How To Write A Health Insurance Claim Form

Transcription

1 Kim Huey, MJ, CPC, CCS-P, PCS, CPCO President, KGG Coding and Reimbursement Consulting April 16, 2015 Elements of Successful Coding in Your Practice Kim Huey, MJ, CPC, CCS P, PCS, CPCO for Medical Association of the State of Alabama April 16,

2 Principles of Medical Record Documentation Documentation of Medical Necessity Emphasis on Diagnosis Coding Risk Adjustment Coding Risks in the Electronic Medical Record General Principles of Medical Record Documentation from CMS Documentation Guidelines 1. The medical record should be complete and legible. 2. The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results; assessment, clinical impression or diagnosis; plan for care; and date and legible identity of the observer. 3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. 4. Past and present diagnoses should be accessible to the treating and/or consulting physician. 5. Appropriate health risk factors should be identified. 6. The patient s response to and changes in treatment, and revision of diagnosis should be documented. 7. The CPT and ICD 9 CM codes reported on the health insurance claim form should be supported by the documentation in the medical record. 2

3 Medical Necessity Wikipedia definition Medical necessity is a United States legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence based clinical standards of care. Other countries may have medical doctrines or legal rules covering broadly similar grounds. The term clinical medical necessityis also used. accessed March 26, 2015 About.com definition Health insurance companies provide coverage only for health related serves that they define or determine to be medically necessary. Medicare, for example, defines medically necessary as: Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. Medical necessity refers to a decision by your health plan that your treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem. 3

4 Attorney definition As explained to a client undergoing a Medicaid audit There is a difference between clinical medical necessity and billing medical necessity Just because YOU think it s medical necessary doesn t mean it s going to be AMA Definition Services or procedures that a prudent physician would provide to a patient in order to prevent, diagnose or treat an illness, injury or disease or the associated symptoms in a manner that is: In accordance with the generally accepted standard of medical practice. Clinically appropriate in terms of frequency, type, extent, site and duration. Not intended for the economic benefit of the health plan or purchaser or the convenience of the patient, physician or other health care provider. 4

5 Medicare Definition Medical necessity from a Medicare perspective is defined under Title XVIII of the Social Security Act, Section 1862 (a) (1) (a): No payment may be made under Part A or Part B for expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Evaluation and Management Per CMS Medicare Claims Processing Manual Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. 5

6 Evaluation and Management From the American Academy of Family Practice Medical necessity of an E&M service is generally expressed in two ways: frequency of services and intensity of service (CPT level) Medicare s determination of medical necessity is separate from its determination that the E/M service was rendered as billed. Medicare determines medical necessity largely through the experience and judgment of clinician coders along with the limited tools provided in CPT and by CMS. During an audit, Medicare will deny or adjust E/M services that, in its judgment, exceed the patient s documented needs Nature of Presenting Problem Evaluation and Management Nature of Presenting Problem (from the Table of Risk) Office Level of Service Inpatient Self limited or minor problem 99201/ Two or more self limited or minor problems One stable chronic illness Acute uncomplicated illness or injury One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis Acute illness with systemic symptoms Acute complicated injury One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment Acute or chronic illness or injury that poses a threat to life or bodily function Abrupt change in neurologic status

7 Claim Form Language Have you ever read the back of the form? I certify that the services shown on this form were medically indicated and necessary for the health of the patient Diagnosis Coding Correct/appropriate/specific diagnosis coding is critical But many diagnosis codes are not specific enough in themselves: For example, one insurer has the following policy for Supartz Failure of conservative treatment, i.e., physical therapy, weight loss, analgesic meds Duration of 6 months or longer X ray confirmation of diagnosis (Grade II or III) None of that information is conveyed by the diagnosis code ICD 10 will help but it will not solve the problem 7

8 Risk Adjustment What is it and how is it measured? Risk adjustment is the process of measuring the disease burden in a population. It is based on the acuity rating of diagnosis codes (ICD 9 CM/ICD 10 CM codes) reported on claims. These codes are derived from physician documentation in medical records. Clinical Information vs. Coding Guidelines Remember that the coder/biller cannot assume anything and that he/she does not have the clinical knowledge that the physician has The coder/biller can only assign a code if given the appropriate detailed information. 8

9 Diagnosis Documentation Issues Documentation must clearly indicate the reason for the visit and any coexisting conditions that affect treatment and care. Documentation for each visit must stand alone. Diagnosis indicated on encounter form/charge ticket/superbill but not documented in medical record If practice uses a problem list, it must be updated at each visit and referenced in the documentation for the date of service. Each progress note should be signed with credentials. (BAD) Examples BOMAMOX Warts. Done. 9

10 Steps to Correct Diagnosis Coding ICD 9 The appropriate code or codes from through V91.99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit. ICD 10 The appropriate code or codes from A00.0 through T88.9, Z00 Z99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit. 19 For accurate reporting of ICD 9 CM/ICD 10 CM diagnosis codes, the documentation should describe the patient s condition, using terminology which includes specific diagnoses as well as symptoms, problems or reasons for the encounter. CRITICAL!!! If the provider does not document the condition, it cannot be coded! No assuming allowed! 20 10

11 ICD 9 CM Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when an established diagnosis has not been confirmed by the physician. ICD 10 CM Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD 10 CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (codes R00 R99) contain many, but not all codes for symptoms. 21 ICD 9 CM provides codes to deal with encounters for circumstances other than a disease or injury. ICD 10 CM provides codes to deal with encounters for circumstances other than a disease or injury. The Factors Influencing Health Status and Contact with Health Services codes (Z00 99) is provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems

12 ICD 9 CM A code is invalid if it has not been coded to the full number of digits required for that code. ICD 10 CM ICD 10 CM is composed of codes with either 3, 4, 5, 6 or 7 digits. Codes with three digits are included in ICD 10 CM as the heading of a category of codes that may be further subdivided by the use of fourth fifth digits, sixth or seventh digits which provide greater specificity. A three digit code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character extension, if applicable. 23 List first the ICD 9 CM/ICD 10 CM code for the diagnosis, condition, problem or other reason for the encounter shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. ICD 10 CM adds the following sentence: In some cases the first listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician

13 Do not code diagnoses documented as probable, suspected, questionable, rule out, or working diagnosis. Rather, code the condition(s) to the highest degree of certainty for that encounter, such as symptoms, signs, abnormal test results, or other reason for the visit. Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s). 25 Code all documented conditions that coexist at the time of the encounter, and require or affect patient care, treatment, or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10 V19 in ICD 9 CM, Z80 Z87 in ICD 10 CM) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. This is the key to appropriate risk adjustment! 26 13

14 Issues with EMR Documentation Is meaningful use really meaningful? Is information available between entities? Is the quality of care improved or even maintained? Is the health information secure? Are medically necessary services provided, documented, billed for, and reimbursed appropriately? Balancing Medical Necessity and Meaningful Use Bringing forward medical history in an EMR is an important aspect of meaningful use Does this mean that you can count that comprehensive history toward the level of service for every encounter now and forevermore? What about medical necessity of elements? For example, vitals on every patient? 14

15 Physician Response Study: What Do Physicians Read (and Ignore) in Electronic Progress Notes? Most attention given to Impression and Plan Very little attention given to vital signs, medication lists, and laboratory results Optimizing the design of electronic notes may include rethinking the amount and format of imported patient data as this data appears to largely be ignored. Applied Clinical Informatics Concerns with electronic records and overcoding The Center for Public Integrity September 2012 coding levels may be accelerating in part because of increased use of electronic health records. 15

16 Sebelius Holder Letter September 24, 2012 False documentation of patient care is not just bad patient care; it s illegal. The indications include potential cloning of records in order to inflate what providers get paid. 9/25/business/25medicare doc.html Congressional Response October 4, 2012 letter to HHS Secretary Sebelius your EHR incentive program appears to be doing more harm than good. Request Suspension of EHR bonus payments and delay penalties for providers who don t use EHR Increase what s expected of meaningful users Block business practices that prevent exchange of information 16

17 OIG Workplan for 2012 We will assess the extent to which CMS made potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service based upon the content of the service and have documentation to support the level of service reported. What are the auditors looking for? Authentication signatures, dates/times who did what? (metadata?) Contradictions between HPI and ROS, exam elements Wording or grammatical errors/anomalies Medically implausible documentation 17

18 Code Generators Is the coding software programmed for the 1995 or 1997 Documentation Guidelines? Has the coding software been programmed to account for medical policies specific to the local Medicare contractor? How does the coding software manage dictated portions of the encounter such as History of Present Illness? How does the coding software distinguish between the levels of medical decision making? Templates Is the provider able to choose only part of a template or to personalize a template? Are there multiple templates, personalized for complaint or diagnosis? Are the various contributors to the encounter identified? Nursing staff, physician, etc. 18

19 Cloned Notes Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. First Coast Service Options, Medicare Part B newsletter 2006 Cloning The November/December 1999 Medicare Bulletin states: Cloned notes are notes that have little or no change from day to day and patient to patient. These types of notes do not support the medical necessity of a visit. More importantly, in some cases, they may not actually support that a visit occurred. Cloned notes may be construed as an attempt to defraud the Medicare program. 19

20 Cloned Documentation Whether the documentation was the result of an Electronic Health Record, or the use of a pre printed template, or handwritten documentation, cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient. Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments made. NGS Medicare Why copy and paste? most physicians use the functionality simply to save time. They have not been given the time and training needed to become fully proficient with their new systems, so they create workarounds to help them get through their day. Heather Haugen, PhD Overcoming the Risks of Copy and Paste in EHRs Journal of AHIMA, June

21 June 2014 JAMA Internal Medicine University of Wisconsin School of Medicine and Public Health and the University of Wisconsin Hospital and Clinics: it is too easy, and often mistaken, to equate a physician s routine use of copy and paste with fraud. Data replication is a feature of electronic health records; facts beyond the mere use of duplicated text are required to establish that a note may be fraudulent. It can be efficient and clinically useful when used properly, and that EHRs are not to blame for the carelessness of individual physicians. Issues with Copy and Paste Outdated or redundant information Inability to identify the author or date of origin of information Unnecessarily lengthy notes Appearance of fraudulent activity e.g., billing twice for the same work Quality of care and medico legal integrity are compromised 21

22 Diagnosis Coding Have the physicians been educated in diagnosis coding? Has the diagnosis code listing been personalized for that practice and that physician? As more physician payment mechanisms are based on severity of illness, correct and specific diagnosis coding becomes more important to the physician. Finalizing the Documentation Code Selection Is the physician able to override the code selected by the EHR? Can he/she override the code to a higher level or only to a lower level of service? Signatures Is the provider able to sign off on multiple items with one sign off multiple encounters, test results, phone calls, prescriptions 22

23 Timing of Billing Is the documentation complete before the encounter is billed? For ancillary services, is the bill dropped based when the order is entered or when the test is performed and results entered? Kim Huey, MJ, CPC, CCS P, PCS, CPCO 205/ /