Electronic Medical Records: Auditing Challenges and Associated Risks

Transcription

1 Electronic Medical Records: Auditing Challenges and Associated Risks HCCA Compliance Institute Georgette Gustin, CPC, CCS-P, CHC Faith Marie Hope, CPC, CCS-P, CHC Nemours, Director Coding & Billing Compliance April 2009 Today s Discussion Points Impact on the coding and documentation auditing process Visit Types Time based services Modifiers Units/Quantities Conflicting diagnoses (lets discuss next time) Incident-to services Teaching Physician services Excision & Destruction Lesions Global Surgical Package Practical auditing tips Best practice discussion Questions/Answers 1 1

2 The way Medicare looks at an EMR, nothing has changed in its rules from using paper. Instead of pencil and paper, it s pixels and bytes. Dr. Debra Patterson Medicare Medical Director TrailBlazer Health Enterprises Medicare Compliance Alert June 2, Auditing Challenges Auditing EMR creates new challenges Integrity of the record Controls around access Who documented what? Signatures/authentication Cut/copy/paste features Cloning (defaulted documentation) Macro s How clinical documentation is filed within the EMR (understanding the protocols) 3 2

3 Auditing Challenges (cont d) Determining appropriate visit type and E&M category New Established Consultation Preventive Medicine Evaluating workflows associated with time-based codes Documentation of drugs, supplies and equipment Identifying consultation requests/written reports Interface with existing programs and processes 4 Auditing Challenges: Visit Types New versus Established Patient Specialty Designation Types Medicare Definition: Physicians Group Practice Consultations Preventive Medicine & E&M Problem Oriented Visit Same Day 5 3

4 Auditing Challenges: Time Based Services Analyzing all CPT codes to understand which have time elements E&M based on >50% of visit dominated by counseling and coordination of care Critical care services Genetic counseling Psychotherapy Neuropsychological testing 6 Auditing Challenges: Modifiers Depending in the EMR system functionality there maybe several places in which a modifier can be assigned at: E&M code level charge capture Procedure charge capture level 7 4

5 Auditing Challenges: Units/Quantities Inaccurate or missing units/quantities when appropriate Essential for time based codes such as, PT/OT services, allergy testing, etc. Applying units for codes that are not unit based (e.g., psychotherapy, E&M, etc) Incorrectly reporting units for administered medications Example, 40 mg of Kenalog injected = 4 units Multiple units to represent number of nerves for Nerve Conduction Studies 8 Auditing Challenges: Incident-to Services Identifying a plan of care has been established by the physician Evaluating whether or not the supervision requirements have been met How is this validated? Determining how new problems or new patients will be triaged with non-physician practitioners\ Make Me the Author feature 9 5

6 Auditing Challenges: Excision/Destruction Pre-malignant lesions Determining how the diagnosis and/or CPT code(s) will be modified for charge capture based on pathology report findings Excision of pre-malignant lesion (face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm) CPT code RVUs 4.53 Excision of malignant lesion (face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm) CPT code RVUs 6.80 Establishing protocols and training around the use of addendums 10 Auditing Challenges: Global Surgical Package Identifying multiple providers and/or specialties that maybe involved in various aspects of the global surgical package Pre-operative Intra-operative Post-operative Evaluating back-end system capabilities Process for appending modifiers Reviewing the workflow Determining which modifiers can be handled by the system vs. requiring providers to append Developing appropriate education and training for providers 11 6

7 Payer Concerns Cigna Cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made. Cigna Government Services Medical Record Cloning Documentation Reminder. Medical Bulletin Part B; March/April First Coast Service Options 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 to see that every patient had the exact same problem, symptoms and required the same treatment. First Coast Service Options Requirements for the Payment of Medicare Claims A Selection of Some Important Criteria. Medicare Part B Update 4, No 3 (3 rd Qtr 2006) 13 7

8 Planning the EMR Audit Identify stakeholders: HIM Clinical Informatics Coders Physicians Compliance Internal Counsel Obtain and review the following: Policies & Procedures Departmental templates EMR process flows Training material 14 Auditing Copy Functionality If utilization of copy functionality is available as an auditable event, review a sample of it s use Review a list of patients re-admitted within a certain amount of time (i.e. within 30 days, 3 months). Randomly audit documentation such as readmissions history & physicals Review patients on a teaching service to verify original documentation by medical students & residents Consider using coders or clinical documentation specialists to identify copy practices when reviewing for chart completeness Determine if you have copy functionalities that originate in software other than the EMR such as copy in Microsoft Windows Source: AHIMA Copy Functionality Toolkit

9 Copy Functionality Policies & Procedures Determine how & when audits will be conducted Who will perform these concurrent audits Establish frequency, time period and sample size Identifies how the sample is determined Identifies a description of the outcome indicators Determines how copy functionalities within the record are identified Establish a corrective action plan based on findings Provides a detailed list of copy functionalities as they exist in the EMR Provides testing of copy functionalities prior to implementation and prior to version upgrades Source: Journal of AHIMA/January Get It Right the First Time Physician education is critical: Not clearly defining the learning objectives upfront Lack of evaluating and understanding the workflows Providing the training to far in advance of the go-live Not allowing adequate time to provide training Providing insufficient training materials or job aides Using the wrong type of instructional trainer Not providing an opportunity for practice and feedback Lack of sponsorship and commitment at all levels 17 9

10 Take-Away Pearls Get involved early and often Identify who is responsible for maintaining and updating clinical content (e.g., masterfiles, clinical content, etc.) Attend EMR Physician Training sessions Partner with Clinical Infomatics Perform audits prior to implementation and soon after install to identify risks 18 Questions/Answers Georgette Gustin, CPC, CCS-P, CHC (317) or Faith Marie Hope, CPC, CCS-P, CHC Nemours Children Health System (302) or 19 10