HCCA Clinical Practice Compliance Conference. October 23 25, 2016

Transcription

1 501 Turning the Physician Auditing Process from The Dark Side to The Force Being With You Vicki L. Dwyer, Chief Compliance Officer, Valley View Hospital, Glenwood Springs CO Nancy C. Kennedy, Chief Operations, Compliance & Privacy Officer, Galichia Medical Group, Wichita, KS Objectives Does the thought of auditing your physician put you in a Dark mood? This session will analyze the barriers physicians put up and techniques you can use to break those barriers down so audits don t turn you to the Dark Side. Learn how to turn the Top 10 Not-To-Do s into the Top 10 What-To-Do s to get your physicians to start coming back for more. Do you wish the Force Was With You when it comes to reviewing audits with your physicians? This session will provide tools, techniques, and strategies that will make you shine and turn the auditing process into a learning process, for both sides. From Not-To-Do to What-To-Do Join the Dark Side (Not-To-Do) 1. Extroversion o Dominates o Need to WIN 2. Agreeableness o Cold, Unapproachable o Argumentative, Antagonist 3. Conscientiousness o Too Cautious Black or White o Unreliable -Lack of Follow-Through o Disorganized 4. Neuroticism o Not Willing to Listen o Always Right o Debate/Argue o Intense 5. Openness o Not Open to Ideas / Suggestions o Makes Assumptions Have the Force Surround You (What-To-Do) 1. Extroversion o Open Discussions, Asks Questions o Finds Common Ground 2. Agreeableness o Approachable Non-Threatening o Kind, Positive Attitude 3. Conscientiousness o Consider the Shades of Gray o Reliable Always Follow Through o Organized 4. Neuroticism o Active Listening o Open to Alternatives and Suggestions, Open Discusses o Calm 5. Openness o Not Open to Ideas / Suggestions o Listen & Learn 1

2 Extroversion The Dark Side Dominates / Intimidates Show them Who s Boss Win at Any Cost Using The Force Open Discussions Ask Questions Find Common Ground Take 5 minutes to let them know you. Narrow the Audit to Focus on one or two elements Make it FUN! Agreeableness The Dark Side Cold & Unapproachable Hassled, So Busy Responds without Thinking Inconsistent Using The Force Be Approachable, Available Ask Questions 5 W s Send a Consistent Message Understand the Physician s Time is Valuable Use Different Strategies for Different Physicians Keep a Positive Attitude Conscientiousness The Dark Side Sees only Black and White OR Needs to Please Too Cautious or Conservative OR too Wishy-Washy Unreliable, Doesn t Follow-up as Promised Disorganized, Scattered Difficult to Follow, Jumps from One Topic to Another Using The Force Consider the Shades of Gray Be Reliable / Always Follow Through Be Organized Know the Materials Keep It Short and Simple (KISS), Uncomplicated Identify What may be Making them Fall Off the Pick-up Truck. 2

3 Neuroticism The Dark Side Doesn t Listen, Preparing Response Does Not Ask or Encourage Questions No Discussion Has to Get Your Point Across Very Intense or Aggressive Will Debate and Argue, Must Win Always Knows the Answer Know-It-All Using The Force Actively Listen to What the Physician is Trying to Tell You Acknowledge Physician s Concerns & Frustrations Encourage Open Discussion REMAIN CALM Openness The Dark Side Does Not Want to Listen to Excuses or Suggestions Makes Assumptions Stuck in a Rut One Way of Doing Things Not Flexible Using The Force Don t Make Assumptions - Observe Take a Walk in Their Shoes Think Outside the Box Ask if the Physician for Suggestions, Alternatives Presentation Strategies Organize Documents Only Use One or Two Use Examples Pictures are Worth a Thousand Words Have References Handy 3

4 One Picture is Worth a Thousand Words HPI: Blood Sugars are up (275) and down (50)on Januvia. Blood pressure is okay but gets Log dizzy frequently. Has started coughing, non-productive. am HPI: Blood Sugars are up (275) and down (50)on Januvia. Blood pressure is okay but gets Log dizzy frequently. Has started coughing, non-productive. am References Novitas Solutions, Inc., Frequently Asked Questions: Evaluation and Management Services (Part B), 10/5/2009, Date Revised: 11/15/2013, mandates the use of the 1997 E/M examination guidelines, the 1995 examination guidelines utilizing the 4x4 tool, or clinical inference in the use of 1995 E/M examination guidelines. The method utilized by internal and external audit staff should be the one most beneficial to the physician. The 4x4 tool is defined as 4 elements examined in 4 body areas or 4 organ systems satisfies a detailed examination; however, less than such can be a detailed exam based on the reviewers clinical judgment. More Presentation Strategies Stick with the Time Set, UNLESS the Physician Wants to Spend More Time Primary Focus - What They are doing Correctly Areas for Improvement Provide Cheat Sheets for Reference 4

5 Cheat Sheets or Documentation Pointers Billing Based on Time / Counselling: Document total face-to-face time with the patient Document more than 50% of the time was spent providing counseling or coordination of care Describe the content of the counseling or coordination of care. Example: 45 minutes total face to face time spent with patient, more than 50% (or 25 minutes) spent counseling. Handouts Audit Tool & Summary Patient MRN & DOS E&M documentation compliant and supports level of service billed? / / / / / / / / / / / / / / / Level of History D D C C C E D D C D D D C D D Level of HPI Ext Ext Ext Ext Ext Ext Ext Ext Ext Ext Ext Ext Ext Ext Ext Level of PFSH Com Per Com Com Com Per Per Per Com Com Per Com Com Com Com Level of ROS Ext Ext Com Com Com Pro Ext Ext Com Ext Ext Ext Com Ext Ext Level of Exam C C C C C E E E C C E C D E C Level of MDM Mod Mod Low Mod Mod Sfw Low Mod Mod Mod Low Mod Mod Mod Mod Diagnoses Ext Ext Ext Ext Ext Mul Mul Mul Ext Ext Lim Lim Mul Mul Ext Data Collection Min Mod Min Min Min Min Min Min Min Lim Min Mod Min Lim Lim Risk Mod Mod Low Mod Mod Sfw Low Mod Mod Mod Mod Mod High Mod Mod Level of Service Billed Level of Service Supported by Documentation LOS Billed Correctly: S S S UB S S S UD S UD S S S UD S Audit Tool & Summary Patient #4 MRN / DOS: was billed, documentation supported a Documentation included a comprehensive history and exam with moderate medical decision making. The medical decision making was moderate with the decision for a screening colonoscopy. The nature of the presenting problem was also moderate with symptomatic left inguinal hernia. A new patient visit was appropriately billed. Patient #14 MRN / DOS was billed, documentation supported a A requires 2 of the following: comprehensive history and examination and high medical decision making. Documentation of the history was detailed due to the ROS and the examination was expanded problem focused. In addition the medical decision making was at a moderate level based on the risk table with 2 or more chronic stable problems and prescription drug management (moderate). The nature of the presenting problems, stable postprandial nausea, periumbilical pan, and constipation, were also of a moderate level. While Dr. Vader documented Between reviewing of the patient s records and the patient s interview time, I spent approximately 75 minutes on this case for the initial evaluation. This statement did not meet the criteria to bill based on time. Only face-toface time spent with the patient can be counted in the office setting for billing based on time due to counseling. In addition, the physician must document the total face-to-face time spent with the patient the time spent counseling, and the content of the counseling. 50% or more of the face-to-face time must be spent on counseling. 5

6 Audit Tool & Summary Other Comments: Encounters reviewed: 15 Documentation supports a higher level of service: 1 ( 6.7%) Documentation supports a lower level of service: 3 (20.0%) Documentation supports the level billed: 11 (75.5%) Corrective Action: Met with Yoda and Dr. Vader on May 20, 2016 to review details of audit and educate on Novitas documentation guidelines. Handout s provided. Will refund overpayment identified. The under-documentation identified in #8 was based on Novitas 4X4 guidelines for a detailed examination. This patient has commercial insurance and documentation of 5 systems was detailed enough to remain a #4 was under billed, however since the account has been paid, we will not rebill at the higher level supported by documentation. Follow-Up Plan: Will conduct f/u audit in 5 weeks (Mid-June). 6

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9 Remember It s All About Perception Herding Cats Ducks in A Row The Gentle Art of Herding Cats 1. Cats don t like to be herded. (in fact, you can t really herd cats) 2. Cats prefer to herd themselves. 3. Cats understand that they sometimes need to be herded. (that doesn t make them any easier to herd) 4. Cats don t like being reminded that they are being herded. The Gentle Art of Herding Cats 4. Harsh herding has negative consequences. 5. Herd gently, but firmly with affection or fish as a reward. Remember, you are a cat, too We all need herding, at one time or another 9

10 Questions? Thank You! Vicki L. Dwyer, RN, MN, CPC, CHC Nancy C. Kennedy, RHIT, CPC, CHC, CHPC