Documentation PAM POTTER, MBA, FHFMA, CMPE, FACHE, MT(ASCP) - PowerPoint PPT Presentation

Documentation PAM POTTER, MBA, FHFMA, CMPE, FACHE, MT(ASCP) Physician Leadership and Management Certificate Program

Disclosure Statement In compliance with the ACCME Standards for Commercial Support, I have been advised to inform you that the content of this conference does not relate to any product of a commercial interest; therefore, there are no relevant financial relationships to disclose.

Learning Objectives • Identify key topics in the changing regulatory environment as it relates to documentation compliance • Apply rules of documentation along with defining the multiple users of this information • Explore pros and cons for managing documentation compliance within the electronic medical record

The Documentation Process • According to the Centers for Medicare & Medicaid Services (CMS), medical record documentation is a “ chronological ” record of pertinent facts, findings, and observations about a patient’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. • What Is Required For Providers to Document? And if you don’t? Linan, Luis Enrique, M.D., Lic. No. H8214, El Paso On December 4, 2015, the Board and Luis Enrique Linan, M.D., entered into an Agreed Order requiring Dr. Linan to within one year complete at least 16 hours of CME, divided as follows: four hours in patient communications, four hours in risk manage-ment and eight hours in medical recordkeeping. The Board found that there was a lack of documentation in the medical record related to Dr. Linan’s counseling of a patient as to the severity of her condition and need for quick evaluation and treatment. http://www.tmb.state.tx.us/dl/AF40A541-5429-9B53-1AF6-65389490E753 4

Legible Documentation Use • A provider’s ability to evaluate and plan the patient’s immediate treatment and to monitor his or her healthcare over time • Communication and continuity of care among providers involved in the patient’s care • Contributes to high quality care • Accurate and timely claims review and payment • Appropriate utilization review and quality of care evaluations • Data collection that may be useful for research and education 5

Legible Documentation Use • Avoidance of denied or delayed payments by insurance carriers investigating the medical necessity of services • Enforcement of medical record-keeping rules by insurance carriers contractually or by regulation, requiring accurate documentation that supports procedure and diagnostic codes • Subpoena of medical records by state investigators or the court for review • Execution of the physician’s written instructions by a patient’s caregiver or other health care team members • Defense of a professional liability claim or medical board complaint 6

The Importance of Medical Documentation • As Defined by the OIG 7 This Photo by Unknown Author is licensed under CC BY-SA

Texas Medical Board Complaints • Over 8000 complaints a year • TMB is authorized under HIPAA to obtain medical records without the patient’s consent. • If standard of care/treatment violations are at issue, all relevant information, including medical records, will be reviewed by at least two members of the TMB Expert Panel who are board-certified in the same or similar medical specialty as the respondent. • Your documentation is then reviewed, for not only the facts of the case, but also if the documentation is complete and accurate. Even if standard of care is met and/or the complaint is dismissed. Physicians may still be cited if medical documentation is not accurate and an administrative or other non-medical care violation can be levied. 8

Comprehensive Error Rate Testing (CERT) • Based on a review of the erroneous claims identified by CMS’s Medicare CERT contractor for FY 2009, HHS/OIG found that 6 types of health care providers accounted for $4.4 million, or 94 percent, of the $4.7 million in improper payments. The provider types were inpatient hospitals, DME suppliers, hospital outpatient departments, physicians, and home health agencies (HHA). Analysis of the erroneous claims also found that 3 types of errors accounted for about 98 percent of the $4.4 million in improper payments : insufficient documentation, miscoded claims, and medically unnecessary services and supplies. HHS/OIG recommended that, as part of its analysis of the FY 2009 CERT improper payments, CMS use the results of this analysis in identifying (1) the types of payment errors indicative of programmatic weaknesses and (2) any additional corrective actions needed to strengthen the CERT program.* • Current CERT Results - from Millions to Billions *https://oig.hhs.gov/publications/docs/hcfac/hcfacreport2010.pdf 9

Legalities of Health Record Billing Patterns • Billing Patterns Causing Possible Audit • Billing intentionally for unnecessary services • Billing incorrectly for services of physician extenders • Billing for diagnostic tests without a separate report in the medical record • Changing dates of service on insurance claims to comply with policy coverage dates • Waiving copayments or deductibles, or allowing other illegal discounts • Ordering excessive diagnostic tests • Using two different provider names to bill the same service for the same patient • Misusing provider identification numbers, resulting in incorrect billing • Using improper modifiers for financial gain – 2019’s gem, modifier 25 • Consistently not following National or Local Coverage Determination guidelines • Failing to return overpayments made by the Medicare program • 60 days from discovery of overpayment 10

Elements of Documentation • Common medical office documents • Problem-oriented record system • Patient registration (demographic • Documents are flow sheets, information) charts, graphs • Medication record • Source-oriented record system • History and physical examination notes or report • Documents stored in sections • Progress or chart notes • Electronic health record system • Consultation reports • Imaging and x-ray reports • Collection of medical information • Laboratory reports about a patient • Immunization record • EHR is a health record with • Consent and authorization forms multiple provider input • Operative report • EMR the record of one provider • Pathology report 11

Documentation Guidelines for Medical Services 12

Documentation Includes the Recording of Hierarchical Conditions Categories(HCC) • HCC documentation is used • HCC include such conditions • As a risk adjustment model for such as Cystic Fibrosis, Cerebral hospital readmissions, VBP Hemorrhage, Acute Myocardial Morality and Hospital Acquired Infarction ….see page 87 Conditions Reduction Programs • CMS HCC risk and payment • Medicare Advantage Plans are reimbursed by the risk adjustment model of the HCC model

Inpatient Coding From Physician Documentation • That follows universal terminology • Coders can use only documentation • physicians need to understand coding principles and • by physicians who are directly caring learn to document using appropriate terminology. for the patient during that admission. • Includes documentation of diagnoses, conditions, • Includes documentation by resident symptoms, or procedures defined by CMS. physicians, physician assistants, or • The large number of vagaries in the coding nurse practitioners if the attending vernacular used by CMS sometimes makes this documents agree. lexicon confusing and difficult for physicians. To • Notes of nurses and allied health ensure appropriate documentation, physicians must abandon ‘‘ doctorese ,’’ the shorthand professionals cannot be used. vernacular that is commonly used for • Consultants’ notes can also be used for documentation. coding, except when their findings • Even when a coder is able to correctly infer the contradict those of the attending diagnosis, he or she cannot use this information physicians because the diagnosis was not specifically documented. • It will either be lost or generate a query; both are negative consequences for the hospital and physician • Reimbursement might be inappropriately low and the true level of severity of illness might not be appreciated . Noel H. Ballentine, MD, FACP

Medicare LCD Novitas • Local Coverage Determination • www.novitas-solutions.com • The Centers for Medicare and Medicaid Services contract with private insurers to administer Medicare claims in every state/district. • Each Medicare carrier is required by CMS to have a physician Contractor Medical Director to oversee the development of local Medicare policies in their jurisdiction. • To assist Medicare carriers in the development of Local Coverage Determinations (LCDs), each state is required to have a Carrier Advisory Committee (CAC). • 2019 Changes: Purpose of the CAC is to discuss evidence in literature. Meetings are now open to the public, though to speak must be invited with COI disclosures. Based on the literature review, new LCD’s will be drafted and comments taken through the internet.

Medicare E&M Guidelines • Medicare-Learning-Network • Signature Requirements • “Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead should make use of the signature authentication process”. • https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf 3.3.2.4 - Signature Requirements Page 34