Abstracts

Rationale:
Ketogenic Metabolic Therapy (KMT) is an effective dietary modification for intractable epilepsy however, resources including qualified ketogenic dietitians, support staff, and ability to bill for services limit the number of patients initiated and managed successfully. Limited data is available to determine adequate dietitian staffing ratios for ketogenic patients. The COVID-19 outbreak led to increased use of telehealth services and a national push to explore outpatient initiation of KMT. Phoenix Children’s Hospital (PCH) has routinely initiated patients in an outpatient setting on all variations of KMT for over 10 years. At the end of 2019, this center started billing for outpatient dietitian services, which allowed for increased contact time with patients outside of their usual epilepsy follow-up appointments with Neurology. The purpose of this study is to analyze time spent face to face with patients (billable time) versus time spent in meal calculation, communication, and coordination of care (non-billable time) in order to improve efficiency in work flow and maximize clinic revenue.
Method:
Two full time equivalent (FTE) ketogenic dietitians (RD-1 and RD-2) employed at PCH tracked work productivity based on 15 minute units for each work day beginning in January 2018. Data collection fell into the following categories: face-to-face time (inpatient and outpatient); patient communication; care coordination; and diet calculations. Averages were calculated for total time spent for both RD-1 and RD-2. For each category, the percent FTE was calculated based on number of 8-hour workdays minus paid-time off and holidays for each month. Reimbursement for total units billed and payment received for outpatient services for both RD-1 and RD-2 were analyzed based on two billing codes: Initial Medical Nutrition Therapy Assessment 97802 and Follow-up 97803. Non-revenue units (visit completed in conjunction with another healthcare provider) were also totaled to determine potential missed revenue.
Results:
From 2018, a total of 205 patients were referred and 121 patients initiated on KMT. Average FTE for face-to-face time with patients, patient communication, and care coordination was 10.7%, 9.5%, and 22.2% respectively. An average of 3 hours is typically required for education prior to diet initiation. Follow-up visit time generally varies from 30-60 minutes. Based on billing data from 1/1/2020 through 5/31/2020, the average reimbursement rate for an initial assessment lasting 60-90 minutes, was $22.22 per 15 minute unit. Average reimbursement rate for a follow-up visit was $21.39 per 15 minute unit. Reimbursement averaged 22% of charges submitted. A total of 148 units were billed as non-revenue, representing revenue potential of $3165.72.
Conclusion:
Given the specialized skills required for safe and effective management of ketogenic patients, time of a ketogenic dietitian is more efficiently and economically spent on direct patient care. Other care coordination duties can be delegated to an Administrative Assistant, Medical Assistant, or Nurse or administrative assistant, which will maximize billable dietitian time to increase clinic revenue. A change in clinic model to more frequent follow-ups via in person or telehealth would minimize indirect patient care between visits, while maintaining high quality care and patient satisfaction. Based on this revised clinic workflow, we estimate care coordination and patient communication between visits completed by the ketogenic dietitian could be reduced in half. This would increase billable hours by approximately 328.6 hours; providing clinic revenue of additional $28,115.02 per year per dietitian. At our institution, this covers ~35% of ketogenic dietitian FTE.
Funding:
:None