I think before we go into our Q&A, we're going to do a couple more polling questions. And while we do those, I invite the rest of our panelists to come online. Key principles for creating a successful APP physician collaborative partnership are practice buy-in, mutual trust and respect, collaborative partnership, APP professional development, or all of the above. And the majority is picking all of the above, Dr. Kahl. Any comments? I think that this group is all set. What are we going to do the rest of the course? Fantastic. Next question, please. All of the following are strategies which contribute to a successful APP physician collaborative relationship except open, constructive communication, clear performance expectations, exclusion from practice discussions, career and professional development opportunities. All right, are you able to see the responses, Dr. Kahl? Yes, I do. Exclusion from practice discussions is an except, and we highlighted that in my talk as well. I think inclusivity is the name of the game and transparency, and the practice will be well served if these principles are kept in mind. I see one response for open, constructive. Yeah, that may have been an error, but anyway, Sarah, back to you. So we'll open it up now for questions and answers. Certainly, we want to hear from you. Eden, if you want to remind them how to ask a question. Absolutely, folks. You can submit questions and comments throughout the course via the Q&A box. Please be sure to use the Q&A box for those questions and not the chat box to submit questions. That'll just help keep us organized. And I'll take us back to kind of earlier in the course for a question for Jill to clarify. If I spend five minutes reviewing previous endoscopy, 25 minutes with the patient, and 10 minutes documenting, I take credit for 40 minutes total for the visit, not 25 minutes or just face-to-face? Hi, just to go over that answer. So for consultation codes, when you're billing the 99414 to 49445, those only follow the 1995 to 1997 guidelines. It's only with the new patient visits or the established patient visits that you can use the 2021 guidelines, which means that you can use the entire amount of work that you do that day, which means your pre-work, your inter-work, and then your post-work. So if you're looking at changing the guidelines for the consultation codes, probably looking at next year, but currently right now you can only use the 2021 guidelines for the new patient and outpatient codes. I'll just add that I think the challenge to that is the day of the service. So if you pre-chart the day before, you cannot count that as time towards it. You have to start your day at 5 a.m. And then work with Dr. Bakari to figure out how to help our burnouts. Right. Sarah, we'll have the next question for you. To Ms. Enslin, Tatiana writes, I am a new APN to my GI practice and the first. Congratulations to you, Tatiana. Is there a source where I can find the four-week orientation preceptor checklist that you mentioned that would be so incredibly helpful in our practice for my successful onboarding? Congratulations Tatiana. I love to hear these questions. I think it's always exciting to be the first and kind of pave that way. I know that it certainly comes with some challenges as well. My email is on the slides. If you want to send me an email, I'm happy to see what we can do to help you get some resources and any materials that we could offer. Wonderful. And then next question is, in our practice, all new patients are seen by APPs. Does this mean we can never bill incident two? So I'll take that one, I think, and then Jill may comment on this as well. One of the requirements for the incident two billing really is that the new patients first are seen by the physician and then the follow-ups are seen by the APPs with the physician being available. So that's really how it's laid out. And yes, there is a 15% traditional difference in differential for the reimbursement. So that exists if you're seeing independent versus incident two. So there is a little bit of loss of revenue, but I think there's a potential for a larger problem if we deviate from those federal guidances. So as of now, I think that's how the construct is laid out, but Jill or Sarah or anybody else can comment on that as well. I was going to agree with Dr. Kaul. In fact, some organizations have actually eliminated incident two billing completely because it's such an onerous auditing task to make sure that you are not seeing a new patient or a new problem and that you're not establishing absolutely any change in that original care plan. Yeah, I alluded to that, that it is a potential red flag item for federal audits. And then obviously if you do it well, you not only gain an increment in the reimbursement, but you also do it properly and you stay out of trouble. But for the most part, practices have found that to be a little difficult to do that consistently and therefore many practices do not do incident two billing. They rather do independent APP visits or shared visits. And the burden for shared visits was just kind of reduced a little bit this year. It might change again next year with the time-based or complexity-based stuff. And our next question is, how does the onboarding of your inpatient APP differ from that of your outpatient APP? I'll take that one. That's an excellent question. I will say that we start the first couple of weeks the same. Our inpatient APP spends some time in the outpatient clinics if they're not previously coming from a gastroenterology practice just to learn GI. And again, to get to know the team members. The way our practice is set up, our inpatient APPs are working primarily with the fellows. And so we want them to integrate with our outpatient group as well. And we found the best way to do that is to start them out that way so that they spend a few weeks just really getting to know gastroenterology, the APP team, and the physicians. And then our inpatient APPs will learn a lot more about the acuity of it when they start to do some of those consults. And they will start doing them kind of in conjunction with the fellows and the physicians to begin, and then really start to take more of an autonomous role as they become well-versed in it. And additionally, starting to learn some procedures and things like that that they could do, such as large volume paracentesis to really help our inpatient patients. Yeah, the inpatient, in our setting, it's an academic setting. So we're lucky to have fellows, residents, and certainly a dedicated attending for the inpatient service. So it's a little bit different than it would typically be in a large health system or a prior practice, where I think it becomes even more important because of the direct one-on-one coordination that's required. It becomes particularly important for the physician champion to onboard, mentor, so to speak, and collaborate with the inpatient APP. And then escalate the level of cognitive complexity and independent nature of that practice as time goes on. So that's the two different settings, but it has been found to be successful in both with the slightly different approaches and slightly different composition with the team. A bit of a follow-up question. How do you assess productivity for the inpatient APPs, given that ideally they would have no obvious productivity, and by that they mean all billing would occur under physician to capture 100% of the charge? So a short answer that I have is that as soon as I know that they are comfortable and they tell me that they're able to do independent consults, I encourage them to bill for those for sure. And remember that a part of the inpatient APP role is also to switch out with some outpatient activity in a hybrid model, if that's the case. And in that case, they'll have some clinics on their own, typically urgent clinics or clinics that come from more acute consults in the outpatient setting. Between the two, that does provide an opportunity to generate some RVUs. But when a practice goes this route and becomes more emancipated in these type of practice paradigms, it becomes really important for the division, the department, the institution, the health system to really factor in that this is an invaluable service that the APP is providing for the betterment of their patient care and for meeting the national metrics for value-based purchasing as well. So all that has to be factored into the business plan. I have been a very firm proponent of the fact that we should not be counting nickels and dimes and cents. This is a team-based collective productivity approach. And yes, one should maximize one's own individual RVU generation. But at the end of the day, this is a team-based approach. So the entire team's productivity, value, and contributions need to be taken as a whole. That's really the main way to success here. I just want to emphasize that last point by Vivek. Especially at the hospital, I think that is so important. It is a team-based approach. The hospitals can just be out of control with volume of work, acuity of illness. And we have to focus on taking care of these sick patients. The teamwork is what counts. And we view the hospital APPs at our practice, they just live in a different world. And the goal is to deliver high-quality care, get home at a decent hour. We are not looking at nickels and dimes at the hospital. Because even if we look at nickels and dimes at the hospital for the physicians, there aren't many nickels and dimes compared to what happens in the clinic in ASC. That and also, if you just factor in decreased length of stay, enhanced value-based purchasing from enhanced HCAHPS scores, and also the time that it allows the endoscopist to spend doing endoscopy. If you just take those three bullet points back to the business table, it's not even a non-starter. It's a non-starter argument. Yeah, I was going to say the way that we've kind of looked at the role is, are we able to reduce that length of stay? And then also importantly, they don't do a continuity clinic, but they do have a transition clinic. And so are they able to see these patients that are discharged within that expected one-week timeframe when they need it? And does that help us to reduce our length of stay? And so looking at those productivity metrics have been helpful for us. There's a question here that asks about the shared practice model in the outpatient setting, asking whether both the APP and the physician have to see the patient. The short answer is yes. You both have to see the patient and both have to document. So there is no way around that. But there are a lot of other questions, Eden. You have a few as well? We do. There was a lot of appreciation for the burnout talk that Dr. Vickery gave. So I kind of want to blend a couple of questions together here, taking it from what obligations the employer has in terms of workman's comp or sick time to how do you approach a colleague that you see starting to experience burnout? So I don't know, Sarah, if we want to start with Dr. Vickery and then go around the table a little, or what are your thoughts? Yeah, absolutely. Sounds good. Yeah. So the first part really comes down to, initially, it comes down to what's in the contract and how that contract is formulated in the beginning. However, APP use in GI is relatively new, but certainly exploding over the last five to 10 years. And I think a lot of this has to be an evolving model. What we do now for our APPs is very different compared to what we did when we only had one for several years. We've learned from our mistakes. And the short answer is it comes from strong institutional leadership, understanding the value of the providers, understanding the value of the team, and understanding some of the unique needs of advanced practice providers because of family obligations, a high percentage of females in that field. And so I think it's just quality leadership that counts. And the second part, how do you approach or where do you start if you're concerned that someone has burnout? I think you can start with your mentor if you have a mentor within your practice. Start with the clinical administrator, especially, again, if you have strong leadership. But if you feel, if you have a mentor, maybe that is the first place to start because you may feel most comfortable talking to that mentor. I don't know that I would not directly go to that person. I would start with a leader in the practice that you trust and believe in. I think the principles... Go ahead, Sarah. That's okay. I was going to say, I agree. I think that we have a leadership structure to help navigate some of these difficult conversations and difficult issues. Many places also have support that's built in that maybe we're not aware of. And so, for example, we have the EAP, the Employee Assistance, they've been really helpful for us when we have talked to some people and suggested that maybe they go there. We've done it for a few different reasons, burnout being one of them. Another one is just that transition from RN to NP can be a really tough transition for some people. And so we've had them meet with them. They do it like an hour every week or every other week and really just help them to come up with some coping mechanisms and work through some things that maybe they're wrestling with in their head that they're either not comfortable coming to us as their leadership or they just aren't sure how to verbalize or how to work through on their own. And so I think bringing that to somebody who's familiar with the resources that's available and also somebody who can have those conversations is really important. Yeah, I think the principles of trust and respect are the founding principles for engaging in this and managing this issue. These conversations have to start out in a private fashion where you deal with the issue with respect and sensitivity and then with the appropriate agreements in place, you can both move forward to the leadership and seek assistance more formally or if it's a matter that can be addressed with one-on-one counseling, then that's it. So every situation is different, but safe to say in the last two and a half years, almost all of us have experienced some degree of burnout. The spectrum varies though, and the interventions need to be escalated according to the problem at hand. There are several other questions here. Sarah, there's a question here asking, how do we go to a 10-hour times four-day workweek? We did that almost a decade ago. So your insights into that will be very valuable. Yeah, so I think the important thing for that, which Dr. Cull will probably attest to is coming with a plan. And so if you are proposing to go to a four-day workweek, what is going to happen on that fifth day? If you have your own in-basket, what do you propose for in-basket coverage? If you had dedicated administrative time, does that then shift to be during those hours where you're not seeing patients? Or are you also proposing that you're expanding the hours you're seeing patients? So I think really thinking about those things and going with some ideas, but also being open to feedback for whatever works for your practice is really important. I do think that it has been a really big thing to help with wellness. I think especially for people who have young children, both moms and dads, to have that ability to be able to be in the classroom, spend some time with the kids, kind of have some flexibility from that aspect is really important. And I think a lot of people, once they see or hear about a plan are more open to it, but you want to go with some kind of idea in place of how you can work that out. And I'll give an example for our group. We do pair up one-to-one with another APP. Occasionally we do three people just depending on the numbers. So they're in the same subspecialty. So the person who's covering me on Fridays knows my practice in and out. And so she can answer my questions a little bit easier. She's off on Tuesdays, I cover hers. And it works fairly seamlessly from that aspect. I would just want to emphasize, sorry, Vivek, what Sarah said, and that's bringing a good plan. We recently switched to this flexible scheduling and the nurse practitioners brought a very good, well-thought-out plan. There were a couple of physicians who were concerned and maybe not 100% on board, but I think this is a very good thing for our practice, but it was a well-thought-out plan. And again, communication, communication, communication, and both sides have to compromise. Yes, and from a practical perspective, the day gets extended on both sides, right? So you come in a little earlier, stay a little later and becomes important if there is no active clinical work going on at that time, such that the patient is not able to come at 6.30 AM for an in-person visit. That time that you're on your own is spent in productivity in a different fashion. That's number one. And the adherence and compliance with the team to the basic principles of utilizing time to still enhance their practice, complete their work is important. And the other issue that comes up is the fifth day, the coverage plans to be in place. That is a buy-in from the rest of the colleagues. That mechanism takes a little bit of time to get cemented. Patience is required from everybody, but once this is in place, the benefits of the four-day workweek are quite apparent. And I would encourage you to try that. There's a question about organization onboarding process. Sarah, you've already addressed that in terms of sending some of those materials. So feel free to email Sarah and she'll share with you what she can. There's another question about coding and billing and how the E&M code is billed and charged by someone else outside the practice entity. A couple of real quick points on that. Our obligation as providers is to know the documentation burden and complete our note based on those guidelines so that we can bill appropriately. The billing coding department's obligation is to stay abreast of the billing coding requirements and appropriate billing coding practices. And I'd like to throw in a shout out here to our ASGE resources. We have a tremendous amount of resources through the practice management committee and other resources that will be able to help with specific questions. On occasion, we've had experts come out to our practice and have FaceTime with our teams. And your in-house billing coding team should have FaceTime with your practice groups from time to time to stay abreast of what you're doing, what you need to be doing, what should be done differently, and how to maximize that aspect of our practice. So just wanted to throw that out. I just wanted to add that medical legally, you're responsible for whatever code is submitted. So if your coder and biller is doing this maybe once a month or if they're doing it, you know, five times, 10 times a week, then they should be obligated to give you that coding feedback. So if you're not coding up to a modern medical necessity, but you have the documentation to show it and they're changing you from a 99213 to 99214, then their obligation is to give you that education. And we'll sneak in one more question before we go to the break. And for any questions that we haven't asked, we always appreciate you all sending questions throughout the lectures. That's perfectly fine. Or just once the Q&A session starts, we'll ask the faculty to respond to any questions that we haven't answered live. So at least we capture those and we may go back and ask them verbally later. But for our final question for this session, I know every practice is different, but how much time do you think should be allotted to an APP for follow-up visits, particularly in an underserved rural area where patient compliance, physician communication, and follow-through is low? I have been in GI for a year now and only work in an outpatient clinic. I have 20 minutes per visit, work four 10s per week. There's also limited support staff. How many patients per day do you think is reasonable in this setting? A tough question. So I think if you're getting 20 minutes for patients, all patients, that's three patients an hour all day, that to me really is unreasonable. And in our practice would be unacceptable. So I think if you have a mixture of new patients and follow-up patients and you get more time for new patients, then 20 minutes for an old patient to me is reasonable. So for example, in our practice, we give 30 minutes to physicians and nurse practitioners for all patients. Our thought process is most new patients can be seen in 30 minutes. Most return to clinic can be seen in under 30 minutes. For the difficult new patient that runs later, we've got some makeup time. For the easy new patient and maybe the more difficult follow-up, we have some makeup time. So we like 30 minutes. If you need a different blend, then I'd say 30 minutes for new patients, 20 minutes for old, that does kind of set the schedule off the clock. Going to 15 minutes for follow-up can be tight in my opinion. I like the 30-30. And it gives you the opportunity to spend enough time with the patients with the burden of the electronic medical record. And in our group, and this is not going to be the answer of all groups, if we're still not seeing everybody, then we hire another nurse practitioner or we hire another doctor. So 30-30 to me is ideal. 30-20 is still very acceptable. Yeah, I agree with that. I think the other thing if you do 30-30 is that you have more flexibility if you have a last minute cancellation. Because we had a long time ago done 30 and 20. And when you had follow-up spots open, they'd try to squeeze a new patient in. 20 is really tight for a new patient. And so I think that that's an added benefit.

physician

APP

collaborative partnership

communication

professional development

underserved rural areas