TABLE OF CONTENTS MEDICARE DOCUMENTATION AND CODING REQUIREMENTS

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1 TABLE OF CONTENTS MEDICARE DOCUMENTATION AND CODING REQUIREMENTS MEDICARE DOCUMENTATION AND CODING REQUIREMENTS IMPORTANT REMINDER MEDICAL RECORD DOCUMENTATION AND EVALUATION REQUIREMENTS IMPORTANT REMINDER DOCUMENTATION AND CREDENTIALS REQUIREMENTS MEDICARE ICD-9-CM CODING REQUIREMENTS QUALITY CODING PRACTICES IMPORTANT REMINDER QUICK REFERENCE TIPS IMPORTANT REMINDER WEB RESOURCES

2 MEDICARE DOCUMENTATION AND CODING REQUIREMENTS Alliance CmpleteCare is required t submit t the Center fr Medicare and Medicaid Services (CMS), all necessary data that characterizes the cntext and purpse f each face-t-face encunter between a Medicare enrllee and a physician/practitiner, supplier, r ther prvider. Yur rle as an Alliance CmpleteCare Prvider r Delegate is t accurately reprt all symptms, identifiable cnditins, and c-mrbidities, in the prvider and hspital medical recrds, and n submitted claims. Failure t dcument diagnses in the prvider and hspital medical recrds, and submit claims fr these services at the highest level f ICD-9-CM specificity, will result in lwer reimbursement t the health plan. Alliance CmpleteCare allws prviders t annually assess their patients thrugh cverage f an annual physical examinatin. The Alliance will ensure that cdes submitted t CMS are cmplete and accurate, by cnducting prvider and delegate medical recrd audits. Medical recrd ntes shuld be as cmplete and accurate as pssible, s yu can prvide the best care t Alliance members. Gd dcumentatin assures that all f the patient s medical cnditins are addressed. Imprtant Reminder Alliance CmpleteCare will cnduct an audit f yur claims and medical recrds fr apprpriate and cmplete cding f all diagnstic cnditins at least twice a year. MEDICAL RECORD DOCUMENTATION AND EVALUATION REQUIREMENTS Managing patient care and reprting services rendered is the critical rle prviders play in dcumenting their face-t-face encunters with patients. Basic dcumentatin shuld always include thrugh dcumentatin f all cnditins evaluated, mnitred, r treated, reasn fr the visit, care rendered, cnclusin, and diagnsis. In additin, the prvider shuld always dcument chrnic diseases, disease interactins, cmplicatins and manifestatins, late effects, cnditins that c-exist at the time f encunter and cnditins that require r affect patient 9-1

3 care, treatment, r management. Prviders are nt required t dcument cnditins that were previusly treated r n lnger exist, unless the previus cnditins impact current care r influence treatment. Imprtant Reminder Prviders must dcument all cnditins evaluated, mnitred, r treated during a facet-face encunter with a patient. Alliance CmpleteCare cvers an annual physical examinatin t assist prviders in assessing and dcumenting patients health annually. Dcumentatin and Credentials Requirements Alliance CmpleteCare prviders are required t dcument as fllws: Only authrized medical staff may dcument face-t-face encunters in the patient s recrd. Authrized medical staff includes physicians, nurse practitiners, nurse anesthetists, physician assistants, and certified midwives. Ensure dcumentatin is clear, cncise, cnsistent, cmplete, and legible. Prvider shuld use the standard SOAP nte frmat when dcumenting the patient s charts as identified belw. Subjective hw the patient describe their prblem Objective Data btained frm examinatins, lab results, vital signs, etc. Assessment Listing f the patient s current cnditin and status f all chrnic cnditins. Hw the bjective data relate t patient s acute prblem Plan Next steps in diagnsing prblem further, prescriptins, cnsultatin referrals, patient educatin, and recmmended time t return fr fllw-up Prvider medical recrd ntes must supprt all diagnses cded n the claim fr the date f service. Listing diagnses is nt sufficient. The recrd must indicate that the prvider mnitred, evaluated, r treated the cnditin. Use nly standard abbreviatins and keep them t a minimum. Prvider ffices shuld have a standard abbreviatins list. Every page f the medical recrd must identify the patient by name, and the date f service. The persn wh dcuments the medical recrd must be clearly identified. The signature identified shuld be a legible printed name with the prvider s credentials and date n the medical recrd ntes. 9-2

4 The signature shuld be identified at least nce per entry in the recrd. If the prvider s signature is nt legible, there shuld be a signature lg with the physician s printed r typed name, credential, and legal signature. If the prvider has different signatures, the variatins n his/her signature shuld reflect this in the lg. See example belw: Prvider Signature Lg Name Credential Signature Jhn De Jhn De D.O. (Dctr f Ostepathic Medicine) D.O. (Dctr f Ostepathic Medicine) CMS states Electrnic Medical Recrds (EMR) require an authenticated electrnic signature indicated n the medical recrd. Acceptable electrnic signatures include ne f the statements belw fllwed by the prvider signature Electrnically Signed By Authenticated By Apprved By Validated By Cmpleted By Prviders using alternative signature methds (e.g., signature stamp) bear the respnsibility fr the authenticity f that infrmatin being attested t. CMS maintains strict plicy n signature; therefre, physicians shuld use the fllwing guidelines: Offices shuld have a plicy and prcedure related t the use f signature stamp. Prviders shuld secure the signature stamp in a lcked lcatin. Only the prvider shuld have access t the signature stamp. Regarding the ffice visit, nly ntes signed by the physician, nurse practitiner, nurse anesthetists, physician assistants, and certified midwives, reflecting face-t-face cntact with the patient and direct attentin t the diagnsis in questin, are valid fr dcumentatin. Prviders shuld dcument clinical impressins derived frm ther surces such as, lab values, radilgy reprts, pathlgy reprts, and hspital and cnsult ntes, in the medical recrd nte. 9-3

5 When pre-printed statinery is used fr medical recrd dcumentatin, and the prvider f service is nt listed n the statinery, then the credentials must be part f the signature fr that prvider. This way CMS can determine that the beneficiary was evaluated by a prvider r an acceptable prvider data surce. Superbills are nt cnsidered sufficient dcumentatin f clinical cnditins. MEDICARE ICD-9-CM CODING REQUIREMENTS The quality f diagnsis cding is imprtant t apprpriately and accurately identify the member s health status. Alliance CmpleteCare prviders are required t assess the health status f their patients at least annually, in a face-t-face visit, and reprt all relevant diagnses in the chart, and during the billing prcess. All face-t-face prvider encunters shuld be cded t the highest level f ICD-9 specificity. The highest degree f specificity is the practice f assigning the mst precise ICD-9-CM cde that mst fully explains the narrative descriptin dcumented by the prvider in the medical chart r hspital recrd f the symptms r diagnses. Quality Cding Practices Alliance CmpleteCare prviders shuld fllw the guidelines belw t ensure quality cding: Assessments: Initial Health Assessment Annual Physical Exam Initial Health Assessment: Alliance CmpleteCare prviders are required t cmplete an initial health assessment within 90 days f member assignment t yur practice. Annual Physical Exam: The Alliance CmpleteCare benefit package includes cverage f an annual physical examinatin t assist prviders in their annual assessment f a member s health status. Cding Bks Use current ICD-9-CM bks updated by the American Medical Assciatin (AMA) yearly in Octber. Access new ICD-9-CM cdes frm the CMS website. Updated ffice super bills annually with current ICD-9 cdes. 9-4

6 Cding Specificity Specificity means cding a cnditin using the mst precise ICD-9 cde that fully explains the written descriptin f the cnditin in the patient s medical chart. Cde all face-t-face encunters t the highest level f ICD-9 specificity. D nt cde prbable, suspected, questinable, rule ut, r wrking diagnses. Cde the actual cnditin t the highest degree f certainty fr that visit, such as symptms, signs, abnrmal test results, r ther reasns fr the visit. Cding Terms When the terms cde als, cde first, r use additinal cde, are included in the ICD-9-CM manual fr a particular cde, fllw the instructins t fully cde the patient s cnditin. Chrnic r Onging Cnditins State that cnditins are chrnic versus acute, r unspecified, fr example, chrnic renal insufficiency versus renal insufficiency. Use dependence diagnses versus abuse diagnses, such as alchl dependence. Specify the type f cnditin, fr example, plastic anemia versus anemia (NOS). The fllwing chrnic cnditins always impact patient care r treatment and shuld be dcumented in the recrd and cded annually: Diabetes Mellitus Cngestive Heart Failure Asthma Emphysema Parkinsn s Hypertensin Atrial Fibrillatin, patient n Cumadin/Warfarin Nte: The abve is a sample f sme cmmn chrnic cnditins. Prviders must dcument all chrnic cnditins annually. Cmbinatin Cdes A cmbinatin cde is a single cde used t classify: Tw diagnses A diagnsis with an assciated secndary prcess (manifestatin) A diagnsis with an assciated cmplicatin Use the single cde when it clearly identifies all f the elements dcumented in the diagnsis. 9-5

7 Cmplicatins and Manifestatins If a cmplicatin exists, cde t the specific cmplicatin and manifestatin, fr example, cde neurpathy due t diabetes. Use the ICD-9 cde that shws the causal relatinship. Cde all dcumented cnditins that c-exist at the time f the encunter that require r affect patient care, treatment, r management. D nt cde cnditins previusly treated that n lnger exist r affect current patient care r treatment. Use histry cdes when the cnditin impacts current care r treatment. Depressin Dcument specificity such as majr depressin, use f antidepressants, and single versus recurring events. Diabetes Cde all cmplicatins and manifestatins. Dcument direct causal relatinships befre diabetes and ther diseases, fr example, ulcer due t diabetes. Disease Interactins Certain cmbinatins f c-existing diseases greatly impact a member s health status. Prviders must dcument in the medical chart and n a claim, cmpletely and accurately, the fllwing cnditins annually: Diabetes Mellitus/Cngestive Heart Failure Diabetes Mellitus/Cerebrvascular Disease Cngestive Heart Failure/Chrnic Obstructive Pulmnary Disease Chrnic Obstructive Pulmnary Disease/Cerebrvascular Disease/Crnary Artery Disease Rheumatid Factr/Cngestive Heart Failure Rheumatid Factr/Cngestive Hear Failure/Diabetes Mellitus Nte: The abve list is a sample f sme disease interactins nly. Prviders must dcument all disease interactins. Histry Cdes D nt cde cnditins that were previusly treated and n lnger exist. Use histry cdes when the cnditin impacts current care r influences treatment. 9-6

8 Late Effects Residual cnditins that remain after the terminatin f the acute phase f an illness r injury, and shuld be cded if the medical recrd states, late, ld, due t (a previus injury r illness), fllwing (previus injury r illness), r traumatic (unless there is evidence f current injury). Neplasms Dcument the primary site, extensin, invasin, r metastasis. Dcument evidence/nn evidence f disease and current treatment. Prtein-Calrie r Energy Malnutritin Cde malnutritin specifically, and d nt cde weight lss as the diagnsis. Old Mycardial Infarctin Cde healed r ld mycardial infarctins currently presenting with n symptms. Dcument crnary artery disease. Other Medical Dcuments and/r Ntes Prvider ntes that reference diagnsis cdes frm ther surces such as, lab, radilgy, pathlgy, and hspital and cnsult ntes must cntain the prvider s clinical impressin f the reprts. Imprtant Reminder Yu can access new ICD-9-CM cdes frm the CMS website at: QUICK REFERENCE TIPS Primary care physicians must cnduct an initial health assessment f all new patients within 90 days f enrlment t yur practice. Primary care physicians must cnduct an annual assessment exam n all patients. Fully dcument all chrnic cnditins at least annually. Dcument evaluatin, mnitring and treatment activities in the medical recrd. Prperly reflect the member s health status and disease interactins by cding all cnditins evaluated, treated, r mnitred during each visit. 9-7

9 Cde t the highest level f ICD-9 cde specificity. Ensure dcumentatin is clear, cncise, cnsistent and legible. Ensure prvider signature is printed r typed n each chart entry with credentials and a legible signature. Ensure every page f the medical recrd identifies the patient by name and date f service. Ensure ffice staff understands the fundamentals f ICD-9 cding thrugh prper training. Update cde, bks and superbills yearly in Octber when ICD-9-CM cdes updated and released. Imprtant Reminder SOAP nte frmat assist in bth quality medical chart dcumentatin and diagnses cding. Fr questins r cncerns, please cntact the Alliance Prvider Services Department. WEB RESOURCES

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