First Auto Policy. Credible Clinical Documentation 10/21/2013. First Recorded Automobile Crash. for Chiropractic - Breakout Session

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1 Credible Clinical Documentation for Chiropractic - Breakout Session Thomas D. Freedland, D.C SW Shady Lane Suite 303 Tigard, Oregon (503) TFreedland@aol.com First Recorded Automobile Crash May 30, Henry Wells collided with a bicyclist in New York City First Auto Policy In 1897 the first auto policy was issued by the Travelers Insurance Company. The policy was a liability-only policy The premium was $11.25, and provided coverage amounts between $5000 and $10,000 1

2 First Automobile Fraud Scheme Also, in 1897, immediately after Travelers issued its first auto policy, Mortimer Scruggins, AKA Morty the Mutt staged this accident in Hollywood Your Exam Evaluation begins when doctor first sees examinee. Ends only when examinee leaves doctor s sight. Observations outside of formal examination. Gait, heel/toe walk, squat and rise. Posture & notations of scars, tattoos, other prominent features. Subjective vs Objective Subjective - What we learned from the patient Mechanism of injury, onset of Disease or Disorder Nature presenting complaint Current History Past History Mechanism of injury Aggravating factors 2

3 Objective Findings A physical finding or diagnostic test result, that can be perceived by an examiner using one or more senses without patient input. Objective means based on observation or other data, and uninfluenced by one s attitudes, beliefs, biases, emotions, and/or prejudices. From AMA Guides to the Evaluation of Permanent Impairment, 6 th edition, 2008 Objective findings in support of medical evidence are verifiable indications of injury or disease that may include, but are not limited to, range of motion, atrophy, muscle strength and palpable muscle spasm. Objective findings does not include physical findings or subjective responses to physical examinations that are not reproducible, measurable or observable. ORS (19) Examples of true Objective Findings Deep tendon reflexes Circumferential measurements Assessment of muscle mass/wasting Imaging studies Fractures, DJD, Foreign body/growth Visible skin changes Bruising Range of Motion?? Requires willing participation by the patient Perhaps ROM should be called a Soft objective finding Your Exam Evaluation begins when doctor first sees examinee. Direct examination Palpation - tenderness, spasms, or guarding ROM measurements for cervical, thoracic, and lumbar DTRs, muscle strength, sensation, mensuration 3

4 Billing Patterns - Questionable Office will hold bills until treatment concludes Then submit bills all at once Meaning - No chance to review during treatment! Billing Patterns Consult? Multiple consultations Billing Patterns - Upcoding CPT Comprehensive History Comprehensive Examination High Level of Clinical Reasoning 4

5 Billing Patterns Wrong Codes Bill CPT View Study Report Identifies Only 3 Views CPT More Modifiers - Imaging If imaging is performed at the office along with interpretation the standard CPT Code is used If images are routinely sent out for a radiological review, bill in office service with modifier TC for Technical Component. (Modifier 90 can also be used, but this is less common) TC Professional Review is billed with modifier Billing Patterns - Imaging Why image? What is significant? How does the study change treatment? Pro and Cons of various procedures Consider NEXUS or Canadian C-spine rules X-rays following trauma Focal neurological deficit Midline spinal tenderness Alter level of consciousness Distracting injury (such as extremity fracture) 5

6 Meaningful Use $44,000 to change to EHR If it sounds to good to be true.. Based on amount collected from Medicare EHR Criteria must be met A good portion of criteria is not applicable e-prescribing, tracking of behavior (smoking) and other health data Deadline for full benefit ended October 3, 2012 Is it necessary? Not required now Lack of approved system may reduce Medicare reimbursement Most entities will transition to EHR No specific product to meet EHR criteria Electronic program must meet basic rules PQRS Qualified (Medicare definition) Notify Medicare by billing G8448 Medicare - PQRS Qualified Physician Quality Reporting System Professionals may choose to report information on quality measures via Medicare Part B via separate form (web site below) via EHR Medicare offers providers an incentive 2011 was 1.0% of allowable Medicare charges % of allowable Medicare charges 6

7 Medicare - PQRS Qualified Physician Quality Reporting System Medicare has over a 100 quality measures Patients age 65 who receive bone density testing Heart attack symptoms treated with aspirin in ER Managed diabetics with elevated sugar levels Physician chooses from list or drawn from EHR Medicare rewards doctors with added payment This is in addition to any EHR incentive Medicare - PQRS Qualified Physician Quality Reporting System If you are participating in PQRS and not using an approved EHR Notify Medicare by submitting G8448 with routine Medicare billing If not participating in PQRS by 2015 You are penalized by 1.5% of your Medicare payment Increasing to 2% in 2016 Penalties are based on your 2013 compliance Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. 7

8 Number types Individual (Type 1) NPI Organizational (Type 2) NPI Note that sole proprietorships may obtain only one NPI. Sole proprietorships must report using their SSNs (not EINs, even if they have EINs). Box 17B Referring/Ordering Physician Box 27J (non-shaded) Performing Provider Box 32A Performing Facility NPI -optional Box 33A (non-shaded) Billing Provider or Group Who needs a number? Any provider of a medical service who can perform services independent of another provider. Doctors (MD, DO, DC, ND, LAc, etc.) Independent ancillary providers (PT, LMT, OT, etc.) A Chiropractic Assistant (CA) cannot function independent of the chiropractor NO NPI 8

9 Who needs a number? What about an employee Acting at the direction of a doctor But is an independent ancillary provider (PT, LMT, OT, etc.) And billed as a service of the doctor Who needs a number? Example: LMT employed by chiropractor Performs massage as directed by doctor Service billed by doctor under a PPO (Prefered Provider Organization) Do you list LMT s NPI on the CMS 1500? Who needs a number? Working at the direction of the doctor places the LMT in a situation similar to the CA But, LMT is an independent provider Bottom line: Either could be argued as correct 9

10 Who needs a number? If in doubt, check with carrier It is hard to allege fraud if you are acting in a reasonable fashion with approval of the carrier However, if it feels wrong, don t do it. If you have any doubt, list the ancillary provider s NPI Federal Programs Medicare Railroad Retirement Federal Workers Compensation Veterans Administration Medicare To bill you must be a registered provider You must bill Medicare Participating Provider (PAR) Required to take assignment Pays 80% of Medicare fee Balance bill only 20% of Medicare fee Secondary automatically billed 10

11 Medicare Non Participating (NON-PAR) Limiting Charge cap on fee Typically patients pays at time of service You submit claim Payment goes to the patient Secondary coverage not always billed Medicare Services are limited to spinal manipulation 98940, 98941, Diagnosis must include Subluxation ICD series Diagnosis must have pain or disease Dx Sprain/Strain, Osteoarthritis Subluxation level(s) are recorded Medicare Pays for curative treatment Acute or Chronic Improvement is expected If no curative benefit is expected care is considered maintenance AT modifier is include with CMT code Signifies Active Treatment 11

12 Medicare Maintenance or Supportive Care is not covered under Medicare Any service rendered that is known to be not covered requires an Advanced Beneficiary Notice (ABN) If an ABN is not on file Patient does not owe for services Medicare Advanced Beneficiary Notice (ABN) Notifies Patient of non-covered services Patient then chooses to accept treatment knowing that Medicare (likely) will not pay. Billing a Medicare Patient for services known to not be covered without ABN on file is a crime! Medicare Why would a doctor submit a bill to Medicare knowing it will be declined? Medigap (Medicare supplemental insurance) or other coverage may cover services Medicare may be secondary Patient is still working and covered by employer Some other policy is primary 12

13 Medicare Modifies & Codes Allows the provider to communicate information to Medicare AT Active Treatment GA ABN on file GP PT as treatment, use if Pt has secondary coverage GX Acknowledgement by patient of payment obligation GY Non-covered Service GZ No ABN signed Audit! Medicare - Documentation History of Current Condition (onset date) Physical Examination (PART) Pain/Tenderness location, quality, intensity Asymmetry/misalignment as related to Hx Range of motion abnormality Tissue, tone changes, associated soft tissue Medicare - Documentation Diagnosis (include subluxation by exam or x-ray) Treatment Plan Duration and frequency Goals Objective Measures 13

14 Medicare - Documentation Subsequent Visits Review chief complaint Changes since last visit? Evaluate involved region for treatment Assessment of change (Hx and exam) Evaluate treatment effectiveness Treatment performed Railroad Retirement Unique, but not different Follow the Medicare criteria Submit bill according to card information Card often looks like Medicare Card states Railroad Retirement Railroad Retirement Reviewing claims CPT codes and and modifier AT Additional Documentation Request (ADR) History, PART Exam, Subluxation, Plan, Goals, Contraindications, Objectives 14

15 Federal Workers Compensation Follows Medicare standards (Pre ) Requires Subluxation by X-ray Subluxation must be related to Work Injury If patient referred by MD, subluxation must be added to accepted condition Pays for spinal manipulation of subluxation related to injury Federal Workers Compensation E/M services usually covered Physical Therapy by DC is covered, but. PT must be in DC s scope of practice DC administers PT As a PT provider, DC cannot perform manipulation DC cannot split role, adjusting one day and PT next Veterans Administration Chiropractors being hired by VA facilities Some patients referred to area DCs Treatment limited to context of referral Submit bills as directed in referral Communicate with referring doctor 15

16 Is your secure?? Is your office computer or network secure? Are you letting data get sucked out of your system? 16

17 Are you using a Firewall? HIPAA requires that you make a good faith effort to keep records secure. Simple precautions are necessary if your system is connected to the Internet. Medically related s can be encrypted using freeware or shareware programs Most EHR programs allow secure communications with patients via the web link within the system. 17

18 Most messages are relatively secure, but a little precaution cannot hurt. The Internet is a great tool, but there are still many unknown factors to consider. Why take a chance? 18

19 Patient Chart Note Assume a straight forward problem and examination Example will use SOAP for convenience Where do we start? What do we say? Patient Chart Note S Subjective what we learn from the patient S: Today Mary Jones complained of persistent neck pain and low back pain for the last four days. She was last seen two months ago for a headache. Since then she has been doing well. There have been no new injuries, and there are no new medical problems. Her current pain start this last weekend. She was working in the yard, pulling weeds, trimming bushes, and mowing the lawn. The next day she was sore, especially in the low back. She tried soaking in a warm tub and has taken two Tylenol tabs 2 3 times a day with little effect. She remembers this happened last year as well when she starting working in the yard. Patient Chart Note O Objective Clinical Findings O: On examination Mary has a slight rightward lean, but her gait was normal. She could bend and turn, but had a slight increase in pain. Visual review of range of motion was normal. Upper and lower extremity muscle strength was good. Sensation was intact to light touch. Palpation showed increase muscle tension in the upper back, moderate muscle spasm seen along the right trapizeus ridge and extends into the low right neck. Joint restrictions seen at C5/6 and C6/7. 19

20 Patient Chart Note Objective Continued There was tenderness at the right upper S/I and the joint was restricted. Slight muscle spasm detected between L3 and L5 on the right. The left low back and S/I were tender, but no spasm seen. There was tension in the mid back, and restriction palpated at T5/6/7/8. No swelling or discoloration. Patient Chart Note Assessment (or Action) A has been described as both A: Cervical and lumbar sprain/strain secondary to overuse and activity, cervical and lumbosacral muscle spasms, more pronounced on the right, and joint restrictions as identified. Patient Chart Note Procedure(s),Plan, and/or Prognosis P: Mary was treated with electrical muscle stim in the low back for 12 minutes to reduce her spasms. A hot pack was placed on her neck during this time to help relax the muscles. A diversified adjustment was performed to the restricted segments. Mary reported her pain dropped immediately. I encouraged her to use ice on the neck and back tonight; she can use heat after the first 24 hours. She should start light stretching, following the instructions she was given on her last visit. A follow up was recommended in 2-3 days. She may need 5 or 6 visits over the next month, but no residual problems are expected. John Smith, DC 20

21 Common Recordkeeping Errors From NCMIC Examiner Spring 2005 Stephen Savoie, D.C. Not documenting phone calls Charting only abnormal Entries not signed Not documenting poor patient compliance No Rationale or Review of requested tests Not documenting home care recommendations No discussion of follow up care (date) No documentation of patient education Common Recordkeeping Errors From NCMIC Examiner Spring 2005 Stephen Savoie, D.C. Failure to perform re-evaluations No documentation of Informed Consent No documentation of treatment of by relief doctors Confusing Subjective and Objective elements Critical remarks about other providers Egotistical remarks Exaggeration of patient symptoms Hiding contraindications to procedures No change in the records over a series of visits Was it really that bad? Questions? This isn t Kansas anymore.. 21