Auditing the EMR e 1 THE GOOD, THE BAD, AND THE AUDITS Topics Regulatory Landscape EMR Concerns Coding and Documentation Essentials Questions Regulatory Climate 3 1
Who s Watching. MACS Medicare Administrative Contractors MICS Medicaid Integrity Contractors ZPICS Zone Program Integrity Contractors RACS Recovery Audit Contractors CERT Comprehensive Error Rate Testing HHS OIG Office of the Inspector General, Department of Health and Human Services And everybody else..including New York Times Ask First, Pay Later.. Beginning in 2011, new legislation requires the Centers for Medicare & Medicaid Services (CMS) to do away with its methodology of paying claims first and asking questions second otherwise known as "pay and chase" and adopt billing software designed with predictive modeling capabilities. OIG Workplan 2012 Evaluation and Management Services: Trends in Coding of Claims. We will review (E/M) claims to identify trends in the coding from 2000-2009. We will also identify providers that exhibited questionable billing for E/M services in 2009. Medicare paid $32 billionfore/mservicesin2009,representing 19 percent of all Medicare Part B payments. Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. (FY 2012; work in progress) 2
OIG Work plan 2013 HHS OIG 2013 Work Plan outlining Payments for Evaluation and Management Services audit includes: Medicare contractors have noted an increased frequency of medical records with identical documentation across services. We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EMR) documentation practices associated with potentially improper payments (CMS s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12, 30.6.1.) (OEI; 04-10-00181; 04-10-00182; expected issue date: FY 2013; work in progress) RAC Expansion e 8 CMS has alerted the AMA that it has approved the RAC (Recovery Audit Contractors) Connolly to begin conducting audits of coding for E&M services in physician offices, specifically CPT code 99215 Complex Medical Reviews of 99215 vs. automated Permitted to extrapolate findings based on a statistical sample audited 2013 OIG Semi-Annual Report e 9 $3.8 billion recovered for the first half of FY2013 $521 million in audit receivables $3.28 billing in investigative receivables $642.3 million in non-hhs investigative receivables (State Medicaid share) 1,661 individuals and entities excluded 484 criminal actions 240 civil actions including FCA, CMP, Admin Recoveries, self-disclosures 3
HHS/ DOJ letter of September 2012 e 10 Sibelius/ Holder notice to American Hospital Association, Federation of American Hospitals Association of American Medical Colleges, Association of Academic Health Centers and National Association of Public Hospitals and Health Systems: The letter outlined troubling indications that some providers are using EMR technology to game the system, including the following fraud and abuse concerns: False documentation; Cloning of medical records in order to inflate provider payments (and risk medical errors); and Use of EMR to facilitate up-coding on intensity of care or severity of patient conditions. EMR Concerns 11 Templates Tools of efficiency tailored vs. generic Macros Auto-fill Concerns of cloning and repetitive documentation Support documentation vs. replace it Final record should reflect patients not template 4
Provider perspective Ease of Use Access, portability Coordination of care Efficiency/interfaces Payer Perspective Access for audit/ oversight Continuity, coordination of care Volume of detail and medical necessity Accuracy of documentation, cloning, up-coding, fraud Payer concerns Easy retrieval of ROS and/or PFSH data Macros on the PE Ease of recording prescriptive, diagnostic, management info and data 5
EMR Vulnerabilities Format and flow issues Clunky blocks of data Ease of integration of some sets of data Sometimes difficult to keep proportion Repetition added DX versus assessed Documentation Fatigue EMR Vulnerabilities, cont d Decision-making path How much was done TODAY vs. what is the entire history Shotgun vs. rifle approach TMI (too much information) Medical Necessity During repeated reviews we have noted the tendency to over-document and consequently to bill for a higher EM code than was medically reasonable and necessary. Word processing systems, the EMR and formatted note systems facilitate the carryover of stored and repetitive information. Even if a complete note is generated, only the medically reasonable and necessary services for the condition of the patient at the time of the encounter as documented can be considered when selecting the appropriate level of EM service. Information that has no pertinence cannot be counted. 6
Cloning Pre-documenting the record Getting the story straight The acid test: Would the clinician have dictated the information? If not, is it medically necessary? Why is the most important information hardest to find in these notes MEDICAL NECESSITY - MEDICARE PERSPECTIVE Information used by Medicare is contained within the medical record documentation of history, examination and medical decision-making. Medical necessity of E&M services is based on the following attributes of the service that affected the physician s documented work: Number, acuity, and severity/duration of problems addressed through history, physical and medical decision-making. The context of the encounter among all other services previously rendered for the same problem. Complexity of documented co-morbidities that clearly influenced physician work. Physical scope encompassed by the problems (number of physical systems affected by the problems). MEDICAL NECESSITY & EM: DOCUMENTATION GUIDANCE Identify all the presenting complaint(s) and/or reason(s) for the visit for which physician work occurred. Demonstrate clearly the history, physical and extent of medical decision-making associated with each problem. Demonstrate clearly how physician work (expressed in terms of mental effort, physical effort, time spent and risk to the patient) was affected by comorbidities or chronic problems listed. 7
In sum Decision-making make it clear Lists of problems or medications don t get it Noting vs. managing a problem How much was done TODAY versus what is the entire history, fabric of the patient. Coding and Documentation Essentials 23 EMR History Issues HPI and ROS (canned) discrepancy Canned ROS (proportion) HPI reports a problem not mentioned in exam (template) Abbreviations in the HPI Preferred HPI And of course everyone gets a full PFSH every time.. 8
The Exam.. PE s pro forma PE s loss of proportion needless detail dangerous detail Extremities versus organ systems Insight and judgment good on an 8 YO? Did you really do ALL THAT? Decision-making and Medical Necessity e 26 A/P lists problems not in HPI or PE Abbreviations in the A/P Preferred A/P discuss Documentation of providers cognitive work Machined A/Ps A/P or MDM Distortions e 27 A ) List of problems with no status A) List of problems with limited status choices (Centricity) P) List of meds with no linkages to the problems in A) P) return to clinic, RTC as needed, F/U 6 months Are those plans? 9
Other Chart Components e 28 The CC: Here for F/U, 6 month visit etc. this should match Canned time statements: (NextGen) Greater than 50% of spent in counseling and/or coordination care Macros Specificity is the key. How easy is it for the Provider to address the comment or other section and tell the whole story? Health education - Don t be alarmed if you weigh 5 lbs more at the end of this visit due to all the handouts the EMR says I gave you Lessons The payer/ auditor must be able to see what is being done within today s encounter Clear sense of what is happening w/the patient Proper language of risk, complexity, severity in the A/P Don t let the data become the chart Other issues 30 10
PATH: Residency Setting New level of generic documentation: 31 Patchwork of attending and Resident statements in the A/P area No longer two sets of handwriting and clear distinction between two providers of service Audit trail for forensic view of who wrote what PATH: Residency Setting, cont d e 32 Epic prints the residents name at the top of the note, and the attending signs at the bottom. Where does the resident work stop and attending begin? Some providers now do a combined note with an attestation that reads something along the lines of The above note reflects the combined entries of the resident and attending physician. I (the attending) have made corrections and additions as needed this is followed by a stock attestation. Does this meet Teaching Guideline criteria? PATH: Residency Setting, cont d CMS Transmittal 811: JANUARY 13, 2006 When using an electronic medical record, it is acceptable for the teaching physician to use a macro as the required personal documentation if the teaching physician adds it personally in a secured (password protected) system. In addition to the teaching physician s macro, either the resident or the teaching physician must provide customized information that is sufficient to support a medical necessity determination. The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date. It is insufficient documentation if the resident and the teaching physician use macros only. 11
Consultations e 34 All notes start with Patient Referred by Dr. XX Stock Header that says Consultation followed by PCP: Dr. YYY Notes finish up with Thank you for the referral and allowing me to participate in the care of your patient. Do we now need a cc:? Combining AVW with an E&M State in the CC that two services are being provided Here for AWV and Management/Assessment of Tell the patient that two services are being provided, i.e. We are here today to Document the Hx, exam and decision-making associated with the problem, and Assign both codes add the modifier Combining a non-medicare Preventive Service with an EM State in the CC that two services are being provided Here for Preventive/Health Maintenance Visit and Management/Assessment of Tell the patient that two services are being provided, i.e. We are here today to Document the Hx, exam and decision-making associated with the problem, and Assign both codes add the modifier 12
Auto-Coding EMRs e 37 Key questions to ask before implementation: What is the algorithm for selecting codes? Will it pick a level 5 established code based on Hx and PE? How does it calculate decision-making? Does it follow the tables strictly? (New problem + Rx = Mod MDM) Auto-Coding EMRs, cont d e 38 Does it down-code many new patients based on HPI? Can it read free-texted entries or only what is selected off the template? What drives the selection of consult codes? (For Medicare?) Does it suggest additional entries to code at a certain level? MD Coding Predispositions. To turn 4 s into 3 s To avoid 5 s To slack off on HPI detail and forget ROS To give the basics in the A/P To forget to code by time. Or to document time improperly 13
IF YOU... considered it suspected it reviewed it discussed it monitored it ruled it out were concerned about it thought about it for a fleeting moment blew it off entirely... DOCUMENT IT! Document Decision-Making In Assessment include DDX and any Suspected problems or concerns R/O Identify the Dx, Status and Rx/Tx or management of each problem This maps best to the Table of Risk Implications Compliance <=> Liability Profile <=> Revenue Quality of care..making it Real 14
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