9/15/2015. Learning objectives. Coding and compliance. Coding Compliance for the IDS Environment. Could Your Coding be Costing You Money?

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1 Coding Compliance for the IDS Environment Could Your Coding be Costing You Money? Nancy Enos, FACMPE, CPC-I, CPMA, CEMC MGMA 2015 Annual Conference Learning objectives 1. Discover how administrators of physician practices can work with hospital administration to create a culture of compliance for the physician practices 2. Outline the importance of individual physician coding benchmarking to assess risk 3. Analyze physician compensation plans that are incentive based and how to avoid coding fraud and abuse Coding and compliance The relationship between a hospital and physician practice can often lead to important coding and compliance risks falling through the cracks. Day to day operational issues in hospital based clinics can have a negative impact on charge capture and documentation completion, leaving the system open to penalties in the event of a compliance investigation. Many hospitals fail to provide auditing, monitoring, and education to providers. 1

2 Auditing and monitoring Auditing and monitoring is the first element of a compliance program. The OIG defines an effective compliance program as one that is designed to detect and prevent fraud. Does your compliance program have an audit protocol that will expose hidden problems? Benchmarking You have to measure before you can manage. Benchmark each division/specialty Benchmark individual providers Compare to MGMA or CMS data Use the benchmark data for provider education 2

3 Beyond the benchmark Trouble may be hidden outside the highly utilized codes Office notes and hospital notes should be reviewed Coding should be scrutinized for missing codes Ex: and 99292, or and Audit selection based on benchmark data CPT Code Units % Audit Sample % % % % % 1 15 Documentation variables When providers see patients outside the clinic or office, and use alternate methods of documentation Lack of training or appropriate templates Multiple EMR s in use Nursing home visits Bedside procedures Wound care centers Home visits Satellite offices that do not have access to EHR Extra services Office procedures that are not specifically documented, but only mentioned in the physical exam (pap smear) or worse, in the assessment and plan (debridement was done..) and a CPT code assigned 3

4 Routine services Pre-op consultations Many providers are required by the hospital to dictate a history and physical prior to admission for surgery Included in the global period for the surgeon if done the day before or the day of surgery How it is medically necessary two days before surgery? Once the surgery is scheduled, use caution when billing for routine services Routine services Pre-op consultations When a surgeon refers a patient to their PCP for a pre-op consultation, Medicare will cover the consultation if it is medically necessary. HPI should document the medical issues that require clearance Review of systems Physical exam Medical decision making Office procedures Wound care Debridement codes are based on the size of the area of the debridement Nurse notes cannot be referenced when the performing provider does not document the area of the wound Procedure notes should be complete: Indication, method, supplies used, condition of the patient at the end of the procedure, instructions 4

5 Office procedures Debridement example: 11042: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less The physician surgically removes foreign matter and contaminated or devitalized subcutaneous tissue (including epidermis and dermis, if performed) caused by injury, infection, wounds (excluding burn wounds), or chronic ulcers. Using a scalpel or dermatome, the physician excises the affected subcutaneous tissue until viable, bleeding tissue is encountered. A topical antibiotic is placed on the wound. A gauze dressing or an occlusive dressing may be placed over the surgical site. Report for the first 20 sq. cm. or less and for each additional 20 sq. cm. or part thereof. Modifier -25 A complete SOAP note supporting the E/M procedure If related to the procedure, may be bundled A complete procedure note supporting the office procedure Indication, approach, instruments, method, extent, size, patient condition at the end of the procedure, instructions Non-physician practitioners Most undercoding occurs with NPPs Selection of the level of service Medical necessity as described by HPI Extent of exam as noted in Objective Risk as noted in Assessment and Plan There is no rule that guides an NPP to downcode services 5

6 Authenticity of notes Copy and paste Cloned notes Conflicts between HPI (bruising) and ROS (hem/lymph - no bruising) Conflicts between HPI and family history Pt here for full skin check, worried because mother has malignant melanoma No family history of skin cancer Medical necessity According to the OIG, if a physician does a detailed exam during a sick visit, and some of the elements do not appear to be related to the chief complaint This is not a problem if the code selection is not higher based on the extra elements If the code selection is higher based on history and physical exam, the code may be too high if not supported by the medical decision making Case studies A hospital group performs compliance audits quarterly as part of their compliance program and the results impact the physicians compensation. 1 of the 4 audits focus on out of office ancillary/secondary services. The results of the out of office audits revealed problems with notes that were not created in the primary EMR system. 6

7 Group A Podiatry Group A s audit results for Q1, Q2 and Q3 were above the benchmark, but Q4 for alternate site were poor Group A Podiatry Reasons Paper forms were used in the hospital wound care center and notes were not entered into the practice s EMR Paper forms were used by the NPP at nursing home Forms were completed by nurse and signed by the physician without a SOAP note being created Encounters were billed with E/M codes (modifier 25) and wound care codes together, with no documentation of the E/M service Group A Podiatry Resolution Physicians met with auditor to go over audit results Education was provided on documentation requirements Nurse notes can only be included when verified/referred to by physician Dictation of SOAP note was initiated 7

8 Group B General Surgery Office notes were audited Q1, Q2 and Q4 Clinic notes were audited Q3 Group B General Surgery Reasons After Q1 audits, an educational session was provided and Q2 audits showed improvement Q3 audits focused on clinic notes, not charted in the EMR Dictated notes were brief and did not include ROS and PFSH, brief exams, although MDM was moderate in many cases (ex: new hernia) Q4 audit of clinic notes after education Group B General Surgery Resolution Re-education using the clinic notes, going over documentation deficiencies for each visit that was under documented Surgeons agreed to dictate notes in the clinic as they cannot access the EMR Hospital administration will work on giving access to EMR 8

9 Group C OB/Gyn Initial audit showed billing compliance to be poor for all 15 providers in the group. Group C OB/Gyn Reasons OB/Gyn practice was acquired by the hospital system with no change in office management Behavior in the office continued based on prior policies Coding increased as the new provider compensation model was RVU based Examples Billing a new OB visit as a Billing prenatal visits and hospital (surgery) rounds Contraception visits billed as sick (E&M) visits Group C OB/Gyn Additional findings High error rate in audit of office notes due to incorrect Documentation of time based services Billing of counseling and contraception Calculations of medical decision making e.g. Pessary change 9

10 Group C OB/Gyn Resolution New policies were put in place to track provider s productivity, allowing for billing for hospital rounds and PN visits with 0 RVUs and $0 First OB visits were tracked in the flow sheet EMR templates modified to capture time Contraceptive visits and other counseling were changed to be documented with time and reported with Group D Urgent Care Medical director of urgent care was enrolled with insurance carriers but NPPs and moonlighters were not all credentialed (high turnover) Incident to rules were used in billing cases under the name of the medical director Medical director did not sign notes Medicare requires the physician or non-physician practitioner to review the progress and co-sign charts. The physician or non-physician practitioner accepts responsibility and liability for incident to services. Incident to rule Performing provider must be an employee of the practice. Auxiliary personnel is defined as any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician. 10

11 Incident to rule The physician or non-physician practitioner (NPP) must perform the initial service, diagnose the patient s medical condition, develop a treatment plan, and remain actively involved in the management of the care of the patient. Such a service could be considered to be incident to when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment. Incident to rule Furnished by the physician or by auxiliary personnel under the physician s direct supervision Direct supervision: The physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the auxiliary personnel is performing services. Group D Urgent Care Benchmarking and chart audit results NPPs were undercoding MDs were overcoding Forms were often completed (paper) with a line drawn down the entire ROS or exam Nurse notes incomplete Medical necessity did not match LOS (level of service) 11

12 Group E Hospitalist Group Reasons The hospitalist group depends on a clerk to coordinate charge entry of hospital cards Clerk is not a certified coder Overlapping charges (same patient, same day) are often entered Critical care time is often incorrectly calculated when more than one provider participates on same date Group E Hospitalist Group Hospital EMR templates may not be set up to capture the elements required for Comprehensive history Comprehensive exam Hospital Admission 3/3 HISTORY EXAM MDM Time Initial Admission, Low Detailed 5-7 Straightforward Initial Admission, Moderate Comprehensive 8+ Moderate Initial Admission, High Comprehensive 8+ High 70 Inpatient Consultation 3/3 Rule of R's Only one per hospitalization 1 Straightforward 20 min Initial inpt consult straightforward Prob. Focused Initial inpt consult Expanded Exp. Problem Focused 2-4 Straightforward 40 min Initial inpt consult Detailed Detailed 5-7 Low 55 min Initial inpt consult Moderate Comprehensive 8+ Moderate 80 min Initial inpt consult High Comprehensive 8+ High 110 min Group E Hospitalist Group Resolutions Provider education on documentation elements of Evaluation and Management services History (Initial H&P) to include complete ROS, PFSH Avoid family history noncontributory Refer to ancillary notes (medication list, past illnesses) Exam - comprehensive exam requires 8 elements When and how to document time Include EMR specialist to modify templates if possible 12

13 It s all about the documentation The detail in ICD-10 depends on the information in the note Coders and billers are trained not to use unspecified codes and Are always directed to query the provider for more detailed information 37 Clinical documentation improvement goals Identify areas in ICD-10-CM that include new terminology for clinical documentation Define areas that enable improved data capture if more specific conditions are documented Identify how documentation affects quality measure reporting and reimbursement 38 Why is clinical documentation important? Documentation is critical for patient care Serves as a legal document Reviews quality Validates the patient care provided Complies with CMS, Tricare and other payers regulations and guidelines Impacts coding, billing and reimbursement Good medical records reduce the re-work of claims processing

14 Documentation do s Complete Accurate Legible Patient Centered Timely Detailed Concise 40 Documentation Improves quality of care Complies with CMS regulations Drives revenue 41 Coding drives revenue New ICD-10 codes will create a demand for more details in the documentation to support ICD-10 codes. Charge entry Payments Denials 14

15 Closing thoughts Does your hospital administration work closely with the physician practices? Is the physician practice administrator included on the hospital compliance committee? Are compensation plans strictly RVU based or are other incentives, such as compliance performance, a component? About the speaker Nancy M Enos, FACMPE, CPC-I, CEMC is an independent consultant with the MGMA Health Care Consulting Group. Nancy was a practice manager for 18 years before she joined LighthouseMD in 1995 as the Director of Physician Services and Compliance Officer. In July 2008 Nancy established an independent consulting practice. As an Approved PMCC Instructor by the American Academy of Professional Coders, Nancy provides coding certification courses and consultative services. Nancy frequently speaks on coding, compliance and reimbursement issues. Nancy is a Fellow of the American College of Medical Practice Executives. She serves as co-chair of the IT Advisory Panel of the Information Management Society for MGMA. She is a Past President of MA/RI MGMA. nancy@enosmedicalcoding.com 15