Responsibility and Liability of Compliance Officer

Transcription

1 Responsibility and Liability of Compliance Officer Cheryl Forino Wahl, VP, Chief Compliance Officer, University Hospitals Lori Oberholzer, JD, MS, RT(R), Director, Compliance and Risk Management, OSUPhysicians Jennifer Kelley, RN, Manager, Compliance and Risk Management, OSUPhysicians Areas of Focus Electronic Medical Records Billing and Coding Issues ICD-10 Meaningful Use 1

2 Templates Cloning Electronic Medical Records Cutting and pasting Self-populating fields and templates Exploding documentation Signature issues Make Me the Author Scribes Templates, Cloning, Copying & Pasting Self-populated field result in inaccurate notes Cloned notes are ignored Adverse effect on patient care Medical necessity questioned Canned notes rejected by payor Provide guidance for proper usage of copy tools 2

3 Self-Populating Fields & Exploding Documentation Self populating fields save time Mostly used in review of systems & exam HPI or plan of care conflict with review of systems or exam Note should accurately represent with work performed and by whom. Signature Issues, Make Me the Author & Scribes Challenge to identify the author Authorship must be clear in print and online version Patient safety risk if author/role not known Potential billing issues Educate providers about the importance of signing the note 3

4 Billing and Coding Issues Areas of Concern Electronic Medical Records (EMR) Copying Records for Payers and Outside Entities Medical Necessity Increased Documentation Notes are too long with irrelevant information Students and Residents Documentation Original Date of Note Incident to Shared Visits Problem Lists/Diagnosis [Need to understand/distinguish between physician and hospital coding] EMR and Sending Records to Payers Practical Issues COs must understand the EMR tools How notes are created Shadow physicians in a clinic and inpatient unit Decide whether to print paper copy send CD Restrict who can copy, by clinical role (medical students more limited ability to copy than attendings) Limit what may be copied by user role and/or the information being copied 4

5 Medical Necessity, Increased Documentation & Excess Notes Long and cluttered notes are risky Pertinent, new and critical information may be overlooked ignored Leads to poor communication, duplication of services or delay in patient receiving appropriate care Remind physicians about upcoding and documentation supporting the medical necessity of the visit Educate providers regarding quality documentation in an EMR and the use of tools that can support it Student and Resident Notes Have workflows geared for academic medical centers Decide whether or not to allow or block portions of medical student documentation Ensure notes authored by medical students clearly identified Link the teaching physician s attestation note with the appropriate resident s note Prohibit copying of medical students notes (other than ROS and past medical, family and social history) 5

6 Original Date of Notes Ensure the accuracy of dated notes Risk to patient safety (possible confusion as to patient status) Difficulty in retrieving note for payment purposes to determine medical necessity Physicians may need to indicate within their progress note the date of service that s/he saw the patient If the progress note is created or signed after the date of service, the date the patient is seen is not accurately reflected in the note Incident To & Shared/Split Visits Create workflows for combining notes of mid-level providers (NPs and PAs) with physicians Allows for easy identification of a service that meets incident to billing criteria Create a workflow created for split/shared visits between a physician and an NP/PA 6

7 Problem Lists and Diagnosis Many times problems lists and diagnosis are shared within the medical record During a patient visit a physician may choose to select a specific diagnosis from the patient list or he/she may choose to associate all diagnoses from the patient list If a physician selects all diagnoses from the patient list, the physician must address each diagnosis on that day of the encounter ICD-10 Delay Training HIPAA 5010 Operational, Finance and Technology Assessments Areas Affected IT Issues Productivity Cost 7

8 Meaningful Use Meaningful Use Enrollment and Attestation Process Ensuring that EMRs are set up meaningful use objectives are met 8