SAN DIEGO: AUDIT & MANAGEMENT ADVISORY SERVICES 0919 February 4, 2011 DUNCAN CAMPBELL Chief Operatins Officer UCSD Medical Grup 8201 JOSH LEE, M.D. Directr f Clinical Infrmatin Systems 8490 Subject: Epic Charge Capture Clinic Prcedures AMAS Audit Prject 2011-55 Audit & Management Advisry Services (AMAS) has cmpleted a charge capture review fr utpatient prcedures perfrmed during clinic visits at the request f UCSD Medical Grup management. This reprt summarizes the results f ur review. Backgrund Certain utpatient prcedures including, but nt limited t, bipsies, clpscpies, and Fley Catheter placements may be perfrmed either as a separately scheduled prcedure, r during a clinic visit. In bth cases, charges fr these separately billable prcedures are generated frm the Epic electrnic medical recrd (EMR) system thrugh ne f tw methds: the charge rder methd r charge entry methd. Charge Order Methd The Epic charge rder methd was implemented in the fllwing specialty clinics that went live n the Epic system prir t the implementatin f the physician charge entry prcess. Family and Internal Medicine Wmen Health Services Cardilgy Neurlgy Hematlgy Onclgy The charge rder methd autmatically generates a charge fr separately billable prcedures when a physician/prvider creates an Epic rder fr the prcedure. The general exceptin is that charges fr sme injectins and immunizatins need t be entered separately in the charge capture tab. T cmplete this prcess, the physician/prvider accesses the Epic rder entry tab, and selects the apprpriate rder in the New rder field, inputs the quantity (if applicable), and adds cmments. Prir t accepting the rder, the rder class must be changed frm nrmal t in- UNIVERSITY OF CALIFORNIA - (Letterhead fr Interdepartmental use)
Epic Charge Capture Clinic Prcedures Audit & Management Advisry Services Prject 2011-55 clinic status (if a default has nt been set) t generate a charge. It is imprtant that this step be cmpleted because the rder class nrmal suspends a charge pending additinal actins t be taken, including securing an authrizatin. All in-clinic prcedures that are crrectly rdered will generate a charge when the patient encunter is clsed. All generated charges will be reflected in Epic the fllwing day. Ambulatry Care management recently became aware that the charge rder prcess was nt generating charges fr sme f the prcedures rdered. The Medical Grup has been analyzing charge rder clinic services rendered since September 2009 t identify missing charges. As a result f missing charges, management is cnsidering cnverting all clinics t the charge entry methd described belw. Charge Entry Methd Physicians in the majrity f clinics capture charges fr all services rendered by entering data int the Epic charge entry screen. Fr each patient visit, a level f service (LOS), which equates t an evaluatin and management (E & M) Current Prcedural Terminlgy (CPT) cde, must be selected in the LOS tab. Sme clinics have created Smart-Sets 1 t assist with this prcess. Regardless f the methd used, physicians must select the apprpriate LOS cde based n the services prvided. T generate a charge, the physician must then access a separate charge entry screen and select the service prvided 2. After the required data fields are cmpleted, the physician exits the charge entry screen, and shuld be able t view the charges generated. Charges will be transmitted t the GE Centricity billing system when the encunter is cmpleted and clsed. Cntrls have been established in Epic t prevent an encunter frm being clsed unless all required patient infrmatin has been cmpleted. Hwever, an Epic encunter may be clsed withut capturing all charges. Because the electrnic charge entry methd requires the physician t access tw separate screens t enter charge data int Epic, Ambulatry Care management has expressed cncern that charges fr prcedures perfrmed during a clinic visit might nt be generated due t an versight, r lack f training. As a result, this review was scheduled. Audit Objective, Scpe and Prcedures The bjective f this review was t determine whether physicians were rutinely submitting Epic charges fr all billable prcedures perfrmed during a clinic visit. T achieve ur bjective, we perfrmed the fllwing review prcedures: Interviewed the Ambulatry Care Directr f Access t discuss charge capture cncerns; Cntacted the Medical Grup Business Services (MGBS) Abstracting Manager t attempt t btain list f in-clinic prcedures; 1 A Smart Set is a pre-ppulated rder r dcumentatin that increases the efficiency f the encunter clsure prcess. 2 The menu f services available is custmized by physician specialty. Page 2
Epic Charge Capture Clinic Prcedures Audit & Management Advisry Services Prject 2011-55 Discussed charge capture issues fr the Epic Charge Order prcess with the MGBS Revenue Manager reviewing charges; Discussed the Epic charge capture and rder prcess with an Epic Team prgrammer analyst; Cntacted the Department f Medicine (DOM) Clinical Operatins Directr (COD) t identify Divisins and physicians with a high vlume f in-clinic prcedures; Obtained a data file that included February 2010 surgical pathlgy rders frm Medical Center Clinical Labratry Administratin, and traced a judgmental sample f rders t clinic visits t determine whether charges were captured fr in-clinic prcedures; Obtained an Epic encunters list fr April 2010 fr selected physicians identified by the DOM COD frm Medical Grup Decisin Supprt (MGDS) and traced a judgmental sample f encunters t charges and; Traced sample f Epic encunters t patient accunt charges in GE Centricity. Medical prcedures perfrmed during a clinic visit are nt dcumented in a separate part f the Epic encunter recrd. Therefre, a query f Epic data fields culd nt be perfrmed t identify a sample ppulatin f clinic prcedures t cmpare t charge recrds. Because the bjective f this review was t identify missing charges, test samples were selected using the fllwing tw appraches t identify clinic visits with prcedure(s): Sample Selectin/Review Prcess: Pathlgy Orders Certain in-clinic prcedures result in a tissue specimen analysis that generates a pathlgy reprt. T identify clinic visits that included prcedures, AMAS btained a data file f pathlgy rders fr the mnth f February 2010 frm Medical Center Clinical Labratry Administratin. Orders were then traced t the Epic encunter and dcumentatin fr the encunter was analyzed t determine whether a separately billable prcedure was perfrmed. A judgmental sample f 10 physicians was selected. Three pathlgy rders fr each physician were traced t clinic visits. Fr each visit, AMAS ensured that separately billable prcedures were apprpriately charged thrugh Epic and transmitted t GE Centricity. Sample Selectin/Review Prcess: Department/Physician Selectin Because the DOM has a number f medical specialties, AMAS cntacted the Clinical Operatins Directr t identify divisins/specialties, and physicians that were likely t perfrm prcedures as part f a clinic visit. Based n the input we received, we selected 14 physicians frm Rheumatlgy, Dermatlgy, Orthpaedic Surgery and Bne Marrw Transplant. AMAS btained a list f April 2010 patient encunters frm MGDS fr each physician. A judgmental sample f 5-10 encunters was then selected fr each physician and traced t the Epic encunter recrd t identify whether in-clinic prcedures had been perfrmed. This prcess yielded a ttal f 27 patient visits fr five physicians as described in the table belw: Page 3
Epic Charge Capture Clinic Prcedures Audit & Management Advisry Services Prject 2011-55 Department Number f Physicians in the Test Number f patient visits Sample Rheumatlgy 1 5 Dermatlgy 3 17 Orthpaedic Surgery 1 5 Ttal 5 27 Cnclusins Based n the audit wrk cmpleted, we cncluded that physicians were rutinely submitting Epic charges fr separately billable prcedures perfrmed during a clinic visit. Charges were crrectly submitted fr 55 (96%) f the 57 encunters in the sample. Althugh physicians were crrectly entering charges in Epic, charges fr sme clinic prcedures were nt being released frm Epic t GE Centricity, as a result f a prgramming errr. Observatins and Recmmendatins A. Missing Charges A charge was nt generated fr tw prcedures in the test sample. AMAS review f the 57 sampled patient visits identified tw prcedures perfrmed by tw Wmen s Health physicians that were nt apprpriately billed. These are summarized in the table belw: Patient # (last 4 digits f MRN) Date f Service Prcedure nt billed Estimate f charges nt billed Cause f Errr 2206 2/5/10 Endmetrial bipsy $350 Incrrect rder class selected by physician 9277 2/4/10 Endmetrial bipsy $350 Order was nt placed by physician The Wmen s Health Services clinic utilizes the charge rder methd fr capturing charges. The MGBS Revenue Manager fr Reprductive Medicine advised AMAS that rders were placed fr the services with missing charges, but the crrespnding charges were nt sent frm Epic t GE Centricity. Hwever, a review f the clinic encunter recrds indicated that fr ne visit an rder had nt been placed, and fr the ther visit, the rder was placed incrrectly. Incrrect r missing rders will prevent charges frm being generated in Epic. Peridic charge capture reminder ntices r training updates shuld be cnsidered t help ensure that the charge capture is well understd and becmes a rutine part f the encunter clsure prcess. Management Crrective Actins: 1. MGBS will create charges fr the tw unbilled prcedures identified during this review. Page 4
Epic Charge Capture Clinic Prcedures Audit & Management Advisry Services Prject 2011-55 2. The Epic Team will cntinue t prvide quarterly training updates and/r reminders n Epic charge capture prcesses. B. Epic Charge Order Prcess The Epic Charge Order prcess did nt generate charges fr sme clinic prcedures. During audit fieldwrk, it was nted that charges fr sme clinic prcedures were nt being released frm Epic t GE Centricity in clinics set up t generate charges using the Epic charge rder methd. A Medical Grup Revenue Manager brught this issue t the attentin f the Epic Team in early 2010. Further analysis f the prblem determined that a change in the Epic cnfiguratin implemented in September 2009 prevented charges fr sme prcedures frm being generated and interfaced t GE Centricity. Fr the perid f September 2009 thrugh June 2010, Medical Grup management identified missing charges fr apprximately 1,300 prcedures. The missing charges were subsequently prcessed and billed. Hwever, the Epic prgramming errr has nt been reslved. In additin, charges generated by the effected clinics have nt been reviewed fr apprpriate crrectins frm July 1, 2010 thrugh the present. Management Crrective Actin: The Epic Team has taken steps t remediate the charge rder prgramming errr that prevents charges frm passing t GE Centricity. AMAS appreciated the assistance prvided during the review. Because we were able t reach agreement regarding crrective actins t be taken in respnse t the audit recmmendatins, a frmal respnse t the reprt is nt requested. The findings included in this reprt will be added t ur fllw-up system. While management crrective actins have been included in the audit reprt, we may determine that additinal audit prcedures t validate the actins agreed t r implemented are warranted. We will cntact yu t schedule a review f the crrective actins, and will advise yu when the findings are clsed. UC plicy requires that all draft audit reprts, bth printed (cpied n tan paper fr ease f identificatin) and electrnic, be destryed after the final reprt is issued. Because draft reprts can cntain sensitive infrmatin, please either return these dcuments t AMAS persnnel r destry them. Page 5
Epic Charge Capture Clinic Prcedures Audit & Management Advisry Services Prject 2011-55 If yu have any questins regarding this reprt, please cntact me at (858) 534-3617, r by email at shburke@ucsd.edu. Stephanie Burke Assistant Vice Chancellr Audit & Management Advisry Services cc: D. Brenner L. Friedman T. Gaines G. Matthews T. McAfee T. Perez C. Saenz S. Vacca Page 6