Alabama Primary Health Care Association October 4, Separating Clinical Documentation, Professional Coding, and Billing: A Workflow Analysis

Transcription

1 Alabama Primary Health Care Association October 4, 2017 Separating Clinical Documentation, Professional Coding, and Billing: A Workflow Analysis Presented by: Gary Lucas, M.Sc., CPC, CPC-I, AHIMA ICD-10 Ambassador Vice President Education Operations Association for Rural & Community Health Professional Coding (ARHPC/ACHPC)

2 Your facilitator Gary Lucas, M.Sc., CPC, CPC-I, AHIMA ICD-10 Ambassador Vice President of Education Operations Contact Information Phone: Web: You may already know John Beard? ARHPC CEO/Founder

3 Session Objectives 1. Discover how to increase an revenue & regulatory compliance with CMS and Medicaid rules 2. Learn how to increase the accuracy of information that patients receive about their care 3. Learn to capture 100% of what is done in their EHR 4. Ensure that 100% of what you do is coded correctly before going to billing This material is owned by the ARHPC & is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of a 2017 ARHPC training session.

4 Workflow: A Shared Definition A progression of steps (tasks, events, interactions) that comprise a work process, involve two or more persons, and create or add value to the organization's activities. In a sequential workflow, each step is dependent on occurrence of the previous step; in a parallel workflow, two or more steps can occur concurrently. Source: The Business Dictionary accessed on at This material is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of the 2017 educational sessions sponsored provided by the ARHPC VP of Education Operations Gary Lucas.

5 Coding and Billing are distinctly different Coding turns medical documentation into usable data regardless of whether it generates revenue Example Vaccines received for free via VFC program aren t reimbursable but are required to be listed in your system to ensure reporting of required vaccinations for kids Just because there is a code doesn t mean you can bill it. Just because you got paid doesn t mean you get to keep it. Remember, the coding/billing side of things is heavily trustbased we don t submit documentation with every claim. P4P/HCC/APM/etc are already here!

6 What is the level of education on documentation, coding, and billing between: 1. Certified Coders (CPC, CCS, etc) 2. Clinical Documentation Specialists 3. Clinical Providers (MD, DO, PA, NP, RN, etc.) 4. Quality Managers and Utilization Staff This material is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of the 2016 ICD-10 educational sessions sponsored provided by the ARHPC VP of Education Operations Gary Lucas. 6

7 Central Questions QUESTION #1: Do patients currently walk out of your door with a full listing of what services/procedures were performed (CPT and HCPCS-2 codes) and why they were performed (ICD-10)? QUESTIONS #2 and 3: How confident are you that all services provided are fully documented? How confident are you that all services are coded exactly the same regardless of the patient s insurance? Key point: Clinical care doesn t change based a patient s insurer or ability to pay; therefore, all patients should be coded the same way. This material is owned by the ARHPC & is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of a 2015 ARHPC training session. 7

8 How does all of this fit into patient care? Are providers trained on documentation requirements? Clinical Documentation Professional Coding Coding is done by people, not EHRs or encoders Depending on who we are reporting to and why, they may not want to know everything that was done and why Reporting = Billing, Quality, and more How much of this should our patients be given access to? This material is owned by the ARHPC & is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of a 2017 ARHPC training session.

9 Additional examples to consider that may have different interpretations from various payers Consultation codes and Surgical package definition (CMS vs. CPT vs. their own) HCPCS-2 G-codes such as G0403-G0405 Commercial insurance adherence to CMS E/M Documentation Guidelines? Is there MAC guidance on the differences between 1995 Expanded Problem Focused versus Detailed exams for your carrier? Cost reports and vaccination reporting Incident-to requirements for nurse visits and supervision requirements School sports physicals and regular physicals charging the same amounts?

10 Workflow What is really involved? Focus audience for today: Facility senior management, revenue cycle staff, all healthcare providers, IT/EHR staff, coders/billers, hospital finance staff who owns RHCs This session will focus on developing an effective plan to prepare for the impacts to your staff, your policies, your systems, and your workflows related to clinical data collection, data extraction, and data reporting. PEOPLE PROCESS TECHNOLOGY

11 PEOPLE PROCESS TECHNOLOGY 1. How would you rate the ability of your staff to work together as a TEAM? 2. How would you rate the technical ability/acumen of staff members with primary authority over creating clinical documentation, capturing 100% of the services documented in the EHR, maximizing revenue, and staying compliant? 3. How would you rate the level of change you have experienced to any of the above items in the last 2 years, for 2017, and beyond? 4. What resources do you utilize to develop and carry out your plan to improve in key areas? This material is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of the 2016 ICD-10 educational sessions sponsored provided by the ARHPC VP of Education Operations Gary Lucas. 11

12 PEOPLE PROCESS TECHNOLOGY 1. Have your EHR/practice management/software vendors provided the support you need? 2. Even something so seemingly simple as transitioning to an virtual version of your clinic s superbill/encounter form/charge ticket may have caused workflow disruptions! 3. Who confirms that all services performed were documented and that all services documented are captured by code(s)? 4. What information do you provide your patients before they leave the clinic? This material is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of the 2016 ICD-10 educational sessions sponsored provided by the ARHPC VP of Education Operations Gary Lucas. 12

13 PEOPLE PROCESS TECHNOLOGY 1. Does your EHR help you understand what a HCPCS Level 1, Category II code is? 2. Does your EHR or encoder provide you with the overall section guidelines, full code view including codes above and below the selected code found during a key word search? 3. Does your system include the individual code guidelines that provide detailed coding, but not billing, knowledge on proper code selection? 4. How do you educate new staff that didn t get initial system training? Do your provider have to learn multiple EHRs? This material is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of the 2016 ICD-10 educational sessions sponsored provided by the ARHPC VP of Education Operations Gary Lucas. 13

14 Integrating optimal workflow with overall clinic goals How to retain our providers and keep their focus on patient care even though EHRs have brought them more coding responsibilities? Have you defined educational objectives and expectations for existing and future staff based on their need? Depend on a well-trained staff working together to overcome existing organizational gaps!

15 Workflow There is no purely technical solution (i.e. software) for a optimal workflow. How do you keep your vendors involved and accountable but not responsible? It is natural to focus on INTERNAL workflow but what about EXTERNAL?

16 Areas to Analyze Workflow Impacts The provider s mind To the medical record To internal business documents To the patient and payers For public health needs, data integrity, and beyond

17 Who Benefits and Why? You Don t Have to be Coder/Biller to Need Coding/Billing Education We turn documentation into usable data & revenue Coders, Billers, Key nonclinical staff All Clinical Staff Members We are the only ones who can document in medical records We manage workflows, money, and regulatory compliance Facility Leaders, IT, EHR, Finance State Offices of Rural Health We facilitate necessary training and technical assistance

18 This material is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of the 2016 ICD-10 educational sessions sponsored provided by the ARHPC VP of Education Operations Gary Lucas. What was needed, did it happen, is it ongoing, or is it still necessary? Manager s Office Any policy or procedure tied to a diagnosis code, disease management, public health tracking Vendor & payer contracts should be evaluated and fully understood What did you learn regarding budgeting (software, training, etc.)? Who in your organization needed (and still needs) training on clinical documentation, coding, and reporting? Did IT/EHR solve your documentation/coding/billing issues? Physician/Provider s Office & Nurse s Station Impact of changes to clinical documentation? Changes to forms (order/prior authorization), and/or more detail needed on referral forms? How do we handle queries while not interrupting patient flow? Coding/Billing/EHR Staff s Office Did ICD-10 point out that coding/billing requires high-level critical analysis skills & requires, teamwork, training, support, and respect?

19 It all starts with translating medical records documentation! It is time to move beyond some costly old familiar phrases recognize these? If you didn t document it, it didn t happen That s what I hired you for. Just get the claim paid and out the door Our vendor told us our EHR/Encoder will code for us Our claim scrubber tells us what will get paid This material is owned by the ARHPC & is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of a 2015 ARHPC training session.

20 Approved HIPAA Code Sets CPT What did we do? Created by AMA (updated annually) CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Healthcare Common Procedure Coding System. Updated January 1st each year About 9,000 codes to select from HCPCS II Around 4,000 codes with CPT look-a-likes Supplies and DME Created by CMS as a supplement to level I CPT codes HCPCS is currently identified by the Centers for Medicare and Medicaid Services (CMS) as Level 2 of the Healthcare Common Procedure Coding System. ICD-10-CM Why did we do a service? ~70,000 codes Overseen by Cooperating Parties (AHA, AMA, CMS, NCHS) ICD-10 (October 1, 2015), leniency period ended 10/1/16 New codes become effective on October 1 each year

21 Codes, codes, and more codes CPT Current Procedural Terminology (HCPCS-Level 1) 5 digit numeric with 2 digit modifiers HCPCS-2 HCFA s Common Procedural Coding System 5 digits numeric & 2 digit modifiers ICD-9/10 International Classification of Diseases 9 th Edition (3-5 digits) and 10 th Edition (3-7 digits) NDC National Drug Codes 10 digit, 3 segment codes Revenue Codes Used on a CMS-1450 (UB-04) form for CMS billing 3 digits and likely requires a CPT/HCPCS-2 code for reporting to Medicare/Medicaid This material is owned by the ARHPC & is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of an ARHPC 2016 training session.

22 Generate more revenue QUESTION: Do patients currently walk out of your door with a full listing of what services/procedures were performed (CPT and HCPCS-2 codes) and why they were performed (ICD-10)? There are likely significant revenue opportunities with Medicaid & 3 rd party payers just with coinsurance and global surgical package guidelines!

23 Summary of observations from recent trainings Coding and billing is a process that requires high-level critical analysis skills Most non-clinical staff receive little to no training and support on these key areas that turn clinical services into revenue to sustain and grow their clinics. Clinical providers have received little to no formal training on how to capture their services and have been given primary responsibilities for coding via their EHR. Team-based Training works the best especially considering workflow changes brought by EHRs were implemented with little cross-functional interaction Many believe that there is an IT solution to documentation>coding>billing it is simply not true This material is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of the 2016 ICD-10 educational sessions sponsored provided by the ARHPC VP of Education Operations Gary Lucas.

24 Why is clinical documentation important? BECAUSE

25 Why is clinical documentation important? Critical for patient care, data integrity, and determination of medical necessity Well-documented medical records reduce rework of claims processing Compliance with CMS and other payers regulations and guidelines Impacts coding, billing and reimbursement Serves as a legal document of care for more than just revenue

26 Once you know documentation and coding. 38 pages of gov t regulations 49 pages of gov t regulations This material is owned by the ARHPC & is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of a 2017 ARHPC training session. 26

27 Medicare-specific Preventive Medicine Services to consider before using the CPT codes Download rather than print these since they are 249 pages of documentation requirements and key information for Medicare s vision of the requirements for documenting and reporting preventive services! Be sure to locate specific guidance for your facility type as these rules are typically focused on FFS providers.

28

29

30 Additional examples to consider that may have different interpretations from various payers Consultation codes and Surgical package definition (CMS vs. CPT vs. their own) HCPCS-2 G-codes such as G0403-G0405 Commercial insurance adherence to CMS E/M Documentation Guidelines? Is there MAC guidance on the differences between 1995 Expanded Problem Focused versus Detailed exams for your carrier? Cost reports and vaccination reporting Incident-to requirements for nurse visits and supervision requirements School sports physicals and regular physicals charging the same amounts?

31 The CMS Global Surgical Package Pre-operative Intra-operative Post-operative The Global Period is determined by the payer [Not AMA] Minor - day of surgery (Modifier 25 is applicable) Major - day of and day before surgery (Modifier 57 is applicable) Minor - 0 or 10 Major - 90 day post-op +1 day pre-op day of surgery 92 global days This is the traditional Medicare Part B definition NOT the AMA s!

32 Understand what information the Resource Based Relative Value System (RBRVS) can provide you (see your earlier hyperlink)

33 After you click here be sure to carefully read and abide by the Disclaimer!

34

35

36 SOURCE: /Medicare/Coding/N ationalcorrectcodinit Ed/index.html?redire ct=/nationalcorrectco dinited/ To know bundling you need to know the Medicare s Correct Coding Initiative(NCCI/CCI)

37 CMS created a very nice How-to Guide on the CCI Create a bookmark for this site at Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To- Use-NCCI-Tools.pdf

38

39 After you follow their instructions, here is a sample of what you will see when looking up if codes are bundled together.

40 Here is the key to when modifiers may be necessary, especially for commercial claims who follow CMS bundling rules

41 Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/GloballSurge ry-icn pdf CREATE a website Bookmark please!

42 What Did Not Change With ICD-10- CM Code reason for visit first Code to the highest level of known specificity Don t code probable, suspected, questionable or rule out Code chronic diseases as often and as long as the patient receives treatment for them Code coexisting conditions affecting patient care at the time of the visit

43 Assumptions and Prerequisites It is assumed that you have already received online, in-person, or other training and education on the ICD-10 Official Guidelines for Coding and Reporting and the differences and similarities between the ICD-9-CM and ICD-10-CM. This is not your initial ICD-10-CM exposure and you fully understand the following ICD-10 terms and concepts: Excludes1 & Excludes2, Code First, Use Additional Code, Base Codes and Family of Codes, Dummy Placeholders When 7 th digits are required for Episodes of Care such as Initial, Subsequent, and Sequela

44 Who should be on your documentation review teams? 1. Certified Coder (RHCS, CHCS, CPC, CCS, etc) 2. Clinical Documentation Specialist 3. Clinical Providers (MD, DO, PA, NP, RN, etc.) 4. Quality Managers and Utilization Staff This material is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of the 2016 ICD-10 educational sessions sponsored provided by the ARHPC VP of Education Operations Gary Lucas. 44

45 What will be your educational approach? How to empower people to have non-clinical careers in Healthcare rather than just a job? How often are we performing internal compliance audits to check for missing revenue or increased compliance risk? What steps are we taking to financial growth? Who benefits from an increased awareness of the accuracy of clinical documentation? Fear/Hope versus active Risk Management & an Education Plan This material is owned by the ARHPC & is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of a 2015 ARHPC training session.

46 Session Objectives Met? 1. Discover how to increase an revenue & regulatory compliance with CMS and Medicaid rules 2. Learn how to increase the accuracy of information that patients receive about their care 3. Learn to capture 100% of what is done in their EHR 4. Ensure that 100% of what you do is coded correctly before going to billing This material is owned by the ARHPC & is protected by assorted copyrights and may not be reprinted or redistributed to any party except for registered attendees of a 2017 ARHPC training session.

47 Your speaker today Gary Lucas, M.Sc., CPC, CPC-I, AHIMA ICD-10 Ambassador ARHPC - Vice President of Education Operations Phone: Gary@RuralHealthCoding.com Web: