Life After Boards

(1)

University of Florida, College of Medicine, Gainesville, FL, USA

(2)

Private Practice:, Orlando, FL, USA

10.1 Advice for Life After Boards

My Personal Words of Wisdom

1.

Stay humble and be kind.

Respect your colleagues, your staff and your patients and be kind to others. I know this sounds so cliché, but I think this is the most important thing to remember as you embark on the next phase in your life. No matter how ‘big’ or ‘important’ you become down the road, always remember that we are fortunate to be in the field of dermatology and there is no reason why we cannot stay humble and be kind to others.

2.

Pay it forward.

Whether it is dermatology or not, find something you feel passionate about and make a difference. Do something that makes the world a better place because you are in it. Teach, publish, discover…whatever it is that suits you. But make a difference somehow.

3.

Try to be extraordinary.

Try to be more than just ordinary. Strive to be extraordinary in life, whether it comes to your career, your children, or your hobbies. After all, we are dermatologists and born overachievers, so being extraordinary shouldn’t be so difficult for us.

4.

Don’t underestimate the importance of health.

No matter how busy you become, remember the most important gift you have is your health. Don’t take it for granted and try to do your best to maintain good health. Yoga, meditation, green tea, exercise, eating healthy…whatever works for you that is healthy, do it and do it often.

5.

Don’t forget about retirement.

If you understood the concept of compounded interest and how fast your money would grow if you saved early, you would never brush off those financial advisors who constantly tried to meet with you during residency. No matter how busy you are (even as a first year resident), do not forget to open a retirement account and put the maximum allowed into it. Learn about the different types of accounts (traditional IRA, Roth IRA, 401k, 403b, SEP IRA, etc.) and start now.

6.

Treat every patient like they are a family member.

If you can remember this one piece of advice every day when seeing patients, you will be an extraordinary physician.

10.2 Taking the Job

Employment Contract

The contract needs to be examined carefully, so it is prudent to hire a contract lawyer before you sign it
It is best to find a contract lawyer with the following:
- Experience drafting and negotiating physician employment contracts
- Experience with contracts specifically in the dermatology field
- Knowledge of state-specific laws (especially if the contract lawyer is in a different state)
Important points in the contract:
- Termination Provision
  
  There are two basic types of termination clauses: ‘with cause’ (with good reason) and ‘without cause’‘Cause’ is typically defined in the contract‘Without cause’ enables the employer to terminate the contract with no stated reason by providing written notice in advance (often 30-180 days)Fair contracts with a ‘without cause’ provision allow the physician employee to do the sameIn ‘without cause’ terminations, be sure the notice period is long enough to allow for securement of other employment
- Restrictive Covenant
  
  Precludes a physician from working in a geographic zone (ranging from one to several miles from the practice) for a given time period after contract terminates
- Bonus
  
  If employee’s production exceeds threshold level (which is often 3 to 4 times the base salary), a percentage of collections in excess of threshold goes to employee as a bonus
- Partnership
  
  ± Track to partnership (ie. 2 years), ± buy-in to become partner
- Fringe Benefits
  
  Typically includes health insurance, malpractice insurance, disability insurance, CME costs, vacation, often week off for CME activities, ± retirement plan
- Malpractice ‘Tail’
  
  If the practice’s malpractice policy is maintained on a ‘claims-made’ basis, someone needs to cover the ‘tail’ of the departing physician (which is very expensive); tail covers any claim brought after the period covered by the claims-made policy
  
  Of note, 2 types of medical malpractice insurance
  
  Occurrence insurance: covers a physician for a claim even after the contract is terminated or expired (thus, do not need to buy ‘tail’ coverage)
  
  Claims-made insurance: covers physician as long as medical incident happened and was reported to the insurance company while the policy was still in force; once the policy is terminated, coverage no longer exists (unless ‘tail’ coverage bought)

Employee Vs. Independent Contractor

There are advantages and disadvantages to both, so it’s important to understand the differences before making the decision
Employee
- Financial stability: you do not need to worry about how many patients are canceling per day or if the clinic is slow when starting out since you receive a fixed monthly paycheck
- Benefits: health insurance, paid malpractice insurance, ± retirement account, ± health savings account, CME time with stipend
- Taxes: not complicated since taxes automatically withheld from the paycheck every month (Medicare tax, Social Security tax, federal and state tax)
- Lack of autonomy: biggest disadvantage
  
  FICA (Federal Insurance Contributions Act): includes Medicare and Social Security tax
Independent Contractor (IC)
- Autonomy: biggest advantage
- Tax deduction: any work-related expense (reasonable and customary) can be deducted from taxes as a business expense, such as (but not limited to):
  
  Travel: commute to/from work (must be from one office, such as home office, to another office) and other related business travel
  
  Licensing and professional association fees, conference dues, journal subscriptions
  
  Insurance premium (health care and malpractice insurance)
  
  Retirement plan contribution (up to 25% of earnings)
  
  Self-employment taxes
- Financial instability:
  
  One receives a fixed percentage from the total amount collected (from insurance company/patients) – not the same as the amount billed (which is often much higher)
  
  When starting out, it can take several months to build your practice and enlist in different medical insurance plans which means the less you will make early on
- Lack of benefits:
  
  You must provide your own health insurance and malpractice insurance; of note, health insurance without a large employer can be quite costly, so weigh this carefully
- Taxes and incorporation
  
  Time and money will be spent to create a corporation, file for an employer identification number (EIN), and to pay an accountant
  
  Paycheck from the employer is typically made to the corporation, and you are an employee of that corporation; this means, you will have to pay yourself from the corporation either through a monthly salary or with regular distributions
  
  Filing taxes will be much more complicated than if you were an employee (ie. pay estimated taxes quarterly [‘estimated’ since you do not have a fixed salary], pay FICA taxes twice since you are both an employee and employer, state and federal unemployment tax, state tax, and federal income tax)

Incorporation: forming of a new corporation (recognized as a legal entity under the law)

10.3 Coding and Documentation

Coding can be a frustrating task initially, but it is crucial to learn how to code properly
You are ultimately responsible for proper ICD-10 (diagnosis) codes and CPT (procedure) codes regardless of who does the billing in the office; you should also review your own explanation of benefits (EOBs) from the insurance carriers
If you don’t code correctly, claims may be denied or you may be underpaid; thus, it is imperative to understand proper CPT codes, modifiers and global periods from the start
ICD-10 and CPT codes may be updated, so its wise to keep up with these changes
Below is a brief outline for proper coding, which is by no means exhaustive so please refer to additional references for an updated and more detailed explanation
The best place to read a more detailed explanation is the Centers for Medicare and Medicaid website: http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp (click on Documentation Guidelines for E&M Services on the left hand side)
Billing form should have the diagnosis listed to the greatest level of specificity

A. Coding for the Office Visit

Current Procedural Terminology: CPT

The office visit or evaluation/management (E/M) level is determined by documentation of three key components: history, physical exam and medical decision making
If counseling accounts for more than 50% of the face-to-face time during the visit, time is considered the controlling factor in determining the level of E/M service (not key components) and the total length of time needs to be documented
For most visits, E/M level will depend on amount of documentation (not amount counseled)
History:
- Chief complaint, review of systems (ROS) and personal/family/social history (PFSHx) can be listed as separate elements of the history or included in the description of HPI
- If a ROS or PFSHx was recorded at an earlier time, it does not need to be re-recorded if there is evidence that the physician reviewed and updated the information (initials/date)
- Elements (each of the following counts as one element): location, severity, timing, duration, quality, modifying symptoms, context, associated sign/symptoms
Physical exam: need certain number of elements (each bullet in table below = one element)
Decision-making: need proper documentation (ie. follow up visit, it should be documented in the chart whether the problem is improving, stable, worsening, resolving, etc.)

Table 10-1:

Elements In Physical Exam

(modified to reflect common circumstances in dermatological skin exam)

System/Body Area	Elements in Physical Exam
Constitutional	• General appearance of patient (e.g. well developed, well nourished) • Vital signs, need 3 or more: BP/P/Temp/Ht/Wt
Eyes	• Inspection of lids and conjunctivae
Ear/Nose/Throat	• Inspection of lips, gum and teeth • Inspection of oropharynx Each bullet counts as one element
Neck	• Examination of thyroid
Cardiovascular	• Examination of peripheral pulses by inspection and palpation
Lymph nodes	• Examination of lymph nodes in neck, axillae, and/or groin
Extremities	• Inspection of digits and nails (clubbing, cyanosis, inflammation, etc)
Skin	• Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities • Head (including the face) • Neck • Chest (including breasts and axillae) • Abdomen • Genitalia, groin, buttocks • Back • Each extremity (ie. RUE and LUE count as two elements) • Inspection of eccrine and apocrine glands of skin and subcutaneous tissue
Neurologic/psychiatric	• Orientation to time, place and person • Mood and affect (e.g., depressed, anxious, agitated, pleasant)