C FMG MA 2016 C MS FO C US & 2017 IC D- 10 UPDAT ES PRE SE - PowerPoint PPT Presentation

C FMG MA 2016 C MS FO C US & 2017 IC D- 10 UPDAT ES PRE SE NT E D BY: T RI SH ST ONE , RHI A, CPMA, CHSP, CPC, AHI MA APPROVE D I CD-10-CM/ PCS T RAI NE R

AGENDA Compliance 1. Security Risk Analysis: A Foundation for HIPAA Compliance 2. Billing Audits: Showing your Intent 3. Effective Documentation: E/M Coding ICD ‐ 10 Updates 2017 2

COMPL IANCE PR OGR AM Can yo u affo rd to lo se Me dic are and Me dic aid inc o me ? Sinc e 2010, a c o mplia nc e pro g ra m ha s b e e n e d fo r Me dic a re a nd Me dic a id pro vide rs. r e quir 8/ 23/ 2016 3

WHAT IS A COMPL IANCE PR OGR AM? • Ope ra tio n Ma nua l • HI PAA po lic e s a nd pro c e dure s Ma nua l • Co ding c o mplia nc e pla n T he de ta ile d po lic ie s a nd pro c e dure s tha t • insure the c o ding a nd b illing pro c e sse s c o mply with a ll rule s a nd g uide line s. 8/ 23/ 2016 4

COMPL I ANCE : # 1 Se c ur ity R isk Analysis: A F o unda tio n fo r HI PAA Co mplia nc e 8/ 23/ 2016 5

HIPAA  Se ts rule s fo r pro te c tio n o f e PHI  HI PAA a pplie s to a b e wilde ring va rie ty o f o rg a niza tio ns, fro m o ne - do c to r pra c tic e s to va st me dic a l syste ms, to e ve ry kind o f spe c ia lty, a nd to Busine ss Asso c ia te s 9/ 17/ 2015 6

A F OUNDAT ION F OR COMPL IANCE E ve r y or ganization should c omple te thr e e pr oc e sse s to lay a foundation for HIPAA c omplianc e : 1. Co nduc t a Se c urity Risk Ana lysis 2. I mple me nt upda te d HI PAA do c ume nta tio n, inc luding po lic e s a nd pro c e dure s, BA Ag re e me nts, a nd the No tic e o f Priva c y Pra c tic e s 3. Co mple te a nd Do c ume nt HI PAA Co mplia nc e T ra ining 9/ 17/ 2015 7

T HE PR IVACY R UL E 1. Pro te c ts e ve ry fo rm o f PHI , whe the r e le c tro nic , writte n, ve rb a l, o r o the rwise 2. Go ve rns use a nd disc lo sure o f PHI 3. Gua ra nte e s pa tie nts the rig ht to a c c e ss the ir o wn PHI 4. Pa tie nts ha ve the rig ht to ma na g e the disc lo sure o f the ir PHI 8

T HE PR IVACY R UL E – COR E PR INCIPL E Minimum Ne c e ssa ry 1. Busine ss Asso c ia te s c a n a c c e ss PHI o nly if it is ne c e ssa ry to the ir se rvic e s 2. Only the minimum ne c e ssa ry info rma tio n fo r a le g itima te purpo se sho uld b e sha re d 9

T HE SE CUR IT Y R ISK ANAL YSIS  T he Se c urity Risk Ana lysis is the first a nd mo st impo rta nt re q uire me nt o f the Se c urity Rule  Co nsists o f thre e pa rts  Risk Asse ssme nt, a de ta ile d list o f a sse ssme nt q ue stio ns b a se d o n ONC/ OCR/ NI ST g uide line s  I T I nfra struc ture Asse ssme nt  Pro duc e s de ta ile d re me dia tio n re po rt to c lo se c o mplia nc e g a ps 9/ 17/ 2015 10

WE L COME T O T HE CIA  T he Se c urity Rule c o nc e rns the Co nfide ntia lity, I nte g rity, a nd Ava ila b ility (CI A) o f e PHI  T he Se c urity Rule re q uire s te c hno lo g y me a sure s suc h a s fire wa lls, b ut the prima ry g o a l is to c re a te a “c ulture o f c o mplia nc e ”  A c ulture o f c o mplia nc e is re a lize d thro ug h pro pe r po lic ie s a nd pro c e dure s, tra ining o n tho se po lic ie s a nd pro c e dure s, a nd sa nc tio ns fo r fa iling to fo llo w the rule s 9/ 17/ 2015 11

R E QUIR E D OR ADDR E SSABL E ?  Spe c ific a tio ns a re e ithe r Re q uire d o r Addre ssa b le  Addre ssa b le do e s NOT me a n o ptio na l  Addre ssa b le spe c ific a tio ns a llo w mo re fle xib ility, b ut o rg a niza tio ns must do c ume nt why the spe c ific a tio n do e s no t a pply o r de mo nstra te a n a lte rna tive me tho d o f sa tisfying it 9/ 17/ 2015 12

BR E ACHE S I nve stig a tio ns c o me in re spo nse to b re a c h re po rts, • pa tie nt c o mpla ints, a nd whistle b lo we rs A b re a c h typic a lly le a ds to a n inve stig a tio n tha t • e xpo se s ma ny o the r vio la tio ns, inc re a sing fine s  T he “Wa ll o f Sha me ” ha s mo re tha n 1,300 b re a c he s o f 500+ re c o rds 9/ 17/ 2015 13

WHAT IS A BR E ACH?  Me re ly lo sing c o ntro l o f PHI is a b re a c h, e ve n if the re is no e vide nc e tha t the da ta wa s e ve r a c c e sse d ❖ L o ss o r the ft o f ha rdwa re sto ring PHI is a b re a c h  Una utho rize d a c c e ss is a b re a c h ❖ A pro vide r who sno o ps in a he a lth re c o rd b ut is no t invo lve d in c a re  Una utho rize d disc lo sure ❖ F a xing PHI to the wro ng pa tie nt 9/ 17/ 2015 14

NOT IF ICAT ION R E QUIR E ME NT S – 500+  Pa tie nts must b e info rme d o f a b re a c h within 60 da ys o f disc o ve ry  Pa tie nts sho uld b e info rme d b y le tte r whe ne ve r po ssib le  Busine ss Asso c ia te s must info rm Co ve re d E ntitie s o f a ny b re a c h, a nd the Co ve re d E ntity must info rm pa tie nts  F o r b re a c he s o f 500 r e , HHS must b e e c or ds or mor info rme d within 60 da ys, a nd the b re a c h will b e liste d o n the “Wa ll o f Sha me ” 9/ 17/ 2015 15

NOT IF ICAT ION R E QUIR E ME NT S – <500 F o r b re a c he s o f fe we r than 500 re c o rds, the • o rg a niza tio n must info rm HHS a nnua lly, within 60 da ys o f the e nd o f the ye a r Ste ps to a ddre ss • 1. I nc ide nt Re po rt 2. I nc ide nt inve stig a tio n 3. I nc ide nt T ra c king lo g 9/ 17/ 2015 16

AUDIT PR OT OCOL E XAMPL E Sanc tion Polic y Audit Pr otoc ol: 1. I nq uire a b o ut fo rma l pro c e ss 2. Ob ta in a nd re vie w the fo rma l do c ume nta tio n 3. E va lua te c o nte nt 4. Ob ta in e vide nc e 5. De te rmine 9/ 17/ 2015 17

HIPAA TRAINING 8/ 23/ 2016 18

2016 SRA TOOL WORKSHEET 8/ 23/ 2016 19

SRA MI T I GAT I ON RE PORT 8/ 23/ 2016 20

COMPL I ANCE : # 2 Billing Audits: Sho wing yo ur I nte nt 21

CMS ANNOUNCE S CMS F ina l Rule Sta te s: • Me dic a re Pro vide rs L ia b le F o r Six Ye a rs Of Ove rpa yme nts. • I nc re a sing the numb e r o f RAC a udits in 2016. • E xpa nd RAC a udit pro g ra m to Me dic a re Adva nta g e • 8/ 23/ 2016 22

WHY PE R F OR M AN AUDIT ? • Ide ntific ation/ Suspic ion of Pr ac tic e De fic ie nc ie s • Pote ntial Me ans to ide ntify Misse d/ Additional R e ve nue • R e duc e Payme nt De nials • Complianc e 8/ 23/ 2016 23

WHAT IS A CHAR T AUDIT ? An unb ia se d re vie w o f a ra ndo m se le c tio n o f e nc o unte rs pe r c linic ia n 1. I de ntify Disc re pa nc ie s Unde rc o ding , o ve r-c o ding , misc o ding , no n-c o mplia nc e 2. Re c o mme nd E nha nc e me nts Co ding , b illing , do c ume nta tio n pro c e sse s a nd re ve nue c yc le 3. Mitig a te Disc iplina ry Ac tio ns a nd F ine s T hird pa rty c a rrie rs, fe de ra l, sta te , a nd o the r re g ula to ry a g e nc ie s 8/ 23/ 2016 24

AVE R AGE PE R CE NT OF E R R OR S CMS e stima te s tha t 30% to 40% o f me dic a l b ills c o nta in • e rro rs T he Ac c e ss Pro je c t, a Bo sto n-b a se d he a lth-c a re • a dvo c a c y g ro up, sa ys it ma y b e a s hig h a s 80% Audits we ’ ve c o nduc te d o ve r the pa st ye a r ha ve e rro r • re sults ra ng ing b e twe e n 20% - 85% 8/ 23/ 2016 25

IT COME S DOWN T O YOUR INT E NT ! T he F alse Claims Ac t (F CA) impo se s c ivil lia b ility o n any pe r son who kno wing ly sub mits, o r c a use s to b e sub mitte d, a fa lse o r fra udule nt c la im to the Go ve rnme nt. T he “ knowing ” sta nda rd inc lude s a c tio ns re la te d to the truth o f the c la im: • De lib e ra te I g no ra nc e • Re c kle ss Disre g a rd Civil pe naltie s fo r vio la ting the F CA ma y inc lude : F ine s o f $5,500 - $11,000 pe r inc ide nt • • AND Up to 3 time s the a mo unt o f da ma g e s susta ine d b y the Go ve rnme nt a s a re sult o f the fa lse c la ims. (E x: 57 e nc ounte r s r e sulting in an ove r payme nt of $4,560. $4,560 x 3 = $13,680. Possible fine s: $313,500 - $627,000) T he re a lso is a c r iminal F CA (18 U.S.C. Se c tio n 287). iminal pe naltie s fo r sub mitting fa lse c la ims ma y inc lude fine s, impriso nme nt, o r b o th. - Cr

DE T E R MINE T HE CODE Ne w Patie nt (3/ 3) 8/ 23/ 2016 27

DE T E R MINE T HE CODE E stablishe d Patie nt (2/ 3) 8/ 23/ 2016 28

E NCOUNT E R / CHAR T AUDIT DE L IVE R ABL E S: Co mple te d a udit she e ts a nd summa ry re po rts fo r • e a c h pro vide r Org a niza tio na l a udit summa ry re po rt • F ina l me e ting fo r pre se nta tio n a nd re vie w o f a udits/ • summa ry re po rts pe r pro vide r a nd o rg a niza tio n 8/ 23/ 2016 29

INT E NT T O COMPL Y 8/ 23/ 2016 30

COMPL I ANCE : # 3 E ffe c tive Doc ume ntation: E / M Coding 8/ 23/ 2016 31

E F F E CT IVE DOCUME NT AT ION E / M, CPT , a nd I CD-10-CM Co de s: Assure me dic a lly ne c e ssa ry se rvic e s we re pro vide d “I f it isn’ t do c ume nte d, it didn’ t ha ppe n!!” 32