Why Templates Can Make You Cry!!!

Transcription

1 Why Templates Can Make You Cry!!! Presented by Angela Jordan, CPC Senior Managing Consultant AAPC National Advisory Board, Southwest Disclaimer The speaker has no financial relationship to any products or services referenced in this program. The program is intended to be informational only. The speaker is not an authoritative source by law. Attendees are advised to reference payer specific provider manuals, on-line or otherwise, for verification prior to making changes to their coding, documentation and/or billing practices. 1

2 Objective EHR s, EMR s and PHR s Where Problems Start Documentation and Link to Coding New Role of the Coder EHR Electronic Health Records (EHRs) focus on the total health of the patient going beyond standard clinical data collected in the provider s office and inclusive of a broader view on a patient s care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the information 2

3 EMR Electronic Medical Records (EMRs) An electronic medical record (EMR) is a digital version of a paper chart that contains all of a patient s medical history from one practice. An EMR is mostly used by providers for diagnosis and treatment. PHR Patient Health Records (PHRs) contain the same types of information as EHRs diagnoses, medications, immunizations, family medical histories, and provider contact information but are designed to be set up, accessed, and managed by patients. Patients can use PHRs to maintain and manage their health information in a private, secure, and confidential environment. PHRs can include information from a variety of sources including clinicians, home monitoring devices, and patients themselves. 3

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6 Complete EMR Patient portal Active Problem List Orders tracking and results Flowsheets and treatment logs Documentation completed timely Outside records and correspondence Patient and staff communication 6

7 Where Problems Start Electronic Notes Step 5: Achieve Meaningful Use Stage 2 Clinical Importance: Providers are encouraged to electronically record progress notes to provide access to the most well rounded patient information available to support continuity of care across patient care settings. Narrative entries in the progress note are an important component of patient records and complement data captured in defined structured fields; together these components create a more complete picture of the patient s status and can be used to track patient progress and sharing of information across care settings. 7

8 Problem Areas E/M leveling Procedure code master Diagnosis code master Typos perpetuated through templates Cloning E/M Leveling Template creation Auto populate Cut and paste Shared templates 8

9 History of Present Illness: 1. follow up Very pleasant 81-year-old white female who started using her Norco and states it has helped significantly with her pain. She denies any side effects with the medications that she is constipation or increased sedation. However she just saw her rheumatologist Dr. who felt that her left knee looks terrible and her arthritis has progressed. Her pain otherwise isn't 10 in intensity. She cannot walk any distance whatsoever although is able to do her activities of daily living. She cannot stand for long periods of time and is usually in a wheelchair. However she still lives independently and drives and does her activities of daily living independently. She would like referral to orthopedic surgery so she could possibly get a total knee replacement and become ambulatory again. She is diabetic she doesn't check her blood sugars however she does check her blood pressures and they've been controlled. She just saw her cardiologist recently who stated everything cardiac-wise was stable. The patient denies any issues with chest pains or shortness of breath. Icemaker was also recently interrogated and was functioning fine. She has had no lightheaded spells. 9

10 History of Present Illness: 1. Swelling The patient has swelling in the bilateral ankle. This is a very pleasant 57-year-old white female patient who is undergoing a lot of family issues. There is multiple issues with incest and sexual assaults. Her brother she was sexually assaulted her daughter when she was 12 passed away. Her issues with her mother who doesn't recognize it and it totally ignores it. Although there is been several reported incidences by the dietitian was sexually falsify her grandfather as well as another in law in the family. The patient denies being suicidal or homicidal. She actually feels better now that the weather has pounds. She has attempted to call or contact her psychiatrist on multiple occasions. According to her they've been unable to talk. Pimpling phone tag. Therefore she has not been into see them. The patient is complaining of intermittent anterior chest wall pain which she feels like it a bicycle around her chest. It sometimes radiates into her neck. She states it lasts for 10 minutes and can occur at rest as well as with activity. Complains of feeling tired all the time and has noticed some swelling in her legs. She has been compliant with taking her thyroid but has not started her vitamin D yet. She still continues to smoke. 10

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14 HPI: Patient is here for an acute visit for hypertension. She has the following cardiac diagnoses: 1. Hypertension 2. Shortness of breath chronically 3. Bradycardia secondary to calcium channel blocker therapy now resolved. 4. Diastolic Dysfunction Grade II 5. Intolerance to norvasc which was back pain. She has had good blood pressures at Rockwell. She has it checked by one of the nurses there and it has been within normal limits with Systolic blood pressures in the 120's to 130's. She states she has been under a lot of stress today. One of her coworkers was found dead and she just heard about it earlier today. She said she has been upset over it. She has a sleep study scheduled through Dr. office on May 15. Physical Exam (No changes noted in this exam, and no notation that no changes from previous exam date is documented) PHYSICAL EXAMINATION: NECK: Supple. Trachea midline. No jugular venous distention noted. Good carotid upstroke. No bruits. No thyromegaly or lymphadenopathy is noted. LUNGS: Clear without any rales, rhonchi or wheezes. Good chest expansion bilaterally. HEART: Tones are regular without any murmurs, rubs, gallops, lifts or heaves. PMI is unremarkable. No subclavian or abdominal bruits are noted. There are good distal pulses. EXTREMITIES: Free of any cyanosis, clubbing or edema. NEUROLOGIC: Grossly nonfocal. Alert, oriented, cooperative. Stable affect and mood and attentiveness during the examination. Moves all four extremities without limitations. Problem List Items Addressed This Visit None PLANS: 1. Hypertension is uncontrolled today. She is under a lot of stress today. She will continue to get her blood pressure checked at work once or twice a week. She states that the blood pressure has been under excellent control at work with SBP of 120's to 130's. She is currently on coreg, hydralazine, hctz, and lisinopril. Her renal artery ultrasound was negative for stenosis. She has a sleep study that has been ordered by Dr. Cearras' office for May 15. She had a normal nuclear stress test 11/ Shortness of breath chronically. This is chronic and controlled. Slightly improved on Advair. 3. Bradycardia secondary to calcium channel blocker therapy now resolved. 4. Grade II diastolic dysfunction. No signs of fluid overload. 14

15 ROS and PFSH A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: Describing any new ROS and/or PFSH information or noting there has ben no change in the information; and Noting the date and location of the earlier ROS and/or PFSH. Exam Policy Staff at WPS It is always important for providers to remember that a note needs to stand on its own. Using a statement indicating the exam is unchanged from the last/prior is a great summary, they must document EXACTLY what they did on that specific visit and bringing forward the previous exam does not do that. So therefore, we would not consider any portion of an exam statement that simply referred back to previous exam. 15

16 Claim Complex Repair Medical Procedures We conducted a wound check and/or repair. Applicable diagnosis: OPEN WOUND OF HAND. Prepared for the procedure by cleaning with hibicleanse. was cm Instructions were provided to the patient as documented elsewhere. Patient's wound was cleansed post-operatively with saline. Patient tolerated the procedure well. A Gauze was used to cover the wound Claim , Treatment / Orders / Work Restrictions Ordered Tetanus/diphtheria/pertussis, acel (Tdap), 5 units-2 units-15.5 mcg/0.5 ml.1 injection I.M. Administer: 1 injection. Prescribed Keflex 500 mg oral capsule, 500mg.1 capsule orally twice a day, for 5 days. Finish all medication. #10 capsules. No refills Medical Procedures We conducted a simple (0-2.5) laceration repair procedure on the finger. Applicable diagnosis: OPEN WOUND OF FINGER. The laceration involved the following elements: epidermis. Prepared for the procedure by cleaning with betadine and saline irrigation. Wound was 1 cm. Wound was closed with dermabond. Instructions were provided to the patient as documented elsewhere. Patient tolerated the procedure well. Patient Instructions The laceration on your finger was closed with skin glue. The glue will stay on for approximately 3-5 days and then start to wear off. Apply a bandaid over the wound anytime you are around a dirty environment, avoid excessive water on your hands, and do not apply any ointments or creams to the wound. Clean with soap and leave dry most of the time. Take the antibiotics to avoid an infection. If you have concerns or feel it is infected then return and be seen again, otherwise no follow up is necessary. 16

17 The Bad Note Defaulted findings History and ROS contradictory Shared template Copy and paste Lack of description Over documentation Unable to identify who contributed to the note 17

18 The Good Note Presenting problem clearly stated PFSH appropriate ROS and Exam patient specific Provider thought process obvious Care plan generates appropriate follow-up Note identifies the contributors Non-Patient Specific Information in Documentation - WPS GHA There appears to be a heightened interest among medical providers to include non-patient specific information in medical record documentation. An example is, "if the patient was a smoker, they were advised to stop," or "education was given, if new medications were prescribed." Providers need to be cognizant that the medical record must demonstrate the existence of a relationship between the patient and the provider and that it is difficult and potentially dangerous to design a medical treatment plan in which "one size fits all." Documentation must support that only medically necessary services were actually provided in order for Medicare to consider reimbursement for otherwise covered services. 18

19 Disclaimers Used as Part of Physician's Signature WPS Medicare has recently been informed of a new trend in medical record documentation - that of using some type of disclaimer. Examples include the following: "Due to possible errors in transcription, there may be errors in documentation"; "Due to voice recognition software, sound alike and misspelled words may be contained in the documentation"; and "I am not responsible for errors due to transcription." Providers are responsible for the medical record documentation. Disclaimers such as those above do not remove that responsibility. The provider should verify the information is complete and accurate prior to attaching his/her signature. More Guidance for Provider Signature Requirements can be found on our website. Flexibility Pros and Cons Physician typing Dragon speak Dictation Templates with only check boxes 19

20 Coders as Educators Front line support Linking diagnosis for all services Selecting appropriate service codes Add on codes Modifier usage NCCI and other payer specific edits Rescue and Recovery James M. Taylor, MD, CPC, is medical director of revenue cycle, Kaiser Permanente, Denver 20

21 Educator and Auditor James M. Taylor, MD, CPC, is medical director of revenue cycle, Kaiser Permanente, Denver Some Things Never Change EMR/EHR CMS Rules 21

22 CMS and Payer Guidelines 95 and 97 E/M Documentation Guidelines NCD s and LCD s ABN s Time based billing Special Payer policies Benefits Records legible Track corrections Documentation complete Orders tracking Audit logs 22

23 Validation Password required at save and sign Physician signature Responsibility to show all work entries Authorship vs. countersigning QUESTIONS Embrace technology, never turn down an opportunity to learn, and you will continue to grow. 23

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