; Deltasone (prednisone) 20-mg tablet

Patient given nebulizer treatment in clinic. Lungs improved, but still have expiratory rhonchi and wheezes. Patient reports breathing is easier but still somewhat tight.


Code also type of asthma, if applicable (J45.-)

Use additional code to identify:

exposure to environmental tobacco smoke (Z77.22)
history of tobacco dependence (Z87.891)
occupational exposure to environmental tobacco smoke (Z57.31)
tobacco dependence (F17.-)
tobacco use (Z72.0)

>>Chronic obstructive pulmonary
disease with (acute) lower respiratory infection 

>>Chronic obstructive pulmonary
disease with (acute) exacerbation 

>>Chronic obstructive pulmonary
disease, unspecified 

This scenario involves a patient presenting with symptoms of chronic obstructive pulmonary disease (COPD); see if you can choose the correct codes.

Coding case study: COPD

Even before COVID-19 began causing respiratory distress around the globe, experts say the United States was experiencing a respiratory crisis. More than 16 million Americans have been diagnosed with chronic obstructive pulmonary disease (COPD), according to the National Heart, Lung, and Blood Institute, and many millions more may be living with it undiagnosed. Experts have been weighing in on the best practices for treating COPD, particularly in light of the changing restrictions imposed by COVID-19.

“COVID-19 is only highlighting the crisis we have faced previously and helping us ask how do we better treat our patients with these chronic respiratory diseases,” says Laren Tan, M.D., director of the Comprehensive Program for Obstructive Airway Diseases at Loma Linda University Health in California.

Tan says that prevention should be the most important goal for physicians treating COPD, as “we don’t want progression of disease.”

Prevention starts with an accurate diagnosis, according to MeiLan Han, M.D., a professor of medicine in the Division of Pulmonary and Critical Care at the University of Michigan in Ann Arbor. She says there are problems with both overdiagnosis and underdiagnosis here in the U.S.

“Many primary care providers don’t order pulmonary function testing,” she says, referring to the spirometry test, the best way to make a COPD diagnosis.

Unfortunately, in the time of COVID-19, pulmonary function tests pose a health hazard because they generate aerosols, which makes the tests challenging to carry out.

Han laments that there is no standard questionnaire to help diagnose COPD as there are for other chronic disorders, such as diabetes, high blood pressure or high cholesterol, other than the COPD assessment test (CAT).

“[Due to COVID-19] it’s as though we’re going back to an earlier stage in medicine where we (don’t) even have the technology of the stethoscope and (have) to focus on what the patient is telling you, what you can hear in their voice and the way they’re talking and breathing,” says Madelyn Rosenthal, M.D., assistant professor of pulmonary and sleep medicine, and codirector of the Martha Morehouse Pulmonary Rehabilitation Program at The Ohio State University Wexner Medical Center in Columbus, Ohio.

She says the difficulty of diagnosing COPD makes it important to do a thorough history of exposures beyond tobacco, including “any environmental exposures such as chemicals, toxins, coal burning stove with poor ventilation, etc.”

Because many symptoms of asthma, bronchitis and COPD overlap, Rosenthal says physicians should “make sure you know what (patients’) triggers are.”

Diagnosis is also made more challenging by the shift to telehealth due to COVID-19. Though telehealth does allow for continuity of care, many physicians agree that it is not ideal for working with patients who have COPD.

Andrew Martin, M.D., chair of the Deparment of pulmonary medicine at Deborah Heart and Lung Center in Browns Mills, New Jersey, shared his experience regarding a patient who called in asking for a refill on an inhaler because of increased shortness of breath. He felt he couldn’t determine the man’s condition over the phone and insisted the patient come in to the office. In person, he realized the man was experiencing heart failure. “Telehealth is good for follow-ups but I don’t use it for an initial visit or evaluating unless I know the patient really, really well,” Martin says.

Once a diagnosis is confirmed or known, physicians can begin to make or continue a treatment plan. Martin’s motto is, “Protocols are nice, but they are no substitute for paying attention.” He treats each patient with COPD as an individual case. “Doctors are not paid to check off boxes and click algorithms—spend time with your patients, ascertain whether they are doing normally or abnormally for themselves, or if disease is progressing,” he suggests.

The most important step in treatment is helping patients cease smoking if they are still smoking, Martin says. That could mean getting them on a medication proven to help, such as bupropion or varenicline, or adding in a nicotine replacement option.

“Smoking itself needs to be thought of as a chronic disease with all kinds of bad health outcomes,” says Benjamin J. Seides, M.D., M.P.H., director of interventional pulmonology at Northwestern Medicine in Winfield, Illinois. “There is nothing we can do for (you) that is as beneficial as quitting smoking, no matter what stage of COPD you have,” adds.

He opts for a harm reduction model. “My philosophy is that if you need to usenicotine replacement for the rest of your life, then use it, because it’s way better than the alternative.”

After handling smoking cessation, Martin turns to three common types of medication to prevent flare-ups and exacerbations: inhaled steroids to reduce inflammation, long-acting bronchodilators to open airways, and anticholinergics to reduce mucous secretions.

A more recent formulation with fluticasone furoate, umeclidinium and vilanterol offers all three medications in one inhaler, which can improve patient adherence and even outcomes, says Seides.

As research varies on which patients should be taking inhaled steroids, which are linked to an increased risk for pneumonia and other infections, Han recommends checking the blood eosinophil levels for high-risk patients, which will give a more accurate sense of who needs to be on steroids.

For more extreme cases where lungs have been severely affected due to emphysema, some patients may qualify for valve placement, Han says. “Emphysema destroys the natural elasticity of the lung, so it’s like a really old rubber band. By taking diseased tissue out you provide more room for the diaphragm to move the lung up and down, and the valve helps the lung de-gas,” she says.

Yet another new treatment is currently in phase three clinical trials, known as targeted nerve denervation, explains Seides. “(It’s) a bronchoscopic therapy where you burn the vagus nerve to reduce vagal tone to the lungs, which helps treat the chronic bronchitis phenotypes.”

Lastly, Tan encourages physicians to remind their patients of basic lifestyle behaviors such as exercise, at whatever capacity they are capable and healthy diet.

When patient adherence is an issue, David Hatfield, D.O., chief medical officer of Hatfield Medical Group, a family practice in Arizona, likes to give his patients a vision of what their health can look like months down the road if they stick to their treatment plan. “Remind them that while COPD is not curable, it is reversible.”

He also encourages learning more about the barriers to patients’ ability to stick to a plan.

“Maybe they have a friend that took a medicine that didn’t sit well with them and now they don’t want to try it,” he says. “Listen to them, understand their concerns.”

Keeping patients with COPD healthy also goes a long way toward improving quality metrics that may affect a physician’s reimbursement. Medicare penalizes physicians whose patients are readmitted to the hospital within thirty days of a discharge.

“The minority ends up costing the majority of health care utilization. The goal is to reduce that utilization, especially during COVID-19,” says Tan.

Han’s health system established a transition-of-care clinic that follows up with anyone who has been hospitalized for COPD exacerbation or flare within 7 to 14 days of discharge. Smaller practices could hire a care coordinator, Hatfield recommends.

Moreover, helping patients with COPD stay healthy can minimize what Tan calls the downstream costs of health care on clinic staff, who could be doing less calling and follow-up.

“No outcomes, no income,” Hatfield concludes.

The best practices for treating COPD, particularly in light of the changing restrictions imposed by COVID-19

How to manage COPD patients during COVID-19

When the COVID-19 pandemic started to sweep through the United States, primary care physicians saw the number of office visits either dramatically drop or cease all together. Between lockdowns that encouraged people to stay home and fearful patients who didn’t want to risk potentially exposing themselves to the virus, many doctors saw their livelihoods threatened as appointment cancellations piled up.

As a result, the Centers for Medicare & Medicaid Services changed Medicare payment policies to reimburse telehealth visits for a wider range of care, and some Health Insurance Portability and Accountability Act (HIPAA) restrictions were temporarily loosened to make it easier for doctors to communicate with their patients through whatever devices they chose. Prior to the pandemic, telehealth would only be reimbursed by Medicare for limited circumstances, such as patients living in rural areas with little access to care. The communication changes removed requirements for patients to only use often clunky HIPAA-compliant platforms, opening up the ability to use smartphones and increasing consumer convenience. Most private payers also followed Medicare’s lead and changed their reimbursement policies.

“The fear from patients and the change in payment policies really drove and facilitated an incredibly high spike in demand for telehealth,” said Anders Gilberg, senior vice president, government affairs, for Medical Group Management Association.

Practices with telehealth capabilities quickly ramped up their capacity, while others installed the technology needed to conduct remote visits. According to the 

® 2020 Telehealth-EHR survey, more than 77% of doctors surveyed used telehealth for the first time because of COVID-19.

“It was a lifeline [for] medical practices,” Gilberg said. Patients and doctors alike embraced the technology and the convenience, and practices began to collect income again.

Gabe Charbonneau, M.D., a family physician in Stevensville, Montana, saw the number of in-office visits plummet early in the pandemic. “We really quickly ramped up doing telemedicine, and about half of our visits were on Zoom,” he said. “Because it was such a financial hit, there was a lot of pressure for us to figure out how to get people back in for visits.”

The pandemic quickly proved that telehealth could be a lifeline for practices.

“If there’s a silver lining to this pandemic, it’s the advances made in telehealth,” said Thomas Ely, D.O., president of the American Osteopathic Association.

But as the intensity of the pandemic wanes and people are becoming more comfortable returning for office visits, the future of telehealth is in question. “We had practices at one point that were almost doing 100% telehealth visits, but that has come down considerably, even though the payment policies from Medicare are still in place,” Gilberg said.

Charbonneau saw his practice’s telehealth visits drop as patients shifted back to in-office visits. “Some days, we might have two or three telehealth visits, if that,” he said.

When the public health emergency ends, so will the changes that have made telehealth viable, Gilberg says. “In order to make telehealth permanent, it needs to have a viable reimbursement structure behind it, and it’s only going to be permanent if Congress steps in at the federal level.”

While there is interest from both Democrats and Republicans in making such changes, there are unanswered questions about telehealth in the long term.

Despite telehealth being a great solution to some challenges the pandemic created early on, there are still questions that Congress will want answered before making any permanent changes to reimbursement for telehealth.

“I think Congress may not necessarily be looking at full, permanent telehealth coverage, but perhaps an effort to cover it beyond the public health emergency, and then [Congress can] study what its impact is on utilization, cost and quality,” Gilberg said. “It still remains to be seen whether you can provide the same quality of service without a hands-on approach with the patient.”

In some areas, such as behavioral health, where a physical examination may not be needed and a patient might be more comfortable not being in a doctor’s office, it might be an easier sell to Congress to allow for more telehealth. The same goes for chronic care management, where a simple check-in may be all that’s required.

But will telehealth still have the same appeal if it’s more difficult to use once the public health emergency is over?

“It’s likely to be limited to HIPAA-compliant platforms, so no more just dialing up your physician on FaceTime or Zoom or something like that,” Gilberg said. “Consumers today, they demand a certain degree of convenience, so there’s that aspect. Then there’s also, especially among the Medicare population, I think they trust that when they go to the doctor they prefer a hands-on examination,” he said.

Congressional leaders, who have already expressed concerns about rising health care costs, also have to wrestle with the idea that a more convenient telehealth service might be unaffordable.

“One of the reasons that telehealth expansion in Medicare hasn’t really become a reality yet is because there has been a concern that if you have broad coverage, that it would increase volume and potentially increase unnecessary care, because it’s just too convenient,” Gilberg said. “The Congressional Budget Office believes it would increase Medicare volume on the physician side and therefore potentially drive up costs of the program to the government. The other side of that is, if you can do some of the preventive things more conveniently and keep patients out of the hospital, that will, in the long run, save money from expensive in-patient types of utilization.”

Even if Congress makes telehealth policy changes permanent, reimbursement rates would likely be lower for virtual visits than they are now. “CMS determined that physicians would largely [have lower] overhead costs and fewer practice expenses when they utilize telehealth, even though I don’t think most medical practices would agree with that,” said Gilberg, who added that the reimplementation of all HIPAA requirements would necessitate using a compliant platform, which entails vendor costs to the practice. “And prior to the pandemic, telehealth visits were reimbursed less than in-person visits, at least in Medicare.”

Most private payers tend to follow whatever Medicare does when it comes to reimbursement, so when Medicare boosted telehealth, most of them did the same. While private insurers remain interested in telehealth, it may not be a boon for private practices, even if they decide to continue reimbursement after the public health emergency ends.

Telehealth came to the forefront of medicine when the pandemic first hit, but how much of a future it has remains in question.

Medical Economics November 2020