Jumping into primary care

Jumping into PrimaryJumping into Primary
CareCare
Kimmer Collison-RisKimmer Collison-Ris
MSN, ARNP, WOCNMSN, ARNP, WOCN

Taking on a New RoleTaking on a New Role
 Find a mentor matchFind a mentor match
 Understanding the learningUnderstanding the learning
curvecurve
 Know what you knowKnow what you know
 Study-study-studyStudy-study-study
 Simplify your home lifeSimplify your home life
 Build routines into your weekBuild routines into your week
 Build in a day of restBuild in a day of rest

Preparing for the visitPreparing for the visit
 Work with your MAWork with your MA
 Know what your RN’s doKnow what your RN’s do
 Delegate when you canDelegate when you can
 Know your patient roomsKnow your patient rooms
 Know your daily scheduleKnow your daily schedule
 Know how long procedures takeKnow how long procedures take
 Know how to billKnow how to bill
 Chart as you goChart as you go
 Plan on 15 min for a visitPlan on 15 min for a visit
 Keep your visit straight forwardKeep your visit straight forward
 Know when to referKnow when to refer

Types of Patient visitsTypes of Patient visits
 1 problem (approx 15 min)1 problem (approx 15 min)
 Assess each system above & downAssess each system above & down
 Know when to include anotherKnow when to include another
systemsystem
 Culture, peak flow, treat as you goCulture, peak flow, treat as you go
 Chart as you goChart as you go
 Account for time spentAccount for time spent
 Plan f/u visit for other issuesPlan f/u visit for other issues

ProceduresProcedures
 Plan ahead & schedule apptPlan ahead & schedule appt
 Can only do on same visit if newCan only do on same visit if new
patientpatient
 Can’t do w/office visit on sameCan’t do w/office visit on same
dayday
 Plan (30-40 min)Plan (30-40 min)
 Know what you can do in officeKnow what you can do in office
 Know when to refer!!!Know when to refer!!!

Being preparedBeing prepared
 Know your daily scheduleKnow your daily schedule
 Know your “go to resource”Know your “go to resource”
 Carry a couple reference booksCarry a couple reference books
 Carry paperwork w/youCarry paperwork w/you
 Know recent labs/studies performedKnow recent labs/studies performed
 Do cultures/dips/sats/screensDo cultures/dips/sats/screens
 Plan next f/u visitPlan next f/u visit
 Enlist MA or Nurse assistanceEnlist MA or Nurse assistance
 Know where local resources areKnow where local resources are

Mid-Level CareMid-Level Care
 Different than student roleDifferent than student role
 Can feel overwhelmingCan feel overwhelming
 Designed for PE’s, wcc’s, episodicDesigned for PE’s, wcc’s, episodic
care, chronic care, & urgent carecare, chronic care, & urgent care
 Increases patient access to careIncreases patient access to care
 Frees MD’s for complex careFrees MD’s for complex care
 Temptation to work out of scopeTemptation to work out of scope
 Need to “tag-team” with MDNeed to “tag-team” with MD
 Know roles/scope of MA’s, Nurses, &Know roles/scope of MA’s, Nurses, &
Office staffOffice staff

New ExperienceNew Experience
 Interpreting odd Lab dataInterpreting odd Lab data
 Interpreting odd diagnostic testsInterpreting odd diagnostic tests
 Keeping visits simple/shortKeeping visits simple/short
 Charting in “real time”Charting in “real time”
 Constant flow of patientsConstant flow of patients
 Temptation to skip breaksTemptation to skip breaks
 Temptation to “do it all”Temptation to “do it all”
 Temptation to do proceduresTemptation to do procedures
 Temptation to work out of role/scopeTemptation to work out of role/scope

Know Practice ExpectationsKnow Practice Expectations
 How many patients dailyHow many patients daily
 Charting expectationsCharting expectations
 Patient follow up expectationsPatient follow up expectations
 Know practice reimbursementKnow practice reimbursement
 Know practice philosophy of careKnow practice philosophy of care
 Know role of practice managerKnow role of practice manager
 Who is your boss?Who is your boss?
 Know practice medical director roleKnow practice medical director role
 Know when to interrupt someoneKnow when to interrupt someone
 Know practice expectation of staffKnow practice expectation of staff

General Family PracticeGeneral Family Practice
 Philosophy of carePhilosophy of care
 Make up of Pediatrics/Adults/GeriatricsMake up of Pediatrics/Adults/Geriatrics
 Charting Requirements for reimbursementCharting Requirements for reimbursement
 Coding Requirements for reimbursementCoding Requirements for reimbursement
 ““Leaky Boat” to a practiceLeaky Boat” to a practice
 High % of HMO, Medicade, Medicare, chronic woundHigh % of HMO, Medicade, Medicare, chronic wound
carecare
 Money MakersMoney Makers
 Labs, proceduresLabs, procedures
 CosmeticCosmetic
 % of Practice Patients% of Practice Patients
 MedicadeMedicade
 MedicareMedicare
 HMO’sHMO’s
 Private PayPrivate Pay
 InsurersInsurers

Surgical PracticeSurgical Practice
 Know pt mixKnow pt mix
 Know insurers/reimbursement foKnow insurers/reimbursement fo
 ConsultationsConsultations
 ProceduresProcedures
 Your role frees up SurgeonsYour role frees up Surgeons
 Surgical assist is reimbursableSurgical assist is reimbursable
 Cosmetic procedures make $Cosmetic procedures make $
 Know your scope of practiceKnow your scope of practice
 Know practice philosophyKnow practice philosophy
 Know expected work & on call hoursKnow expected work & on call hours

Specialty PracticeSpecialty Practice
 Know patient mixKnow patient mix
 Know philosophy of careKnow philosophy of care
 Know your expected roleKnow your expected role
 Know how you benefit practiceKnow how you benefit practice
 How do you bring in moneyHow do you bring in money
 Know reimbursement differencesKnow reimbursement differences
 ConsultationConsultation
 Stream-lined care, specializedStream-lined care, specialized
 Usually affords more timeUsually affords more time
 Know money-pitsKnow money-pits
 Know money makersKnow money makers

Becoming a Smart ProviderBecoming a Smart Provider
 Fill out your own paperworkFill out your own paperwork
 Know your numbersKnow your numbers
 Know Coding/billing/reimbursement processKnow Coding/billing/reimbursement process
 Consider becoming a P.S.Consider becoming a P.S.
 Carry your own Malpractice InsuranceCarry your own Malpractice Insurance
 Get an accountant (file quarterly)Get an accountant (file quarterly)
 Know your tax write-offsKnow your tax write-offs
 Get quickbooks and record receipts dailyGet quickbooks and record receipts daily
 Employee, Consultant, Sub-ContractorEmployee, Consultant, Sub-Contractor
(Locums)(Locums)
 Signing up w/insurersSigning up w/insurers
 Medicare (know probs & pitfalls)Medicare (know probs & pitfalls)
 Regence, Premera, UniformRegence, Premera, Uniform
 HMO’s expectationsHMO’s expectations
 MedicadeMedicade

Charting the basicsCharting the basics
 Write out chief complaint cc:Write out chief complaint cc:
 State new or “pt is new to me”State new or “pt is new to me”
 Write out timing, duration, location, severity, worseningWrite out timing, duration, location, severity, worsening
sxsx
 Include pertinent (+) and (-)Include pertinent (+) and (-)
 ROS (at least 2)ROS (at least 2)
 Exam (1 system up, 1 system down, others asExam (1 system up, 1 system down, others as
indicated)indicated)
 Assessment: Dx &/or diff. dxAssessment: Dx &/or diff. dx
 Determine stability, acute, chronic, worseningDetermine stability, acute, chronic, worsening
 Plan of care: address all pointsPlan of care: address all points
 If referring use “consultation”If referring use “consultation”
 Describe when f/u will occurDescribe when f/u will occur
 Include labs reviewed/discussed/MD specialistsInclude labs reviewed/discussed/MD specialists
conferred withconferred with
 Include rx meds orderedInclude rx meds ordered

MedicalMedical
Coding/ReimbursementCoding/Reimbursement
Remember that carrying out care is differentRemember that carrying out care is different
than what you learned in schoolthan what you learned in school
Need to know the basics to include in chartingNeed to know the basics to include in charting
to meet coding criteriato meet coding criteria
Always include amt of time spentAlways include amt of time spent
assessing/counseling if poss to help visitassessing/counseling if poss to help visit
codecode
Know difference between new, estab,Know difference between new, estab,
consultation, well visit, and timed visitconsultation, well visit, and timed visit
Write out detail diagnosis codes or addWrite out detail diagnosis codes or add
descriptorsdescriptors
If poss use more than 1 dx to help justify yourIf poss use more than 1 dx to help justify your
codecode

Coding/ReimbursementCoding/Reimbursement
 You need to know as much as medical coderYou need to know as much as medical coder
(your totally responsible)(your totally responsible)
 Know procedures need body identification andKnow procedures need body identification and
code and have return time requirementscode and have return time requirements
 Know office visits (OV) and proceduresKnow office visits (OV) and procedures
generally can’t be billed on same day unlessgenerally can’t be billed on same day unless
new and require code “25”new and require code “25”
 Know code modifiersKnow code modifiers
 Reimbursement classes from medical billersReimbursement classes from medical billers
vary per practice settingvary per practice setting
 Can’t bill for visit same day as other specialistCan’t bill for visit same day as other specialist
visit for Medicare pts as is consideredvisit for Medicare pts as is considered
“duplication of services”“duplication of services”
 Medicade coding is differentMedicade coding is different

How to get paid/reimbursedHow to get paid/reimbursed
 Know Credentialing ProcessKnow Credentialing Process
 Know Cash reimbursement rulesKnow Cash reimbursement rules
 Can’t charge non-insured less thanCan’t charge non-insured less than
reimbursed for by insurers or consideredreimbursed for by insurers or considered
fraudfraud
 Can’t pay someone’s co pay or licensure canCan’t pay someone’s co pay or licensure can
be revokedbe revoked
 Know HMO rules before signing upKnow HMO rules before signing up
 Know how your practice is paidKnow how your practice is paid
 Can’t “forgive” debt unless funding is set upCan’t “forgive” debt unless funding is set up
 If private practice, find reliable subcontractedIf private practice, find reliable subcontracted
medical biller and call their referencesmedical biller and call their references
 Match charting to coding on fee slipMatch charting to coding on fee slip

Organizing your timeOrganizing your time
 First: look at daily scheduleFirst: look at daily schedule
 Review abn labs, pass normals to MA to call ptReview abn labs, pass normals to MA to call pt
 Have MA room pt as arrivesHave MA room pt as arrives
 Don’t double bookDon’t double book
 Keep visits to around 15 minKeep visits to around 15 min
 Clean as you go in roomClean as you go in room
 Clarify needs to MAClarify needs to MA
 Ask for teaching help from RNAsk for teaching help from RN
 Send pt for necessary tests, sched f/uSend pt for necessary tests, sched f/u
afterwardsafterwards
 In pt visit: Pick 1 or 2 probs onlyIn pt visit: Pick 1 or 2 probs only
 Carry resource books w/youCarry resource books w/you
 Keep interruptions to minimumKeep interruptions to minimum
 Get your lunch, leave the facility-re energiesGet your lunch, leave the facility-re energies
 Get help if need second opinionGet help if need second opinion

Keeping an office visit on trackKeeping an office visit on track
 After “hello” _____________After “hello” _____________
 What can I do for you today? (cc) have themWhat can I do for you today? (cc) have them
pick top 2pick top 2
 Let them they can set up add’l appt for otherLet them they can set up add’l appt for other
issuesissues
 Explain you want to ask specific questionsExplain you want to ask specific questions
 Chart as you go your observations and whatChart as you go your observations and what
they saythey say
 Assess system up and down of cc:Assess system up and down of cc:
 If you find other things may need sep. apptIf you find other things may need sep. appt
 Exam & ask clarifying questionsExam & ask clarifying questions
 Explain observations as you goExplain observations as you go
 Discuss poss tx/tests as you goDiscuss poss tx/tests as you go
 Teach & Type-stating when to call/seek careTeach & Type-stating when to call/seek care
 State visit finished end w/giving rx/apptState visit finished end w/giving rx/appt

Plan for Patient EncountersPlan for Patient Encounters
 Know visit: components, worrisome findings,Know visit: components, worrisome findings,
gen tx/meds, tests to order, pt education, f/ugen tx/meds, tests to order, pt education, f/u
 Practice visit types:Practice visit types:
 New born examNew born exam
 Jaundice/poor feeding NB examJaundice/poor feeding NB exam
 Well childWell child
 Well adultWell adult
 Sick childSick child
 Sick adultSick adult
 Initial, f/u, & emergency OB visitInitial, f/u, & emergency OB visit
 Postpartum f/u visitPostpartum f/u visit
 Chronically ill adultChronically ill adult
 Urgent care type visitsUrgent care type visits
 Emergency type visitsEmergency type visits

Balancing Work/Home LifeBalancing Work/Home Life
 Your family is your lifeYour family is your life
 Don’t sacrifice your spouse/S.O.Don’t sacrifice your spouse/S.O.
 Don’t sacrifice your kids-set time asideDon’t sacrifice your kids-set time aside
 Learn to say “no”Learn to say “no”
 Incorporate daily/weekly routinesIncorporate daily/weekly routines
 Know you can’t “do it all”Know you can’t “do it all”
 Make time to studyMake time to study
 Make time to exerciseMake time to exercise
 Plan out meals aheadPlan out meals ahead
 Keep work out of family timeKeep work out of family time
 Don’t talk to patients at homeDon’t talk to patients at home
 Date your spouse/S.O.Date your spouse/S.O.
 Plan out vacation/away timePlan out vacation/away time

Building your C.V.Building your C.V.
-Work history-Work history
-Specialty focus-Specialty focus
-Professional Membership/Affiliations-Professional Membership/Affiliations
-Professional Lectures given-Professional Lectures given
-Professional Publications written-Professional Publications written
-Continuing Education-Continuing Education
-Professional Education-Professional Education
-Preferred Provider w/list of insurers-Preferred Provider w/list of insurers
-Community Involvement-Community Involvement

NetworkingNetworking
 Look beyond your instructor/schoolLook beyond your instructor/school
 Visit your colleagues/classmatesVisit your colleagues/classmates
 Join a professional organizationJoin a professional organization
 Lecture at a universityLecture at a university
 Lecture within the communityLecture within the community
 Host/participate in health eventsHost/participate in health events
 Write a local health newsletterWrite a local health newsletter
 Participate in conferencesParticipate in conferences
 Participate in a studyParticipate in a study
 Specialize in a field of interestSpecialize in a field of interest
 Join a study group/peer review groupJoin a study group/peer review group

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