8/3/2011. Presented by: Brenda Edwards, CPC, CPMA, CPC I, CEMC AAPCCA Board of Directors. Documentation. Results ? 2

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1 Presented by: Brenda Edwards, CPC, CPMA, CPC I, CEMC AAPCCA Board of Directors 1 Documentation Auditing Results? 2 1

2 HANDWRITTEN Legibility Personalized DICTATED Concise Personalized Timely? EMR Lengthy, cloned notes Shared record 3 Paper Electronic 4 2

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4 Review of Systems Constitutional Denies: fatigue, malaise, excessive weight change Eyes Denies: double vision, blurred vision, vision loss, floaters Cardiovascular Denies: chest pain, palpitations, irregular heart beats, syncope, dyspnea on exertion Respiratory Denies: shortness of breath, wheezing, cough Neurologic Denies: tingling, memory difficulties, seizures, tremors, loss of balance Endocrine Denies: polyuria, polydipsia, significant hypoglycemia, significant hyperglycemia Physical Examination Constitutional person, place well nourished, seems more confused today, alert, oriented to and time, no acute distress Eyes Neck conjunctiva normal, sclerae nonicteric no masses or tenderness Respiratory breathing unlabored, clear to auscultation Cardiovascular regular rate and rhythm, no murmurs present Skin Neurologic Psychiatric no rashes or lesions present cranial nerves II-XII grossly intact judgement and insight intact, confused, memory difficulties, normal mood and appropriate affect 7 8 4

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7 Learning curve Passwords and authentication Free text narrative Better coding Under coded by computer Customize clinical care EMR Amended Records Improved charge capture Tracking mechanism Paperless office Savings in processes and staff cost Template carrying forward 13 Double standard If it isn t documented it, isn t done, and therefore not billable If it is documented, did you really do the work? Irrelevant information = search for pertinent findings Time saving or over dictating? Think in categories instead of personal opinion Clicking boxes instead of writing what they think and feel based on observations Medical legal standpoint Nearly identical documentation on large numbers of patient records 14 7

8 Chart Review/Audit Audit Review Assessment Whatever makes your physicians comfortable (or equally uncomfortable) 15 Current OIG work plan Annual internal work plan How to perform audits Under attorney client privilege Frequency Quantity Location Specific codes or services Specific providers New Outliers Teaching Facility Specialty Payer mix 16 8

9 Upcoding Lack of checks and balances Opportunities Threats Lack of qualified coding staff Financial impact over time 17 Services 2 3 months prior to review Remittance advices Charge tickets Medical records Appointment schedule Patient account detail Internal documents Abbreviation list Provider signatures Specific policies 18 9

10 Codes reported on charge ticket Compare date of service Medical record to encounter form Encounter form to claim Claim to remittance advice di Consistency of codes Compare progress note Document Discrepancies Compare submitted charges to allowed charges Date claim paid versus date of service 19 Date of service Handwritten template dictated or EMR CPT 4 ICD9 and HCPCS Modifiers Patient identifiers Minimum of 2 Front and back Identity, authentication by performing provider 20 10

11 Familiarize Forms, H&P, Problem List, Drawings Review chart organization Have you seen this drawing? Coding criteria Time Critical care IP/OP Office procedure 21 A new patient has not received professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years

12 Photo: Kaptain Kobold 23 Required Exception subsequent inpatient hospital visits Concise Patient s own words IT IS NOT F/U Right lower extremity He swallowed something Patient here for routine check Patient seen in f/u for other No complaints lit at this time 24 12

13 Patient presents with 2 day history of cough. Has tried Robitussin with no relief. He has not been able to sleep well; sore throat due to drainage in his throat and he missed work yesterday (bus driver for the school district). No fevers. 25 Location Quality Severity Duration Timing Context Area of body Dull, sharp, stabbing Scale of 1 10, mild, significant, moderate When symptoms first occurred Intermittent, continuous Associated with a specific activity Modifying factors What relieve symptoms, circumstances surrounding a certain activity Associated signs or Associated with the presenting problem symptoms 26 13

14 The HPI can only be performed by the physician or non physician practitioner and that the only way another staff member can document it adequately is if he or she is taking dictation i or scribing (Part B News, 6/11/07) The physician must do the work and document it themselves, simply reviewing the documentation obtained and indicating I have reviewed the HPI and agree with above is not acceptable. If the history cannot be obtained from the patient or other source, document why and code the visit appropriately. 27 Two types of HPI Brief requires documentation of 1 3 elements Extended requires documentation of 4+ elements or as changed in the 1997 guidelines, documentation of the status of 3 chronic conditions 28 14

15 Patient presents with 2 day history of cough. Has tried Robitussin with no relief. He is unable to sleep much; sore throat due to drainage in his throat and he missed work yesterday (bus driver for the school district). i t) No fevers. Elements: Duration, Modifying Factor, Context, Associated Sign and Symptom Type of History HPI Problem Focused (99201, 99213) Brief (1-3) Expanded Focused (99202, Brief (1-3) Detailed (99203, 99214) Extended (4+) Comprehensive(99204, 99205,99215) Extended (4+) 29 Typically weakest documentation Templates or forms acceptable Patient s responses to signs/symptoms experiencing Complete ROS, must document any positive and problem pertinent negatives All other systems negative for remaining 30 15

16 Patient presents with 2 day history of cough. Has tried Robitussin with no relief. He has not been able to sleep well; sore throat due to drainage in his throat and he missed work yesterday y( (bus driver for the school district). No fevers. Systems Reviewed: ENT Constitutional ROS Problem Focused (99201, 99213) N/A Expanded Focused (99202, Problem Pertinent(1) Detailed (99203, 99214) Extended (2-9) Comprehensive (99204, 99205,99215) Complete (10+) 31 Past Allergies, current meds, immunization, surgeries, previous illness, age appropriate feedings Family Health of parents, siblings or children, hereditary diseases that put the patient at risk (blood relatives) Past Family &/or Social History Social Age appropriate review of past and current activities Marital status Employment Drug, alcohol, and tobacco use Education Sexual history 32 16

17 Patient presents with 2 day history of cough. Has tried Robitussin with no relief. He has not been able to sleep well; sore throat due to drainage in his throat and he missed work yesterday (bus driver for the school district). No fevers. Social History: Employment PFSH N/A (99201, 99213) N/A (99202, Pertinent (99203, 99214) (1-3) Complete (99204, 99205,99215) (3) 33 Which Set of Guidelines? 34 17

18 Problem Focused a limited examination of the affected body area or organ system. Expanded Problem Focused limited exam of 2 7 body areas or organ systems (2 4?) Detailed Exam extended exam of 2 7 body areas or systems (5 7?) Difference between limited and extended exam has never been clarified in writing 1995 Exam Guidelines Comprehensive Exam 8 of 12 systems 35 Temperature: 99.6, BP: 120/72 Patient is 42 year old white male in no acute distress. HEENT: Exam reveals no edema or effusion noted. Cardiovascular: RRR, no murmurs Respiratory: Palpation normal. Expiratory wheeze bilaterally; improves occasionally with deep cough Abdomen: Negative 36 18

19 Temperature: 99.6, BP: 120/72 Patient is 42 year old white male in no acute distress. HEENT: Exam reveals no edema or effusion noted. Cardiovascular: RRR, no murmurs Respiratory: Palpation normal. Expiratory wheeze bilaterally; improves occasionally with deep cough Abdomen: Negative 1997 Guidelines Organ Systems 1995 Expanded Examination 1997 Examination Guidelines Expanded Expanded 4 systems examined Limited exam of affected body area or organ system and other related systems 3 bullets Problem focused exam 38 19

20 Tie It All Together 39 MDM should be the primary factor in determining the level of service History and physical Match the severity of the problem(s) Complexity of decisionmaking 40 20

21 Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of E&M service when a lower level of service is warranted. MCM Section A 41 Chest x ray ordered to rule out pneumonia CBC ordered due to fatigue Impression: No infiltrates found on x ray; upper respiratory infection. Z pack for 5 days given as well as prescription for Tussin Pearls. Will see back next week if not improving

22 What is Additional Work Up? 43 Artist: Caroline Shotton A B C D Problem Categories Number Points Score Self-limit limit or minor (stable, improved, or Max= 2 1 worsening) Established problem: stable, improved 1 Established problem: 2 worsening? New problem, no additional work-up 3 3 planned New problem: additional work-up 4 4 planned Total: 44 22

23 Table of Risk Number of prescriptions i Assessment of risk Presenting problem Diagnostic procedures Prescription drug management 45 Level of established patient office visit= Level of new patient office visit= Level of consult visit= History Problem Focused Expanded Detailed Comprehensive Exam MDM Problem Focused Straight Forward Expanded Detailed Comprehensive? Low Moderate High 46 23

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29 KaMMCO 8/3/2011 Quantify the data Visuals Use as educational opportunity Deliver results inperson Provide resources and solutions Communicating Results Project confidence Approach from the positive, not the punitive Provide coding specifics in writing Involve staff in educational sessions 57 Chart Review Patient # DOS Auditor CPT: CPT Progress Note Auditor HISTORY ELEMENT History of Present Illness Chief Complaint: Location: Quality: Severity: Duration: Timing: Context: Modifying Factors: Signs & Symptoms: Review of Systems Constitutional Eyes Ears, Nose, Mouth, Throat Integumentary Neurological Psychiatric Cardiovascular Endocrine Respiratory Hematologic Gastrointestinal test a Allergic/Immunologic egc/ oogc Genitourinary Lymphatic Musculoskeletal All others negative History Past: Family: Social: EXAMINATION ELEMENT Body Areas Organ Systems: Head Constitutional Genitourinary Neck Eyes Musculoskeletal Chest Ears, Nose, Throat Integumentary Abdomen Cardiovascular Neurological Genitalia, Groin, Buttocks Respiratory Psychiatric Back Gastrointestinal Hematology/Lympahtic/Immunology Each extremity 1995 Guidelines: 1997 Guidelines: MEDICAL DECISION MAKING Diagnoses/Mgmt Options: Data Reviewed: Risk to Patient: CONCLUSION 58 29

30 Data Comparison within a Practice 70% 100% 60% 90% 80% 50% 70% 40% 30% 60% 50% 40% 20% 30% 10% 20% 10% Dr. A 0% MGMA* Medicare* % 3.05% 41.73% 46.56% 8.46% 2.14% 14.89% 66.13% 15.79% 1.04% 3.95% 6.33% 55.23% 31.64% 2.86% Dr. B 0% MGMA* Medicare* % 1.19% 91.90% 5.87% 1.04% 2.14% 14.89% 66.13% 15.79% 1.04% 3.95% 6.33% 55.23% 31.64% 2.86% 59 Data Comparison of different periods 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Dr. A 1/ /2004 Dr. A 1/2007-7/2007 MGMA* Medicare* % 4.80% 93.43% 1.77% 0.00% 1.05% 2.09% 26.46% 69.98% 0.42% 2.14% 14.89% 66.13% 15.79% 1.04% 4.09% 7.35% 57.75% 28.17% 2.64% 60 30

31 Physician National Trend ABC Family Practice E&M Office Visit Trend Compared to Family Practice Physicians 1/ / % 80% 70% 60% 50% 40% 30% 20% 10% 0% Dr. A 0.65% 87.95% 9.45% 1.30% 0.65% 0.02% 19.98% 74.95% 1.61% 3.44% Dr. B 2.35% 35.88% 58.82% 2.94% 0.00% 0.24% 7.78% 66.38% 25.39% 0.21% Dr. C 0.64% 4.49% 76.92% 17.31% 0.64% 0.00% 3.70% 85.82% 10.05% 0.43% MGMA 9.24% 38.66% 40.05% 10.47% 1.58% 1.87% 18.60% 65.61% 12.90% 1.02% Medicare 2.79% 21.34% 42.91% 25.93% 7.02% 3.96% 9.75% 60.82% 23.03% 2.44% 62 31

32 Over Coded/ Billed, 5, 3 6% Accurately Coded, 8, 57% Under Coded/ Billed, 1, 7% 63 Establish a method for monitoring trends and tracking progress Document all actions taken to honor your compliance plan Ongoing Monitoring Provide feedback to physicians on a regular basis Request involvement from your compliance committee Request second opinions if necessary 64 32

33 Ongoing Monitoring Chart Audit Trend Analysis 90% 80% 70% 60% 50% 40% Dr. A 30% 20% 10% 0% 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 65 Challenges Higher presenting problem lacking documentation Requirements for consultations not met Quantity of documentation inconsistent with presenting problem Weak review of system Misuse of templates and poor form design Unfamiliar with documentation guidelines Emotional coding Payment reactive coding Illegible documentation Services documented but not performed Services not documented but performed Provider disinterest 66 33

34 Thank you for participating today Happy trails to you As you review your records (sung to the tune of Happy Trails) 67 34