Under the Magnifying Glass

Transcription

1 5 6 Most Common Documentation Mistakes And What to Do About Them Kathy Mills Chang, MCS-P, CCPC KMC University Why Is Documentation So Important? Ensures quality patient care Meets licensure requirements to protect the public Guards against malpractice action Secures appropriate reimbursement Because if it wasn t written down, it didn t happen! Under the Magnifying Glass MACRA Section 514 Pre-Authorization Beyond 12 (855)

2 Improvement Initiative This Isn t Going Away Soon Know your Audience Another health care provider Your board A malpractice attorney Third party payer's medical necessity auditor Good Documentation Tells a Story 5 6 Most Common Errors Signatures and Identification of the Doctor and patient not clear No rationale for diagnostics or tests ordered Lack of all required elements of a treatment plan Lack of understanding of medical necessity Daily Assessment consisting only of diagnosis Performing and billing for full spine adjustments, without proper documentation of medical necessity (855)

3 Signature and Patient Name Issues Why Authenticate? To verify provider who treated Prove services were provided Indicate and verify who provided them Validates the entry and legally binds the physician for the included info Can we Identify Provider? Review Signature Requirements Familiarize providers and office staff with signature requirements to ensure more complete compliance with signature authentication policies How do we authenticate signatures? Signature Log Update Signature Log Every year have each provider sign again, even if it hasn t been a year since the last signature Add new providers to the log as they join the group Replace previous logs with most recent signatures, however save old copies Make sure every log has a start and end date (855)

4 How it all comes together... Create Signature Log Update Signatures Review Signature Requirements Sign and Check Patient Identifiers Patient name must appear on every item or piece of paper Electronic name is ok Front and back both Especially important when sending records Patient number can identify as well Provide Appropriate Rationale Tell Us What You re Thinking Why are the tests being ordered? Why did you decide to do what you did? What s between your ears must appear in the documentation X-rays, labs, other diagnostic tests, referrals, and DME (855)

5 Your Medical Records Must Tell the Story Rationale for Films MD Rationale for CT Scan Possible X-Ray Rationale Offer a Complete and Compliant Treatment Plan (855)

6 Treatment Plan Your treatment plan is your pre-determined plan of action. It will take into consideration the tissue specific issues defined in your patient work-up and diagnosis Soft-tissue diagnosis and soft-tissue targeted treatment Meet the Requirements Frequency and duration Treatment goals for each region/treatment to include long term goal An evaluation of treatment effectiveness measurement Date of the plan Frequency and Duration Indicate initial part of the treatment It s ok to have an end game projection Don t be so specific that you appear canned or boxed into a plan Each section should end with an evaluation Treatment Goals Best Practices for Goals Treatment goals need to be functionally based. What functions are we restoring with our treatment plan? How will we measure that corrective change? What goals are outlined for each type of treatment? (855)

7 Goal Algorithm Evaluate the Effectiveness Measurably! OATS make it easy Pain is difficult to track and measure Use an accepted measure that you can document simply Improvement in function = success!! Make it Shine! Home care recommendations Prognostic factors Inclusion of all possible treatment and DME options What if you treat today? (855)

8 TX Plan Samples Win with a Robust Daily Assessment Medicare Documentation Guidelines Initial Visit History Description of Present Illness Physical Exam Diagnosis Treatment Plan Date of initial treatment Subsequent Visits History Review of chief complaint Physical Exam Document daily treatment Progress related to treatment goals/plan Subsequent Visits Documentation Requirements History: (29% Documentation Error Rate) Review of Chief Complaint Location of Symptoms Changes since last visit Subjective (P) Quality of Symptoms System review if relevant Intensity of Symptoms Physical exam: (43% Documentation Error Rate) Exam of area of spine involved in diagnosis Objective (A, R, T) Assessment of change in patient condition since last visit (PE, OA, ADL, QVAS) (Same, Better, Worse) Assessment Evaluation of treatment effectiveness (Same, Better, Worse, How and Why) Daily Treatment Documentation : (15% Documentation Error Rate) Plan (855)

9 Best Practices for Defining your Doctor s Assessment Remember it is all about Function, Function, FUNCTION Identify HOW the patient has improved Identify WHY they need continued care That is Medical Necessity by definition! Does This Truly Outline Assessment? (855)

10 Tale of Two Styles What I Hope to See Types of Cases In Chiropractic Lack of Understanding of Medical Necessity Regulated Carriers CMS - Medicare and Medicaid Worker s Comp 3 rd Party In Network Managed Care (ASHN, Optum, Orthonet) Out of Network (OON) Managed Care (ASHN, Optum, Orthonet) Cash/PI All Carriers Need Guidelines Without guidelines there would be chaos All claims would be paid! CMS would collapse due to no money There would be no 3 rd party coverage because no money to support them or shareholders Medical Necessity Guideline Guidelines declare what the carrier will pay for and will not pay for All payers see in black and white (red) Universal rules Some unique rules (855)

11 Why CMS Sets Minimum for MN Why re-invent the wheel? Because it is the Law! Exclusions of MN require published research Most of the work already done Carriers just add a few extra studies to fit their needs CMS Medical Necessity Definition Items or services which are for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member All provider types must follow this rule Each service (CPT) gets a more detailed explanation as it relates to this Chiropractic as a CPT All carriers see Chiropractic Services as a set of CPT codes used by a provider type Medicare sees Others may see more MN is determined for the code set MN: Chiropractic Per CMS Acute and Chronic Subluxation The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient s condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical examination (PART) If above not met or exceeded = Not Medically Necessary! Is All Care Medically Necessary? Clinically Appropriate Care Maintenance care Supportive care Palliative care Life enhancing and wellness care Symptom relieving only Care that doesn t have as its goal improved function and correction Medically Necessary Care Acute problems Care that can provide measurable functional improvement Chronic care with expected functional improvement Often defined by the carrier s medical policy (855)

12 Acute CMS defines Acute as: "A patient's condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of, the patient's condition." Examples: Slip and Fall at home and now having neck pain Sudden or recent onset of symptoms When lifting a box the patient started having sciatica symptoms Acute Chronic CMS defines Chronic as: "A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered" Examples: Numbness and tingling in the fingers that has been going on for years Post laminectomy syndrome Decreased ability to sit due to increased lower back pain since golfing Inability to dress easily due to neck pain where a disc has become unstable Chronic Incident Examples After not being seen for a few months, the patient is having an increasing amount of headaches again. Last time they were treated, the amount of headaches resolved with a few treatments. Patient is having low back pain after working in the garden and has an antalgic forward lean. They can t garden in this condition. You expect a visit or two will correct the problem (855)

13 Burst Example During a hand plant while skateboarding, the 23 year old patient hurt her wrist due to an improper grip. No break but a sprain is present in the wrist. She cannot write for more than 15 minutes due to pain. Additionally, she is having elbow and shoulder pain on the same arm. Episodes are easy! There is a clear delineation of: The beginning The middle And the end of care They are Black & White Episode at a Glance Episode Examples When trying to answer the door, the 76 y/o patient slipped after stumbling over her dog and fell hard on her back. She is having a lot of pain in her back and radiating pain down her left leg to her and ankle. She cannot lay supine for more than 20 minutes and she wakes up frequently due to pain. Maintenance Wellness Prevent disease Promote health Prolong/enhance the quality of life Supportive Maintain or prevent deterioration of a chronic condition MN per 3 rd Party Carriers If you want them to pay the bill, you have to follow their rules All are based in CMS s guidelines Additional requirements specific to each (855)

14 Cigna Chiropractic MN Greater than CMS Expanded services Type of Tx described DC only More Documentation Requirements Established Pt. rules Max Therapeutic Benefit with prior chiropractic Home care program Short term expectation *Cigna Medical Coverage Policy: # 0267 Chiropractic 2/15/16-2/15/17 Aetna Chiropractic MN Greater than CMS Expanded services Improvement time frame Improvement must be documented within 2 weeks of care If no improvement within 2 weeks change chiropractic treatment If no improvement by 30 days then no chiropractic care is MN No Scoliosis Treatment Limits techniques that are allowed for treatment *Aetna Clinical Policy Bulletin : # /14/16-1/28/16 (sic) Anthem MN There are many different groups of Anthem Normally broken up by state Each has its own MN guidelines Some use managed care: Premera Blue Cross (Optum health) California (ASHN) Illinois (Orthonet) Anthem MN (MA Plan) Greater than CMS Chiropractic must be as effective (cost and clinical) as other treatments No athletics improvement Uses EM 1997 guidelines only (in another section of coverage) *Blue Cross/Blue Shield of Massachusetts: Reimbursement Policy and Billing Guidelines for Chiropractic Services 2005 (2007) United Healthcare They follow CMS guidelines very closely Very few (if any) chiropractors are directly contracted with UHC Optum handles claims despite submission to United Healthcare Visits tend to need pretreatment review (855)

15 United Healthcare MN Greater than CMS Expanded services Not covered for patients who are at pre-symptom state Improvement time frame If no improvement by 30 days then further chiropractic care is not MN No scoliosis treatment Limits technique that are allowed for treatment Non-standard techniques *United Healthcare Medical policy # 2015T0541F Manipulative Therapy Compliance Considerations Researching the MN policies of 3 rd party payers and their managed care entities that you work with often can drastically improve your error rate Knowing the specifics of the carrier is like reading the map before driving to a new city. Sure, all cities have roads that are organized in similar fashion. A little bit of knowledge of where you are going can save frustration, time, and money compared to just assuming all cities are the same. How to Look Up a Medical Policy 1. Determine 3 rd party to look up 2. Are you in network directly or through a managed care entity? 3. Go to the 3 rd party website and search for policy that fits the code or services best 4. If not available on website do an internet search for the service and the 3 rd party. Example Aetna Chiropractic policy 5. Contact provider relations of the 3 rd party if all else fails Managed Care Entities Many carriers hire 3 rd parties to handle claims and interactions with providers to decrease costs by: More intense scrutiny of MN standards Fewer employees handling providers and members Mitigating and deferring legal responsibility for payment The 3 rd party carrier may: Send your submitted data to the managed care when they receive it Have you submit everything to the manage care directly Common 3 rd Party Managed Care American Specialty Health Network (ASHN) Landmark Optum Health Secure Care Orthonet (855)

16 Even CMS Uses Managed Care Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and B medical claims or DME claims for Medicare Fee -For-Service All owned indirectly by Anthem now Each limits what is MN with rational Region of the county dictates what Managed Care you are in Require special paperwork to PROVE medical necessity ACN (Advanced Care Notification) Proof of medical necessity forms Show your finding before we give you visits Extra Paperwork Optum Health/ACN Paperwork *BCBSIL PPO Physical Medicine UM Program Quick Reference Guide Chiropractic Care OrthoNet Example OrthoNet does not add onto the MN restrictions or definition It authorizes visits based on expected treatment needs to meet MN defined by the 3 rd party payer Details of the condition are very important to get enough visits Mostly textbook Dx driven Co-morbidities can increase visit expectation In Network Consideration Network providers If no paperwork is turned in or they find no MN your contract WILL NOT ALLOW you to bill the patient for any services We choose to follow these rules in order to see the patients business relationship Optum Health/ACN Paperwork (855)

17 *BCBSIL PPO Physical Medicine UM Program Quick Reference Guide Chiropractic Care OrthoNet Example OrthoNet does not add onto the MN restrictions or definition It authorizes visits based on expected treatment needs to meet MN defined by the 3 rd party payer Details of the condition are very important to get enough visits Mostly textbook Dx driven Co-morbidities can increase visit expectation In Network Consideration Network providers If no paperwork is turned in or they find no MN your contract WILL NOT ALLOW you to bill the patient for any services We choose to follow these rules in order to see the patients business relationship Out of Network MN Out of network is MN defined by: State scope of practice Peer review standards A chiropractor who s scope does not allow delegation of massage would not meet medically necessity guidelines because they are practicing outside of their scope If 99.9% of chiropractors would say that CMT over the phone is not medically necessary OON Considerations Always the patient s responsibility for payment (Even if you submit for them) There may be a managed care party to deal with even though no contract 3 rd party may still request records and the like If a patient is choosing you to provide service and you are not in their 3 rd party network, expecting the 3 rd party to pay easily is like using a non-network phone and expecting a clear and stable call while in the white areas of the map ASHN Cover Sheet = Extra PART Extra Paperwork Angry people to talk to Rationale to get payment Time spent by team members Still you may not be paid by them Learn the system of the carrier if you choose to bill OON and see if you can function in or with it Applying What You Learned Get a list of the 3 rd party payers you deal with most Research their MN and treatment guidelines Download and place them into your compliance binder Check for updates at regular intervals (855)

18 Starts May 2, 2016! Document, Code, and Bill Properly as a Full Spine Adjuster Are You an Outlier? Statistics tell us that the improper coding of fullspine treatment can cause you to appear to be an outlier You therefore can be subject to more scrutiny, red flags, and even an audit Error Rate Information Insufficient documentation is a known issue in the chiropractic profession Failure to provide any documentation to auditors represents nearly 50% of the poor scores (855)

19 So? I m a Full Spine Adjuster! Medical necessity definition dictates that you must prioritize each area of complaint Every visit: S + O (P + ART) for every region treated 2 DX codes for each region Treatment plan for each/short and long term goals Issues Appearance of Evil Why It LOOKS Fishy And Recently (855)

20 Set Up to Fail? In the world of compliance, DCs who routinely adjust the full spine are challenged Because documentation and coding must match exactly Coding 98942, because all five regions have been adjusted, may be asking for trouble Philosophically Driven Whether you are subluxation-based chiropractor or simply believe that every patient requires a full-spine adjustment, you need clarity Proper coding and case management for these technique-specific and philosophically driven coding conundrums need to be defined by you for your office You Define Your Intentions Clarify your motivations so you can describe your situation and your intentions Create and implement a policy in order to describe why it could appear that your documentation doesn t match your coding Outline in writing in advance of any requests for records to help to keep you and your practice safe SOP - Example Policy Code for Subluxations Only How This Looks on Paper (855)

21 Code This as Code This as Code This as Billing Should Be Put on Your Auditor Hat What is expected/typical 98940: 40-60% 98941: 40-60% 98942: 1-10% How would your office look? Run Your Ratios! Take Action Look at your CMT coding ratios to evaluate code usage Spot check documentation for codes billed to find out if the documentation meets requirements Determine how you can improve coding/documentation as a full spine adjuster (855)

22 Coding and Documentation Must Match Determine ONE thing you can do by year end What can you change in Q1 2016? How can you delegate to take small, manageable steps? Work on one project at a time to manage time and expectations Take Action Now We re Here to Help! info@kmcuniversity.com (855)