5 Most Common Documentation Mistakes And What to Do About Them Kathy Mills Chang, MCS-P, CCPC KMC University Why Is Documentation So Important? Ensures quality patient care Meets licensure requirements to protect the public Guards against malpractice action Secures appropriate reimbursement Because if it wasn t written down, it didn t happen! Under the Magnifying Glass Know your Audience Another health care provider Your board A malpractice attorney Third party payer's medical necessity auditor (855) 832-6562 1
Good Documentation Tells a Story 5 Most Common Errors Signatures and Identification of the Doctor and Patient Not Clear No rationale for diagnostics or tests ordered Lack of all required elements of a treatment plan Daily Assessment consisting only of diagnosis Performing and billing for full spine adjustments, without proper documentation of medical necessity Why Authenticate? Signature and Patient Name Issues To verify provider who treated Prove services were provided Indicate and verify who provided them Validates the entry and legally binds the physician for the included info Can we Identify Provider? Review Signature Requirements Familiarize providers and office staff with signature requirements to ensure more complete compliance with signature authentication policies (855) 832-6562 2
How do we authenticate signatures? Signature Log Update Signature Log Every year have each provider sign again, even if it hasn t been a year since the last signature Add new providers to the log as they join the group Replace previous logs with most recent signatures, however save old copies Make sure every log has a start and end date How it all comes together... Create Signature Log Update Signatures Review Signature Requirements Sign and Check Patient Identifiers Patient name must appear on every item or piece of paper Electronic name is ok Front and back both Especially important when sending records Patient number can identify as well (855) 832-6562 3
Tell Us What You re Thinking Provide Appropriate Rationale Why are the tests being ordered? Why did you decide to do what you did? What s between your ears must appear in the documentation X-rays, labs, other diagnostic tests, referrals, and DME Your Medical Records Must Tell the Story Rationale for Films MD Rationale for CT Scan Possible X-Ray Rationale (855) 832-6562 4
Offer a Complete and Compliant Treatment Plan Your treatment plan is your pre-determined plan of action. It will take into consideration the tissue specific issues defined in your patient work-up and diagnosis Soft-tissue diagnosis and soft-tissue targeted treatment Treatment Plan Meet the Requirements Frequency and duration Treatment goals for each region/treatment to include long term goal An evaluation of treatment effectiveness measurement Date of the plan Frequency and Duration Indicate initial part of the treatment It s ok to have an end game projection Don t be so specific that you appear canned or boxed into a plan Each section should end with an evaluation (855) 832-6562 5
Treatment Goals Treatment goals need to be functionally based. What functions are we restoring with our treatment plan? How will we measure that corrective change? What goals are outlined for each type of treatment? Evaluate the Effectiveness Measurably! OATS make it easy Pain is difficult to track and measure Use an accepted measure that you can document simply Improvement in function = success!! Make it Shine! Home care recommendations Prognostic factors Inclusion of all possible treatment and DME options What if you treat today? Win with a Robust Daily Assessment (855) 832-6562 6
Medicare Documentation Guidelines Initial Visit History Description of Present Illness Physical Exam Diagnosis Treatment Plan Date of initial treatment Subsequent Visits History Review of chief complaint Physical Exam Document daily treatment Progress related to treatment goals/plan Subsequent Visits Documentation Requirements History: (29% Documentation Error Rate) Review of Chief Complaint Location of Symptoms Changes since last visit Subjective (P) Quality of Symptoms System review if relevant Intensity of Symptoms Physical exam: (43% Documentation Error Rate) Exam of area of spine involved in diagnosis Objective (A, R, T) Assessment of change in patient condition since last visit (PE, OA, ADL, QVAS) (Same, Better, Worse) Assessment Evaluation of treatment effectiveness (Same, Better, Worse, How and Why) Daily Treatment Documentation : (15% Documentation Error Rate) Plan Best Practices for Defining your Doctor s Assessment Remember it is all about Function, Function, FUNCTION Identify HOW the patient has improved Identify WHY they need continued care That is Medical Necessity by definition! (855) 832-6562 7
Does This Truly Outline Assessment? Tale of Two Styles What I Hope to See (855) 832-6562 8
Document, Code, and Bill Properly as a Full Spine Adjuster Are You an Outlier? Statistics tell us that the improper coding of fullspine treatment can cause you to appear to be an outlier You therefore can be subject to more scrutiny, red flags, and even an audit Error Rate Information Insufficient documentation is a known issue in the chiropractic profession Failure to provide any documentation to auditors represents nearly 50% of the poor scores So? I m a Full Spine Adjuster! Medical necessity definition dictates that you must prioritize each area of complaint Every visit: S + O (P + ART) for every region treated 2 DX codes for each region Treatment plan for each/short and long term goals 98942 Issues (855) 832-6562 9
98942-Appearance of Evil Why It LOOKS Fishy And Recently Set Up to Fail? In the world of compliance, DCs who routinely adjust the full spine are challenged Because documentation and coding must match exactly Coding 98942, because all five regions have been adjusted, may be asking for trouble Philosophically Driven Whether you are subluxation-based chiropractor or simply believe that every patient requires a full-spine adjustment, you need clarity Proper coding and case management for these technique-specific and philosophically driven coding conundrums need to be defined by you for your office You Define Your Intentions Clarify your motivations so you can describe your situation and your intentions Create and implement a policy in order to describe why it could appear that your documentation doesn t match your coding Outline in writing in advance of any requests for records to help to keep you and your practice safe (855) 832-6562 10
SOP - Example Policy Code for Subluxations Only How This Looks on Paper Code This as 98940 Code This as 98941 Code This as 98942 (855) 832-6562 11
Billing Should Be 98940 Put on Your Auditor Hat What is expected/typical 98940: 40-60% 98941: 40-60% 98942: 1-10% How would your office look? Run Your Ratios! Take Action Coding and Documentation Must Match Look at your CMT coding ratios to evaluate code usage Spot check documentation for 98942 codes billed to find out if the documentation meets requirements Determine how you can improve coding/documentation as a full spine adjuster Determine ONE thing you can do by year end What can you change in Q1 2016? How can you delegate to take small, manageable steps? Work on one project at a time to manage time and expectations Take Action Now (855) 832-6562 12
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