Objectives Addressing Documentation Insufficiencies ICAHN June 9,2015 Glenn Krauss, BBA, RHIA, CCS, FCS, PCS,CCS-P, CPUR, C-CDI, CCDS, C- DAM Understand and appreciate physician frustrations with the EHR structure and format of documentation Learn how to identify documentation insufficiencies and how to address them Promote the notion of physician patient advocate Appreciate and understand the Medicare Billing Revocation rules Clinical Documentation Clinical documentation was developed to track a patient's condition and communicate the author's actions and thoughts to other members of the care team. Over time, other stakeholders have placed additional requirements on the clinical documentation process for purposes other than direct care of the patient. Data registries Core Measure Process measurements Outcome studies PQRS measures Patient engagement Clinical Documentation Observe, record, tabulate, communicate. Sir William Osler (1849 1919) The medical record was first used by physicians to record their findings and actions and as a vehicle to communicate with other physicians who might care for the patient in the future Medical Record Documentation The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication. The clinical record should include the patient's story in as much detail as is required to retell the story As value-based care and accountable care models grow, the primary purpose of the EHR should remain the facilitation of seamless patient care to improve outcomes while contributing to data collection that supports necessary analyses EHR Today Over-structuring the clinical record and overloading it with extraneous data Electronic health records should be leveraged for what they can do to improve care and documentation, including effectively displaying prior information that shows historical information in rich context; supporting critical thinking; enabling efficient and effective documentation; and supporting appropriate and secure sharing of useful and usable information with others, including patients, families, and caregivers. Limitations: Format and content of clinical documentation are primarily based on coding and other regulatory requirements 1
Cut and Paste The word 'cloning' refers to documentation that is worded exactly like previous entries. This may also be referred to as 'cut and paste' or 'carried forward. Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter. Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made. (Palmetto GBA-Medical Record Cloning) Misrepresentation "Cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient, (NGS Medicare, September 2012) Question: What is Cahaba GBA s stance on cloning of medical documentation and what constitutes appropriate editing of a note that has been copied pasted into a medical record? Answer: The medical necessity of services preformed must be documented in the medical record and Cahaba GBA would expect to see documentation that supports reasonable and medically necessary services and any changes and or differences in the documentation of the History of Present Illness, Review of System and Physical Examination. The medical record must be authenticated by the provider of services. CMS acceptable signature methods are hand written and electronic signatures. Stamp signatures are not acceptable Current State of Affairs Coding Perspective Difficulty assigning principal and secondary diagnosis Difficulty determining if secondary conditions meet the UHDDS guidelines for coding Inability to determine whether diagnoses have been ruled out or ruled in. Cut and paste and carry forwards Physician Record Keeping When submitting medical records to the CERT contractor, be sure the medical record submitted is complete and legible. Documentation must support the level of care and treatment and must be reasonable and necessary. Codes documented on the claim must be reflected in the medical record. Coders should ensure they use the correct code when coding services on the claim. Palmetto GBA-Jurisdiction 11 Part B-Submitting Complete and Legible Medical Records is Key; June 4, 2015 Important Message From Medicare LACK OF DOCUMENTATION AFFECTS PROVIDER REIMBURSEMENT Remember the Golden Rule: If it isn t documented, then it wasn t performed. Reviewers do not know the services provided if there is no documentation. You are paid for what you document, not what you did Document, Document, Document Effective is always better when it comes to documentation Palmetto GBA-Jurisdiction 11, Part B- 3/13/2015 Documentation Points for Accurate Medical Records The record must support reasonable and medically necessary services and provide an accurate account of all patient care services provided by healthcare professionals. To ensure CMS compliance and assist in lowering claim payment errors, medical professionals are expected to accurately document in the medical record and include an authenticated identifier. 2
All records must document the following, as appropriate: Evidence of; (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. (ii) Admitting diagnosis. (iii) Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. (iv) Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia. (v) Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. (vi) All practitioners orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient s condition. (vii) Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care. (viii) Final diagnosis with completion of medical records within 30 days following discharge. Documentation Points.. The record must support reasonable and medically necessary services and provide an accurate account of all patient care services provided by healthcare professionals. To ensure CMS compliance and assist in lowering claim payment errors, medical professionals are expected to accurately document in the medical record and include an authenticated identifier. Palmetto GBA-Documentation Points for Accurate Medical Records; Cahaba GBA, Part A, 02/18/2015 Provider Responsibility According to the Medicare Claims Processing Manual, Chapter 30, Section 40.1, providers and suppliers are responsible for knowing the rules and regulations that apply to all services billed by the provider to the Medicare program. Provider Responsibility In accordance with regulations at 42 CFR 411.406, evidence that the provider, practitioner, or other supplier did, in fact, know or should have known that Medicare would not pay for a service or item includes: A Medicare contractor's prior written notice to the provider, practitioner, or other supplier of Medicare denial of payment for similar or reasonably comparable services or items; Medicare's general notices to the medical community of Medicare payment denial of services and items under all or certain circumstances (such notices include, but are not limited to, manual instructions, bulletins, carriers' written guides, and directives); and Provision of the services and items was inconsistent with acceptable standards of practice in the local medical community (refer to 40.1.3 and 40.1.4) 3
Provider Responsibility The provider is responsible to know the rules and regulations that are made available through publications from the Medicare carriers and fiscal intermediaries, which include, but are not limited to, the Medicare publications, articles and email updated published on the CMS Medicare Administrative Contractor websites. Palmetto GBA, Provider Responsibility, Jurisdiction 11, Part B, 03/09/2015 Tips for Documenting Medical Records Documentation helps to answer these questions: Who?- Who is performing the services? What?- What type of services are performed? How many?- What are the quantities of services performed? Where?- What is the place of service? When?- When is the date of service? Why?- Establish medical necessity and diagnosis Quality Documentation Compliance Quality Documentation Quality Outcomes CMS Contractors Verify Compliance CMS employs several review contractors to measure, prevent and identify improper payments. These review contractors manually review claims against the submitted medical documentation to verify the providers compliance with Medicare rules and regulations. These review contractors include: Medicare Administrative Contractors, Comprehensive Error Rate Testing Contractors (CERT), Recovery Auditor Contractor (RA) and Zone Program Integrity Contractors (ZPIC). With so many 'eyes' watching, ensure documentation is complete prior to submitting. Palmetto GBA, CMS Contractors Verify Compliance (2/27/2015) http://www.palmettogba.com/palmetto/providers.nsf/docscat/prov iders~jurisdiction%2011%20part%20b~cert~cert%20tips~9u5h9j0 678?open&navmenu=CERT Purpose of CERT Contractor KNOW THE PURPOSE OF THE CERT CONTRACTOR The CERT contractor checks to see that providers are billing correctly and contractors are paying correctly. They select and review claims, assign improper payment categories, calculate improper payment rates and provide education to change behaviors. CERT Error Categories No documentation errors These errors result when the provider fails to respond to the request for medical records, or responds to the request untimely Insufficient documentation errors The majority of errors are due to insufficient documentation, such as missing lab results, radiology reports, therapy minutes, or hospice election statements Claims are placed into this category when the medical documentation submitted is inconclusive to support the rendered service (medical reviewers could not conclude that some of the allowed services were actually provided, provided at the level billed, and/or medically necessary). 4
CERT Error Categories Medically Unnecessary Services Claims are placed into this category when claim review staff receive enough documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based on Medicare coverage policies. Incorrect Coding Claims are placed into this category when providers submit medical documentation that supports a different code than the code /billed, the service was done by someone other than the billing provider, the billed service was unbundled, or a beneficiary was discharged to a site other than the one coded on a claim) Other This category includes claims that do not fit into any of the other categories (e.g., duplicate payment error, non covered or unallowable service). Insufficient Documentation Examples Incomplete progress notes (for example, unsigned, undated, insufficient detail); Unauthenticated medical records (for example, no provider signature, no supervising signature, illegible signatures without a signature log or attestation to identify the signer, an electronic signature without the electronic record protocol or policy that documents the process for electronic signatures); and Insufficient Documentation Rabbit Out of a Hat No documentation of intent to order services and procedures (for example, incomplete or missing signed order or progress note describing intent for services to be provided). Physician hospital encounter without evidence physician actually saw the patient Physician assessment incongruent with the physical exam and/or History of Present Illness Physical exam incongruent with HPI Putting it in Proper Perspective Medicare has identified E & M codes as consistently problematic Initial hospital care: 99221-99223 Subsequent hospital care: 99231-99233 Emergency Room care: 99281-99285 Critical care: 99291-99292 The Specifics Common errors associated with these codes are as follows. Documentation is incomplete/insufficient: Documentation does not support the level of service billed (i.e., upcoding or downcoding of services). Required components (as required by the CPT book) are not documented in the medical record. The history component is incomplete or absent. The medical decision-making documented is inappropriate or incomplete. Services were rendered by one physician and billed by another. 5
The Specifics Documentation does not support a face-to-face encounter between physician and patient. The medical record contains conflicting information (e.g., the diagnosis on the claim is inconsistent with the diagnosis in the medical record; documentation in the patient's history conflicts with the examination; the date of service in the documentation is different from the date of service billed). The service is not performed on the date of service billed, not dictated on the date of assessment, or not documented on the date of the visit. Medical documentation does not support medical necessity for the frequency of the visit. The Big Deal Documentation Relevance Clinical Documentation Communication of patient care Transition from Fee-for-Service to Value, Cost and Performance Based healthcare delivery model Measures of efficiency Providing and ordering a level of service that is sufficient to meet a patient s healthcare needs but not excessive, given the patient s health status Merit Based Incentive Payment System Accountable Care Organizations Shared Savings and Gain Sharing Bundled Payment for Care Improvement Initiative Clinical Context Solutions Identifying clinical documentation insufficiencies Categorizing insufficiencies Forming a coalition of stakeholders Involve Medical leadership Develop an action plan Define effective, sufficient documentation Provide education, training and feedback Monitor and continually educate Get started Thanks for attending Glenn Krauss@earthlink.net (603) 303-3337 Questions 6