Medical Documentation Barry H. Block, DPM, JD

Transcription

1 Medical Documentation Barry H. Block, DPM, JD 1

2 Why is Documentation Important? Why is Documentation Important? Reimbursement 2

3 EMR DOCUMENTATION ABSURD ICD 10 CODE V97.33XD: Sucked into jet engine, subsequent encounter. 3

4 From PM News 4

5 Why is Documentation Important? Malpractice Compliance Why is Documentation Important? Your spoken word vs. patient spoken word = Patient victory Your chart vs. patient spoken word = Doctor victory 5

6 Why is Documentation Important? Adds value to your practice. PATIENTS RIGHTS Patients have an absolute right to their records under HIPAA and state laws. Patients have rights to copies, NOT originals. 6

7 PATIENTS RIGHTS You have a right to reasonable reimbursement for copying costs. But a copy machine is not a revenue generator. PATIENTS RIGHTS In NY, you are allowed to charge $.75 per page. In NJ, $1 per page (up to 100 pages). X rays are also chargeable at your cost. 7

8 Patients Rights to Records You CANNOT hold charts as hostages You can SUE the patient for copying fees Medical Documentation You should include, test results such as x rays, lab reports, and outside consultations. 8

9 Medical Documentation The doctor is charged with the responsibility of reading and understanding all chart entries, including associates and notes sent to you from other specialists. Medical Documentation Notes should be linked to one another to demonstrate continuity of care. 9

10 Medical Documentation Entries should be comprehensive Entries should be comprehensive Patient medical history, including family history, social history, medicines, and allergies. Chief complaint, including onset, duration, previous treatment, and self care. Other complaints. 10

11 Entries should be comprehensive Physical Examination Orthopedic Vascular Dermatological Neurological Medical Documentation SOAP notes are still valid. Subjective Objective Assessment Plan 11

12 Medical Documentation Entries should indicate Medical Necessity Medical Documentation Entries should be legible 12

13 Entries Should Be Legible Entries Should Be Legible If you use abbreviations, you should have a glossary of abbreviations in your office manual. You should attach this glossary when sending your records. 13

14 Check Voice Dictated Notes for Accuracy "She was a bitch and grinned" (she was a bit chagrined). 49 year old occasional male (Caucasian male) The patient had a baloney amputation. (below knee) Medical Documentation Entries need to be signed as close to the time of the examination/ treatment as possible. 14

15 Medical Documentation Do NOT use Whiteout. Draw a single line through the mistake. Sign and date. Electronic Medical Records The wave of the future (if not now) Dangerous for doctors to alter 15

16 Forensic Podiatry DPM BEWARE Use of FBI Labs Hard drives leave time encrypted records. Electronic Medical Records Charts must be individualized. Be careful with the use of templates. 16

17 FORMER EMR INCENTIVES Physician Quality Reporting Initiative (PQRI) 2% Bonus E Prescribing 2% Bonus $44,000 Rebate Under Stimulus Bill 2015 NON EMR PENALTIES The electronic medical records mandate requires that eligible providers who fail to adopt and demonstrate meaningful use of EHR technology by 2015 will have Medicare reimbursements reduced. 17

18 NON PQRS PENALTIES Fee schedule reductions start at: 1% in % in % in NON PQRS PENALTIES Physician Quality Reporting System (PQRS) Payment Adjustment Information % % 2017??? 18

19 Electronic Medical Records Make back ups of all records. Store back ups off site. Medical Documentation Photo documentation A picture is worth a thousand words. Use a digital camera for wound/ fungal nail documentation. 19

20 Photo Documentation Photos should be marked in the same way as x rays. Patient s name Date taken Use a ruler to show lesion size. 20

21 Forms are Still Acceptable Six Ways to Avoid a RAC Audit 1. Avoid copy and paste documentation While it is acceptable to use templates, your documentation must be patient specific. 21

22 Six Ways to Avoid a RAC Audit 2. Focus on medical decisionmaking The OIG and RACs are focusing on the complexity of medical decision making as your primary determinant for selecting an E&M code. Six Ways to Avoid a RAC Audit Do not use a higher level code when the complexity is not there, regardless of how great your documentation may be. 22

23 Six Ways to Avoid a RAC Audit 3. Know where you stand on E&M coding Physicians who over code evaluation and management services (E&M) relative to their peers remain at a greater risk of audit. Six Ways to Avoid a RAC Audit Compare your E&M coding averages to a national benchmark. The American Association of Professional Coders (AAPC) offers an easy and free way to get national E&M coding averages by specialty. 23

24 Six Ways to Avoid a RAC Audit 4. Don't rely on your EHR's E&M code selector Nobody (other than EHR salesmen, of course) believes these codeselection engines are consistently accurate. Six Ways to Avoid a RAC Audit 5) Have a certified professional coder (CPC) review several chart notes for every provider, every year, for appropriate coding and documentation. Most office based coders do not conduct ongoing coding and documentation audits. 24

25 Six Ways to Avoid a RAC Audit 6. Document medical necessity When ordering a test or procedure, make sure you document why it is needed. MRIs and outpatient physical therapy are two of the services the OIG feels are overutilized. The 2015 OIG Work Plan identifies many OIG/RAC targets. QUESTIONS 25