Infographic Shows Increasing Healthcare Demand Is a Revenue Opportunity

Lea Chatham March 31st, 2014

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At some point in recent years, you’ve probably heard that there is a projected shortage of primary care physicians on the horizon. But have you heard that there is already, and will continue to be, an increase in demand for healthcare services as well? In the infographic below you can see the details of the impact the Affordable Care Act (ACA), aging baby boomers, and a growing population are having on the demand for healthcare services. In fact, all the combined factors will result in an increase of 100 million more doctor’s office visits per year by 2025.

If you see this as a challenge, it’s time to change your perspective.

This is an opportunity for independent practices that are interested in growing their businesses.
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By optimizing your practice operations, you can retain your current patients, increase the appointment slots available for prospective patients, and recruit new patients who are looking for new providers and services.

How can you do this? Simple, by ensuring that you have implemented a seamlessly integrated practice management, billing, and EHR solution in your practice. Once you have that in place, it’s important to implement best practices and take advantage of advanced tools like email or text reminders and statements, patient portal, and online appointment scheduling. You may also want to look at alternate scheduling models like modified wave scheduling that can increase the number of patient visits by as much as 20%. How can your physicians see 20% more patients a day? Again, by streamlining tasks and reducing time spent on administrative duties. The average primary care physicians spends a quarter of the day on administrative tasks

The use of technology can reduce a physician’s administrative time and free more time for patient visits. Tweet This

What does all this mean for your bottom line? It could mean serious revenue. The average primary care physician sees 78 patients and works 50 hours a week. If you could reduce your time on administrative tasks and add more patients by using improved scheduling and other tools, each provider could see 15 more patients a week. If your average visit reimbursement is $100, you’d reap an additional $75,000 a year per provider. In addition, a UBM white paper showed that the average increase in revenue when using an EHR was $33,000 per FTE provider per year! You could be looking at an additional $100,000 a year or more.

As an added bonus having an EHR and patient portal can help you keep all those new patients, 73% of whom are more loyal to a physician who has a portal. Check out more interesting facts and figures in this infographic. Download a high resolution version here and share with your colleagues.

Kareo infographic

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4 Things to Remember about Building Physician Referrals

Lea Chatham March 26th, 2014

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Kareo Webinars Recently, at the free webinar 3 Ways to Cultivate Rapid Growth through Referrals, speaker Cheryl Bisera talked about her three A’s for building patient and physician referrals. She provided many great tips and there were tons of terrific questions. Cheryl and Kareo have answered those questions, highlighting a few of her best ideas for strengthening your referrals.


  1. Q: How can we reach out without seeming salesy? Aren’t programs like lunch and learns often seen as a sales pitch?
    A: They certainly can be seen that way. It’s important to be sure your program is offering real value.
    Again, you aren’t trying to sell yourself, you are trying to build a relationship and provide tools and resources to potential referral sources. Tweet this Kareo story
    You just want to help them see the value for both of you in building that relationship. Don’t do a lunch and learn that is just an overview of your practice. The focus should be educational and have value. For example, if your practice offers a unique program that isn’t available elsewhere, a lunch and learn for other providers to educate them about that service could have real value. It could be a new tool (robotic surgery) or service (PTs who provide incontinence treatment) or a procedure that is so new they didn’t even know it existed—bringing them up to date in your specialty keeps them at the top of their game too.
  2. Q: What are some realistic goals we should set around improving referrals? How do we know if our efforts are successful?
    A:  The best way to measure success is to understand your current metrics, then set goals and track how you are doing over time. Tweet this Kareo story
    Who is referring and how often? Is your goal to increase referrals from existing sources or find new ones? Your goals will depend on these questions and your unique situation (practice size, specialty, location, etc.) For example, if you are a smaller practice and haven’t done any outreach or marketing to build your referral network, you should expect that with an aggressive campaign you have a lot of room for growth and can improve your referral revenue by as much as 20% in six months. After that time, you can gauge whether or not that is an appropriate goal to repeat or adjust as needed. Your results will also depend on how much time, money, and resources you are going to invest in your outreach campaign and that may change with your results as well. A marketing plan includes data that can help with these goals such as looking at like communities and finding out the capacity of your specialty in your community (how many like specialists are in your area), these demographics and the demographics of your community (how many potential patients exist) determine your competitive landscape.
  3. Q. How can I get the doctor in my office to get behind these kinds of initiatives?
    A: Showing your physician reports on the referral source revenue—average revenue each referral source has provided for that year to your practice. Then suggest what it would mean to the practice in revenue if “we could increase that by 50%”? Or if you were to reduce your revenue by that which comes through your three top referrers—how would that affect your practice revenue (what if our top three referrers disappeared due to a move, retirement, or other cause)? That’s a good reason to practice the three A’s! The numbers will speak for themselves. If the issue is that your physician feels like a salesman, appoint or recruit a marketing specialist for your practice to be the liaison between your practice and referring practices and to reach out to potential referrers—but remember the skillset listed in the webinar, the wrong person, wrong message, and wrong approach could hurt your reputation and relationship with other practices.
  4. Q. At what point do you give up on a practice you are trying to connect with?
    A: I would never recommend “giving up” entirely. If you have tried many times to reach out and you aren’t getting a response, there could be any number of reasons why. We often give up too soon because we misinterpret a lack of response due to their busyness as rejection. Remember the rule of 7, be sincere and keep at it while respecting their time and honoring their ques. It’s not always easy and that’s why there are marketing specialists and liaisons. If you feel it is appropriate, ask outright if there is a reason they aren’t interested. Maybe it is something you can fix. If not, or if you can’t get an answer, then scale back to a more limited outreach program. It might be just once or twice a year to keep your name in front of them. You never know when something might change. Perhaps the issue was specific to the practice manager and then one day that person leaves. The replacement manager might be more receptive. So don’t give up all together.

If you found this information interesting, join us for our next free webinar with practice management expert Laurie Morgan, The Patient Portal: Meaningful Use, Engaged Patients & More. And if you have tactics that have helped strengthen referrals at your practice, share them in the comments!

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6 Questions to Assess Your Practice’s ICD-10 Readiness

Lea Chatham March 24th, 2014

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By Lisa A. Eramo

Kareo ICD-10 resourcesIf there’s anything that most of us learned in school, it’s that procrastination is never a good thing. It can cause unnecessary stress and result in a potentially disastrous outcome (failed final exam, anyone?).

Physicians: Apply this lesson to ICD-10. Do you know whether your practice is ready?

Waiting until the last minute to prepare for this monumental change can delay cash flow and impede even the most efficient practice. Why not plan in advance and save yourself the headache?

Unfortunately, many physician practices aren’t getting the message. Only 4.7% of practices have made significant progress toward ICD-10 readiness, according to a June 2013 survey published by the Medical Group Management Association. Fifty-five percent haven’t begun implementation at all.

Jacqueline J. Stack, BSHA, CPC, CPB, CPC-I, CEMC, CFPC, CIMC, CPEDC, AAPC director of ICD-10 training and education, says practices—particularly smaller practices and solo practitioners—need to assess their readiness for ICD-10 so they can get the ball rolling. It’s time to face the music and ask those difficult questions to see just how ready you are, she says.

Question #1: Have you accepted ICD-10, or are you still in denial? Hoping for another delay is not the answer. Use this precious time to begin preparations rather than bury your head in the sand of denial. If your staff members see that you’re embracing this change, then they will too.

Question #2: Is someone in charge of the effort? Putting someone in charge of ICD-10 allows you to focus on patients while ensuring staff readiness. Tweet This
In most practices, either the practice manager or a lead coder will assume the responsibility of ICD-10 coordinator. Once identified, ask your ICD-10 coordinator to create a formal task list and identify those who need training. Does your ICD-10 coordinator know where to find ICD-10-CM resources?

Question #3: What does your documentation actually reveal? Ask your ICD-10 coordinator to run a frequency report of your top 50 most frequently reported diagnoses. Your coordinator should review documentation for these diagnoses to ensure that it can support the assignment of ICD-10 codes. If the documentation results in assignment of an unspecified code, ask your ICD-10 coordinator to explain why. Does the diagnosis require laterality? Anatomical specificity? Your coordinator should be able to provide you with a cheat sheet or other tool to aid in your documentation. Ensure that this individual has the time and resources to compile and develop this information.

It may also be helpful to undergo an ICD-10 clinical documentation assessment using an outside company or consultant, such as the American Academy of Professional Coders (AAPC). The best way to prepare for ICD-10 is to ensure quality documentation through multiple audits and corrective action.

Question #4: Are your staff members are ready? Ask your staff members how comfortable they are with ICD-10. Don’t assume that they can learn easily or that they are learning it on their own. Establish a formal assessment and training process. Your ICD-10 coordinator should be able to assist with this.

Question #5: Have you contacted your vendors and payers? If your answer is no, strive to change this quickly. Ensure that your ICD-10 coordinator adds these tasks to his or her to-do list:

  • Compile a list of each payer and vendor along with its contact information.
  • Ask each payer and vendor when (i.e., a specific date) it will be able to display or process ICD-10 codes. Track each vendor’s and payer’s progress toward this goal by periodically contacting them.
  • Ask each payer (including Medicare and Medicaid) as well as any vendors when they will be ready for ICD-10 testing. End-to-end testing is important. This means that your ICD-10 coordinator should send claims through your practice management software to each payer. Ensure that each payer is able to receive those claims and send responses back.
  • Contact worker’s compensation and auto insurance companies. These entities are not mandated by HIPAA to adopt ICD-10. Inquire whether they will transition to the new coding system or not. Note that some states mandate that worker’s compensation move to ICD-10.

Question #6: Do you know how ICD-10 may affect productivity? The only way to know for sure is to allow your coders to code a few records each week using ICD-10. How long does it take them to complete each record? Does a delay translate to a potential disruption in cash flow? Will you need to hire temporary staff to answer phones and book appointments so that your staff can concentrate on coding accuracy for a period of time after implementation?

About the Author

Lisa A. Eramo

Lisa A. Eramo is a freelance writer/editor specializing in health information management, medical coding, and healthcare regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal and AHIMA Advantage. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

Kareo ICD-10 Resources

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Free Physician CME ICD-10 Webinar

Lea Chatham March 19th, 2014

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ICD-10-CM: What Physicians Need to Know
April 3, 2014
10:00 AM PT, 1:00 PM ET
Cost: FREE

Do you understand how ICD-10 will impact your practice and the way you document patient encounters? Learn about the four steps you need to take to ensure that you and your practice are ready to make the transition to ICD-10 on October 1, 2014. This FREE CME webinar provides the tools you need to get prepared.

You’ll learn:

  • What ICD-10 is and why the change is happening
  • What the four steps are you need to take now to transition to ICD-10
  • How to improve your documentation to ensure ICD-10 success

The event is presented by Tom Giannulli, MD, MS, and CMIO at Kareo and Abhinav Gautam, MD, CMO, and Cofounder of Nexus Clinical.

Join the conversation today!  You don’t want to miss this.

For CME credit information, click here.

Register now for this CME webinar on ICD-10

About the Speakers

Tom Giannulli, M.D., M.S. is the chief medical information officer at Kareo. He is a respected innovator in the medical technology arena with more than 15 years of deep experience in mobile technology and medical software development. Previously, Tom was chief medical information officer at Epocrates and he was the founder and chief executive officer of Caretools, which developed the first iPhone-based EHR. He holds a M.S. in biomedical engineering from the University of Utah and earned his M.D. from the University of Texas at Houston where he completed his residency in internal medicine.




Abhinav Gautam M.D. is the Chief Medical Officer of Nexus Clinical. Dr. Gautam is one of the architects of Nexus Clinical’s solutions portfolio and is also closely involved in developing new intellectual property (R&D). Additionally, Dr. Gautam also has authored several peer-reviewed medical articles in the fields of Anesthesiology, Critical Care, Surgery, and biosemiotics. Dr. Gautam completed his residency in Anesthesiology from the University of Miami’s Miller School of Medicine.


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Check Out March Newsletter for Great New ICD-10 Tools

Lea Chatham March 14th, 2014

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The March edition of the Kareo Getting Paid Newsletter is packed with medical billing tools and tips to help you improve your practice. The newsletter also provides a chance to discover upcoming events, new ICD-10 and Meaningful Use resources from Kareo, and links to connect with Kareo on social media channels. You’ll discover more about how to register for our upcoming free educational webinar, 3 Ways to Cultivate Rapid Growth through Referrals, presented by Cheryl Bisera. Read all this and more now!

Kareo Getting Paid Newsletter


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3 Ways to Improve Physician Referrals

Lea Chatham March 12th, 2014

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By Cheryl Bisera

Register now to improve referralsIf referrals are the lifeblood of a practice, then why do many practices neglect the outreach necessary to expand and grow them? In the day-to-day business of running a practice it’s easy to focus on urgent and obvious needs, but when referral sources aren’t nurtured, the results can be financially devastating. If your practice isn’t reaching out with an intentional, organized approach, the door is wide open for another smart practice to come in and begin to win over your potential and existing referral sources.

Whether it’s a slow bleed or severe changes in referral patterns, the result of neglecting referral outreach is declining revenue, costly setbacks, and failure to maximize your practice potential. However, none of this is out of your control. By taking steps to implement a proactive outreach program, you can grow new referral sources and strengthen existing ones.

First identify who you want to reach. You might want to target a new physician that joined an existing referral group or break in with physicians who have been in the community much longer than you and have referral patterns that don’t include you yet. Be open-minded, sometimes our assumptions are wrong about who will and won’t refer to us and why. You might be exactly what they’ve been waiting for! An example is when one of the specialists they commonly refer to doesn’t contract with an insurance that many of their patients have, or isn’t available certain days or hours.

If physicians are your target, consider these steps:

  1. Start by introducing your practice to the managers of the physicians on your target list.
    Begin with a self-introduction and an invitation to lunch. The goal is to begin building a relationship. When meeting with each manager explain who your providers are and what services your practice offers. You might discuss special services or procedural offerings that make your practice unique. Suggest dropping off a stack of business cards and other information about the practice.
  2. Physician-to-physician lunch meetings are a powerful source for strengthening referrals. Tweet This
    It’s a welcome opportunity for colleagues to meet and collaborate on ideas within their own practices (what EHR are you using?) as well as a chance for your providers to talk about what conditions they treat, the latest treatments and techniques being used in their specialty and helpful information about identifying patients that might need their services. It’s important that physicians are sensitive and respectful of potential referrers, never giving the impression they expect referrals and affirming that the best interest of patients—as they see it—is always top priority.
  3. Invite a referring or potential referring practice to a “lunch-n-learn”. Tweet This
    They can come experience your practice while enjoying lunch on you. One of your physicians can share a short presentation on his or her specialty with helpful information about what your practice can do for their patients. These programs provide an opportunity for staff to socialize and feel valued. Remember, every staff member is a potential referrer, treating them with respect and equipping them with knowledge of your services is smart and strengthens the practice-to-practice relationship.

A practice that reaches out and builds relationships based on mutual respect will be rewarded with loyal referrers. Putting best practices to work in cultivating rapid growth through referrals is not a vague idea; it’s something every practice can do.

To learn more about building a strong referral network with physicians and patients join me at my upcoming webinar, Three Ways to Cultivate Rapid Growth through Referrals, on March 19. Register now.

About the Author

Register now to improve referralsCheryl Bisera is a consultant, author and speaker with extensive experience in marketing and business promotion that spans more than ten years in which she worked with professionals to strengthen their position in the marketplace. She is the founder of Cheryl Bisera Consulting, a California-based image development and marketing company that focuses on the healthcare industry. Cheryl has spoken for regional medical management organizations, conducted customer-service workshops, and written numerous articles for publications such as KevinMD, Physician Magazine, and the Journal of Medical Practice Management.

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5 Topics in the OIG Work Plan that May Apply to You

Lea Chatham March 12th, 2014

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By Lisa A. Eramo

OIG Work Plan


If your practice hasn’t already taken the time to review the FY 2014 OIG Work Plan released in January, now is as good a time as any. It’s heady stuff but necessary all the same.


Betsy Nicoletti,
co-founder of, a wiki devoted to physician reimbursement, suggests practices use the Work Plan as a guide for internal audits. She says to ask these questions when reviewing the 101-page document (luckily, not all pages pertain to physician practices, and some of the topics are specialty-specific):

  • What topics in the Work Plan apply to your practice?
  • Is your practice maintaining compliance in these areas?
  • What is your practice doing to monitor compliance over time?

Following is a discussion of some of the highlights of the Work Plan and what you should keep in mind.

Diagnostic radiology studies
The OIG will closely examine the medical necessity for high-cost tests. Nicoletti says this likely includes PET scans, CT scans, and MRIs.Tweet this Kareo story

What you should keep in mind:

  • Diagnosis codes: Only certain diagnosis codes justify each test. Ensure that the correct diagnosis code is reported and that this code accurately reflects the patient’s condition.
  • Timing of testing: Ensure that the timing of the particular radiology test is appropriate given the patient’s clinical presentation. For example, back pain may be a covered diagnosis for a CT scan but only after the patient has undergone physical therapy.
  • Volume of testing: According to the Alliance for Integrity in Medicare, numerous articles and studies have demonstrated that physicians who own their own diagnostic imaging equipment are more likely to refer patients for tests than those who don’t. Always consider whether the test is truly medically necessary before rendering it.

Lab tests
According to the OIG, Medicare’s payments for lab services in 2008 represented an increase of 92% over payments in 1998. Tweet this Kareo story
Much of this growth has occurred due to an increased volume in lab tests ordered. The OIG will closely examine billing and ordering patterns for these services.

What you should keep in mind:

  • Volume of testing: All labs can potentially be over-ordered. Ensure that the test is performed at a reasonable rate to monitor for changes.
  • Lab panels: When ordering labs as part of a panel, be sure to report the code for the panel rather than code each test separately. Coding tests separately can result in higher reimbursement that isn’t warranted.
  • Diagnosis codes: Only certain diagnosis codes justify each lab test. Ensure that the correct diagnosis code is reported and that this code accurately reflects the patient’s condition.

Evaluation and management services
Copy and paste documentation for E/M services is high on the OIG’s priority list this year. Tweet this Kareo story
More specifically, the OIG states it will review “multiple E/M services associated with the same providers and beneficiaries to determine the extent to which electronic or paper medical records had documentation vulnerabilities.”

What you should keep in mind:

  • Policies and procedures: Create a policy that outlines what specific documentation physicians can—and can’t—copy and paste. If providers are allowed to copy, they must verify and clearly update that information during the current visit. Verbiage such as “Since the patient’s last visit” can help to identify newly-updated information.
  • Monitoring compliance: Ensure that someone in the practice monitors documentation to ensure that physicians aren’t abusing the functionality. Compare previous notes with current documentation to flag and closely examine any identical information.

Place of service codes
Physicians receive a higher reimbursement when performing services in a non-facility setting (e.g., the office) than they do when performing that same service in a hospital outpatient department or ambulatory surgical center.
As a result, the OIG will determine whether place of service codes submitted on Part B claims submitted to and paid by Medicare contractors are correct.Tweet this Kareo story

What you should keep in mind:

  • Important place of service codes: Note the following commonly-reported codes, and refer to the CPT Manual for a complete list:
    • 11 – office
    • 20 – urgent care facility
    • 22 – outpatient hospital
    • 23 – emergency room hospital
    • 24 – ambulatory surgical center
    • 72 – rural health clinic
  • Communicating with coders: Ensure that coders and billers can clearly identify the location in which the service was rendered. Physicians must document this information when documenting the service rendered.

Chiropractic services
The Work Plan includes three items related to chiropractic services. More specifically, the OIG will closely examine Part B payments for non-covered services and questionable billing for maintenance therapy. It will also create a portfolio report compiling results of prior OIG audits to better identify trends in payment, compliance, and fraud vulnerabilities.

What practices should keep in mind:

  • General compliance: Because chiropractic practices are under particular scrutiny, it’s important to develop a strong compliance program and perform regular audits of coding and billing. It may be helpful to hire an outside auditor to accomplish.
  • Manual manipulation of the spine to correct a subluxation: The OIG specifically identifies this service in its Work Plan. Physicians must document a neuro-musculoskeletal condition for which such manipulation is appropriate treatment. Be sure to audit and monitor for medical necessity.
  • Maintenance therapy: The OIG also specifically identifies this service in its Work Plan. This service is not medically reasonable or necessary and is therefore not payable.

Nicoletti says chiropractic practices should always ensure that documentation reflects how or why the patient is improving as a direct result of the treatment. When providing repetitive services, providers should always question whether those services are truly medically necessary.

The Work Plan also includes items relevant for physical therapists, ophthalmologists, anesthesiologists, mental health providers, and more. Take the time to review the information pertinent to your practice and specialty and ensure that you are prepared.

About the Author

Lisa A. Eramo
Lisa A. Eramo is a freelance writer/editor specializing in health information management, medical coding, and healthcare regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal and AHIMA Advantage. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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Are You Maximizing All Your Referral Sources?

Lea Chatham March 11th, 2014

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Register now to learn how to maximize referrals3 Ways to Cultivate Rapid Growth through Referrals
Wednesday, March 19
1:00 PM ET, 10:00 AM PT

Referrals are the lifeblood of any practice.

Securing patient, physician, and other professional referrals is crucial to building a strong, thriving practice—but not everyone knows how.Tweet this Kareo story

Healthcare marketing and image development consultant Cheryl Bisera has years of experience helping her clients expand their practices, build relationships, and increase visibility in their communities. In this webinar she will explain why it’s so important to cultivate your referral sources and how to do so.

You will learn strategies that will empower you to:

  1. Expand existing physician referrals and become the go-to practice for new providers
  2. Strengthen referrals from current patients and discover an often-overlooked referral source
  3. Equip referral sources to identify patients in need of your services

By improving these three areas, you can grow and strengthen referral sources for your practice and boost your revenue.

Join the conversation!  You don’t want to miss this opportunity.

Register now to learn about how to maximize referrals

About the Speaker

Register now for Cheryl's webinarCheryl Bisera is a consultant, author and speaker with extensive experience in marketing and business promotion that spans more than ten years in which she worked with professionals to strengthen their position in the marketplace. She is the founder of Cheryl Bisera Consulting, a California-based image development and marketing company that focuses on the healthcare industry. Cheryl has spoken for regional medical management organizations, conducted customer-service workshops, and written numerous articles for publications such as KevinMD, Physician Magazine, and the Journal of Medical Practice Management.

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Order Your ICD-10 Success Poster

Lea Chatham March 6th, 2014

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There is a new ICD-10 tool available to help you achieve 100% Success with your ICD-10 transition. The “100% Success Plan” Checklist is now in a write-on, task-based poster format. The post clearly lays out exactly what to do and when with room to assign a project owner and due date. Getting ready to make the change couldn’t be easier with this full size guide. Hang it up in your practice to keep everyone on track and working towards ICD-10 success! Just click here to order yours today.

Order Kareo ICD-10 Success Checklist Poster

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Warding Off Back and Neck Pain in the Workplace

Lea Chatham March 5th, 2014

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Our sedentary lifestyle can exacerbate back issues.

Kareo Marketplace partner Backchart recently shared this helpful post for those of you who help people who spend a lot of time sitting and may suffer from lower back pain.

Though many injuries are associated with a specific event, back pain is often the result of gradual strain. As many as one in four adults in the United States experience some form of discomfort in their lower back, and given how much time the average American spends sitting down, it’s highly likely that aspects such as posture and positioning play a role in this prevalence.

So, as a chiropractor, is there anything you can do to help your patients ease this strain?

In addition to regular consultations and adjustments…

providing tips about workplace layout can be a great way to give your patients a bit of relief while further establishing you as a trustworthy authority. Tweet This

In terms of chiropractic marketing, sharing such information via your website and social media channels can also serve to draw new clientele.

Standing desks are becoming a popular method for men and women to stay a bit more active and maintain better posture throughout the day. In addition, kneeling chairs and yoga balls can provide seating that also reinforces core back muscles. Recently, the technology news outlet CIO Magazine showcased desktop arms as a way to give users greater control over the placement of their monitors. This seemingly small accessory can make a world of difference for patients who stare at a screen for most of the day, allowing a bit more flexibility and comfort as they work.

Maintaining a consistent level of physical activity and reducing sedentary time in general can have substantial benefits for the overall health of your patients. With chiropractic EHR, you can make note of any lifestyle habits that could potentially exacerbate back issues and other medical concerns.

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