Does Your Documentation Meet ICD-10 and Medicare Requirements?

Per the rules of the Florida Board of Chiropractic Medicine, each attendee is required to have his/her badge scanned 4 times a day with Photo ID at the attendance desk regardless of which classes you attend. Attendance Desk Hours: Thursday 12:30pm 2pm 4:30pm 5:30p Friday 7:00am 9am 11am 12:30pm 12:45pm 2pm 4:30pm 5:30pm Saturday 7:30am 9am 11am 12:30pm 12:45pm 2pm 4:30pm 6pm Sunday 7:30am 9am 11:45am 12:30pm 2:30pm 3pm 4:30pm 5pm CLASS NOTES Please pick up a lecture handout located in the back of the room. In order to retrieve an expandable version of our class notes, you will need the access code located at the end of your lecture handout. You WILL NOT be able to access the expanded version of these notes without this code. If you are looking for diplomate hours, your badge must be stamped at the registration desk with a red ACBN stamp. Your hours will be automatically credited with your required class scan at the door to pertaining classes. Programs that mention or promote specific products, services or companies are not eligible for approval to offer continuing education credits in the State of FL. Today s speaker has agreed to not mention specific products, services, or companies in this presentation. If this agreement is violated, please report to the FCA verbally, or via the feedback form in your convention packet / show guide. Does Your Documentation Meet ICD-10 and Medicare Requirements? Presented by: Abbie Miller, MCS-P Documentation requirements for Medicare are clear Obvious what s to be provided within both initial and routine visit notes Interpretation has become more intense since ICD-10 Requirements? Why Is Documentation So Important? Ensures quality patient care Meets licensure requirements to protect the public Guards against malpractice action Secures appropriate reimbursement Because if it wasn t written down, it didn t happen! Under the Magnifying Glass (855) 832-6562 1

Know your Audience Another health care provider Your board A malpractice attorney Third party payer's medical necessity auditor Good Documentation Tells a Story 5 Most Common Errors Signatures and Identification of the Doctor and Patient Not Clear No rationale for diagnostics or tests ordered Lack of all required elements of a treatment plan Daily Assessment consisting only of diagnosis Performing and billing for full spine adjustments, without proper documentation of medical necessity Radiculitis NOS vs. With Radiculopathy Radiculitis (M54.1-)is included with M50.1 or M51.1 disc disorder with radiculopathy series The Excludes notes are clear! Lumbar radiculopathy (M54.16) could be used if the pain is not known to be a disc yet but it does radiate from the lumbar spine Could also be Sciatica (M54.3-) w/o disc confirmation and radiation down the back of the leg Resist the Urge! Do not code symptom codes like cervicalgia and lumbago with disc codes Symptoms are included within the more definitive DX codes of the more complicated condition (855) 832-6562 2

Signature and Patient Name Issues To verify provider who treated Prove services were provided Indicate and verify who provided them Validates the entry and legally binds the physician for the included info Why Authenticate? Can we Identify Provider? Review Signature Requirements Familiarize providers and office staff with signature requirements to ensure more complete compliance with signature authentication policies How do we authenticate signatures? Signature Log Update Signature Log Every year have each provider sign again, even if it hasn t been a year since the last signature Add new providers to the log as they join the group Replace previous logs with most recent signatures, however save old copies Make sure every log has a start and end date (855) 832-6562 3

How it all comes together... Create Signature Log Update Signatures Review Signature Requirements Sign and Check Patient Identifiers Patient name must appear on every item or piece of paper Electronic name is ok Front and back both Especially important when sending records Patient number can identify as well Provide Appropriate Rationale Tell Us What You re Thinking Why are the tests being ordered? Why did you decide to do what you did? What s between your ears must appear in the documentation X-rays, labs, other diagnostic tests, referrals, and DME (855) 832-6562 4

Your Medical Records Must Tell the Story Rationale for Films MD Rationale for CT Scan Possible X-Ray Rationale ICD-10 Codes Match Findings/Language Offer a Complete and Compliant Treatment Plan (855) 832-6562 5

Your treatment plan is your pre-determined plan of action. It will take into consideration the tissue specific issues defined in your patient work-up and diagnosis Soft-tissue diagnosis and soft-tissue targeted treatment Treatment Plan Frequency and duration Treatment goals for each region/treatment to include long term goal An evaluation of treatment effectiveness measurement Date of the plan Meet the Requirements Frequency and Duration Indicate initial part of the treatment It s ok to have an end game projection Don t be so specific that you appear canned or boxed into a plan Each section should end with an evaluation Treatment Goals Treatment goals need to be functionally based. What functions are we restoring with our treatment plan? How will we measure that corrective change? What goals are outlined for each type of treatment? (855) 832-6562 6

Evaluate the Effectiveness Measurably! OATS make it easy Pain is difficult to track and measure Use an accepted measure that you can document simply Improvement in function = success!! Make it Shine! Home care recommendations Prognostic factors Inclusion of all possible treatment and DME options What if you treat today? Win with a Robust Daily Assessment (855) 832-6562 7

Medicare Documentation Guidelines Initial Visit History Description of Present Illness Physical Exam Diagnosis Treatment Plan Date of initial treatment Subsequent Visits History Review of chief complaint Physical Exam Document daily treatment Progress related to treatment goals/plan Subsequent Visits Documentation Requirements History: (29% Documentation Error Rate) Review of Chief Complaint Location of Symptoms Changes since last visit Subjective (P) Quality of Symptoms System review if relevant Intensity of Symptoms Physical exam: (43% Documentation Error Rate) Exam of area of spine involved in diagnosis Objective (A, R, T) Assessment of change in patient condition since last visit (PE, OA, ADL, QVAS) (Same, Better, Worse) Assessment Evaluation of treatment effectiveness (Same, Better, Worse, How and Why) Daily Treatment Documentation : (15% Documentation Error Rate) Plan Best Practices for Defining your Doctor s Assessment Remember it is all about Function, Function, FUNCTION Identify HOW the patient has improved Identify WHY they need continued care That is Medical Necessity by definition! Does This Truly Outline Assessment? (855) 832-6562 8

Tale of Two Styles What I Hope to See Document, Code, and Bill Properly as a Full Spine Adjuster (855) 832-6562 9

Are You an Outlier? Statistics tell us that the improper coding of full-spine treatment can cause you to appear to be an outlier You therefore can be subject to more scrutiny, red flags, and even an audit Error Rate Information Insufficient documentation is a known issue in the chiropractic profession Failure to provide any documentation to auditors represents nearly 50% of the poor scores So? I m a Full Spine Adjuster! Medical necessity definition dictates that you must prioritize each area of complaint Every visit: S + O (P + ART) for every region treated 2 DX codes for each region Treatment plan for each/short and long term goals 98942 Issues 98942-Appearance of Evil (855) 832-6562 10

Why It LOOKS Fishy And Recently Set Up to Fail? In the world of compliance, DCs who routinely adjust the full spine are challenged Because documentation and coding must match exactly Coding 98942, because all five regions have been adjusted, may be asking for trouble Philosophically Driven Whether you are subluxation-based chiropractor or simply believe that every patient requires a full-spine adjustment, you need clarity Proper coding and case management for these technique-specific and philosophically driven coding conundrums need to be defined by you for your office You Define Your Intentions Clarify your motivations so you can describe your situation and your intentions Create and implement a policy in order to describe why it could appear that your documentation doesn t match your coding Outline in writing in advance of any requests for records to help to keep you and your practice safe SOP - Example (855) 832-6562 11

Policy Code for Subluxations Only How This Looks on Paper Code This as 98940 Code This as 98941 Code This as 98942 Billing Should Be 98940 (855) 832-6562 12

Put on Your Auditor Hat What is expected/typical 98940: 40-60% 98941: 40-60% 98942: 1-10% How would your office look? Run Your Ratios! Take Action Look at your CMT coding ratios to evaluate code usage Spot check documentation for 98942 codes billed to find out if the documentation meets requirements Determine how you can improve coding/documentation as a full spine adjuster Why Bother to Self-Audit? Do Some Self-Auditing Self-audit can improve standards of documentation considerably and increase doctor and team member s knowledge and confidence Self-auditing is used as a continuous improvement incentive for all clinical staff Self-audit can deliver an improvement in practice at no extra cost Baseline Audits Definition - Baseline audits are preliminary assessments to develop a reference point. By performing an audit in advance, your practice can identify improper billing and coding practices and make necessary corrective actions prior to any government or third-party payer audit. Baseline Documentation Audit Why do we need to do a Baseline Documentation Audit? Identify coding/documentation problems and fix them before they get out of hand Find ways to increase revenue by finding faulty systems Audit yourself before They audit you! Create a list of significant goals for improvement and time period to achieve those goals Ultimately offer better care to your patient (855) 832-6562 13

Like a Physical Exam of a New Patient You are palpating the tissue of your practice by looking at documentation Quantifying the movement, range of motion, and appearance of how well the documentation compares to "textbook" normal Finding asymmetry in documentation (some areas functioning well while others are misaligned) Get a "listing" of what needs to be adjusted in the practice How to Do a Documentation Audit Start by looking at your Medicare documentation guidelines for initial and routine visits. All of the 3 rd party carriers base their policies on these This is like the Textbook Normal you will judge your practice s documentation health against Do You Know? In order to audit documentation, you must understand what s required Don t rely on memory Rely on guidelines, like the carrier will It s OK if you don t know just know someone who does Medicare Documentation Guidelines Coding and Documentation Must Match Initial Visit History Descripton of Present Illness Physical Exam Diagnosis Treatment Plan Date of initial treatment Subsequent Visits History Review of chief complaint Physical Exam Document daily treatment Progress related to treatment goals/plan (855) 832-6562 14

Review Every Aspect of the DX Pull a random chart Identify the DX Check coding book: Is this the highest degree of specificity? Review the history and exam documentation Do you know what SHOULD be there based on the DX? Review Every Aspect of the DX If appropriate, does the site specific DX match the complaint? Is the Diagnostic Impression obvious? Has the assessment been updated since October 1? Is there a mechanism of injury? Did you use an external cause DX code? Example: Sprain vs Strain Sprain and strain codes have been separated in ICD-10 DCs tend to clump them together Sprain codes must represent pain on passive ROM Strain codes must represent pain on active ROM OK to use both when the documentation demonstrates both Tests demonstrate tendons vs. ligaments M50 series: Cervical Disc Disorders M51 series: Thoracic, Thoracolumbar, and Lumbosacral IVD Disorders Example: Disc Disorders 4 th Characters 0 = disc disorder with myelopathy 1=disc disorder with radiculopathy 2=other disc displacement 3=other disc degeneration 4= Schmorl s Nodes (not cervical) 8=other disc disorders 9=unspecified disc disorder Example: Disc Disorders What s a Disc Disorder? Protrusion Bulge Herniation These are appropriate when using 4 th character 0 or 1 Disc Displacement-4 th character 2 may include these also However, doesn t include cord or nerve root complications M40.12: Other secondary kyphosis, cervical M40.292: Other kyphosis, cervical region Example: Cervical Kyphosis Choose 1: Patient had an incident that resulted in cervical kyphosis Choose 2: Acquired kyphosis with no evidence or knowledge of another condition that may have prompted it (855) 832-6562 15

Example: Restricted Motion Stiffness or restricted motion is included in the segmental dysfunction codes for the spine Segmental dysfunction can include reduced or restricted ROM M25.6 = Stiffness in joint, NEC These are for extremities Example: Contracture vs. Spasm M62.49 (Contracture of Muscle multiple sites) Muscle contracture is a more severe condition with actual tightening and stiffening of a muscle More long lasting, more difficult to heal Reoccurs periodically Difficult to manage M62.830 (Muscle Spasm of the Back) More likely what is revealed in documentation findings More intermittent and more likely to come and go More easily managed Radiculitis NOS vs. With Radiculopathy Radiculitis (M54.1-)is included with M50.1 or M51.1 disc disorder with radiculopathy series The Excludes notes are clear! Lumbar radiculopathy (M54.16) could be used if the pain is not known to be a disc yet but it does radiate from the lumbar spine Could also be Sciatica (M54.3-) w/o disc confirmation and radiation down the back of the leg Resist the Urge! Do not code symptom codes like cervicalgia and lumbago with disc codes Symptoms are included within the more definitive DX codes of the more complicated condition Determine ONE thing you can do by year end What can you change in Q1 2016? How can you delegate to take small, manageable steps? Work on one project at a time to manage time and expectations Take Action Now We re Here to Help! info@kmcuniversity.com (855) 832-6562 16