1/21/2011. Cindy C. Parman, CPC, CPC H Coding Strategies, Inc.

Transcription

1 Cindy C. Parman, CPC, CPC H Coding Strategies, Inc. The format and/or content of this presentation is copyright 2011 by Coding Strategies, Inc. (CSI), Powder Springs, GA. This handout was created to accompany a verbal presentation and may not have value in the absence of the complete presentation material. Copyright 2011 CSI 2 Introduction 1. Compliant E/M 2. Over Documenting 3. Corrections 4. Cloned Notes 5. Patient Involvement 6. Valid Record 7. Stolen Data Final Thoughts 1

2 CERT Illegible signatures/dates Other errors Missing documentation Insufficient documentation CERT Missing/ incomplete doc Incorrect codes Other errors 2

3 Whether a manual or electronic health record is maintained, there is still a need to ensure that the information generated by the healthcare provider is accurate, timely and available when needed. Software systems may allow submission of noncompliant or potentially fraudulent E/M claims May document a higher level than medically necessary May have shortcuts that create documents automatically Could result in distorted workflow Or questionable data integrity Coding Engines May code visit level solely based on history and examination May fail to consider medical necessity 3

4 All encounters may default to comprehensive history and examination Regardless of chief complaint Or presenting problem Or visit frequency Identical vital signs Identical diagnosis EMRs cut physician patient time Doctors don t look patient in the eye Decreased patient satisfaction? Restructure exam room? A hospital EMR/electronic coding combination: Recognizes when data is missing or invalid Suggests correct data Detects coding errors (non covered diagnoses) Suggests correct codes to ensure payment Automatically loads charges for supplies May double bill for these items But, results in fewer rejections! 4

5 If the electronic template selected does not conform with either the medical condition of the patient or the service provided by the physician, an inappropriate code will be generated. Thus, for physician practices that utilize an electronic medical record, the review and monitoring program must include the ability to determine whether the template description of the service provided or medical condition of the patient as selected by the physician is accurate. Notes that should be focused may become voluminous and templated Not a product of clinical thinking Distracts from providing care 5

6 Physician may have to search through repetitious notes for a single line that documents a new medical condition. Normal may have different meanings Exploding notes Verifying author Patient completed documents Informed consent Pattern of coding may change with implementation of EMR EMR documentation may not match codes 6

7 96% of physicians concerned about losing the unique patient story with the transition to point and click (template driven) EHRs 94% said that including the physician narrative as part of the medical record is important t or very important Less than 10% of physician respondents were confident that the federal government s health information technology and reimbursement standards will lead to higher quality patient records Don t use pencil Don t use red pen No blank spaces No removed pages No obliterated entries 7

8 Never write over, or otherwise obliterate the erroneous passage. Draw a single line through the incorrect entry, keeping the original data legible. Sign and date the deletion and state the reason for the correction. Document the correct information or reference its location in the medical record. Follow the same principles! Track original entry, and The correction, with the date, time and reason for the change. Any corrected record submitted must make clear the specific change made, the date of the change and the identity of the individual making that entry. Supplies additional information that was omitted from the original entry. 8

9 Used to provide data that was not available at the time of the original entry. Should be timely List reason for addition or clarification of information Late entries, addendums or corrections to a medical record are legitimate occurrences. Bears the current date of entry Signed by individual making entry How is the addendum or late entry linked to the original document? Need to be certain that when original document is printed or accessed, the late entry or addendum is as well 9

10 Most EMR system designs fail to include protections to ensure the correct use of shortcuts. October 4, 2010 But CMS and Medicare contractors are wary of classic EHR physician documentation shortcuts cloning (cut and paste), macros and templates and audits are bearing out their concerns. 10

11 Default notes Copy Forward Copy & Paste Make it Mine Typo will be repeated in every document Physicians copy information from previous patient encounters (e.g., demographic, history of present illness, exam, medical decision making) and paste it in the current encounter. 11

12 Macros are a type of EHR shortcut that allows the entry of generous customized data quickly. Physicians can fill out templates for patient encounters or other services that cover a lot of ground with a few key strokes. The ROS may be prefilled with the term negative for each organ system. While CMS has not taken a position on templates, the agency has conveyed that they are meant to prompt physician documentation, not do the lion s share of it. 12

13 Question: Our office uses a template for office visits. Does Medicare prefer one type of template to the others? Answer: Medicare does not endorse any templates In reviewing medical records, a pattern of template use sometimes has a cloning effect between patients. The patients medical records tend to lose the patientspecific information. When using a template for documentation, take care to note your findings in a patient specific manner. When designing a template for your practice, beware of the following pitfalls: Templates can limit providers ability to enter free text information Templates can encourage physicians to document more services than they rendered Users might inappropriately interpret the template 5. The PSC and the ZPIC shall determine if patterns and/or trends exist in the medical record which may indicate potential fraud, waste or abuse. Examples include, but are not limited it to: The medical records tend to have obvious or nearly identical documentation; 13

14 Encounter records can be created in advance Even if patient did not show up Would the physician have dictated the information? If not, is it medically necessary? If not relevant, has it only been added to increase the level of service? 14

15 Some information was taken from billing records Billing codes easier to link Standard definitions Some medical data was historical, but listed as current conditions Reflected codes required by insurers Insurance data, by contrast, is already computerized and far easier and cheaper to download. But it is also prone to inaccuracies, partly because of the clunky diagnostic coding language used for medical billing, or because doctors sometimes label a test with the disease they hope to rule out Patients who discover mistakes in their health information can dl delete information, add notes or ask providers to correct inaccuracies! 15

16 That may mean that the healthcare provider has to correct diagnosis codes on insurance claims? Most current EMRs do not have any responsibility for documentation and coding compliance. By contract 16

17 The documentation must constitute a valid medical record in all its attributes. Follow established rules for medical records. Currently EMRs are: Not standardized Minimally certified May decrease data quality May increase fraud Physician orders and/or CMNs Patient questionnaires (ROS, PFSH) Progress notes of all providers Treatment logs Patient visit reports Procedure, lab, imaging and diagnostic reports Integrity of clinical documentation recorded Variability in records management Usability and quality of clinical care guided by the electronic record Variability in system access Variability in auditing or quality assurance Perceived lack of malpractice protection 17

18 The patient s medical record is considered incomplete without t authentication ti ti that t the information is a true and accurate representation of the services provided. Have a password log on requirement which irrefutably identifies the author of every entry. Authorship vs. countersigning g No auto authentication Non repudiation assurance that the signer cannot deny signing the document in the future User authentication verification of the signer s identity at the time the signature was generated Message integrity certainty that the document has not been altered since it was signed 18

19 All individuals entering or reviewing information in the medical record may require an electronic signature. Locum tenens Students Scribes Auditors Once an organization is party to litigation, it has a duty to preserve evidence. In the old days, the paper chart was locked in a filing cabinet. Digital information is readily accessible and easily changed. However, electronic information, including EMRs, must be preserved and not altered. Patient data may include: EMR information Queries s Spreadsheets External hard drives Back up files Organizations must be able to search all systems to retrieve records related to a subpoena. 19

20 May have to create a segregated database to ensure proper protection of records. Difficult at best May require the purchase of separate software tools! May have to demonstrate to the court that the tool works For these reasons, it is nearly impossible for electronic records to reproduce exactly what the physician saw on his or her screen at the time of an incident especially one that occurred years ago 20

21 February 26, entities reported a breach affecting 500 or more individuals Hospitals Insurers Physician practices Due to: Theft of computer, portable device, paper records, films, EMRs Loss of backup tapes, portable electronic device, laptop Hacking Incorrect mailing of postcards, unauthorized access mailings Misdirected or phishing scam Unauthorized access to computers or EMRs 80% of healthcare organizations surveyed had experienced at least one incident of lost or stolen electronic health information in the past year 4% had more than 5 patient data breaches The average cost of a data breach exceeded $210 per compromised record 21

22 There needs to be a policy on printing documents. Copies that are printed should be tracked by an audit trail to identify users who have printed reports from the system. amednews.com, January 17, 2011 EMR may not be designed to work with specialty Work flow problems Systems provided to physicians by hospitals Could cause productivity to fall 10% first year Monetary loss of approximately $120,000 No system will be an exact match Only after becoming a user can the physician apply the EMR tool 22

23 EMRs complicate the ROI process Multiple databases Pi Privacy regulations State regulations 3 rd Party requests HIM policies Outsource? EMRs will be easier to audit than requesting paper The payors will just access the electronic records directly Questions? 23