9/17/2018. Critical to Practices

Transcription

1 Critical to Practices Provides: Reviewing quality of care provided to patients. Education to providers on documentation guidelines. Ensuring all services are supported, and revenue captured. Defending against external audits, malpractice litigation, and health plan requests and denials. Protection Up-coded Down-coded Chief complaint documented Assessment clearly documented Signature, correct tie language Diagnosis(es) Medical Necessity Fraud Abuse 1

2 Internal Auditor Costly for the solo or small group Finding an auditor with the level of training and expertise Can be conducted periodically by the coding staff or a practitioner trained in audit and compliance At a minimum it should be conducted quarterly External Auditor Provides an objective approach Costly but for a short period of time Typically conducts a baseline audit, sampling various levels Can be done quarterly, biannually, or annually depending on strengths and weakness in coding and compliance Auditing Examining the medical record Verifying information Gathering information to identify risks Monitoring Review auditing problems Review utilization patterns Review computerized reports Review reimbursements Facilitate maintenance Completeness of the medical record Documentation in medical records supports the code(s) Reimbursement practices Ensure compliance External regulations Internal policies for reporting to insurance carriers Areas needing improvements Education provided 2

3 Start out by determining the type of audit Prospective Retrospective Focused Review Random Determine the date range Determine the code range(s) Specific providers/ specialties Determine the insurance coverage Audit charts Per physician, provider Pick documentation over several weeks Pick different types of services Outpatient, Inpatient, Critical care, Observation, Prolonged visits, Surgeries, Procedures, New patient Established patient Medical record or Electronic record 1995 CMS Documentation Guidelines 1997 CMS Documentation Guidelines Audit tool/form Remittance advice (Retrospective) For Non-Medicare payers, policies regarding E/M services Final audit report Corrective action plan 3

4 1. Reason the patient presented. 2. Complete details provided by patient, family members, or other caregivers. 3. Complete details of the evaluation. 4. Results of diagnostic, consultative, and/or therapeutic services. 5. Assessment of the patient s condition. 6. Plan of care, including advice from other specialists. 1. Other services, procedures, and supplies provided. 2. Time spent counseling or coordinating care. 3. Abbreviations or shorthand should be listed on an identification key accessible to all who read the documentation. 4. Acronyms are acceptable as long as they are commonly recognized. 11. It is important that any reader of the medical record be able to understand, from the documentation, the service rendered and the medical necessity. General History Exam Medical Decision-Making Time/Counseling SOAP Subjective Objective Assessment Plan 4

5 TEMPLATES Physician fill in spaces for chief complaint, history, exam and medical decision making. Needs to be patient specific and date of service specific. ROS all others negative is allowed, if there is other documentation that others were reviewed. Seeing the same auto-populated paragraphs in the HPIs of different patients. 5

6 CMS is looking for an evaluation of each diagnosis on the note, not just the listing of chronic conditions, i.e., DM w/neuropathy-meds adjusted, CHF-compensated, COPD-test ordered, and HTN-uncontrolled. CMS considers diagnoses listed on the note without an elaboration as a problem list, which is unacceptable. Each note must be able to stand alone. Do not refer to diagnoses from a prior note without commenting. Diagnosis(es) can also include chronic diagnosis that will effect managing of other diagnosis(es). Ex: cerebral palsy. Must be documented by physician or other healthcare. To support medical necessity, the assessment and plan must define clearly the following: All diagnoses the provider is managing; For an established visit; whether the patient s condition is stable, improved, worsening, etc.; Diagnostic tests are ordered, the rationale for ordering the tests are either documented or easily inferred; Management of the patient is documented clearly (surgery, prescriptions, over the counter medication, etc.) Statement like feels well and no complaints do not establish medical necessity Some carriers will deny a claim with no chief complaint, so check with your carriers. 6

7 When Counseling and Coordination of care dominates greater that 50% of the visit Time becomes the key or controlling factor. Physicians should document the total time of visit and the amount of time counseling and subject of counseling. Example: Total time of 45/25 minutes counseling on diabetic meds Part of the E/M codes when <50% of the time is counseling and/or coordination of care Critical Care ( ) Prolonged Time ( ) Medicare Care Conference ( ) Care Plan Oversight ( ) Neonatal Critical Care ( , ) Complex Chronic Care ( ) Medicare & As of 1/1/2010 no more consultation codes Outpatient Use - Office visit codes Inpatient use - Initial Hospital Care codes and for Subsequent Hospital Care use If the physician does not do a detailed history or exam for then you will need to drop to subsequent codes. 7

8 Violation of official coding guidelines Documentation inadequate to support level of service Noncompliance with third-party payers Service billed to the wrong provider Incident-to Shared/Split Teaching Physicians Scribes Incorrect date of service Incorrect place of service Cloning Incorrect category of service (hospital, office, consult, etc.) Signature requirements Incorrect modifier usage Medicare Part B covers services rendered by physicians or auxiliary personnel under the physician s direct supervision. These services and supplies are commonly furnished in an office setting or clinic. The service are furnished as an integral, although incidental, part of the physician s professional services in the course of the diagnosis or treatment and require personal physician supervision. Physicians personally treat on initial visit and establish the treatment plan and diagnosis. Services must be within the NPP s scope of practice and in accordance with the state s law. Physician needs to be in the suite when service is rendered and then reimbursement is 100% using the provider number who provides direct supervision of the service. NPP can see new patients but only reimbursed at 85% if licensed and billed under their name (not as incident-to). CA Law requirement VS your state No Hospital 8

9 Documentation should include: Who performed and recorded the service Scribe s documentation should include: Name, title and signature of the scribe Must log on to EMR under their own login number Name of the practitioner providing the service Practitioner s documentation should include: Affirmation the practitioner personally performed the services documented Confirmation he/she reviewed and confirmed the accuracy of the information in the medical record Acceptable practitioner signature Cloning is referred to as cut and paste or carried forward Every patient tends to look the same Every visit has the same HPI (especially inpatient documentation) Every ROS tends to read the same. All negative except for system related to HPI Documents the same ROS on each patient and then under that it states all others negative for new or established patients Every exam tends to read the same Every visit code level tends to be the same When Assessment/Plan is copied then where is medical necessity Documentation does not correlate to the chief complaint Time statements is the same on all visits Female Patient Abdomen: soft, non-distended, non-tender, no hepatosplenomegaly Genital: prostate is non-tender, no masses, negative enlargement Male Patient Female genital exam reveals-non-tender, no bulging, dimpling or lumps, normal nipples Pap done by GYN 9

10 Total number of charts audited Service date range Total that support: The level of service Higher level of service Lower level of service No level of service Documentation on coding issues Observations documenting specific findings Recommendations to correct the problem(s) Identify any under- or overutilization patterns Good policy is to consult legal counsel before corrective action and repayment Take action based on findings Meeting with physician(s), group Education and training Set time limits Re-audit Signature(s) Stay aware of changes and pass the information on to other staff members Conduct internal or external audits on an annual basis Review Results Physicians that are non-complaint, train and do extra audit Inform provider that a false claim to Medicare may be a crime punishable under both civil and criminal False Claims Act statutes Consider reviewing and showing OIG YouTube videos to staff members Importance of Documentation Federal Anti-Kickback Statute Physician Self-Referral Law 10