Ask FPM

Billing costs

Q I think I may be paying too much for my billing. Are there any industry averages for billing costs as a percentage of net revenue?

A No. However, you can calculate a reasonable estimate using data from your practice and the Medical Group Management Association's (MGMA) Cost Survey: 2003 Report Based on 2002 Data. MGMA reports net fee-for-service revenues from $399,248 to $584,335 per physician and "patient accounting" staff costs from $13,497 to $25,426 per physician. (In each case, the range is defined by the 25th and 75th percentiles.) We estimate that practices spend an additional $10,000 per physician per year on the billing-related costs listed below:

• Postage costs of $4,000 (8,000 mailings at 50 cents each),
• Computer costs of $3,000 (including depreciation, maintenance and service),
• Space costs of $1,500 for three-fourths to one full-time-equivalent employee per physician (70 square feet),
• Phone costs of $1,500.

The table uses these estimates to calculate billing costs as a percentage of net revenue.

George Conomikes*
Conomikes Associates
Los Angeles

Online consultations outside your patient base

Q I am planning to implement electronic communication in my own practice one day. Under the current guidelines, must patients who request online consultations necessarily be from your own practice?

A There are online physicians offering advice to patients without an established physician-patient relationship. Such care should be limited to advice rather than the primary care management given by a family physician. Once more family physicians are available to their patients online, fewer patients will need to resort to online advice from a stranger.

Joseph E. Scherger, MD, MPH
San Diego

Documenting E/M services with checklists

Q I find checklists valuable for documenting evaluation and management (E/M) visits; however, I have heard mixed comments about whether they are legal. Do payers accept checklists to document E/M visits?

A In general, using checklists to document E/M services is an accepted practice, and I am not aware of any payer that has refused to recognize them as part of the documentation of E/M services. While the Documentation Guidelines for Evaluation and Management Services specifies the content and qualities (e.g., "complete and legible") of E/M documentation, it does not specify the form. That said, checklists in and of themselves would be insufficient documentation in most cases. For example, a check mark that indicates an abnormality in the patient's respiratory system upon exam should be accompanied by a notation of the specific abnormality. Thus, checklists can be used in conjunction with other documentation to ensure a complete medical record.

Kent J. Moore
AAFP
Leawood, Kan.

Delayed dictation

Q I'm concerned that one of my colleagues continues to have trouble keeping up with dictation. We are often paid for Medicare and Medicaid visits before the dictation is in the chart. Is this legal?

A It is not patently illegal, even if reimbursement is received prior to completion. However, physicians should make every effort to complete their dictation in a timely manner. If delaying office dictation hinders a physician's ability to adequately document a patient's health history or clinical care plan, it risks future findings of inappropriate billing or inadequate patient care.

If hospital records are involved, prompt and appropriate documentation by the responsible physician is required by Medicare's conditions of participation. Physicians with particular questions regarding their state's documentation requirements should contact their local attorneys.

Jeffrey B. Miller, JD
Mercy Health System
Conshohocken, Pa.

* Denotes member of FP Assist, the AAFP's online clearinghouse for consultants and attorneys.