11/6/2013. Presented by. Brenda Edwards, CPC, CPB, CPMA, CPC I, CEMC. Documentation Consent Auditing ICD 9 CM to ICD 10 CM example

Transcription

1 Surgical Auditing for Orthopedics Presented by Robin Zink, Zink CPC Brenda Edwards, CPC, CPB, CPMA, CPC I, CEMC 1 Agenda Documentation Consent Auditing ICD 9 CM to ICD 10 CM example 2 1

2 Documentation Purpose Outlines logic used in treating patient Brief history of the problem Demonstrates why a particular surgery was performed Pre and post operative information Consent to treat Basis for f reimbursement Supports medical necessity 3 Documentation 4 2

3 DISCHARGE STATUS: ALIVE BUT WITHOUT PERMISSION 5 Elements of Operative note Identifiers Procedure Summary Procedure Story Findings Additional Information 6 3

4 JCAHO Standard IM.6.30 Elements of Performance (EP) 3 details data elements for dictated operative report p p Operative reports (dictated) immediately after a procedure must record Name of primary surgeon and assistants Findings Procedure(s) performed p p Description of procedure Estimated blood loss, as indicated Specimens removed Post operative diagnosis 7 JCAHO Standard IM.6.30 Element of Performance (EP) 4 details authentication requirements Completed operative report is authenticated by the surgeon and made available in the medical record as soon as possible after the procedure 8 4

5 JCAHO Standard IM.6.30 Element of Performance (EP) 2 references operative progress note An operative progress note is entered immediately after the procedure 9 1. Identifiers Hospital information Name and address Patient s medical record number Admit date/status IP, OP, SDS Patient identifiers Minimum of 2 required Date of service 10 5

6 2. Procedure Summary Preamble (indication for procedure) Emergent/elective Start and stop time Pre and post operative diagnosis Documentation of additional diagnoses Title of procedure Procedure performed Procedure specific information Surgeon, co surgeon, assistant surgeon AND credentials Surgeon is responsible for procedure note Anesthetic type and anesthesiologist Blood loss Other h Type of internal fixation if appropriate Hardware, components, grafts, drains Complications Tourniquet time Material left in place Procedure Story Prep and draping of patient Summary of procedure Approach Protection of internal structures Complications and unusual services Estimate of blood loss and replacement Fluids given and invasive tubes, drains, catheters used Hardware or foreign bodies intentionally left in the operative site Correct sponge and needle count Closure (including who performed it) Dressings applied Immediate postoperative condition 12 6

7 4. Findings Summary of what was found during surgery Post op care and instructions Patient s condition when sent to recovery room If patient was admitted or discharged and where? Additional Information Approved abbreviations Log of abbreviations Legibility Corrections Amendments 14 7

8 Orthopedic Hospital Your town, USA Identifiers Procedure Summary Procedure Story Findings Additional Information? 15 SHE IS NUMB FROM HER TOES DOWN 16 8

9 JCAHO Standard R12.40 Element of Performance (EP) 3 D t ti by b physician h i i that th t potential t ti l benefits, b fit risks, ik Documentation or side effects, including potential problems related to recuperation were discussed 17 Consent vs. Informed Consent Consent Diagnosis Nature and purpose Risk and side effects Probability of success Consequences No guarantees Questions answered Informed Consent Discussed p proposed treatment p Discussed risks and alternatives Patient understood the discussion Patient had all questions answered to his/her satisfaction Patient consented P i d to the h treatment Written consent is not informed consent 18 9

10 Orthopedic Hospital Your town, USA 1. All procedures performed 2. Procedure details Bundled procedures Work described in detail Repair vs. reconstruction Identify ligaments, nerves (what was done to protect) 3. Preoperative and Postoperative diagnosis 4. Additional diagnosis codes coded to highest l l specificity ifi it level 5. Primary surgeon Include new findings Supports medical necessity Role of assistant surgeon (MD, DO) or assist at surgery (PA, NP) Medical necessity of assistant Work assistant performed 19 PATIENT HAS TWO TEENAGE CHILDREN, BUT NO OTHER ABNORMALITIES 20 10

11 Problematic Areas Procedures included in heading but not in op note Procedures not in heading that are in op note Laparoscopic procedure billed as open Timeliness of documentation Incorrect terminology Provider indicates osteotomy, op note describes ostectomy Modifier usage Modifier 22 what should be documented? Insurance MVA vs. health insurance vs. WC Amendments/addendums 21 Ortho Audit Tool (Courtesy of Ruby Woodward) 22 11

12 Ortho Audit Tool (Courtesy of Ruby Woodward) REVIEWER General Comments: Recommendations: CODER Coder Signature: Date: Reviewer Signature: Date: 23 ON THE SECOND DAY THE KNEE WAS BETTER AND ON THE THIRD DAY IT DISAPPEARED 24 12

13 Office Procedure

14 HEALTHY APPEARING DECREPIT YEAR OLD MALE, MENTALLY ALERT BUT FORGETFUL

15 29 EXAMINATION OF GENITALIA REVEALS THAT HE IS CIRCUS SIZED 30 15

16

17 OCCASIONAL, CONSTANT, INFREQUENT HEADACHES

18 35 RECTAL EXAMINATION REVEALED A NORMAL SIZE THYROID 36 18

19 Day 1 37 Day

20 Day 2 39 Day

21 BOTH BREASTS ARE EQUAL AND REACTIVE TO LIGHT AND ACCOMMODATION

22 43 THE SKIN WAS MOIST AND DRY 44 22

23 ICD 9 to ICD ICD ICD 10 The Importance of Details May 20,2013 Before the storm After the storm Kristi Dunn CPC,CGSC 23

24 May 20,3013 My son, daughter and her boyfriend s 3 year old daughter took cover in the bedroom closet during the tornado. They put a bicycle helmet on the 3 year old and my daughter held on to her and covered her up to protect her. My son put his body on top of both of them to shield them from the debris and they p with blankets. As the storm was bearingg covered up down, my daughter described the sound as a paper shredder and thought it would never end. continued She held down on the little girl and then realized her brother was no longer in the closet with them but she couldn t get up yet to go look for him because the tornado was still there. The noise stopped and she went searching for her brother calling his name. He was dazed but found on a pile of ruble about 50 feet from where theyy took shelter. He was unable to stand and walk. 24

25 continued A passer by immediately took them to waiting ambulances staged at the damaged Moore medical center. Tacie received minor injuries to her arm and a chipped shoulder blade. The little girl she had been protecting only had a few scratches. Thank God she was wearing the bicycle helmet as it took a huge dent to the back of it. Brian Tacie 25

26 Procedures Performed Percutaneous skeletal fixation of metacarpal fracture, each bone , closed treatment acetabulum fracture closed treatment pelvic ring fracture intermediate repair leg wound simple repair scalp, flank and buttock wounds Percutaneous Skeletal Fixation Brian s Injuries Injury ICD ICD 9 ICD ICD 10 Superficial cuts and abrasions to the face S00.81XA S01.81XA Abrasion other part of head, initial encounter Laceration without foreign body of other part of head, initial encounter Open fractures to the 3,4, 5th metacarpals S62.303B S62.305B S62.307B Unspecified fx 3rd metacarpal, lt hand Unspecified fx 4th metacarpal, lt hand Unspecified fx 5th metacarpal, lt hand Closed pelvic ring fracture S32.811A Multiple fx pelvis with unstable disruption of pelvic ring Closed acetabulum fracture S32.409A Unspecified fracture of unspecified acetabulum Open wound to the scalp 3cm S01.01XA Laceration without foreign body scalp, initial encounter Open wound O d flank fl k 2 cm S31.109A S31 109A Unspecified U ifi d open wound d off abdominal bd i l wall, ll unspecified quadrant without penetration into peritoneal cavity, initial encounter Open wound buttock 4 cm S31.809A Unspecified open wound of unspecified buttock, initial encounter Open wound lower leg 12 cm S81.802A Unspecified open wound, left lower leg, initial encounter Cataclysmic storms, tornado E908.1 X37.1XXA Tornado, initial encounter 26

27 The Clean Up Would any one like a used hot tub? Resources hcpro com/him /Auditing for /Auditing for coding mistakes on outpatient orthopedic cases.html Orthopedic surgical auditing tool courtesy of Ruby Woodward Ingenix Coding Lab: Coding from the Operative Report Medical Record and Documentation Requirements by Kevin Townsend, CPME, CPC, CPMA and Beth Lensgraf, DC 54 27

28 Ortho Audit Tool (Courtesy of Ruby Woodward) 55 Ortho Audit Tool (Courtesy of Ruby Woodward) REVIEWER General Comments: Recommendations: CODER Coder Signature: Date: Reviewer Signature: Date: 56 28

29 Thank YOU for attending! CEU # 57 29