Welcome To The Digital Learning Center. Billing Compliance: Today s Presentation. Course Faculty. Presented by

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1 Welcome To The Digital Learning Center Presented by Your Partner In Building High Performance Practices Today s Presentation Billing liance: Avoiding Fraud & Abuse in Your Medical/Surgical Practice Course Faculty R. Thomas (Tom) Loughrey, MBA, CCS-P Chairman, CEO & Co-Founder of Economedix Certified Coding Specialist BS Degree from Pennsylvania State University Earned an MBA in Health & Hospital Administration from the University of Florida Former Hospital Administrator Former Owner of a Medical Billing any Consultant to Physician Practices & Medical Societies Member of Various Professional Organizations Dealing with Medical Practice Management Developed and Presented Thousands of Seminars & Workshops Dealing with Practice Management 1

2 ACCME Disclosure R. Thomas (Tom) Loughrey, MBA, CCS-P In accordance with the policies on disclosure of the Accreditation Council for Continuing Medical Education, presenters for this program, except for any noted below, have identified no personal relationships with a health care product company which, in the context of their topics, could be perceived as a real or apparent conflict of interest. No conflicts were disclosed Today s Course Fraud & Abuse Guidelines How to Audit Proof Your Documentation History Physician Exam 1995 vs Criteria Medical Decision Making New vs. Established Patients Consultations SOAP Notes Summary The Difference Between Fraud and Abuse Abuse occurs when unintended violations of the guidelines results in improper payments on a repeated basis Fraud occurs when there are intended violations of guidelines that result in improper payments. The difference is the intent 2

3 Guidelines Based on documentation Must be readable can be handwritten Must be clear for intended users organized Must be secure Properly stored Identification on each sheet Subject to 1995 and 1997 Medicare Guidelines Guidelines HCFA (now CMS) created guidelines based on AMA CPT criteria that went into effect in January 1995 HCFA amended the guidelines in 1997 by changing the Physical Examination criteria and minor changes in the History criteria These revised guidelines went into effect in January 1998 April of 1998 HCFA elected to delay the final rules and stated that for audit purposes documentation criteria would be based on either the 95 or 97 Guidelines, whichever was most beneficial to the physician. Audit Proof Documentation Three Key onents History Chief laint History of the Present Illness (HPI) Review of Systems (ROS) Past, Family and Social History (PFSH) Physical Examination (PE) Medical Decision Making (DM) Amount/lexity of Data Number of Diagnoses or Management Options Risk of treatment 3

4 Other onents Counseling Coordination of Care Nature of the presenting problem Time The Chief laint History This answers the question, Why is the patient being seen? Documentation will often express this in the words of the patient I have sharp pains in my left lower abdomen I have difficulty swallowing I ve noticed some rectal bleeding My family doctor wants me to see you about a possible hernia My daughter swallowed a coin History History of the Present Illness (HPI) 1. Location What area of the body is affected by the complaint? 2. Quality What are the characteristics of the chief complaint? 3. Severity Are the signs and symptoms mild, moderate or severe? 4. Duration How long has the patient been experiencing the symptoms 4

5 History History of the Present Illness (HPI) 5. Timing How often is the patient 6. Context What situation surrounded the onset of the symptoms? 7. Modifying factors What influences the symptoms making them better or worse? 8. Associated signs and symptoms - Besides the chief complaint are there other symptoms related to the present illness? History History of the Present Illness (HPI) Audit Criteria Brief HPI Documentation of 1-3 of the 8 criteria Extended HPI 1995 Criteria Documentation of 4 or more elements 1997 Criteria Documentation of four or more elements or the status of at least three chronic or inactive conditions History Review of Systems Usually asked on intake form and updated on each visit 1. Constitutional Temperature, BP, height, weight, etc 2. Eyes 3. Ears, nose, mouth and throat 4. Respiratory 5. Gastrointestinal 6. Genitourinary 7. Musculoskeletal 8. Integumentary 9. Neurological 10. Psychiatric 11. Endocrine 12. Hematologic/Lymph atic 13. Allergy/Immunology 5

6 Review of Systems Audit Criteria Problem pertinent documentation of review of system related to the problem Extended ROS Review of 2-9 systems lete ROS 1995 criteria review of 10 or more systems or a problem pertinent ROS plus a notation that all the other systems appear negative or unchanged since the last encounter 1997 criteria review of at least 10 systems with individual documentation of positives and pertinent negatives. May note all other systems as negative or unchanged Past, Family and Social History Documentation of the patient s past experience with illness, surgeries, injuries, etc Documentation of patient s family history of diseases, causes of death,etc An age-appropriate social history of the patient including past and current activities, lifestyle, work, etc., usually includes use of alcohol, tobacco and drugs Past, Family and Social History Audit Criteria Pertinent PFSH specific information for one of the history areas directly related to the problem identified in the HPI lete PFSH 1995 criteria Specific information for two or three history areas 1997 criteria specific information for: One specific item from 2 of the three areas for an established patient or subsequent hospital visit One specific item from each area for a new patient or consultation or an initial hospitalization 6

7 Determining the Type of History If all three intensities are met in one column, look at the bottom of that column for the level of history If no column has all 3 intensities, choose the column farthest to the left with any intensity HPI Brief Br ief Extended Extended ROS None Problem Pertinent Extended Extended PF SH None None Per tinent lete Type of History Proble m Focused Expanded Problem Focuse d Detailed rehensive Determining the Type of History Patient has an brief HPI, an extended ROS and a complete PFSH: HPI Brief Br ief Extended Extended ROS None Problem Pertinent Extended Extended PF SH None None Per tinent lete Type of History Proble m Focused Expanded Problem Focuse d Detailed rehensive The resulting level of History is Expanded Problem Focused Tips on Documenting the History Nurse should always ask and document: Why are you here today? New patients should complete a history and systems form. It should be reviewed & documented by the nurse for positives and pertinent negatives This information should be reviewed by the nurse with the established patient and updated. If there is no change since the last visit this should be documented The physician should review the nurse s documentation and initial it and date it. 7

8 The Physical Examination There are four intensities of Physical Examination (PE): Problem focused limited exam of the affected body area or organ system Expanded problem focused above plus any other symptomatic body area or organ system Detailed an extended exam of the body area or organ system and any other symptomatic or related body area or organ system rehensive a general multi-system exam or complete exam of a single organ system and other body areas or organ systems Physical Exam 1995 Criteria Body Areas: Head, including the face Chest, including breasts and axillae Genitalia Each extremity Neck Abdomen Back including spine Physical Exam 1995 Criteria Organ Systems Constitutional Eyes Ears, nose & throat Cardiologic Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymp hatic/immunologic 8

9 Physical Exam 1995 Criteria Explain specific abnormal and relevant negative findings. A note of abnormal and no explanation is insufficient If other body areas or organ systems are examined unrelated to the problem, note the findings. If negative simply note negative or normal lete single-organ examinations constitute a comprehensive exam. HCFA did not specify any appropriate documentation for the 1995 criteria. Physical Exam 1995 Criteria Audit criteria Problem focused documentation of exam of one body area or organ system Expanded problem focused or detailed documentation of up to 7 systems. Whether it is detailed or expanded problem focused is an interpretation of the auditor rehensive documentation of 8 or more body areas or organ systems Physical Exam 1997 Criteria System Specific Examinations General, multi-system Cardiovascular Ear, Nose & Throat Eyes Genitourinary Skin Musculoskeletal Neurologic Psychiatric Respiratory Hematologic/ Lymphatic/ Immunologic 9

10 General Multi-System Exam 1. Constitutional Measurement of any 3 of 7 vital signs General appearance 2. Eyes Inspection of conjunctivae and lids Exam of irises and pupils Ophthalmic exam of disks and posterior segments 3. Ears, nose, mouth & throat External exam of ears & nose Otoscopic exam of auditory canal Hearing assessment Inspection of nasal mucosa, septum & turbinates Inspection of lips, teeth & gums Examination of oropharynx, oral mucosa, glands, palates, tongue, tonsils & posterior pharynx 4. Neck General Multi-System Exam Exam of neck (masses, appearance, symmetry, crepitus, trachea) Exam of thyroid (enlargement, tenderness, mass) 5. Respiratory Assessment of respiratory effort Percussion of chest Palpation of chest Auscultation of lungs 6. Cardiovascular Palpation of heart Auscultation of heart Examination of carotid arteries (pulse amplitude, bruits) Abdominal aorta Femoral arteries Pedal pulses Extremities for edema General Multi-System Exam 7. Chest (breasts) Inspection of breasts for symmetry, nipple discharge, etc) Palpation of breasts (masses, lumps, tenderness) 8. Gastrointestinal (Abdomen) Examination of abdomen with notation of masses or tenderness Examination of liver and spleen with notation of any organomegaly Exam for presence or absence of hernia Examination (when indicated) of anus, perineum, rectum Obtain a stool sample for occult blood when indicated 9. Genitourinary (male) Examination of scrotal contents Examination of the penis Digital rectal exam of prostate gland 10

11 General Multi-System Exam 9. Genitourinary - female Pelvic exam (with or without specimen collection) Examination of genitalia and vagina for general appearance, lesions, discharge, pelvic support, cystocele, rectocele, estrogen effect, etc. Examination of urethra Examination of bladder Examination of cervix Examination of uterus Examination of adnexa/parametria (masses, lesions, organomegaly, nodularity) 10. Lymphatic Palpation of lymph nodes in two or more areas: Neck Axillae Groin Other General Multi-System Exam 11. Musculoskeletal Exam of gait & station Inspection of digits and nails (clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes) Exam of joints, bones & muscles of 1 of the 6 following areas 1. Head & neck 2. Spine, ribs and pelvis 3. Right upper extremity 4. Right low er extremity 5. Left upper extremity 6. Left low er extremity Includes inspection for misalignment, asymmetry, crepitation, etc Assessment of range of motion, note pain, crepitation or contracture Assessment of stability notation of luxation, subluxation Assessment of muscle strength and tone General Multi-System Exam 12. Skin Inspection of skin and subcutaneous tissue Palpation of skin and subcutaneous tissues 13. Neurologic Test cranial nerves with notation of deficits Examination of deep tendon reflexes (e.g., Babinski) Examination by sensation 14. Psychiatric Description of patient s insight and judgment Brief assessment of mental status Orientation to time, place and person Recent and remote memory Mood and affect (depression, anxiety, agitation, etc.) 11

12 1997 Criteria for Physical Exam Problem focused 1 to 5 elements in one or more system or body areas Expanded Problem focused 6 or more elements in one or more system or body areas Detailed At least 2 elements from each of 6 system/body areas or 12 elements in two or more system/body areas rehensive Perform all elements for each selected system/body area; document at least 2 elements from each of at least 9 system/body areas Medical Decision Making Deals with the complexity of establishing a diagnosis or selecting a management option rised of three elements: The amount /complexity of data reviewed Number of Diagnoses or management options Risk of treatment or non-treatment Medical Decision Making The level of decision making is defined as: Straight-forward Low lexity Moderate complexity High lexity 12

13 Medical Decision Making Parameters for auditing Amount/complexity of data: Minimal amount 0 to 1 point Limited amount 2 points Moderate amount 3 points Extensive amount 4 or more points Medical Decision Making Parameters for auditing the number of Diagnoses/management options: Self-limited minor problem, stable established problem 1 point Established worsening problem 2 points New problem, no work up 3 points New problem, additional work-up planned 4 points Minimal amount 1 point Limited amount 2 points Multiple amount 3 points Extensive amount 4 or more points Medical Decision Making Levels of risk: Minimal Limited problem, simple Dx tests ordered, minor treatment plan Low 2 or more minor problems, 1 stable chronic problem, acute uncomplicated problem; more significant Dx tests not under stre ss; OTC drugs, minor surgery, PT/OT, IV fluids Moderate 1 or more chronic illnesse s w/ exacerbation, 2> stable chronic illnesse s, Undiagnosed new problem, acute illness w/ complications; Dx tests under stress, endo tests; minor surgery with risks, elective major surgery High Illness/Injury posing a threat to life or body function; Tests with risk factors; Emergency surgery ; major elective surgery, parenteral controlled drugs, DNR 13

14 Medical Decision Making Determining the level of Decision Making Number of Diagnoses or Management 0-1 Minimal 2 Limited 3 Multiple >4 Extensive Options Amount and lexity of 0-1 Minimal or None 2 Limited 3 Moderate >4 Extensive Data Overall Risk 1 Minimal 2 Low 3 Moderate 4 High Type of Decision Making Straight-forward Low lexitymoderate lexityhigh lexity Documenting the Level of a Code Generally, new patients or initial encounters require that a specified level for each of the 3 key components be met Established patients or subsequent encounters only require that specified levels be met for 2 of the 3 key components If time is the key component then only the time and the content of the counseling be documented New Patients Office or Other Outpatient All 3 key components required History PF EPF Det Exam PF EPF Det Decision Making SF SF Low Mod High Time (minutes)

15 Established Patients Office or Other Outpatient 2 of 3 key components History none PF EPF Det Exam none PF EPF Det Decision Making none SF Low Mod High Time (minutes) Consultations Office/Outpatient History PF EPF Det Exam PF EPF Det Decision Making SF SF Low Mod High Time (minutes) Consultations Inpatient History PF EPF Det Exam PF EPF Det Decision Making SF SF Low Mod High Time (minutes)

16 Subjective SOAP Notes Chief complaint; HPI; ROS; PFSH Objective Examination Assessment Review of data and records, research, determination of diagnoses and treatment options Plan Ordering of tests or treatments, Rx, referrals, surgery or even wait and watch, return appointments, etc Summary The penalties for even abusive claims can be significant including refunds, interest, fines and other penalties Good documentation is also good practice and reflects high-quality patient care Documentation of medical records involves anyone involved in direct patient care share the work and define the responsibilities Thank you for participating in this seminar presentation from Economedix! Please direct questions to To earn CME credits for this course please complete the Evaluation / CME Form and FAX it back to Economedix within 7 days of the teleconference. 16