Family physicians know all too well that medical care for their elderly patients takes time. The list of chronic conditions can be long, and the roll call of medications even longer. Counseling and care coordination are time-consuming, as is exchanging critical information with family members and caregivers. And the time required is not always profitable for the physician.
"Geriatrics is the only specialty where you do more training to make less money," says Ariel Cole, M.D., of Orlando, Fla. "The truth is, I can see three 25-year old women with urinary tract infections in the time it takes me to see one 85-year old with the same problem."
Cole, who is the director of the geriatric medicine fellowship at Florida Hospital in Orlando, has been serving elderly patients almost exclusively for the past 10 years. "I'm a family physician by training, but once you hang out your shingle as a geriatrician in a town this big with this many people who are looking for someone to care for their elderly mother, well …"
- Geriatric patients often deal with multiple chronic diseases and other comorbidities and take numerous medications.
- Providing medical care for these patients often is more time-consuming than for younger patients with fewer medical problems.
- Physicians can help close the payment gap by using Medicare's annual wellness visit, learning good coding practices and following care tips from expert colleagues.
When dealing with elderly patients, it's important that family physicians -- particularly those in private practice -- know how to manage the business side of geriatric medicine, says Mina Zeini, M.D., of Orlando, Fla. Zeini, a certified medical director in long-term care, says that Medicare's annual wellness visit is an "excellent tool," for helping keep geriatrics patients healthy.
Once a year, the physician sits down with the patient to review issues that relate to, among other things, safety, cognition, depression and home health needs.
"(That visit) allows you to plan for preventive care for the next five to 10 years and talk about advance directives. Even in healthier patients, there's a lot to talk about, and you usually have to follow up with other visits," says Zeini, who is a faculty member for geriatric education at Orlando's Florida Hospital, the hospital's geriatric medicine fellowship and the Florida Hospital Family Medicine Residency.
Zeini's ample experience with elderly patients makes her a valuable resource for her family physician colleagues. The first three items on Zeini's must-do list can help physicians who are coding for time-based, face-to-face care coordination. Zeini recommends that physicians
- contact other members of a patient's care-coordination team, such as the home health nurse or physical therapist, when the patient is in the office for a visit;
- get a family member or caregiver on the phone if a geriatric patient comes to an appointment alone; and
- order prescriptions and contact members of the home health team, such as hospice, while still in the home of a homebound patient.
Ariel Cole, M.D., and Mina Zeini, M.D., both of Orlando, Fla., are family physicians who specialize in geriatric medicine. The pair served as co-presenters for a course at the AAFP's 2011 Scientific Assembly in Orlando titled "Nursing Home Care: What You Need to Know in 2011."
Cole and Zeini agree that accurate coding is key to keeping payment for geriatric services at manageable levels. They point out that Medicare has set up time-based coding to cover the counseling and coordination services that are a crucial part of geriatric care. The physician can bill based on time when he or she documents that services provided accounted for more than 50 percent of the patient visit.
For example, Cole says she sometimes spends an extended amount of time with an elderly patient and the family determining whether "Mom" is able to continue to live independently or should consider other options. In that instance, Cole would bill
- CPT code 99215, the highest evaluation and management (E/M) code, plus
- CPT code 99354 for the first hour of counseling and coordination services, and
- CPT code 99355 for each additional 30 minutes.
Cole notes that Medicare rules regarding time-based coding are quite specific, and physicians who are unclear about what's acceptable would do well to double-check their coding references to avoid claims denials.
She also points out that physicians can bill for the Medicare annual wellness visit and E/M services in the same visit, as long as they include the modifier 25 with the E/M code. "I have successfully billed both, and I've been paid for both," says Cole.
In addition, Zeini urges family physicians to
- arrange for a colleague to provide intermittent home visits when the FP doesn't offer that service but wants to keep the patient under his or her care,
- use the local agency on aging to find resources available to help with the provision of health care and services for seniors, and
- encourage patients and their families to take charge of the patient's care, especially when multiple physicians at various locations are involved.
It is also important that FPs maintain balance in their panel of patients. Many family physicians who have been in practice for a number of years may see a significant graying among their patient panels. It's worth the time to ensure that the practice is also drawing in younger patients.
Thomas Weida, M.D., of Hershey, Pa., has learned how to keep his family medicine practice flush with younger patients. Weida spent many years in private practice before moving to a hospital-owned clinic in Hershey. He says when he was in private practice he tried to keep the proportion of Medicare patients in his practice to about 20 percent of his patient panel and Medicaid patients to about 5 percent.
One of the best ways to infuse a practice with younger patients is to provide obstetrics (OB) services, says Weida. "If you like doing OB, continue, and your practice will stay younger because you're going to get the babies."
Another way Weida has maintained a good balance of young patients is by working with the local hospital to send its unassigned pediatric patients and routine newborns to his clinic.
Other ideas that have worked for Weida include
- getting involved with corporate medicine by providing workers' compensation and pre-employment physicals for local companies;
- hiring young physicians because they tend to attract younger patients;
- gaining visibility in the community by doing talks at local schools and local health-oriented programs, such as a volunteer ambulance course; and
- implementing walk-in hours.
The last item, in particular, revitalized the youthful side of Weida's patient panel. He points out that walk-in services tend to draw parents with sick kids who can't get appointments with their own physicians or who don't have a physician. "It doubled our new patient business four years ago from 75 to 80 new patients a month to about 160," said Weida,
Although she recognizes that a practice top-heavy with geriatric patients is not as cost-effective as a practice that serves a broad spectrum of patients, Cole says she will continue to care for her elderly patients, mostly to honor the close ties she had with her grandmother.
"The reality is our population is aging, and these patients need care," says Cole. "I enjoy these patients. I enjoy their life stories. I find it amazing that I still get to meet people who served in World War II, who experienced the world before motor vehicles crowded the roads and who knew Orlando before Disney. It's amazing stuff."
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