Jill M. Young, CPC, CEDC, CIMC Young Medical Consulting, LLC East Lansing, MI 4883 This material is designed to offer basic information for coding and billing. The information presented here is based on the experience, training, and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This handout is intended as an educational a guide and should not be considered a legal/consulting opinion 2 1
The Social Security Act, Section 1862 (a)(1)(a) states: "No payment will be made... for items or services...not reasonable and necessary for the diagnosis or treatment of an injury or illness or to improve the functioning of a malformed body member. Overarching criterion for the payment for all services billed to Medicare Medical reasonableness and necessity 3 Even if a "complete" note is generated, only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter as documented can be considered when selecting the appropriate level of an E/M service. Information that has no pertinent to the patient's situation at that specific time cannot be counted. Priority Health 4 2
Cut & Paste Macros/ Cloned EHR Compliance Pre- Populated Template Carry Forward 5 CMS does not prohibit the use of templates to facilitate recordkeeping. CMS also does not endorse or approve any particular templates. A physician/lcmp may choose any template to assist in documenting medical information. Some templates provide limited options and/or space for the collection of information such as by using check boxes, predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met. Medicare Program Integrity Manual Chapter 3 Transmittals for Chapter 3 3.3.2.1.1 3
Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met. If a physician/lcmp chooses to use a template during the patient visit, CMS encourages them to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria are met. Medicare Program Integrity Manual Chapter 3 Transmittals for Chapter 3 3.3.2.1.1 Structured templates have the potential for charting by exception Findings are prerecorded/pre-populated as negative Clinician documenting the record must specifically change a data set to record a positive finding If EMR automatically fills in documentation May lead to "over-document Leads to selecting and billing a higher E/M code than medically reasonable and necessary. 8 4
45 out of 100 claims analyzed were paid in error Also noted that patterns of over coding services were found with template-generated records. Trailblazers 9 Providers may use templates, checklists, and/or electronic medical records to assist in documenting services and saving time. Medicare considers these as acceptable documentation. However, the documentation submitted must be specific to the patient and the service in question. 10 5
CMS condemns it. Payers won t reimburse for it. Auditors will take you to task for it but vendors flaunt it and physicians embrace it unreservedly. What s wrong with using an EHR to automatically copy information from one patient note to the next? The time-saving practice known as cloning is one of the things that makes EHRs so popular, and yet the government sees it as a breeding ground for fraud and abuse. EHR Intelligence January 2013 11 '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. Palmetto Medicare Noridian Medicare 6
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. CGS Medicare Palmetto Medicare Noridian Medicare 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. Identification of this type of documentation will lead to denial of services. They warned doctors that it would refuse to pay them if they submitted cloned documentation. NGS 14 7
Definition When each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. When medical documentation is exactly the same from beneficiary to beneficiary Cutting-and-pasting the information entered in the Electronic Medical Record (EMR) from one date of service to another Cloned documentation does not meet medical necessity requirements for coverage of services Lack of specific, individual information Documentation must be specific to the patient and her/his situation at the time of the encounter Priority Health 15 Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Falsification of medical record Do not pertain to specific visit to which they are added Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made. Failure to provide appropriate documentation to support a billed service Priority Health 16 8
Study by the Society of Critical Care Medicine 82% of medical residents and 74% of attendings copy and paste more than 20% of their EHR patient progress notes from one session to the next. The authors found that after a vacation day, 94% of attendings copied information from their own notes, with cloned information making up an average of 61% of the new progress note. 17 HHS Only 24% of hospitals have any policy regarding cut and paste 61% of the policies shift the responsibility to the user to verify data is correct 44% hospitals audit log systems could record whether cut and past was used to enter data 44% hospitals can delete contents of internal audit logs anytime 18 9
unique information should be entered into EHRs for every yp patient, but notes that EHR vendors should not necessarily be blamed if physicians over-rely on default features. Instead, EHR users should keep communications with vendors open in order to customize their EHR software. Jeremy Duca NGC warns against cloned notes 19 Computers do not have logic Computers do not have common sense Document what was done E&M codes must be based on medical necessity 20 10
Alphabetizing diagnoses Counseling & Coordinating care Although total time and counseling time were entered, final printout only shows greater than 50% What does final report actually look like How does normal translate for ROS or Exam ROS negative except for HPI 21 Physicians selecting diagnosis code numbers Training Specificity Coding guidelines 22 11
Defined as Examination of the entire colon From the rectum to the cecum May include examination of the terminal ileum or small intestine proximal to an anastomosis. Additional comments in section Use of modifier 52 & 53 CMS has defined four new HCPCS modifiers to selectively identify subsets of Distinct Procedural Services (-59 modifier) as follows: XE - Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter XS - Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure XP - Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner XU - Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service 12
These modifiers, collectively referred to as - X{EPSU} modifiers, define specific subsets of the -59 modifier. CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. The -X{EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line. Old with or without New including when performed Old bowel New intestine 13
Under the new process, payment changes will go through notice and comment rulemaking before being adopted beginning for 2016. We are also proposing to define screening colonoscopy to include anesthesia so that beneficiaries do not have to pay coinsurance on the anesthesia portion of a screening colonoscopy when furnished by an anesthesiologist. jill@youngmedconsult.com 28 14
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