Compliant RA Coding and the EHR

Transcription

1 Compliant RA Coding and the EHR Sheri Poe Bernard, CCS-P, CPC, COC, CPC-I Today s goals Consider factors that brought us to the EHRs we are coding from today, and what a compliant EHR is Explore benefits of taking a proactive approach to EHR compliance issues and policies in the RA workplace Learn to discern difference between good and bad data within an EHR Discuss impact of EHRs on diagnosis support and reporting 2 1

2 Meaningful use Office of the National Coordinator for Health Information Technology (ONC): EHR goals: Improve quality, safety, efficiency, and reduce health disparities Engage patients and family Improve care coordination, and population and public health Maintain privacy and security of PHI Ultimately, it is hoped it will result in: Better clinical outcomes Improved population health outcomes Increased transparency and efficiency Empowered individuals More robust research data on health systems 3 A Perfect Storm CMS: Pressured for implementation of certified plans with $$$ Certifiers: Standards ignored coding/documentation compliance HHS and Office of National Coordinator of HIT: Did not publish coding/documentation guidance for EHRs Med Schools: Clinical documentation addressed without any focus on EHR platforms, compliance and coding is barely mentioned Software vendors: Promised time and personnel cutting, advised to omit coders from selection process Providers and facilities: Drank the Kool-Aid, often did NOT involve coding staff in purchase decisions Group practices and facilities: Impose productivity standards RA auditors: Usually do not have access to providers and bounce between many different EHR platforms 4 2

3 Unintended consequences Electronic health records Feature-by-feature review What is CMS position Affect on RA compliance 5 esignature issues EHR may not include all elements of esignature requirements Name, credential, date, electronically signed by esignature at beginning of record Identifying author doesn t authenticate record Most of what CMS has to say about electronic signatures is regarding safeguards of access to the electronic record, and identification of authorship. An e-signature should be dated and the author s credentials should be included. RA compliance Communicate to clients any system-wide shortcomings 6 3

4 esignature issues Differentiating between authorship and approval 7 Authorship errors EHR doesn t differentiate among documentation authors, line by line or entry by entry Abuse describes incidents or practices that may not be fraudulent but are not consistent with accepted medical or business practices or may result in unnecessary costs. Some such incidents directly relate to EHR software features, such as allowing multiple providers to add text to the same progress note but not allowing each provider to sign, making it impossible to verify the actual service provider or the amount of work performed by each provider. RA compliance Policy to ensure authorship issues are flagged Policy to alert clients when EHRs have faulty software features 8 4

5 Authorship errors EHR doesn t date problem list or med list Defaulting or copying and pasting clinical information with previous existing documentation from other patient encounters in a different health record facilitates billing at a higher level of service than was actually provided. RA compliance Policy to accept only dated or referenced med lists Policy to omit all problem lists, or accept only dated or referenced problem lists 9 Moving to Documentation Check boxes instead of free text Templates: Using predefined text and text options to document the patient visit within a note Macros: Expanding text associated with abbreviations or specific keystrokes Populating via Default: Generating content without positive action or selection by author Some EHR systems use templates that complete forms by checking a box, macros that fill in information by typing a key word, or autopopulation of text when it is not entered. Problems can occur if the structure of the note is not a good clinical fit and does not accurately reflect the patient s condition and services. These features may encourage over-documentation even when services are not medically necessary or are never delivered

6 Check boxes instead of free text Templates: Using predefined text and text options to document the patient visit within a note Policy should require providers to modify templates so that documentation clearly reflects specific conditions and observations unique to the service, and to clearly identify the services provided. Policy should also require the physician to provide additional information to describe the patient in the specific episode of illness Sample Checked Boxes In a template, the boxes are blank. 12 6

7 Check boxes instead of free text Macros: Expanding text associated with abbreviations or specific keystrokes. Macros allow users to generate a lot of documentation with one click. This practice is also referred to as charting by exception Populating via Default: Generating content without positive action or selection by author Policy should require the provider to verify the validity of information on entry. Providers should incorporate policies and control structures that require the addition of free text when auto-population methods are used Check boxes instead of free text Templates: Using predefined text and text options to document the patient visit within a note Macros: Expanding text associated with abbreviations or specific keystrokes Populating via Default: Generating content without positive action or selection by author RA compliance Create policies addressing good clinical fit and accurately reflect patient s condition Train coders to understand auto-generation of text and macros so they can interpret documentation better Do not use anything populated by default as support (if you can detect the methodology) Policy should require the provider to modify copied information to be patient-specific and related to the current visit. 14 7

8 Unintended consequences: template Click boxes to complete system reviews Designed after old templates like those produced by T Systems Templates do not reflect the complexity of the diagnosis or medical decision making Qualitative data missing: Chest pain (intermittent, with exercise, constant, debilitating) Cough (at night, productive, dry, reactive, crouplike) Type 2 diabetes (affecting daily living, managed with diet, with oral meds, in a confident or unconfident patient) RESULT: Support often missing when ROS/PE is templated list 15 Unintended consequences: template Patient presents with nausea, vomiting and abdominal pain Before EHR PHYSICAL EXAM: VITALS; BP 136/82, P 76, R 16, afebrile. W 178, RBS 96. HEART: regular rate and rhythm without murmur or gallops. LUNGS: clear to auscultation all fields without rales, rhonchi or wheezing. ABDOMEN: soft with active bowel sounds, no muscle guarding, lower left abdominal tenderness noted, no palpable mass or organomegaly noted. EXTREMITIES: no edema After EHR PHYSICAL EXAM: This is a well-developed, well-nourished male in no acute distress. VITALS: BP 138/74, P 62, W 164, P02 95 R 16 RBS 99 BMI 32. TEMP 98.6 HEAD: Normocephalic, atraumatic, no visible or palpable masses, depressions or scaring. PERRLA. TMs translucent and mobile. Remainder of the ENT exam is unremarkable. NECK: Supple. Euthyroid with no lymphadenopathy and nontender. Carotid pulses equal bilaterally. No bruits noted. LUNGS: Clear to auscultation and percussion. HEART: Regular rate and rhythm. There are no murmurs or gallops noted. No cardiomegaly or thrills. ABDOMEN: soft, lower left abdominal tenderness noted. There are no masses noted. There is no hepatosplenomegaly noted. Active bowel sounds. EXTREMITIES: There is no edema, clubbing or cyanosis noted. Peripheral pulses are +2 bilaterally. NEUROLOGIC: CN 2-12 normal. Deep tendon reflexes are +2 bilaterally. Strength 5/5 and symmetrical. Babinski negative, no clonus, gait normal. PSYCHIATRIC: oriented x3, judgment and insight good, normal mood and affect. Recent and remote memory intact. 16 8

9 Check boxes instead of free text Some EHR systems use templates that complete forms by checking a box, macros that fill in information by typing a key word, or autopopulation of text when it is not entered. Problems can occur if the structure of the note is not a good clinical fit and does not accurately reflect the patient s condition and services. These features may encourage over-documentation even when services are not medically necessary or are never delivered. RA compliance Seek support of any checked diagnosis boxes elsewhere in the documentation Identify those documents in which free text is permitted with checked boxes. This may provide support. 17 Automated narrative function (template translated into documentation narrative) 18 9

10 Sample Automated narrative function Checked boxes like Headache, cough, sputum production and negative findings translate into a narrative in the electronic record s ROS. 19 Automated narrative function (template translated into documentation narrative) Problems can occur if the structure of the note is not a good clinical fit and does not accurately reflect the patient s condition and services. Templates may encourage over-documentation to meet reimbursement requirements even when services are not medically necessary or are never delivered RA compliance Be aware it is difficult to determine whether documentation is cloned from another visit, or a template narrative as for some patients, the ROS is unchanged over time

11 Auto-forward of clinical data System pulls details of last visit (H&P, med list, past medical history, etc.) into today s encounter to streamline documentation This can affect the quality of care and can cause improper payments due to: Potentially false impression of services provided to the patient Coding from old or outdated information that may lead to upcoding Policy should require the provider to modify copied information to be patient-specific and related to the current visit. RA compliance Internal policies should address how to handle pull-forward information and when it can be reported with support, or used as support 21 Auto-forward of clinical data 22 11

12 Cloning Copy and Paste: Selecting data from one location and reproducing it in another; also called cloning, cookie cutter, copy forward, and cut and paste. Clinical plagiarism occurs when a physician copies and pastes information from another provider and calls it his or her own Policy should require the provider to modify copied information to be patient-specific and related to the current visit. Copied information should include proper notation and clear attribution. Best Practices: Providers must recognize each encounter as a standalone record, and ensure the documentation for that encounter reflects the level of service actually provided and meets payer requirements for billing and reimbursement Code drop-down lists for providers Often list unspecified first May have truncated definitions Don t include guidance Begin in the Index. Then access the code in the Tabular section and read all guidance there. RA compliance Display may not include narrative diagnosis, only code Display may include code and truncated description 24 12

13 Code drop-down lists for providers No links between etiology and manifestation 25 Unintended consequences Note bloat, meaningless repetition Provider ability to think in ink impaired Lack of detailed, narrative descriptions of the progress qualitative details -- of the disorder 26 13

14 UTI 27 OM Incomplete pulldown menus of diagnoses Otitis media in ICD

15 OM Incomplete pulldown menus of diagnoses Otitis media in ICD OM ICD-10-CM instructions Use additional code for any associated perforated tympanic membrane (H72.-) Use additional code to identify exposure to environmental tobacco, to tobacco smoke in perinatal period, history of tobacco use, occupational exposure to tobacco, tobacco dependence, tobacco use Excludes1 otitic barotrauma, otitis media (acute) NOS 30 15

16 Unintended consequences 31 Coding from codes OIG ICD 9 CM codes reported on the health insurance claims form should be supported by documentation. In addition to facilitating high quality patient care, a properly documented medical record verifies and documents precisely what services were actually provided. The medical record may be used to validate: (a) The site of the service; (b) the appropriateness of the services provided; (c) the accuracy of the billing; and (d) the identity of the care giver (service provider) -- The OIG Compliance Program for Individuals and Small Group Physician Practices (Federal Register, Oct , Page 59440) 32 16

17 Coding from codes Guidelines The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. -- ICD Official Guidelines for Coding and Reporting 33 Unintended consequences: Codes Actual example of provider coding 30-week multigravida seen today for an uncomplicated OB office visit. Diagnoses: V22.2 Intrauterine pregnancy and V45.89 History of cesarean section. V22.2 Pregnant state, incidental V45.89 Other postprocedural status Correct code: Previous cesarean delivery, antepartum 34 17

18 Other issues to consider Written policy for when the system goes down And what happens when the system goes back up to recreate the documentation? Written policy on what is considered the legal medical record. Once was all the paper in the chart. Now, it could have wider scope. What will you exclude from a request for a medical record? Audio dictation files; audio patient telephone files Nursing reports Videorecordings of procedures Recorded telemedicine consults 35 EHR Toolkit from CMS Prevention/Medicaid-Integrity-Education/electronic-healthrecords.html Or Google: CMS EHR toolkit program integrity

19 Decision Table

20 Monitoring and Auditing 39 Your takeaway Expand your policies and procedures Keep vigil on evolving compliance requirements Consider clinical as well as coding implications of EHR flaws Download CMS EHR Toolkit at Prevention/Medicaid-Integrity-Education/electronic-health-records.html 40 20

21 Thank you Contact information Sheri Poe Bernard, CPC, CPC-I, CCS-P Phone