Improve Your Revenue for the Services Your Provide with Proper Coding and Documentation. by Christina Rock, BSN, RN Supervisor, Clinical Education

Transcription

1 Improve Your Revenue for the Services Your Provide with Proper Coding and Documentation by Christina Rock, BSN, RN Supervisor, Clinical Education

2 Objectives Awareness of resources and reference materials to assist in the pursuit of quality documentation and accurate coding of medical encounters. Learning how precise documentation leads to better overall patient care, healthier outcomes for patients, and the benefits to the patient and provider. Understanding of the purpose of consistent coding and its effects on reimbursement. Recognizing how documentation quality translates to accurate coding and beyond, integrity of claims data, and how claims data accuracy benefits everyone.

3 Risk Adjustment A method used to adjust bidding and payment based on the health status and demographic characteristics of an enrollee. A payment methodology, which typically relies on diagnosis codes to determine the health risk/status of person or population. Payment Structure: Higher payments for less healthy members and lower payments for the more healthy members. The Medicare payment model is referred to as the CMS- Hierarchical Condition Category (CMS-HCC) payment model. The Medicaid payment model is referred to as Chronic Illness and Disability Payment System (CDPS).

4 Medicare Risk Score Medicare (HCC) and Medicaid (CDPS) use two different models for payment, but both carry the same rule of thumb: capture all current diagnoses and include all known status codes and history codes. Care and diagnoses documented in chart ICD-10 CM codes submitted on claims Claims data codes are converted to HCC/CDPS codes HCC/CDPS codes submitted to CMS CMS calculates risk score

5 Why is Medical Record Documentation Important to Risk Adjustment? CMS requires that all applicable diagnoses codes be reported and that all diagnoses be reported to the highest level of specificity, and this must be in the medical record. CMS requires that the medical record validate the diagnoses codes that have previously been reported by the physician. Medical record documentation plays a critical role in risk adjustment because accurate risk adjusted payment relies on complete medical record documentation and diagnosis coding. It is important for physicians and their office staff to be aware of Risk Adjustment Data Validation (RADV) audits because medical record documentation may be requested.

6 You Play a Critical Role Your assistance and commitment to this process is critical, by supplying the most accurate and complete diagnosis coding and medical record documentation, you will help meet reporting requirements and obligations to CMS.

7 Disease specificity makes a difference Some diagnoses are risk-assessed or have a higher ranking in the same HCC/CDPS category: Does not risk adjust/score lower Other and unspecified asthma J45.90 Chronic kidney disease, unspecified N18.9 Unspecified, viral hepatitis C B19.9 Cardiac Arrhythmia, unspecified I49.9 Risk-adjusted/score higher Chronic obstructive asthma J44.9 Chronic kidney disease, stage 1-5 N18.1-N18.5 Chronic viral hepatitis C B18.2 Chronic atrial fibrillation I48.2

8 No Conditions Coded (Demographics only) Some Conditions Coded (Claims data only) All Conditions Coded (Chart review by coder) 76-year-old female year-old female year-old female.468 Medicaid Eligible.177 Medicaid Eligible.177 Medicaid Eligible.177 DM not coded DM (no manifestations).118 DM with Vascular Manifestations.368 Vascular Disease not Coded Vascular Disease without complication.299 Vascular Disease with complication.41 CHF not coded CHF not coded CHF coded.368 No interaction No interaction Disease Interaction Bonus RAF (DM + CHF).182 Patient Total RAF.645 Patient Total RAF Patient Total RAF PMPM Payment of Care $452 PMPM Payment of Care $743 PMPM Payment of Care $1,381 Yearly Reserve of Care $5,418 Yearly Reserve of Care $8,921 Yearly Reserve of Care $16,573

9 Did You Really Mean? If you document Bronchitis Cardiac Dysrhythmia Essential tremor CAD Reflux disease/ Heartburn Diabetes and CKD Increased Lipids Renal Insufficiency Open Wound S/P CVA with R sided weakness Neuropathy Did you really mean? Chronic Bronchitis Atrial Fibrillation Parkinson s Old MI GERD Diabetic Nephropathy Hyperlipidemia Chronic Kidney Disease (specify stage) Skin Ulcer Late Effect of CVA- Hemiparesis Peripheral Neuropathy

10 Use of History of History of means that the patient no longer has the condition. Frequent documentation errors regarding use of history of Coding a past condition as active Coding history of when the condition is still active Exception: It is appropriate to document/code history of when documenting some status codes. Incorrect documentation H/O CHF, Meds Lasix H/O COPD, Meds Advair Correct documentation Compensated CHF, stable on Lasix COPD controlled with Advair

11 Chronic Conditions For patients with chronic conditions, we recommend at least two office visits yearly to facilitate assessment and monitoring of complete information. All existing chronic illnesses should be documented in the medical record, have an assessment, and a plan of care. Assessment Stable Improved Tolerating Meds Deteriorating Plan of Care Monitor D/C Meds Continue Current Meds Refer

12 Chronic and Status Conditions All chronic conditions can be addressed at each office visit Congestive heart failure COPD/asthma/emphysema Diabetes mellitus Schizophrenia/bipolar Active status conditions Amputations- Z80 category Ostomies- (i.e., Colostomy-Z93.3) Oxygen dependence/therapy- Z99.81 Dependence on dialysis- Z99.2 Cardiac pacemakers- Z95.0; Cardiac defibrillator- Z95.810

13 Documentation Tips Mandatory areas needed to be documented in medical records for each office visit by CMS guidelines: Date of Service (DOS) Patient name Date of Birth (DOB) Complete history and physical exam Address all chronic diagnosis and update past medical history if needed Document any other areas addressed during visit. (e.g., medications, counseling, or screenings, etc.) Provider signature with credentials Code all diagnosis codes that were addressed and document accordingly and to highest level of specificity. Only using diagnosis codes without the written description in the documentation is unacceptable. Legibility of all documentation and signatures preferred otherwise the medical record will need to be attested if audited.

14 Coding Tips Code all additional diagnosis that are documented. Code any history of relevant diagnosis (h/o cancer). Code significant social history (smoking, alcoholism, drug abuse). Do not code any diagnosis listed as probable, possible. Code to the furthest number of digits and highest level of detail. Z-codes should be coded for each encounter. Clarify if Chronic or Acute (e.g., chronic Hepatitis B vs. acute Hepatitis B). Mental health issues/recurrent depressions need to be addressed and coded even if stable on medications.

15 Coding Tips CVA is to be only coded in a inpatient setting; Once released from the hospital the code should be history of. Elevated BP or arrows cannot be coded as hypertension. Do not use abbreviations that may have multiple meanings. e.g., CRF (chronic renal failure or chronic respiratory failure) Code the accurate code for diagnosis codes that relates if documented. Assume relationship, unless documented by the provider, that it does not. Chronic kidney disease and hypertension Coronary artery disease and angina COPD and asthma

16 Unacceptable Signatures Found in Paper Medical Records Illegible signature NOT over a typed/printed name, NOT on a letterhead. Initials NOT over a typed/printed name. Unsigned typed note with provider s typed name. Unsigned typed note without provider s typed/printed name. Unsigned handwritten note, the only entry has one page.

17 Unacceptable Signatures Found in EMR Administratively signed Dictated but not read Dictated but not signed Signed but not read Signature on file Filled by Electronically signed by agent of provider

18 Best Practices for Provider Documentation Addressing each of the patient s issues will: Better explain the complexity that is involved with the patient s care Illustrate the medical necessity of the encounter In the documentation: Use the assessment to review the patient s history and identify the severity of the patient s condition Use the exam to form an opinion on how to best treat the patient Include content that: Connects the dots of the entire evaluation in one to three sentences Identifies the work performed during the assessment process Incorporates history that may have impact

19 Physician Benefits of Proper Documentation Improve Patient Care: Provides an accurate picture of patient s acuity Improves communication with other providers Physician Comparison: Physician will be compared to their peers Accurate Coding Leads To: Appropriate reimbursement to health plan and physician Supports Pay for Performance and Physician Quality Reporting Systems *The documentation should be as specific as known at the time of service*

20 Questions?

21 Resources Network-MLN/MLNProducts/Downloads/CERTMedRecDoc- FactSheet-ICN pdf Guidance/Guidance/Transmittals/2017Downloads/R3824CP.pdf Guidance/Guidance/Manuals/Downloads/pim83c03.pdf Systems/Monitoring-Programs/Medicare-Risk-Adjustment-Data- Validation-Program/Other-Content-Types/RADV-Docs/Coders- Guidance.pdf