SPECIALTY TIP SUMMARY

Transcription

1 ICD- 10 SPECIALTY TIPS SPECIALTY TIP SUMMARY Medical recrd dcumentatin, as we all knw, seems t be experiencing ever increasing demands. If it s nt dcumented, it wasn t dne is a phrase we have heard repeated cuntless times. If there is ne wrd that wuld sum up the infrmatin in this series, it wuld be DETAILS. Mre than ever, the details in yur dcumentatin supprt the CPT and ICD- 10- CM cdes assigned fr yur services. Yur detailed dcumentatin prvides the supprt fr: Cntinuity f Care Legal Prtectin, hpefully yu will never need it Reimbursement and supprt fr any appeals Medical Necessity fr every service perfrmed We have presented Specialty Tips in the varius prblem specialty areas t help yu understand what is needed in yur dcumentatin and why. Specialty Tip #1 Pregnancy Specialty Tip #2 Traumatic Injuries Specialty Tip #3 Orth Traumatic Injuries Specialty Tip #4 Orth Musculskeletal & Cnnective Tissue Specialty Tip #5 Eyes Specialty Tip #6 Clnscpies Specialty Tip #7 Pst- Operative Pain Management Specialty Tip #8 Cnsults vs. Visits Specialty Tip #9 Dcumentatin Specialty Tip #10 Urlgy Specialty Tip #11 TEE Specialty Tip #12 General Surgery Specialty Tip #13 Evaluatin and Management Specialty Tip #14 ENT Specialty Tip #15 Anesthesilgy Specialty Tip #16 Plastics Specialty Tip #17 Pdiatry Specialty Tip #18 Oral and Maxillfacial Specialty Tip #19 Spinal Prcedures Specialty Tip #20 Knee Prcedures The Basics Thrughut this series, a number f basics have emerged. Each encunter with a patient shuld answer the questins f what happened during the encunter r surgery in detail, why did the patient need the encunter r surgery, and wh did what? In General The dcumentatin must be cmplete and legible. The medical recrd shuld include the legible authenticatin (either via handwritten signature r electrnic signature) and clear identity f the prvider with the crrect date f service. The dcumentatin must be timely. Sme institutins have a time frame fr dcumentatin. Outside f that timeframe, the dcumentatin is cnsidered delinquent. Carriers watch fr delayed dcumentatin and it can send up a red flag. Their viewpint is that yu are unable t recall vital details as time passes. SUMMARY 1 f 5

2 ICD- 10 SPECIALTY TIPS With yur signature, yu are attesting t the accuracy f the dcumentatin s read yur dcumented reprts carefully. Make sure there are n hles in yur dcumentatin PRIOR t signing. Especially in electrnic medical recrds, the dcumentatin des nt g away; it can nly be amended after signature. Treatment is determined by medical necessity and yur dcumentatin shuld supprt the need fr treatment. Often an H&P/Cnsult, film interpretatins, r tests are needed t additinally supprt a prcedure. Charge tickets r superbills are nt a part f the patient s permanent medical recrd; therefre, if yu want t claim it, dcument it in the medical recrd. Be careful using abbreviatins that they are clearly understd. Prir t implementing any new prducts r prcedures, we suggest checking with yur cding staff. Many new prcesses d nt yet have cdes in place and may have t be cded with the unlisted cdes in spite f what the sales representatives may say. Keep in mind; it is their jb t sell a prduct nt their respnsibility fr yu receiving payment fr yur investment and it is nt easy t receive payment fr unlisted cdes. Often we will submit questins regarding the apprpriate cde(s) t assign t the AMA t ensure we are cding accurately as directed frm an authritative surce. Surgery Dcument yur apprach. Often a surgery is planned and is mdified during the curse f the surgery. If this happens, be sure t supprt the change by explaining why the change in plans within yur dcumentatin. If a specific surgery has been authrized, nly yur dcumentatin may prvide supprt fr payment f a different (ptentially unauthrized) cde. Include pertinent details regarding the histry and cmrbid cnditins in the perative reprt. This wuld minimize the need t request the H&P fr additinal infrmatin. Prvide adequate histry t identify any frmer surgeries r cnditins affecting r prmpting treatment. As cders cannt assume. Just as there are translatrs frm ne language int anther, Cders, t, are translatrs; they translate yur written dcumentatin int prcedure and diagnstic cdes t submit t insurance cmpanies fr reimbursement, therefre be specific and detailed in yur dcumentatin. Detail a change in lcatin r incisin site. State laterality especially when addressing cntralateral lcatins. Sme surgeries are nt cvered in an ASC facility (inpatient prcedures versus an utpatient setting). Belw is the link t the CMS website shwing the apprved cdes in an ASC setting fr 2016 and since mre cdes are added each year, yu wuld need t stay infrmed. In rder t ensure yur surgery is cvered, check with the carrier regarding authrizatin and make sure the authrizatin(s) cvers nt nly the surgen but the facility. Fee- fr- Service- Payment/ASCPayment/Dwnlads/CMS FC- CY2016- FR- ASC- Addenda- AA- BB- DD1- DD2- EE.zip Anesthesia Detail the diagnsis (es), prcedure(s), and any additinal infrmatin that may shw the increased care yu had t utilize in administering the anesthesia. SUMMARY 2 f 5

3 ICD- 10 SPECIALTY TIPS Details may change the ASA cding chice, which may impact the fee fr yur service (arthrscpic cnverted t pen, with r withut instrumentatin fr spinal surgery, sitting psitin fr cervical r cranial surgery, etc.) Cdes are assigned based n YOUR dcumentatin and shuld never be dependent n the dcumentatin f ther prviders. If cding has t submit a query r request the perative reprt fr the diagnsis and/r prcedure, it will increase the amunt f time required t submit the claim. Evaluatin and Management In this age f electrnic Health Recrds (EHR), the ability t bring frward dcumentatin frm a previus visit may be very tempting and be a time saving tl; hwever, there are sme cautins that need t be kept in mind: Watch that yu d nt bring frward the wrng patient file Review, update, and crrect all infrmatin which includes diagnsis and plans If a new cnditin arises, it is nt relevant unless addressed within the bdy f the nte (i.e., examinatin, diagnsis/plan) Yur authenticatin indicates that yu reviewed and cmpleted the dcumentatin and accept the accuracy Watch fr ckie cutter ntes. Each dcument shuld be a unique reflectin f the care prvided per encunter and the diagnsis(es) necessitating the service Addenda are valuable fr crrecting and clarifying yur dcumentatin, just use cautin in using this t frequently The medical recrd shuld accurately reflect a snapsht f each encunter t the highest degree f certainty at its cnclusin. While histrical infrmatin may be valuable, is it really impacting yur care TODAY? It shuld dcument the patient s prgress, respnse t treatment r changes in treatment, and revisin f diagnsis. Avid using Nn- Cntributry fr elements f the histry. In essence, this may be interpreted as didn t ask. Higher level Initial encunters with patients (except fr Emergency Visits) require that all three elements f Past/Medical, Scial, and Family histry be dcumented. N dcumentatin f the Family Histry wuld impact the entire level f service. If the histry is unbtainable, dcument reasn (GCS 3, intubated & sedated, AMS, etc.) and this element culd still be credited. Every effrt shuld be made t get the infrmatin frm ther surces (i.e., translatr, family, parents, spuse, n ther surce available fr histry, n translatr available, etc.), nte surce if infrmatin btained frm ther than patient. Clarify the INTENT f any visits (Cnsult, pre- p fr surgery, emergent, etc.) Remember, Cnsultatins are the request fr yur pinin. Yu cannt self- refer. There must always be a request fr yur services in the medical recrd in rder t qualify fr a cnsult and dcumentatin f yur respnse back t the requesting prvider. If the cmmunicatin is verbal, the phne call and/r discussin shuld be dcumented. If yu assume all r any prtin f the care f the patient, the service is n lnger cnsidered a cnsult but shuld be cded as a visit. SUMMARY 3 f 5

4 ICD- 10 SPECIALTY TIPS Diagnsis ICD- 10 has caused a lt f cnsternatin amng prviders, cders, insurance carriers, and institutins alike. Thankfully, it has generally nt caused the chas riginally predicted. It has, hwever, brught t light the need fr mre detail in dcumentatin t supprt apprpriate diagnstic cding. Yur cder is yur best ally in jumping the hurdles fr accurate cding. They are trained t find the best cdes t supprt the services perfrmed and t illustrate yur decisin making. As they are never allwed t assume a cde they need yur help with dcumenting the details in rder t arrive at the crrect cdes t describe yur services. S what d yu need t remember? ICD- 10, while it is initially verwhelming in the number f cdes increasing frm apprximately 19,000 t ver 68,000 cdes, it has fcused n specificity. If applicable, always state laterality Detail anatmical lcatins Fr musculskeletal cnditins and injuries, state whether the patient is: In the treatment phase (surgery, Emergency Department, evaluatin and treatment by new physician, etc.), In the healing phase (cast change r remval, medicatin adjustment, aftercare fllwing treatment), Or is this a late effect/sequela f an injury? Rather than a current cnditin, are yu treating a late effect r shuld this be termed a histry f? When treating a sequela fr an injury yu need t gather infrmatin n the mechanism f the injury: Details f the riginal injury ( clsed spiral fracture f the right radius ) When did the riginal injury ccur? (Date) What happened? ( driver in an MVA, slip and fall in hme, bitten by a neighbr s dg, etc.) Update yur diagnsis when applicable. A cnditin may nt currently be under treatment r impact the cnditin under treatment; if nt, then it is nt cnsidered relevant. Cding rules dictate that when cding fr multiple cnditins, the mre severe r acute cde is sequenced first with chrnic cnditins as secndary. Be sure t qualify the severity f each cnditin under treatment (i.e. severe OA, stable HTN, COPD exacerbatin, mild Asthma, etc.). Diagnstic sequencing depends n severity (acute ver chrnic, etc.) Fr chrnic patients, new cnditins are relevant and can impact the medical decisin making IF they are addressed (i.e. during the examinatin, within the plan, etc.) State acute r chrnic, ld injury, any descriptive wrding that help t illustrate the cnditin Acute dudenal ulcer with perfratin, Glaucma, early stage, Insulin dependent diabetes, trn meniscus, recurrent injury State any due t r precipitating cnditins Pst- traumatic stearthritis, gut due t renal impairment, Pathlgical fracture f hip due t metastatic carcinma f bne Include cmrbid and relevant cnditins that impact decisin making r cmplicate surgery Apprpriate health risk factrs shuld be identified. Mrbidly bese patient- BMI 40, smkes 2 packs f cigarettes per day x 20 years, patient is fragile, 87 year ld wh lives alne with limited access t medical care Fr pregnant patient, regardless f the setting, dcument trimester and number f weeks gestatin The nly time pregnancy is cnsidered incidental is when it is dcumented as such. Otherwise it is cded as Pregnancy cmplicated by... t supprt the increased medical decisin making required. Fr deliveries, nte utcme f delivery and whether full term and uncmplicated SUMMARY 4 f 5

5 ICD- 10 SPECIALTY TIPS If cmplicated, state cnditin Be sure that yu are listing as yur diagnsis the cnditin YOU are treating (i.e. COPD under treatment by a Pulmnlgist, atrial fibrillatin treated by a Cardilgist, etc.) Certain cnditins (neplasms, respiratry, etc.) ask fr additinal infrmatin regarding alchl and tbacc use, abuse, expsure t, r histry f which influence the cnditin. Dcument whether cnditin(s) is/are; pathlgic, traumatic, r nn- traumatic acute, chrnic r recurring Dcumentatin tells a stry that enables a cder t translate int numbers the explanatin f what yu did and why. The mre detailed and cmplete the stry, the less difficult it is t supprt and ask fr reimbursement. abe has an abundance f tls t help with yur dcumentatin and we are always here fr yu. Thank yu fr jining us during this series. The infrmatin prvided is nly intended t be a general summary and nt intended t take place f either written law r regulatins. SUMMARY 5 f 5