Coding for Risk Adjustment: Clinical Documentation Best Practices Module: 2 Presented by: Revenue Program Management Highmark

Transcription

1 Coding for Risk Adjustment: Clinical Documentation Best Practices Module: 2 Presented by: Revenue Program Management Highmark NOTE: This information is intended to assist with documentation only, in an effort to meet Centers for Medicare and Medicaid Services (CMS) documentation guidelines. Reference official ICD-10-CM coding guidelines and manuals or electronic medical coding software for accurate ICD-10-CM codes and specificity. This document is not intended to provide legal advice. This information is subject to change without notice. Updated November Highmark is a registered mark of Highmark Inc Highmark Inc., All Rights Reserved

2 Contents Importance of Clinical Documentation in Risk Adjustment...3 Medical Record Best Practice for Risk Adjustment Clinical Documentation Examples References

3 Importance of Clinical Documentation in Risk Adjustment CMS Risk Adjustment reimbursement to Medicare Advantage Plans is driven by the health status of members Diagnosis coding is how CMS gauges chronicity and severity of illness Results of targeted Risk Adjustment Data Validation audits suggests that 15% to 28% of diagnosis codes submitted through claims may not be supported in the medical record Because a health plan is the direct recipient of payment from CMS, they are responsible for inaccurate diagnosis code submissions and corresponding overpayments Medical Record (chart) reviews are how MAO s demonstrate the integrity of the claims and data submission process to CMS Chart reviews provide an opportunity for health plans and provider office staff to collaborate on improving patient care and accuracy of coding When Clinical Documentation is comprehensive, everyone wins! Clinical documentation is the basis for current and future medical care of a patient Treatment includes one-to-one care AND documentation of what transpired during the episode of care Provides strong legal protection for the provider and practice if legally challenged Thorough documentation helps a provider meet a variety of Stars and Quality measures 3

4 Importance of Clinical Documentation in Risk Adjustment What is Clinical Documentation? Refers to any and all information which relates to the care of a patient, during an encounter Each encounter with a patient is an opportunity to assess health and comprehensively document chronic, coexisting, historical, and acute disease, illness, injury Disease, illness, and injury captured through ICD coding is used by teaching hospitals, professional associations, and government entities for clinical research How does Clinical Documentation impact Providers? Strong, consistent, and thorough documentation communicates the aspects of care being provided Ability to share current clinical facts for the coordination of care to medical peers Documenting specificity demonstrates medical necessity Ensures appropriate benefit application and claims payment Minimizes the risk of being out of compliance with government-based and private payer contracts Assists your practice in managing requirements for Quality Programs Medical intervention for many chronic conditions aligns among programs 4

5 Importance of Clinical Documentation in Risk Adjustment How does Clinical Documentation impact Members? Improved quality and standard of care Clinically relevant data is available to other treating providers if it is written in a medical record Providing the accuracy of condition status results in more appropriate levels of patient care and benefit application Providing timely clinical intervention Moving away from secondary and tertiary care to a prevention platform Analysis results from the conditions documented and billed within a practice How does Clinical Documentation relate to ICD10? ICD10 has 141, 000 diagnosis codes to choose from; most of which are tied DIRECTLY to the specificity of a disease/illness/injury Explicit detail regarding the severity, chronicity, and location of disease/illness/injury must be documented to assign the correct code ICD10 will improve interoperability across the care continuum 5

6 Medical Record Best Practices for Risk Adjustment The medical record refers to any medical record document that results from a face to face encounter with an acceptable provider source Office visits Pathology reports Consultative reports Colonoscopies Discharge summaries Surgery Embedded diagnostic results and labs if interpreted in the medical record Documentation must show that the condition meets clinical documentation criteria during the encounter M.E.A.T-Monitor, Evaluate, Assess, and Treat T.A.M.P.E.R.-Treat, Assess, Monitor/Medication, Plan, Evaluate, and Referral When interpreting diagnostic reports, be sure to include reference to the date of service of the diagnostic study illustrate interpretation of the diagnostic report utilizing either MEAT or TAMPER criteria Document all diagnoses effecting patient care (i.e. medical decision-making) in the medical record at the time of the visit Main reason for the visit (i.e. History of the Present Illness, Subjective, Reason for Visit) Co-existing acute and/or comorbid conditions addressed during the visit Chronic conditions should include the words Chronic, Long-Standing, or reference the period of time for which a given condition has been treated (i.e. over the past 10 years, etc.) ICD-10 codes must be accurately assigned to each condition documented, and should not be more or less specific than what is in the medical record Ensure that all treated diagnoses are entered on the claim form and submitted to the MAO 12 Diagnoses codes can be submitted in most cases for submission. Please verify that your billing and clearinghouse does submit all diagnoses codes. 6

7 Medical Record Best Practices for Risk Adjustment Patient s name and date of service (DOS) must appear on all pages of the record Inclusion of patient date of birth/reference to age and sex is also recommended to appropriately identify patients/members Electronic medical record systems should be set to print name and DOB on each page of record Electronic Medical Record (EMR) clinical documents should have the following wording as part of the signature line Electronically signed, Authenticated by, Signed by, Validated by, Approved by, or Sealed by All clinical documentation must be signed by All of the provider(s) rendering services Handwritten signature must be legible to someone other than the provider and immediate office staff Dictated notes and consults must be signed by the provider. The provider s credentials must either follow the signature or be pre-printed on the stationary Dictated But Not Read is not an acceptable signature in all Medicare jurisdictions Stamped signatures are not acceptable* NOTE: An Office Best Practice is to maintain a signature log that can be made available to outside parties upon request. A signature log is a typed listing of the provider(s) identifying their name with a corresponding handwritten signature. This may be an individual log or a group log. A signature log may be used to establish signature identity as needed throughout the medical record documentation. Reference: CMS Medicare Program Integrity Manual (Pub ), Chapter 3, Section B *EXCEPTION: CMS would permit use of a rubber stamp signature in accordance with the Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document. 7

8 Medical Record Best Practices for Risk Adjustment Terms such as probable, rule out (r/o), versus, likely consistent with or possible do not confirm diagnoses for outpatient treatment Does not correlate to any diagnosis simply implies you are using your medical decision-making skills in an attempt to diagnose a given problem (i.e. work-up) Instead, report and code signs and symptoms Begin to link orders to specific conditions and include directions for follow up Valium 7.5 mg PO tid for 7 days for generalized anxiety disorder CT scan ordered for evaluation of recurrent lung cancer 7/11/15 Do not use the numeric ICD-9-CM codes only in the medical record in place of the diagnosis description Use of specific descriptions within the record to allow for selection of the most accurate ICD code Pt has controlled DM2, no complications, order A1C 4/19/15 Use of up or down arrows in place of hyper- and hypo- does not convey a medical condition Follow the Taber s Medical Dictionary approved list of abbreviations The presence of an increased blood pressure/glucose reading and/or lipid level does not indicate a diagnosis Document Hyperlipidemia, Hypertension, Increased Fasting Glucose 8

9 Medical Record Best Practices for Risk Adjustment Assessment/Plan language Use Stable, improved, tolerating meds, deteriorating to convey the status of the assessment Monitor, D/C meds, Continue current meds, Refer to convey plans for further treatment History Of Risk Adjustment reimbursement is linked to accurate submission of current medical conditions ICD coding guidelines categorize history of diagnoses as those that are resolved Specific remission codes should be used instead of history of as some of them do risk adjust in the remission stage i.e. Leukemia, Myeloma Some history codes are Risk Adjusted i.e. Alcohol Dependence in remission, Amputations State Causal Relationships Coding guidelines prohibit coders from making assumptions Is the glaucoma a manifestation of the diabetic process? If so state Pt s glaucoma related to DM2 Show a clear causal relationship between any condition and its respective manifestation(s) Association is not causation- Is the patient s hypertensive state a direct result of specified cardiovascular conditions or do they have hypertension and generalized heart disease? Stating patient has a co-morbid condition does not clarify the relationship Use phrases such as due to, because of, complication of, with, or related to to establish this relationship State where cancers have metastasized To Lymph nodes, soft tissue, liver, brain Document complications from treatment such as polyneuropathy due to chemotherapy 9

10 Medical Record Best Practices for Risk Adjustment What can coders do to assist? Establish a collaborative process between you and the providers Bridge the gap between what is contained in a medical record and what information is missing to correctly assign ICD 10 codes Education about CMS and HHS Risk Adjustment reimbursement processes MA organizations and health plans who offer Affordable Care Act products are reimbursed based on risk scores of their members Risk scores are directly linked to ICD code assignment Coding resources are available through a variety of sources Evaluate the medical record Is there M.E.A.T./T.A.M.P.E.R. provided in a medical record to ensure support of ICD code selection? Select the appropriate ICD code, to the highest level of specificity based on the clinical documentation provided in the medical record Become a Certified Professional Coder (CPC) or (CCS) from AHIMA Professional expertise in reviewing and assigning accurate diagnosis codes Knowledge of medical coding guidelines, coding regulations, and proper reimbursement 10

11 EXAMPLE ONE of M.E.A.T. Holly Wood, DO Patient: Joseph Doe, 07/04/1937, ID DOS: 6/29/14 CC: Mr. Doe presents today for recheck of labs ordered 6/15/14 for lipids and glucose and go over results of latest PSA. HPI: Hyperlipidemia since 2001, complicated by HTN and pre-diabetes. Pt is also being treated at Best Oncology associates for treatment for recurrent prostate neoplasm. Vitals: Ht: 64 in. Wt: 140 lbs.t: 98.0 degf. T site: oral P: 72 Rhythm: regular R: 16 BP: 158/90 Meds: lovastatin, bystolic, tums, calcium 12,000 units. Reviewed 6/29/14-SM ROS: All systems negative and unremarkable Exam: Elderly gentleman in NAD appearing stated age. Trace edema, lower ex and heartrate increased. Genitourinary declined, recent confirmed cancer biopsy. Endocrine denies hypoglycemia, frequent urination. Assessment: Dyslipidemia, refill for lovastatin Hypertension, refill for bystolic and add baby aspirin (OTC) Prostate Cancer, increased PSA, will begin radiation therapy with Best Prediabetes, counseled on 1200 cal ADA diet and increase physical activity (walk 30mins daily) Plan: Continue cancer tx at Best Onc, repeat labs 2 wks, and continue meds as prescribed. RTO 3 weeks for follow up. Record Authenticated by: Holly Wood, DO

12 EXAMPLE TWO of M.E.A.T. Elite Pulmonology 555 West Wood Pittsburgh, PA Dear Dr. Samson, I had the pleasure of seeing our mutual patient Sam Doe (2/23/50), in our office today 9/29/14 regarding his continued pulmonary difficulty. As you know, he is oxygen-dependent, struggling with severe emphysema 12 years affecting his exercise regimen. Continues to have SOB, DOE, but does deny nicotine use. PFT is attached for your review. I completed a 15-point exam of Sam and found lung sounds positive for crackles in LL lobe and saturation 96% on 2L O2 by nasal cannula. Clinically, Sam Doe is approaching end-stage emphysema/copd and I am ordering an increase of nightly oxygen to 3L and prescribing Brovana 2x bid. Thank you for allowing me to treat this pleasant gentleman. Greg Brady, MD (Pulmonology) 9/29/14 12

13 References CMS websites for Clinical Documentation Best Practices: MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN pdf MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN pdf 3.pdf/$File/2013_RA101ParticipantGuide_5CR_ pdf Other resources: 13

14 Thank You! This concludes Module 2- Coding for Risk Adjustment: Clinical Documentation Best Practices