Shellie Sulzberger, LPN, CPC, ICDCT-CM Coding & Compliance Initiatives, Inc.

Shellie Sulzberger, LPN, CPC, ICDCT-CM Coding & Compliance Initiatives, Inc.

Reasonable efforts have been made to provide the most accurate and current information on CPT 2015 code changes. However codes, guidelines, and policies are subject to change and interpretation. No guarantee is given that this presentation is free of errors, omissions, misuse, or misinterpretation and this presentation should not be considered a legal or authoritative opinion. This presentation does not replace coding manuals or other authoritative resources. Current Procedural Terminology (CPT ) copyright 2014 American Medical Association.

The audience will have a better understanding on the importance of submitting the correct CPT, HCPCS and ICD-9 codes for billing The audience will have a better understanding of how ancillary staff can assist the providers with documentation (i.e. what can the staff perform and document versus the provider)

We will outline some areas of documentation mishaps in an EMR and discuss the importance of specific documentation for each patient encounter

Proper procedure (CPT/HCPCS) and diagnosis (ICD) coding is not only critical for obtaining full and fair payment, it is also critical to ensuring proper compliance with the law.

Eliminating healthcare fraud and abuse has become a top priority for the federal government. "Fraud," "abuse," unbundling, overcoding," incorrect coding," and "compliance" have all become buzzwords in the industry.

Investigations are on the rise for providers in Healthcare. OIG Office of Inspector General DOJ Department of Justice CERT Comprehensive Error Rate Testing RAC Recovery Audit Contractors ZPICS Zone Program Integrity Contractors

Coding is how we communicate and report data within this federal entitlement system. Coding describes/documents the work and medical necessity for the services.

Determine reason for encounter Routine exam Wellness coverage through employer? Medicare patient needing to sign waiver for a complete physical or is this for a covered wellness visit? Medical illness Aids physician in prompting HPI questions Establishes intent of patient

Determine lab services Office should charge Resource lab should charge Assure encounter form is complete All charges captured Ancillary services marked Diagnosis indicated for services Record accident information If encounter form does not have this-record it for charge entry Chart services rendered by ancillary staff

Complete referral forms (when applicable) Obtain pre-certification/prior authorization Obtain Medicare waivers (ABN) for services that Medicare may not pay for Must have knowledge of LCDs and NCDs

Know billing regulations How to assign a level of service based upon the documentation and service rendered Know when you can and cannot charge OV with procedures Know the documentation requirements for billing specific services

Proper and needed for diagnosis and treatment of patient s medical condition Provided for diagnosis, direct care, and treatment of patient s medical condition Meet standards of good medical practice Not mainly for convenience of patient or physician Every service billed must indicate specific sign, symptom, or patient complain necessitating the service

Ability to evaluate and plan treatment and monitor health over time Communication and continuity of care Accurate and timely claims review and payment Utilization review and quality of care evaluations Data collection

1. Medical record should be complete and legible 2. Each encounter should include Reason for encounter, relevant history, physical examination findings, and prior test results Assessment, clinical impression, or diagnosis Plan for care Date and legible identity of observer

3. Rationale for ordering diagnostic tests 4. Diagnoses accessible to treating/consulting physicians 5. Identify health risk factors 6. Document patient's progress, response to and changes in treatment, and revision of diagnosis 7. CPT and ICD-9-CM codes on health claim form supported in medical record

Must be educated on documentation and coding guidelines Must understand what is required for the levels of E/M coding Must know the individuals providing the education are on their side Must show them what they have done well or need to work on with their own documentation

Assign ICD-9 diagnosis codes and may link diagnosis to procedures Assure diagnoses and procedures correlate Wellness exams with V codes E/M services with numeric ICD-9 codes E codes for accidents Understands modifier usage Review the instruction notes in the ICD-9 book Query physician when medical necessity has not been indicated

Must always be at least one (can be more) ICD-9 diagnosis The codes must apply to that particular visit The diagnosis code(s) should be linked and correlate with the procedure code(s) each procedure code must have a related ICD-9 diagnosis code

ICD-9 codes describe the patient s condition, not what was performed ICD-9 codes generally do not affect reimbursement for professional services, although is useful for physician profiling and for matching level of service to the patient s condition

Computerized physician order entry (CPOE) Legible Safeguards Improved compliance Timely testing Better patient care Improved tracking of ancillary and diagnostic tests combined Reduce duplicative services Broaden provider access

Improved documentation of the service actually provided when the EMR is used correctly Time and date stamping Legible notes Improved storage capabilities Paper charts were limited sometimes patient s had 2 and 3 volume charts Accessible from remote sites

Better communication Clinical summary Improved efficiency Allows you to track outcomes for quality care initiatives Improved outcomes Financial incentives More accurate billing and more efficient charge entry

There can be cloning notes from previous appointments The word 'cloning' refers to documentation that is worded exactly like previous entries. Medical necessity issues Source: Palmetto GBA Jurisdiction 11 Part B

Learning curve for the providers = decreased productivity Inadequate training can lead to increased coding Identical documentation

Inadequate training or lack of interest and attention can have negative impact on the provider and/or facility Mistakes Credibility Billing Liability

Loss of human touch and individuality Difficult to determine what the provider is recommending for the patient

Documentation is not always patient and chief complaint specific Inconsistencies in the documentation Difficult to determine who performed specific elements Power outages and computer crashes

Time and date stamping CPOE Templates limitations

The EMR can drive a provider to include documentation that is not applicable for the severity of the presenting problem. A 25 year old patient who comes in for a cough has documentation to support a complete review of systems (i.e. 10 or 12 point) and a family history because the EMR can automatically imports such text from the previous visit. Medicare and other payors will look to see whether the severity of the patient s problem matches the documentation, and if it doesn t it s a red flag.

Documentation templates default to multisystem reviews, exams, past problems that are no longer active, but still indicate Active Problems, etc. whether you do them or not. Usually it takes too much time and trouble to edit them out so the providers leave the information in the note for that date of service. Although excellent features of EMR systems, default settings and documentation templates can be dangerous

Patient presented with knee pain. A complete review of systems was documented including breasts and ob/gyn this was a male patient and breast and ob/gyn issues would be unrelated and not relevant for knee pain.

A specialty provider (cardiologist) saw a patient for heart issues. The provider saw the patient multiple times and on the initial visit the history and review of systems indicated the patient was coughing up blood and also their weight was down 10 pounds. Every note after the initial had the exact same review of systems, however, the history outlined the weight was up by xx pounds, etc.

I was asked to review several notes for a Work Comp case because the provider had a very high percentage of 99214. I reviewed 5 patients and looked at 3-4 dates of service for each patient. Only a few items changed with each review and there were documentation errors due to pulling the information forward, such as visit #1 when it was the third visit.

A gastrointestinal provider had a complete physical including genitourinary when evaluating the patient for a colonoscopy.

I was reviewing documentation in a surgeons office and noticed several instances where the ROS was positive for several items that were not addressed (i.e. short of breath, heart palpitations, chest pain, depression, etc.)

During a chart audit for a specialty provider I noted several instances where the documentation in the Review of Systems included several positives (i.e. shortness of breath, anxiety, depression, etc.) which may or may not have been related to the presenting problem. The provider did not address the positives anywhere in the record.

Obtain an independent assessment of your EMR documentation Evaluate the documentation in comparison to the presenting problem Review several dates of services, types of services, etc. Review 2-3 dates of service in for the same patient by the same provider Ask the auditor to look at the templates you have Is the template prompting for more information than required for the presenting problem

Ask for a list of everything that automatically pulls forward and a list of everything that can pull forward Query the provider on how they are using the EMR. Print out the note Can you tell who did what work?

Training done up front Reduces risk (legal liability) Saves time Saves money Improves compliance Decreases frustration Improves efficiency Assists in more accurate and timely documentation

Secret Patient A secret patient is similar to a secret shopper. Ask the patient to see a few of the providers with different issues and then determine if the documentation adequately reflects the work performed. Example: if a complete Review of Systems is documented was a complete Review of Systems performed?

Clearly understand who is doing what in the EMR. Audit trails offer a back end view of system use. Technology is only as good as the user. The leading cause of failure for Electronic Medical Record usage is inadequate training. Investing time and effort on the front end will ensure you get the best out of your system.

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.

Is your coding module turned on? Should we turn it on or leave it off?

Do your providers understand CPT coding? Do you perform internal and/or external chart reviews? If yes, what is your process? Do you offer lunch and learn sessions? Shadowing? Do the providers have a vested interest in coding correctly or is it not my problem?

Purchasing resources or contracting for assistance ask you self the following questions: Will the resource help mitigate compliance risk? Will the resource improved our bottom line? Will the resource improve accuracy? Will the resource help us be more efficient and effective?

Maintain your knowledge Specialize Monitor the coding patterns in the office Audit Educate all staff members Build payer relations Monitor appropriate Reimbursement

ssulzberger@ccipro.net 913-768-1212 www.ccipro.net