And so now I'm going to introduce our next moderator to start our second symposium. Dr. Bruce Cohen is going to moderate the second session, which is managing your orthopedic practice. I love the entry music. Thanks, Becky. While everybody gets set, just welcome to our second symposium. This one's on managing the practice, and those of you who know me, I have a little experience in that, and I am stepping down from that at the end of the year, so eight years of managing 140 physicians has gotten my hair gray and gotten me really, really tired. So hopefully we can all add some insight in this symposium all the way to our last speaker, who's going to talk to us about financial health, and maybe it's too late for some of us, but hopefully never too late. So let's get started, and Andy Hsu's going to start, and he's going to talk about coding and billing optimization. So, I'm gonna say something, I'm gonna say it again at the beginning of the end, and I want you to really, really digest this comment. Mastering coding can give you clinical freedom, okay? Mastering coding can give you clinical freedom. So, I'm a consultant for Arthrex, I'm also obsessed with coding, as you'll find in a few slides. So, coding is one of the weakest areas of residency and fellowship, for the most part. No one really wants to talk about it, no one really wants to discuss what these little five-digit numbers mean, and how we actually make money at the end of the day, they say, oh, you'll be fine. You're a good guy, you're a good girl, you'll make plenty of money, you'll be happy. But obviously, what does that even mean? There's gonna be huge standard deviations as to what you're gonna bring home at the end of the day. And it all resides in these little five-digit codes. So, my experience was in residency, I started stalking some of my attendings, just looking at their op notes, because it is a little bit hard to get this information out of people. A lot of people are a little bit shy about exactly what their collections, their billing, their RVUs are. I was very fortunate to go to OrthoCarolina with Dr. Cohen and Dr. Davis, and if you see Dr. Davis, please congratulate him on his clinical retirement. But he, in particular, was one of the first people that got me thinking about, when you look at all these different procedures that we do, all 100 of you in the room, we all do a bunion, why is it that we're all gonna code this thing out differently and therefore get paid differently for it? What's the variability from? So, I started studying his operative notes, I started looking at this, which is oftentimes public information within your Epic or your health system in general. They're saying, there is huge variability between how one person does it and the other, and this other person's getting paid three times more for it? I need to understand that a little bit better. So, even though I'm at the University of California, Irvine, which is an academic center, my first two years were pure salaried and this really wasn't discussed very much, but it was very clear that in 2018, we were moving to an RVU-based system, which most academic hospitals, most hospital-based jobs are moving towards. The days of pure salary are pretty much long and gone unless you're maybe at like a Kaiser. So, I started studying this a little bit more, saying, okay, well, what can I do better? And my personal experience was that with the same clinical volume, with the same operative volume, by just getting more serious every day about getting better with coding, I was able to two to three times X what I was making. So, effort doesn't equal accomplishment. That's a little bit of a, kind of a rude awakening thing to say, but it's true. You can do 100 cases a month and still be making barely your overhead. So, you really have to take that in consideration, that it's not just about pounding cases, being busy. We have this culture in America about wanting to be busy all the time. How you doing? Busy. Okay, is that good? Busy. Busy isn't necessarily good. Busy is busy. You wanna be productive. You wanna be efficient at your job. You wanna maximize every single moment you have in your clinical practice and your OR, so that when you go home and you see your spouse and your kids, you know that you did everything you possibly could and you got better. No one wants to sit around wasting time. So, one of the first things you have to do is you have to get comfortable talking about money between yourselves with yourself. Hiding your salary doesn't serve any purpose. If I make more money, I want you to make more money as well. Not talking about it just makes it an insecurity. It's like talking about your health and ignoring if you have major medical problems. It's not gonna do you good any at the end of the day. So, you have to leave your ego at the door. One guy makes five million, another guy makes 500,000, another one makes 100,000. What does that matter? Is there some sort of inherent social value we give to money? We do artificially, but that shouldn't matter. You're a surgeon first, you're a physician first, you're a kind human being first. The money, it doesn't place any important value, but yet we get so shy about talking about it all the time. So, you can't ignore the finances of medicine. It's just a plain fact. You cannot just pretend like coding doesn't exist and then at the end of the day, hope that you're gonna make partner and become CEO and be a managing director. That's just not how it's gonna work. So, really, you can get your freedom back by learning how to code better. So, even just clinical coding, E&M, evaluation and management coding, you have to know that in 2021, MDM rolled out, medical decision making, and it fundamentally changed the way that most of our notes should be templated. I'm not gonna get into the details of that, but essentially it's this. MDM means the more complicated, the more issues that you see, the more you're gonna get paid level four, level three service. There's really no reason why most of us shouldn't be doing level four news and established for the vast majority of our practices. This was designed to not help us in this room. This was designed to help family medicine doctors, internal medicine doctors, people who cannot have high RVUs from procedures and operating rooms. Look at the numbers. Seven to 28% bump in value for doing evaluation and management codes in the clinic, meaning just the sheer volume of patients you're seeing level four established. A 30% raise between 2021 and 2020 just for that. What do we always hear about from the AOS? Cutbacks on CPT codes for total hip, total knee, bundled payments, chipping away at all these different procedures, getting rid of certain procedures within the shoulder. Now this is a 30% raise you just got here, so you have to look at that pretty critically and say where is the money really coming from? There's a tremendous amount of revenue to be generated within clinic. So when you look at ICD-10s in general, you wanna template this within your EHR system, Epic or something like that, but really you wanna just have all of them listed. You can't have this very complex five-page note and at the end of the day say bilateral foot pain. No, no, no. Ankle instability, perineal tendonitis, Achilles tendon contracture, ankle synovitis. You need to add more complexity to reflect what you're actually talking about because I know all of you are talking to patients about it, but are you putting it into writing? The more you have the ICD-10s, it'll also unbundle if you're doing clinic injections, clinic procedures, things like that. Make it more efficient. This is the same sheet that I used from 2014 that Dr. Carol Jones gave me when I was a fellow just to have it all down so I can quickly enter in those ICD-10s which are now saved as my favorites. Don't ever pull out a book. We have phones. You heard Dr. Kaplan talk. Use your phone. Use it productively. You can use it for coding in a very productive manner by having all of these pre-templated inside your phone so you can look it up very quickly. Fracture code math. When you're taking care of fractures, we are very fortunate. We are not like our hand surgeons where every single week you have to monitor this distal radius if it's gonna fall apart on you. Oftentimes, you see somebody for a toe fracture. Let's be honest. There's gonna be one follow-up visit maybe in about five weeks for a follow-up X-ray. 99204 plus the 28510 code for the fracture. Grab it all up at the front. They come back again. You talk a little bit more. But for us, it's to our advantage mathematically to actually grab some of those fracture code global periods up front. Somebody comes into the ER, six, seven non-displaced avulsion fractures of the foot. Those are each closed fracture management codes. You can do a total HIP for 20 RVUs. You can take care of six non-displaced fractures in a foot patient with a 30-second visit with a CAM boot for the same amount. It's not fair, but it's the math of it. The math doesn't lie. So do the math. Study your CT scans. I'm a very big proponent of making your clinic an OR. How many injections do we do? How many different debridements do we do? How many different hardware removals or things like that do we do? My wife is a dermatologist. How does she make all of her money? Procedures in clinic. Minimal liability. She never goes into the OR. And so it got me thinking, why can't my clinic also be a bit of an OR? If we're all fighting for OR time, if we're all struggling to say, oh, where's my block time? I don't have this and this and this. What can you actually do? Can you do PRP? Can you do nanoscope? Can you do other things like that in the office? It's intriguing. But those CPT codes in the OR, if you can do it in the clinic, it still bills the same. I've taken off X-fixes in the clinic. Why do I have to go to the OR to do it if I have proper anesthesia? So you have to get thinking, why are we so dogmatic about this is operative, this is clinic? There is a blend here, and especially with nanoscopes and things like that in the office, it's getting much and much, that line is blurring more and more as time goes on. So some of these debridement codes too, you have to realize, you're debriding a diabetic ulcer in clinic, 10-day global period. See them again in two weeks. Do it in a hospital setting, zero-day global period. So some of these globals are not 90 days, and you have to be really cognizant of that. Modifier codes, 24, 25, 51, 59, those are the key ones. 24 modifier, new issue in a global period. Hey, I see your left foot bunions doing well at week six. Yeah, but doc, you know, my right foot's killing me right now. Let's talk about that. Let's talk about that. Are we gonna plan a surgery for that? Is that really included in the global period or not for that procedure? 25 modifier overall, if you're gonna do an additional procedure, like an injection or some sort of other additional thing that you're gonna do, like a PRP injection. The 51 versus the 59, I'm happy to talk about this in private, but really the 51 modifier is the one that oftentimes gets us. 100% and 50% and 25% and 12.5% of every subsequent code. 59 modifier was one that got me thinking based off of our general surgery colleagues. Separate distinct procedures. How many separate distinct procedures can you do from an overall procedure? What is considered bundled within the overall procedure that you're doing? Because we all do surgeries different. An open bunion is obviously very different than an MIS bunion. So obviously the procedure codes are gonna be different depending on what we're doing. This may seem counterintuitive, but if you're gonna be more of a generalist, what does that mean? It means you can go into that room in the global post-operative period and you can say, how's your toe fracture doing? I gotta get out of here. I got 20 more patients to see. Or you can, how are you doing today? What's new? And obviously most of your patients are gonna say something. They're gonna say, oh yeah, actually my toe's doing pretty good. My ankle's been bogging you. Would you mind looking at my ankle for me? The global 24 period basically lets you break out of that to really establish another level four established visit. And it also helps with patient satisfaction and care because they wanna be heard. They want you to talk about what's going on. They don't wanna just kinda check the box and move on for what the initial injury was. So at the end of the day, ED consults as well, if you're gonna take a lot of calls, especially if it's a junior attending, you're gonna take a lot of ED calls. See as many consults as you can. The overall RVU value for 99254 ED visit is the highest out of everything. It's 3.5 RVUs compared to a new patient 2.4 RVUs. So if you're on top of your call schedule, if you know when you're on call, you can coordinate that with your residents, your PAs and who not. You should attest every single one of these. You should leave no money on the table. It's insanity how you would just have all these consults in the EDR that you don't attest to. It's bad for patient care first of all. It's also bad for the business. 57 modifiers if you're gonna do a procedure or a surgery during that overall period while you're seeing that consult to protect your consult notes. Round into breed, round into breed. It's very unglamorous, but a lot of the junior attendings are gonna get stuck with PUS call. I still do PUS call every single day, I'm eight years out. Round into breed every single day. There is a zero day global for your 11044, 11043, et cetera. Zero day global. It's not glamorous. Pays the bills and it counts. And it's good for patient care. Again, all of this is very good for patient care. Maximize your OR coding. There are five separate codes for ankle arthrotomy. Someone please explain to me who in Washington with CMS decided that there should be five codes for ankle arthrotomy. One's nine RVUs, one's four RVUs. You have to look at the details to understand what's really going on with the codes and which one applies to you. So study the codex. Pay attention to descriptions. If nothing else from this entire talk, write these three codes you're about to see down. 13160, secondary closure of surgical wound or dehiscence, extensive or complicated. How do you define that? That could be any wound dehiscence. One centimeter, 15 centimeters, that's 12 RVUs. That code alone is more than a bimal ankle fracture. 35860, exploration for postoperative hemorrhage, thrombosis, or infection. That's a vascular surgery code. You can use that with the ICD-10, infection following a procedure superficial or deep. 15 RVUs, that is more than a tibia nail to go and explore a dehisced wound. Explore, not do the other stuff, just explore. These codes exist, they're out there. They move the needle in a massive way. 20692, your delta frame for your XFIX. 16 RVUs versus putting on a medial-based frame. These are big numbers when you consider that like a bunion is seven RVUs and how much work goes into that. So studying the coding will give you the shortcuts that you need. Personalized coding lists, I started working on this since 2014 when I was a fellow. Really, what goes with what? Is it really just insertional Achilles debridement or is it insertional Achilles debridement, reconstruction, Hagelin excision, retrocaneal bracectomy, possible posterior compartment release, possible IVHL tendon transfer? Well, you tell me, it depends what the case needs. The combo coding, just like if you're playing a video game, that's what's gonna move the needle. Combo codes together, understanding the full spectrum of everything that you're doing to move the needle overall, meaning that that one operative case that you do can have much more value rather than just saying, I need to do 12 cases today. I need to take on 12 more liabilities. I need to take on 12 more potential stressors in my life versus doing two or three very, very well-done surgeries. So at the end of the day, you wanna put this into an operative note, make it easier for yourself, make it so that you can template it so you're not reinventing the wheel every single time. I keep a secure spreadsheet of all of this on my Google Drive so that I can go back and say, you know what, that was a great case that I coded. I don't wanna have to do that again because that took 30 minutes. So you can look back at your spreadsheet and you can copy and paste and modify it as needed. At the end of the day, coding is a community. Much like these little kids doing Rubik's Cubes, it doesn't happen overnight. It takes practice, it takes a little bit of neuroses and OCPD, if you will. But there is a coding community that's out there. If you start talking to people about the coding, you'll get them talking, they love talking about it. But it takes tons of practice. Ask for help, get better. It will change your life. It will give you your clinical freedom back to know that you're not under so much pressure to just see two or three times more patients. You can see the same volume of patients that you're doing, but you can make two to three times more. So that's my email. I'm always happy to talk if you email me directly. But again, if you master coding, it will give you your freedom back. Thank you. Thanks, Andy. I think we've created a monster. You definitely are obsessed with coding, so that's awesome. So we're going to switch gears a little bit. And the next talk was scheduled for David Pedowitz, but due to a family issue, he's not here. So his partner, Rachel Shaked, is here to talk about podiatry, both in and outside of your practice. All right, good morning, everyone. Thanks for coming to this program. So I'm here in place of Dr. Petto. I'm Rachel Chiquette, I'm his partner at Rothman Orthopedics in the Philadelphia area. So we're going to be talking about how podiatry plays a role in our practice. And in order to begin the talk, I'm going to start by telling you a little bit about how our practice is run so that you understand how podiatry plays a role in it. So these are our disclosures. Rothman Institute was established in 1970. We have over 300 physicians, 40 offices in four states. We have two private hospitals, multiple surgical sites, and we are team physicians for multiple professional teams. We do about 60,000 surgeries per year. We just celebrated our 50-year anniversary. It was started by Dick Rothman, and our current chairman is Alex Vaccaro. We are a private-demic model, so we're very closely affiliated with Jefferson University. Our locations are growing, so we're in New York, we're in Orlando, Atlantic City. Our home base is in Philadelphia. And we have a very large foot and ankle division, including orthopedic surgeons and podiatrists, both operative and non-operative. And it goes without saying that any success that we have as a team is due to our working together. So in our practice, as you know, we're all very busy. There's so many things pulling us in all different directions, and it's really sometimes hard to find time for anything. So we probably can't work any harder. And if we can't work harder, can we work smarter? We can use allied health providers to help, like physicians' assistants and nurse practitioners. We can use non-operative providers and, that should say, podiatric cooperation. Non-operative providers can free you up as a physician. It can lower your non-surgical patient load to allow you to spend more time with fewer patients and become more efficient. So this is our podiatry group. We have 11 podiatrists, 6 are non-operative. All of these were previously doing surgery, and 5 are surgical. Our paradigm is truly a division of labor. The surgeons do surgery, and the non-operative providers see non-operative pathology. So for example, in spine, we have PMNR, who see the non-operative pathology and refer to the spine surgeons if surgery is indicated. In our joints and sports, we have primary care sports medicine. And for foot and ankle, we have podiatrists. So each non-surgical podiatrist sees patients 5 days a week, and they direct surgical cases to 1 to 2 surgeons, depending on the office location. We really have a mutual respect for everyone's contribution to the care provided for our patients. We work as a team. The non-surgical podiatrists don't work for us. They work with us. And this is a very important distinction. So the podiatrists call or text X-rays whenever they want. We have a secure texting program. It's a very open line of communication. So this is an example of a fifth metatarsal fracture seen by one of the podiatrists while Dave Pedowitz was in the operating room and arrangements were made for this patient to be seen in his office. We work with the podiatrists to come up with protocols, surgical indications and non-operative standardized protocols. So we meet every year to go over these protocols. And it's not a one-way street. We work together and see what works best for each of our services. So why would anyone sign up for this? How do you get good people for this? We are a large organization. We have a large volume. And the podiatrists who come and work with us generally collect more as non-operative providers than they made as low-volume surgeons. There are also partnership opportunities for them that can be very lucrative. So what about the surgical podiatrists? We do have some as part of our practice because of expansion, where we've purchased other groups that have existing surgical podiatrists. And we have hired some surgical podiatrists as well in areas where orthopedic surgeon recruitment has been a challenge. But generally, these podiatrists that we've hired are high-volume surgeons. They're leaders in podiatric organizations. And they also have partnership opportunities at Rothman Orthopedics. They're really treated like surgeons as part of our group. And they're included in our surgical conferences. And you may not know, but there are actually patients that you have no access to. Many podiatrists in the community do not refer to orthopedic surgeons. The outstanding surgical podiatrists in your practice can actually be referral destinations for non-surgical podiatrists in the community and for difficult cases that may come up in the podiatry community. So let's look at our experience with this. We'll look at the hit rate, which is the number of new patients needed to see to book a surgery. So this is Dr. Perowitz's data. In 2011, he was seeing almost 60 patients a day, working three days a week. Really can't work more than that. This is his metrics, where in 2011, he was seeing around 850 new patients. And by 2017, he was seeing 1,100 new patients. The hit rate went down from 4.3 to 1.49. And then by 2019, when he had two non-surgical podiatrists working in his various offices, he was able to see only 34 patients a day, 12 to 15 new patients a day, working three days a week. And his hit rate came all the way down to 1.2. So our offices are set up so that we each go to about three offices. We have three days in the office, two days in the OR. We have medical assistants. We have residents. Sometimes the fellow rotates with us. We try to involve our team in academics. So Dr. Pedersen's his medical assistant to the office events. We have them involved in our resident lectures. And we have our staff come to the OR occasionally so that they can see what's going on in the operating room to understand what the patients are going through. We have our academic conferences. All the surgeons participate in this. We have social events with the podiatrists every quarter or so to enhance camaraderie and foster a better working relationship. So in summary, our podiatrist partners are an invaluable part of our practice, surgical and non-surgical. The non-surgical partners help facilitate a surgical practice and triage care in our practice most effectively. And the surgical partners add to our value in the community and expand our services to larger geographic region, often reaching patients that we cannot access. Thanks, Rachel. We're going to switch gears. And Aaron Geyer from Tallahassee is going to come up and talk about running an efficient practice, particularly the ASC component. Good morning. I'm Aaron Geyer. I'm a orthopedic surgeon that's in private practice in Tallahassee, Florida with a large private practice group there. And today I'm going to talk about running These are my disclosures, none of which are really relevant to this talk. So first, let's start by defining efficiency. Efficiency is the act of achieving maximum productivity with minimum wasted effort or expense. No matter what kind of medical practice you're in, whether it be academic, private practice, et cetera, we need to strive to maximize patient care while utilizing as few resources as possible and in the least amount of time. Now, what does efficiency do for us? Well, it's a very simple thing. It's a very simple thing to do. Now, what does efficiency do for our practice? Well, it not only benefits us as surgeons, it also benefits our patients. If we are running an efficient practice, we can get patients in in a timely manner. We also can get them through the system more timely. And they like that. They don't like sitting around your waiting room for three hours when they can be out of there in 30 minutes. So that's a big plus for the patients. It also helps us as surgeons as it preserves our time. If we're efficient, we get out of the office, we get out of the OR more quickly, get home to our families, or doing whatever activities we want to do outside of medicine. And it also helps to maximize our revenue if we're efficient, which are benefits to us. And as we go forth in the current health care environment, we need to be efficient in order to maximize the limited resources that are available for patient care. And this is becoming much more evident as we go along into our current health care system. So I'm going to break this talk down into two different areas. One is the efficiency of your overall clinical practice. And the other is with ambulatory surgery centers. So first, practice efficiency. I think there are three pillars of our clinical practice that can make us more efficient. Those are time efficiency, resource efficiency, and ancillary staff efficiencies. First, time efficiency has to do with our schedules and how we run our daily clinic and OR days. This is always a work in process. My clinic and OR schedules are different today than they were five years ago, or 10 years ago, or 15 years ago. Because over time, you have to keep evaluating how efficient your practice is. You need to have outside input as to how efficient your practice is. And there are many things you can do to determine how efficient you are. You can use patient satisfaction surveys. Patients can a lot of times point out things you may never have realized you're doing poorly that decreases your efficiency. But also, we have at our practice, like our COO, our office managers will review our clinic schedules and look for things that may be always getting stuck in the system and try to fix those. So this is always a work in process. When we look at our clinic schedule, we have to determine what is the best mix of patients in each day to make you most efficient. This includes looking at the best mix of new and rechecked patients. But also, are there other types of patient visits that you really, yourself as the surgeon, don't need to see? In my practice, for example, I have a nurse that works for me. And she sees all my post-ops at the two and six-week mark. Those are clinical visits you don't really need to do yourself, I mean, the overall visit, because they're very routine. And we have instructions that can be done there. You're there in clinic and get to see the patients and pop in and say hello. But all the work that's done on that day, like suture removals, cast removals, things like that, can be done by nursing staff if you have good protocols. And that frees up your schedule to see more patients that are not in their global, things like new consults, rechecks, things like that. You also have to look at your insurance mix and coding and billing, which other speakers have talked about a little bit. But that also will help make your practice more efficient. I'm a big believer in using ancillary staff to make my clinic efficient. And your ancillary staff, including PAs, nurse practitioners, nurses, athletic trainers, all those can make or break your clinic. If you use them properly, however, this makes your clinic much more effective, much more efficient, basically by offloading your schedule yourself and making the actual clinical experience for patients also more efficient. There are many potential benefits to our practice from having ancillary staff. Like I mentioned, if you have ancillary staff like PAs and nurses, you can free up our schedule to see more lucrative visits, things that you can bill that are outside the globals. This also allows you to have more time in surgery and outside of clinic. For example, I have my physician assistant. She will see a lot of the common things we see, like plantar fasciitis or new fractures that are very common, she's very familiar with. We know how to treat these. We have treatment protocols set up. All those patients are offloaded from my schedule so that I can see more complicated consults in clinic. But also, when I'm in the OR working, she can also be seeing some of these patients in the clinic. Having ancillary staff also enhances patient service. A lot of patients really like talking to my nurses and PAs because they spend a lot more time and a lot more detail and answer more questions than I can. And I'm always seeming rushed as I'm going through clinic. They don't have that with the ancillary staff. So it does make patients feel a lot better when they're in clinic as well. The other thing to think about is a lot of ancillary staff visits are billable. It's obvious with PAs and nurse practitioners, those visits can be billed. However, the other thing to think about, there are other services that can be billed in some places, and this depends on different states and different insurances. Sometimes athletic trainers that you have working for you can bill for their casting, their brace applications, home physical therapy exercise, treatments. Those are all things that can be billed. And of course, a lot of people argue, well, if you have all these mid-levels or you have these nurses working with you, that's gonna be expensive. Well, that's a yes and no because a lot of times, mid-levels and nurses will pay for themselves. Mid-levels obviously pay for themselves through billing. However, nurses, like for example, in my clinic, my nurse that sees all my post-ops, even though I pay her a salary, she is seeing all of these global period patients that I can't bill for anyway, and that frees up my schedule to see paying patients. And so it makes your practice much more efficient. Other part of practice efficiency is resource efficiency. I'm big into standardization. I standardize a lot of our post-op protocols, surgical packets, forms, things like that that can move your clinic along. For example, here are two examples of that. On the left side is our stretching sheet. This is the stretching sheet that we have as part of a treatment of plantar fasciitis. When I have a patient that has plantar fasciitis or my nurse does, they get this sheet. My medical assistant can go over the stretches. They get this sheet to go home with. The patients love that because they have a reference to go home with. And it also makes things more efficient. On the right side here is one of the pages of the laminated surgical protocol book that I have my nurse using. I've gone through all my usual surgeries and made protocols as to what do you do at week two? What do you do at week six? And she has this reference that she can use. And I always say in my operative note, we're gonna follow this protocol. So that can make it much more efficient. You can also make the time of your staff more efficient. When my patients come in for an H&P, they get this folder on the right side that has all these different sheets in there. It has details about their different medications that are gonna be put on it. As you can see on the left side, a common question after surgery form. This helps my staff in that they don't have to go through all this in as much detail. It also saves them from getting emails and phone calls about things because the patients have references. And the patients love it too because they have something to go home with to look at as well. So that can make your staff's time more efficient and make your overall practice more efficient. Moving on to ambulatory surgery centers, there's a big push to put a lot of our surgeries in the ambulatory surgery centers basically because they are much more efficient than hospitals and there's a lot of other benefits. In order, however, to be efficient at your surgery center, there's a couple things we need to look at. First of all is cost over revenue. Now what I mean by that is this is determined by different insurance carriers. Some insurance carriers in our area will cover implants, others will not. And as a result, you have to think about what cases you're putting in your surgery center. If you have a case that needs 20 anchors, you don't want that in your surgery center if your insurance carrier isn't gonna cover that since it will actually cost you money to do that. So that's one thing you have to look at and you wanna see how much revenue per case are you making. Is it efficient to have it there at your surgery center or should you do it at the hospital? The other thing is case mix and scheduling. You really have to think about this. You wanna think about how long do cases take? Do you have a flip room available? Can you move back and forth between two rooms? And do you have assistance available? And that's also something you need to look at to be efficient. As an example here, this is, for example, I pull up my surgery schedule the day before every surgery and the surgery center usually will put in order what they think the cases should do. Well, I look at, on the right side here, as you can see highlighted, are the times of the cases then I look at the actual cases. On the left side, you see these handwritten numbers. Well, this is how I want the order to go. And the reason I put it that way is I've looked at, okay, how long is this case gonna take? How long is the next one gonna take? Can they turn over the trays efficiently? Do I have a flip room? Do I have an assistant? You gotta take all those things into account to see how quickly can you move through the day and how efficiently. And this does take some time to figure out when you're getting into practice. Assistance. So, an assistant can make your clinical practice more efficient or less efficient. Usually, it makes it more efficient, but you gotta think about how you use assistants. Of course, your PAs can make you money in the clinical setting, but we aren't always able to bill them for assistant fees with a lot of foot and ankle codes like our joint colleagues can. However, they still may make your OR day more efficient if you have a big case or you need to flip rooms. There are, however, some other people you can use. For example, I have an RNFA that I use, and even though I pay him his salary and he cannot bill for his services, he makes my day go better because he can be putting on splints, closing wounds, setting up the next room. It allows me to do more cases if I have a flip room since I'm in the other room starting a case. As a result of that, even though he has a salary I have to pay, I can do more cases in a day. So that's something to keep in mind as well. So in summary, there's a lot of considerations that you need to think about to make your practice more efficient, but the goal of being efficient is it will help both you as the surgeon as well as your patients. Patients like an efficient practice because it helps them get treated in a timely manner and it improves their satisfaction because of what I've talked about here, but it also helps the physician by preserving our time and maximizing revenue. Thank you. Thank you. That's perfect. The guy we gave efficiency finished exactly on time. So that's good. The next is RJ Sullivan's gonna come up and talk to us about ancillary revenue streams. So thanks to Becky and the AOFS for inviting me. I'm gonna talk about something near and dear to my heart, which is ancillary revenue. Which is it? These are my disclosures. I'd be happy to have more. So why ancillary revenue? As Willie Sutton famously said, because that's where the money is. The ancillary income, we're in a private practice of 30 docs and 34 PAs. And obviously the PAs don't see any ancillary income, but we do. It really depends on what you own. I can't get into specific numbers because some of them are private. I'd be happy to talk to you afterwards. But you can expect a minimum of $120,000 a year. And for a lot of private groups, ancillary revenue has become really important to them. And it's anywhere between 25 and 60% of yearly income. So this is my bias. That's what I put it on the disclosures. Ancillary revenue continues to increase because you're adding more ancillary revenue streams and the reimbursement continues to improve. But your orthopedic practice revenue continues to decrease. For us, our co-management agreement with our healthcare system has been critical. And I'll explain that a little bit later. MGMA, the national median salary for orthopedic surgeons is a little over $629,000. For foot and ankle specialists in private practice, it's $524,000. And for academic foot and ankle specialists, it's $445,000. With these numbers, there's no real defined ancillary income. We're part of the orthopedic forum with Bruce's group in North Carolina. And all of those numbers are proprietary so we can't share them. But what we do is we meet twice a year and we go over what we do well and what we don't do well and what we can do better. So total compensation historically has been really just office, which includes patient visits, in-office ancillaries such as x-ray, ultrasound, which has become more prevalent over the last 20 years, durable medical equipment and injectables, and then your surgical practice, which is outpatient and inpatient. But what it should include is also the administrative work that you do, the surgery center work that you do, the real estate that you've invested in, call pay that you get paid from from the hospital, physical therapy that you own, pharmacies that you might own, urgent cares that you should own, gain sharing, and then if you're lucky enough, physician-owned hospital. Our ancillary income in our group, we're in Connecticut and it's a certificate of need state, which means that it's difficult to get surgery centers, MRIs and CAT scan without the approval of the state. But we own one surgery center outright and we co-own with the healthcare system two other surgery centers. We've more recently invested in real estate. We own our own physical therapy and we have all of our offices with physical therapy in them. We own MRI, we do not own CAT scan, and that's been a difficult topic for us because it's a certificate of need. We own ultrasounds and multiple ultrasounds in every office and every surgery center. We also do pharmacy with workers' comp patients. We run a large DME company, including orthotics and prosthetics. We have two separate urgent cares. Most of us do consulting with industry. And then the specialty hospital that the healthcare system has helped us get allows us to get paid for administrative things that we do. Call pay, professional service agreements, and service line agreements are all helpful to increase your ancillary revenue. This is our freestanding surgery center. This is the one surgery center that we own outright. We co-own two others. And this is typically your largest source of ancillary income. Again, we recently started owning our own real estate, and we own the real estate for one of our offices and our surgery center, and that's gonna be an important part of our revenue going forward. You can also co-own real estate. This is not our real estate. This is the hospital's real estate. It's the Bone & Joint Institute of Hartford. But just to the left of this is the medical office building that we used to co-own that we used to co-own with the hospital, and then we ended up getting bought out by private equity. Our co-management agreement with our hospital has been very important to us, especially because we're a sick and in need state. What it does for us is it allows the hospital to lobby with us rather than against us. It also allows the hospital to help us because we help them. If we do any administrative role at the hospital, we can get paid in an hourly rate. Professional service agreements, you get paid to be on call both for trauma, because we're a level one trauma center, but also for hand and spine and hopefully soon to be foot and ankle. We have service line agreements so that all the specialists who do work at the hospital can get paid for the extra work that they do on top of the surgery. We also get paid if we do research at the institution. The key to this is that it must be based on a fair market value assessment and an hourly rate, and you have to keep excellent track of this. Physical therapy, as I said, we have all of our offices with physical therapy. It can be owned or co-owned. Ours is owned. It can be on-site or off-site. All of ours are on-site because that helps with all of the stark issues. MRI, CAT scan, and ultrasound also have stark implications. The important thing here is not to over-utilize, especially with ultrasound in the office, because people are looking. Pharmacy, as I noted before, all of our offices have workers' compensation pharmacies, and that used to be a reasonable ancillary revenue for us, but no longer is, but we never want to get rid of anything. Drug or medical equipment can be on-site or off-site. Again, ours is on-site. It could be owned or you could lease space to another company. Ours is all owned, and we have an orthotics and prosthetics lab in one of our offices. Urgent care, we just started urgent care six or seven years ago. We have two of our offices that do urgent care. Our hours of operation are 4 to 10 at night during the week and then 9 to 1 on the weekends. The thing you have to be careful here is the distribution of patients, it needs to be fair for all partners and all subspecialties. Most of us do some consulting for industry. We've struggled a little bit with this in establishing what the overhead rules are. Some of it should probably be based on whether you're doing this during your work hours or whether you're doing it off time at night and weekends, which is usually the case, but we've struggled with this. Same thing with medical legal work. We've established what we think is reasonably fair with overhead, but again, it differs with each practice. So foot and ankle compensation in 2023, you must look at your total compensation. So if you're negotiating for your salary, you actually have to look at what you do entirely. The private practice foot and ankle surgeon and the 25th percentile generates nearly $4 million in gross revenue yearly. That's all in, including all of your ancillaries. And I would ask you, how much of that do you deserve? Thank you. Thanks, RJ. Our last speaker is going to be Jason Kaplan. Jason's going to, in eight to 10 minutes, tell us how to get our financial health better. Jason's been working with the Foot and Ankle Society for the last five years, and I remember being on the search committee when we were picking our financial advisor for the society and has done a fantastic job. Thanks. So with all this ancillary income you're going to get from RJ, you need to figure out how to invest it. Investing wisely, this could also be called managing risk, because I think it's really important when you're looking at your investments to really be managing the risk. So there's all kinds of risk out there. Specifically, you've got market risk versus company risk, right? Investing in any stock, you're going to have some market risk. But within individual companies, there's a lot of idiosyncratic risk. So it's really, really important as you sort of look to invest the assets and the revenues that you're going to start to generate, how to really manage that going forward. Concentrating positions is something you have to really, really be careful for. It's easy to have certain positions become very large percentages of your portfolio, which create a lot of risk. One of the things I always like to say is if you start with $100 and you lose 50% of your money, you're at $50. To get back to that $100, you have to make 100%. So it's really, really difficult to make money back when you've lost it. So trying over time to smooth out that sort of return perspective I think is really, really, really valuable. Opportunity cost. When you're investing in one alternative, you may forego some other alternative. And I think it's really important to understand that risk reward balance that you're making. For example, you may decide to own more in stocks than in bonds or vice versa. And those decisions are going to have an impact on the returns that you're going to generate over time. So I think it's really important as you look to invest your money to make sure that you're taking into account those opportunity costs. Liquidity. As you continue to build your practice or have an established practice or might even be winding down your practice, there may be times where you're going to need that liquidity. And certain investment opportunities are going to have less liquidity than others. As I said, as you grow your practice and become more successful, you may get opportunities to invest in private opportunities, limited partnership opportunities, real estate opportunities, which may very well be good investment opportunities. You just have to be very careful that you don't tie up too much of your liquidity if you may need it at some given point. And then understanding your investments. My guess is over time, many of you will have financial advisors who may pitch certain kinds of products. And those products may be hard to understand. I would really challenge you to try and understand the investments. And if you don't understand them, to maybe steer clear of them. Because it's really, really easy to have somebody pitch you something that sounds great on the surface. But if you don't understand what exactly you're investing in, it could present some challenges going forward. There's a lot going on here. But really thinking long term in big picture, this is a chart of the last 43 years of stock market returns. And you can see in 75%, 32 of those 43 years, the markets have finished up. But in a given year, the average entry year decline is over 14%. So it's really important when you're investing to really think long term and understand that there's going to be volatility. And you need to sort of ride that volatility out from time to time. Because it just doesn't make sense to try and time yourself in and out of the markets. So that's really something that I think is important to sort of focus on. Bull versus bear markets. You hear about this all the time. Since 1962, we've had sort of eight of each. And you can see in a given bull market, they tend to last about 70 months, where bear markets only last about 14 months. The average total return for a bull market is over 200%. Where a bear market, the market's down 37%. So it feels really, really bad when you're in a bear market. But taking that long term perspective and continually understanding that this is a marathon, not a sprint, I think is really, really valuable when investing and thinking long term. And then diversification. I think this is a really, really important aspect of investing. If you really focus on having a diversified portfolio over a long period of time, I think you will smooth out those returns. There's a lot going on here in the slide as well. But as you can see, what could be great in one year could be the worst performer in the following year. So it's really important not to marry one particular asset class and to get married to that and to really have that diversified portfolio that will allow you to, as I said, smooth out your investment returns over a long period of time. I think that's the key to building wealth, creating wealth, and getting yourself in a really, really healthy financial position on a long term basis. And then some investment truths. Tax-free compounding and time are your best friend. If you continue to compound your returns over time, you're going to see the magic of compounding and how much you can grow your assets. Don't let the tax tail wag the investment dog. It's okay to pay taxes from time to time. You want to make sure that your portfolio is healthy. And sometimes having too large of a position and not sort of paring that down can create a situation where you feel like, oh my God, I got to pay some taxes here if I sell this. It's okay to do that. Dollar cost averaging. That means over time continuing to reinvest as you're making more money. There's not going to be a great time or a horrible time to invest. I think if you do it over a long period of time, you establish a portfolio that continues to sort of be healthy year in and year out. Balance portfolios. It's easy when you're younger to want to take maybe more risk. I think it's important over time to really balance that risk and to make sure that, as I said earlier, you're smoothing out your returns over a long period of time. And inertia. It can be a friend or an enemy. I think it's easy to sort of set it and forget it and invest your portfolio and then sort of not think about it. I think it's really important to constantly be taking a look at your portfolio and your investments and making sure that you or your advisor who you're working with are on the same page in terms of where you are in life, where you are in your practice, and making sure that that portfolio represents what you're trying to achieve over a long period of time. And I think last but not least, if it's too good to be true, you're going to over time have people come to you and present opportunities that just seem too good to be true. In my 25 years, I've found that it almost always is too good to be true. So you have to be really, really wary of opportunities that just don't seem to make sense on the surface. And with that, thanks for having me. Thanks, Jason. We've got about nine minutes for questions. So please come up to the microphones and ask a question. If not, I have some. While people are hopefully coming up to the microphone with questions, let me ask Jason a question. So we learned a lot about liquidity in COVID. Running a large group, I basically came to the group, a lot of unknown, and said, prepare yourself for three, four months without any income, without any compensation. Didn't happen, but prepare yourself. Get credit lines, home equity lines. You need to have whatever, and I'm going to ask you what that should be. What we learned was we had a lot of people that were completely overextended, had no liquidity options, had no backup. What I found two years later, three years later, is they still don't. So what's your recommendation? We have a lot of young physicians in this room. What's your recommendation on liquidity? Liquidity doesn't mean cash in your mattress or under your mattress, but what would your recommendation for people five to 10 years in their practice? For me, it's too late for me. I'm done. Yeah, no, I think that's a great question. The sort of rule of thumb out there is six months of liquidity. You want to make sure you have the ability in case things come to a screeching halt that you have six months to sort of make sure you can feed your family and support your lifestyle. And again, I don't think liquidity means cash under the mattress. I think it means having the ability to turn whatever those investments are into that cash in a short period of time. We're fortunate now in that interest rates over the last 18 months have risen significantly. So you're actually able to generate some yield on your cash where 18 months ago you were earning 1% having your money sitting in a savings or a money market. Now that's 5%. So you actually are generating a little bit of liquidity now and yield having that money in sort of a safe place. So I think there's opportunities there. But six months seems to be a good rule of thumb. And that's an important point. And it's not just a global pandemic. It could be an illness. It could be some financial hardship that you don't anticipate. And if you can't manage and put away something or have access to capital, it creates stressors in your life. It creates financial stressors that affect your clinical performance. And we've seen that a lot in running a big group. When people start to have problems, it's usually a personal problem at home or a financial problem. And it affects how they take care of people, complication risk, litigation risk. It all goes up. So just something to learn. Learn from other people's mistakes. We've got a question here. Hey, how are you? I have a quick question for Dr. Hsu. This is about coding. In the time that you've been following, has the strategy been pretty stable? Are you having to go back and forth with Washington and kind of relearn how you do things? And if so, how frequently do you have to do that? I think one of the biggest things with coding is you're not in isolation. You need to identify all the players involved in your coding. And these are very different practice groups that you've seen so far. Private practice, university, mixture, private devics. You need to figure out what is the flow of money, right, from the minute that the patient comes to your door. You control some part of that coding, right? So you control the E&M coding, and you code the CPTs and the ORs. Where does that actually go to? It probably goes to some sort of physician billing group. You need to know that person and have them on speed dial to consult with them about is what you're putting into the system actually going out to the insurance carriers, and are the insurance carriers actually paying that? Or is it getting rejected because things are bundled? So CMS coding itself doesn't change very often, right? These books are archaic. They're like Encyclopedia Britannica, for God's sakes. These old books, because they're not made by us. They're made by Centers for Medicare and Medicaid in Washington. So the codes themselves don't change. So very rarely they'll adjust the code here or there. But I think the thing that's most important when you're learning how to do it is not just learning the terms and the codes and the vernacular, but also who are the people involved? Because you may know coding inside and out. If your biller on the end side of this changes and you don't know that, and they're eliminating 50% of your codes because they don't understand what a 59 modifier is, your revenue will just get obliterated. So you have to really vertically integrate that whole process and keep track of it. No different than keeping track of your PA, your MA, your nurse. You are in charge of all of it. And the fact that we don't talk about it enough is kind of why I've become somewhat obsessed with it, is that we talk about all these things about efficiency, but if you don't follow the money from completion to end, you don't really know what you're doing. You just think you know what you're doing. But the codes in the ICD-10s really don't change very much, which is why in the past five, six years, I've maybe adjusted a handful of codes. More than anything, I'm adding on the 35860, the 13160, ones that I didn't know and I go, Jesus, how much money have I been losing the past six years by not knowing that? So the list always compounds and I'm always keeping more track of it. You have to be involved in the process. You cannot be passive in this. We have a question over here. Yes, a question for Dr. Hsu. Can you give us a distribution of your level one through five new patients and established and could you give an example of a level five established or new patient problem? Yeah, so it's interesting. Before 2021, if you were doing a five, put on your orange jumpsuit, right? Because nobody's doing a level five. That's like a tumor one hour visit. None of us would dare do that. But what's so interesting now, though, is that with MDM, because they've given you the option of time-based coding or medical complexity coding. So a level five, I don't use a lot. I use pretty much all level fours, news, and established. I don't ever go to threes. Before, 10 years ago, most people in the room who are a little bit older would say, just circle the three for everything. You won't get audited. You'll be fine. Time-based coding for a level four says that it's 45 minutes for a new patient visit. If you start doing time-based coding, you can get audited pretty quick because someone's going to go, how did you do 10 level fours in three hours? Because obviously, the math doesn't add up. But the medical decision-making of a level five, which I have used on occasion, be somebody where, listen, I really was in there for a long period of time. But it was somebody that had a tumor of their foot that I then had to bring in my oncology specialist. And I basically was dealing with multiple issues, very complex patients. I usually save those for the ones where, by the end of the visit, if you're 30 minutes in and you're like, wow, we've covered 10 different things, I will code that out as a level five. My spine and my tumor partners right now are routinely coding out level five new patient visits. And it is going through fine. I usually stick with the fours. But with very complex bilateral issues or CRPS, things where it takes a lot of consultation, I will do a five, not based off of the time, but based off of the amount of complexity. And you need to make sure that's written paragraph by paragraph in your note to reflect why it was so complicated. How many different issues did you have, point by point by point? And you can template that out and dot phrase it so you don't have to reinvent the wheel. And I would say the level fives are achievable, especially in pre-op patients with multiple medical comorbidities, big procedures that are going to affect their ambulatory ability. If that's all templated in your note, you can get to a level five. We review all our level fives at our group, and we're getting to that 10% level. Some of our joint and spine docs are at 20%, 30% on their pre-op patients. Let's go here, and then John will be our last question. I've got a question about private practice and hiring help. We've got a lot of young physicians in the room. I'm just wondering when you guys felt it was financially sound to either hire a dedicated PA or a nurse to help you guys be more efficient in your clinic? I think that's a great question. In my group, we generally will start out a new physician with a medical assistant. And then as they build their practice and it gets busier, we actually have a process where we'd evaluate, okay, what's your volume, what's your wait time of getting into the clinic, things like that, and then determining when do we need to add a physician assistant or a nurse to help with you. So it does depend a lot on volume. It seems to be different for every physician. Where I am, we are, when we have a foot and ankle physician hired, they're busy from the get-go, and usually within six months they have a PA because they just can't handle the volume past that. And then when to hire a nurse to see post-ops and stuff, that also depends on your surgical volume. So that can vary, sometimes one to two years down the road. But it is kind of a stepwise process depending on how busy you are, and you should have a mechanism in your practice to evaluate how busy is that physician. Thank you. Great. Okay, John, last one. Thanks. John Kwan from Mass General. This is a question for Dr. Su. Andrew, I appreciate you giving a very open and candid discussion about this. I've struggled with my coding for years throughout my entire career, but my struggle has been on the potential financial impact on my patients. I know their insurance types, but I don't know their plans or their deductibles. And the truth is a distal fibular avulsion fracture is a sprain. It's not a fracture of the lateral malleolus. So how do you reconcile maximizing your coding with the potential financial hardship on your patient? Yeah, I think it's a very good point. And I think, one, you have to recognize the environment that you're in, right? Running a small private practice versus being in an academic setting, I think, changes things quite a bit. I do a lot of indigent care where a lot of care is somewhat free from Medicaid and CalOptima. So I think it's a discussion worth having. I think at the end of the day, the more 30,000-foot view is, if you're providing excellent service, you should be compensated excellently for it. Anybody in this room, if you're going to go stay at a nice hotel, a nice resort, you're paying that money upfront because you're wanting that care. So some of the pressure I put on myself is, if I am coding out this distal fibular avulsion fracture as a distal fibular nonoperative code, I'm going to be there and talk to you about it. I'm going to be the one seeing you. I'm not pushing you off to another provider. I'm not being in there in 60 seconds. I'm going to sit down and actually talk with you and explain what's going on. So I think it does put the onus or responsibility on you to provide better care. But in a certain private practice setting, I would be up front with it and say, listen, we may have a bill for a closed fracture management, and this is why. But I think if patients understand why you're billing them and you're doing it up front and you're providing good care, they don't care. What they will care about is you're billing them like crazy. They're never in the room. They're only seeing the PA. They can never get follow-ups with you. So I think it's important for us to protect ourselves, that we are financially healthy, that it does affect our overall psychological well-being. But I think you also take very good care of the patient. So I would bill accordingly for that and discuss it with your hospital and your insurance carriers as well in terms of who's getting billed here. Is it this person with a $1,000 deductible, or is it CalOptima and they're getting it for free? But I think you should do everything consistently. You shouldn't vary because you feel bad for this person or good for this person. Because just like timing in the markets, it's highly variable. You need to be consistent throughout and then really kind of define what that's going to be for you. If you're a level 4 guy, a 5 guy, a 3 guy, what is it going to be? But just be very consistent within whatever moral and ethical code that you have. Well, great. On that note, we're going to conclude. Great session. Thanks to all the speakers, and thanks to you guys. Thank you.

symposium

managing orthopedic practice

clinical freedom

integrating podiatry

practice efficiency

coding mastery

improve patient care

investment management

liquidity

ambulatory surgery centers