5/16/2014. Revenue Cycle Impact Documentation risks in an EMR AGENDA. EMR Challenges Related to Billing and Revenue Cycle

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1 EMR Challenges Related to Billing and Revenue Cycle Lori Laubach, Principal Health Care Consulting California Primary Care Association Billing Managers Peer Conference May 20 21, The material appearing in this presentation is for informational purposes only and is not legal or accounting advice. Communication of this information is not intended to create, and receipt does not constitute, a legal relationship, including, but not limited to, an accountant client relationship. Although these materials may have been prepared by professionals, they should not be used as a substitute for professional services. If legal, accounting, or other professional advice is required, the services of a professional should be sought. 2 AGENDA Revenue Cycle Impact Documentation risks in an EMR o AHIMA Areas of Concern o Other Areas of Concern 3 1

2 Reporting/ Benchmarking Patient Access & Scheduling Charge Description Master Optimize Revenue Cycle Systems Patient Collections AR Follow Up Revenue Cycle Phases and Processes Charge Capture Clinical Documentation Improvement & UR Review Denial Management Payment Posting Coding & Documentation Review Payer & Managed Care Contracting Claims Processing 4 COMPREHENSIVE ERROR RATE TESTING EXAMPLE Service Type Error Rate No Docum Insufficient Docum Medically Unnecessary Incorrect Coding Other Chiropractor 43.90% 0.0% 39.5% 57.1% 0.7% 2.7% Hospital Visit-Initial 28.20% 0.6% 38.3% 0.0% 60.8% 0.3% Specialist - Psych 27.70% 2.8% 74.8% 21.2% 1.1% 0.1% Office Visits New 24.00% 0.7% 30.5% 2.1% 64.5% 2.3% Lab Tests 23.30% 0.3% 21.6% 0.0% 78.0% 0.1% Nursing Home 21.70% 3.8% 51.6% 0.4% 44.1% 0.2% Hospital Visits-Sub 20.50% 1.4% 62.8% 0.0% 35.8% 0.0% Consultations 19.90% 1.2% 66.4% 31.8% 0.3% 0.3% Chemo 19.80% 0.0% 95.1% 4.6% 0.3% 0.0% Minor Proc 18.10% 1.7% 82.8% 12.4% 2.0% 1.1% Echo/US 16.70% 0.0% 52.2% 47.1% 0.7% 0.0% Ad Imaging 16.00% 3.9% 72.7% 21.0% 2.4% 0.0% Other Tests 14.70% 3.1% 53.6% 39.3% 3.9% 0.1% Office Visits - Est 12.30% 1.5% 54.4% 0.5% 42.8% 0.8% Rad Therapy 10.60% 0.0% 100.0% 0.0% 0.0% 0.0% ER 9.40% 1.8% 33.9% 0.0% 63.8% 0.5% Other Drugs 8.40% 0.1% 63.1% 30.9% 5.9% 0.0% Lab Tests 8.10% 0.1% 62.5% 25.5% 11.9% 0.0% Spec - Opthalm 7.10% 0.3% 93.7% 4.7% 1.3% 0.0% Ambulance 4.10% 7.3% 19.5% 62.2% 11.0% 0.0% 5 Provider documents service Coder reviews or abstracts Provider submits codes for Charges Claim scrubber Submit services for charge capture Claim submitted Denial Received Claim Paid Coder receives denial and resubmits 6 2

3 AHIMA AREAS OF CONCERN 7 FROM TESTIMONY OF LEWIS MORRIS, OIG For example, electronic health records (EHR) may not only facilitate more accurate billing and increased quality of care, but also fraudulent billing. The very aspects of EHRs that make a physician s job easier cut and paste features and templates can also be used to fabricate information that results in improper payments and leaves inaccurate, and therefore potentially dangerous, information in the patient record. And because the evidence of such improper behavior may be in entirely electronic form, law enforcement will have to develop new investigation techniques to supplement the traditional methods used to examine the authenticity and accuracy of paper records. Underline added for emphasis 8 AHIMA EMR/EHR AREAS OF CONCERN Authorship integrity risk Auditing integrity risk Documentation integrity risk Patient identification and demographic data risks Guidelines for EHR Documentation to Prevent Fraud 9 3

4 CONCERN 1 - AUTHORSHIP INTEGRITY Borrowing record entries from another source or author and misrepresenting or displaying past as current documentation and (in some instances) misrepresenting or inflating the nature and intensity of services provided AHIMA Guidelines for EHR Documentation to Prevent Fraud hcsp 10 CONCERN 1 - AUTHORSHIP INTEGRITY Inaccurate representation of authorship of documentation Duplication of inapplicable information Incorporation of misleading or wrong documentation due to loss of context for users available from the original source Ability to take over a record and become the author Inclusion of entries from documentation created by others without their knowledge or consent 11 AUTHORSHIP INTEGRITY CONTINUED Inability to accurately determine services and findings specific to a patient s encounter Inaccurate, automated code generation associated with documentation Lack of monitoring open patient encounters Cut, copy and paste functionality Incident to 12 4

5 CLONING Cloning Cut & Paste = Blocks of text or even complete notes from another MD Copy & Paste = Carry forward of prior notes Other terms used = Copy forward, Re use, and Carry forward Two varieties: o Word (Ctrl C) o Computer generated Concern: o Copying and pasting is not noncompliant. It is how the information is used or counted. 13 COPY AND PASTE Examples: o Nurse was updating her resume (using Word) and copied a portion of her resume into a patient chart o ED nurse copied part of Patient A s record into Patient B s record drug use and bi polar diagnoses showed on Patient B s medical record and billing information In an EMR, the error never truly goes away 14 EXAMPLE OF COPY AND PASTE Patient presents for a routine follow up for diabetes. The RN reviews the patient's current diabetic medication dose and asks if there are any other issues to discuss with the provider. The patient indicates no. The RN selects the "marked as reviewed" or "no changes" button in the review of systems section of the template. This action blows in the previous ROS from the prior encounter. The provider's diabetic template offers a detailed examination. The provider selects normal for all elements associated with the template. This detailed exam, combined with the carried over ROS, that results in upcoding a routine follow up with standard lab orders to a The correct code for this visit is without the erroneous ROS and the mislabeled detailed exam. 15 5

6 EXPLODING NOTES: EXPLOSIVE TOPIC Check a box, get a sentence. Exploding notes and Natural Language Processing reads and assigns code to the automated information. o Does not sort out Medically Necessary information o EHR assigns code on word quantity not PERTINENCE Things can get even more perilous with the use of exploding notes, the compliance officer says. Exploding notes or exploding macros means a simple check off of normal or negative prompts the documentation of a complete organ system exam. 16 WHAT ELSE CAN WE DO? One message Medical Director support Mandatory education Discuss the importance of appropriate documentation in the EMR Outline and describe the ground rules to establish and maintain content integrity Discover further resources for reference and support 17 CONCERN 2 - AUDITING INTEGRITY Inadequate auditing functions that make it impossible to detect when an entry was modified or borrowed from another source and misrepresented as an original entry by an authorized user AHIMA Guidelines for EHR Documentation to Prevent Fraud

7 AUDITING INTEGRITY RISK Inadequate auditing functions Amendment/correction issues Addition of more text to the same entry Auto authentication Lack of monitoring activity logs Versioning 19 AUDITING INTEGRITY QUESTIONS Does the EHR system establish a process for logging all activity on the EHR? How long after an entry can the documentation be amended or corrected? Does the EHR system preserve data produced in response to a specific request, or can it be recreated reliability? How does the audit record maintain the first entry to a medical record? Is the record amenable by the original creator or another staff? Does the organization have policies that define retention periods and procedures for log records, and know if a record is finalized or completed on the system? 20 CONCERN 3 - DOCUMENTATION INTEGRITY Automated insertion of clinical data and visit documentation, using templates or similar tools with predetermined documentation components with uncontrolled and uncertain clinical relevance. AHIMA Guidelines for EHR Documentation to Prevent Fraud

8 DOCUMENTATION INTEGRITY RISK Automated insertion of data Templates Auto population of clinical data Problem list maintenance Inaccurate, automated code generation associated with documentation 22 DOCUMENTATION INTEGRITY RISK Other areas of documentation risk o Does the Discharge Summary stand alone and include required information? o Does the EHR assign codes based on documentation? o If so, how does it account for medical necessity? o Can the provider drop a charge before documentation is complete? 23 TEMPLATES: A NECESSARY EVIL Reminders for important red flag questions One size fits all templates are incomplete, not comprehensive enough, and only work for one problem. Multiple problems not handled in one template Subjective observations go undocumented. Potentially unnecessary documentation. Despite the well intended questions, all the visits look exactly the same 24 8

9 LCD GUIDANCE ON TEMPLATES Noridian Administrative Services, LLC Documentation to support services rendered needs to be patient specific and date of service specific. These autopopulated paragraphs provide useful information such as the etiology, standards of practice, and general goals of a particular diagnosis. However, they are generalizations and do not support medically necessary information that correlates to the management of the particular patient. Part B MR is seeing the same auto populated paragraphs in the HPIs of different patients. Credit cannot be granted for information that is not patient specific and date of service specific. Source: tion_and_management_services_ _Documentation_and_Level_of_Service_.htm 25 CMS MANUAL SYSTEM - MEDICARE PROGRAM INTEGRITY MANUAL Chapter 3 Verifying Potential Errors and Taking Corrective Action Some templates provide limited options and/or space for the collection of information such as by using check boxes, predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met. Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met. 26 PROBLEM LISTS PLANNING Prevention of auto population without clinician confirmation Efficient and reliable problem search capabilities Present problems from a designated problem list value set Streamline the task of problem list maintenance by incorporating natural language processing Allow for correcting errors on the problem list Linked to a corresponding code from a controlled structured nomenclature for consistency Provide for audit trails 27 9

10 CONCERN 4 - PATIENT IDENTIFICATION & DEMOGRAPHICS ACCURACY Automated demographic or registration entries generating erroneous patient identification, leading to patient safety and quality of care issues as well as enabling fraudulent activity involving patient identity theft or providing unjustified care for profit. AHIMA Guidelines for EHR Documentation to Prevent Fraud 28 PATIENT IDENTIFICATION & DEMOGRAPHICS ACCURACY Automated demographic information Quality of Care Fraudulent activity 29 PATIENT ID & DEMOGRAPHIC ACCURACY QUESTIONS What processes are in place to ensure that the availability of system functionality would not lead to clinical issues not being updated to reflect a clear change in patient s condition? How is this controlled? How is this monitored? What processes are in place to ensure that the availability of system functionality would not lead to or prevent the propagation of misinformation or error? 30 10

11 OTHER RISK AREAS Monitoring of coding by EHR is not done Assume EHR coding matches billing system Coding assistance via the EMR product itself (CPT & ICD) Modifiers Abbreviations Coding in EMR is valid although based on predetermined design Lack of policies and procedures related to: Coding and documentation related to EHR EHR retention policies 31 EACH AREA IMPACTS THE REVENUE CYCLE 32 CODING AND DOCUMENTATION - EMR Treatment Plan Coding accuracies Missing charges Reduced productivity/revenue 33 11

12 Medical coders usually deal in a wider variety of codes, adhering more to the ideal of coding theory. They provide the most complete picture possible of a medical encounter, leaving the money related aspects to the billers. Medical billers are more knowledgeable about commercial insurance requirements, what codes can be billed, claim submission rules, and how to assemble a clean claim. They focus on providing accurate, timely reimbursement based on the codes used. 34 CLAIMS PROCESSING Treatment plan Faster reimbursement Electronic claims and electronic attachments Real time processing information 35 DENIAL MANAGEMENT Complete and accurate claims First time denial rate Electronic claims allow for real time management Follow Up 36 12

13 TRACKING IMPROVEMENTS Determine which benchmarks to use to gauge improvement Apply a simple pre \posttest method to determine improvement Use the data your EHR collects to determine improvements Determine which intervals to check for improvements 37 THANK YOU Lori.laubach@mossadams.com 38 13