Rehabilitation Management
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Transcript Rehabilitation Management
Coding, Documentation, and
Data Management
Kyle C. Dennis, Ph.D.,
Deputy Director, Audiology &
Speech Pathology Service
Department of Veterans Affairs
Session Objectives
Understand basic code systems and
development of codes
Understand basic organization and principles of
procedure and disease coding
Understand basic principles of coding and billing
Understand basic principles of documentation
Topics for Discussion
Coding systems
Procedure codes
Disease codes
Coding, billing, and compliance
Documentation
Referral guidelines and service
agreements
How are codes used?
Revenue generation (reimbursement)
Documentation of services
Workload and utilization
Productivity
Cost analysis
Provider profiles (privileging)
Analysis, health research, and trending
Why is coding compliance so
important in data management?
Critical to workload and data capture
Critical to resource allocation
Critical for health care planning
Critical to third-party (insurance)
reimbursement
Must conform to uniform national
standards (CMS compliance)
…and more importantly
Demonstrates adherence to community
standards of care
Demonstrates accountability to patients
and stakeholders
Demonstrates to stakeholders that critical
services and special programs are
maintained
Basic Management Questions
How much work did my clinic do?
What did it cost?
Can I bill for it?
If I can’t bill for it, does it affect my costs
and productivity?
How much revenue did I generate?
Is my clinic a “value-added” service?
Is my clinic efficient?
Basic Data Elements
Patient demographics (name, SSN)
Diagnoses, conditions, symptoms, or
problems
Procedures or services
Provider
Successful capture of encounter data
requires these basic elements.
Basic Data Flow
AppointmentVisitEncounter
Encounter datadatabase=management
reports, analyses, and trends
Encounter databilling
system=reasonable charges=revenue
Important…accurate coding is essential
because data management systems are
linked. It all starts with the basic data
elements.
The Manager’s Task
Use various data systems to optimize workload,
efficiency, utilization, costs, and revenue generation
Benefits to the organization
data-driven decision making
maximized value
quality improvement
accountability
justification of resources
tracking of utilization, costs, and health care trends
predictable, consistent health care delivery
Coding Systems
Topics for Discussion
Coding Systems
Procedure Codes
Disease Codes
Coding and Billing
Documentation
Procedure Coding Systems
Healthcare Common Procedure Coding
System (HCPCS)
Current Procedural Terminology (CPT)
HCPCS Level II (National or HCPCS)
ICD-9 PCS
Future: ICD-10 and ICD-10 PCS
Disease Coding
International Classification of Diseases,
Ninth Edition, with Clinical Modifications
(ICD-9-CM)
Future: International Classification of
Diseases, Tenth Edition (ICD-10-CM)
Future Code Systems
ICD-10-CM
Developed by World Health Organization
Clinical modification for U.S. developed by
National Center for Health Statistics
ICD-10 PCS developed by 3M under
contract from CMS
HIPAA mandates universal code system.
ICD-10-CM
Ear and hearing problems found in
Chapter 8
More descriptive than ICD-9-CM
Examples:
H90.3--bilateral SNHL
H90.4--unilateral SNHL with unrestricted
hearing on contralateral side
ICD-10 PCS
Greatly expands procedures codes
Not proprietary
Example: Pure tone audiometry-9C03Z1C
9=Rehabilitation and Diagnostic Audiology
C=assessment
03=test method (pure audiometry)
Z=body system (none)
1=equipment (audiometer)
C=qualifier (individual)
HCPCS Codes
Level I--Current Procedural Terminology
(CPT-4)
Level II--National codes
Level III-local codes used by Medicare
intermediaries, no longer used
Modifiers for Level I and Level II
CPT Codes
Copyrighted and published by AMA
Five digit codes (e.g. 99211)
Revised annually by AMA
Describes physician and non-physician
services by specialty
Complexity- or time-based
Includes modifiers
Organization of CPT Codes
Evaluation & Management (99201-99499)
Anesthesiology (00100-01999, 99100-99140)
Surgery (10040-69990)
Radiology (70010-79999)
Pathology and Laboratory (80049-89399)
Medicine (90281-99199)
Miscellaneous Services (99000-99090)
CPT Modifiers (Appendix A)
Categories of CPT Codes
Category I--procedures and services
(5 digits)
Category II--performance measurement
(4 digits followed by a letter)
Category III--temporary codes (4 digits
followed by a letter)
HCPCS Level II (National) Codes
Supplemental codes
Updated annually by CMS
Designated by letter and four digits (e.g.
V5020)
Ambulance services, dental services,
durable medical devices, drugs and
injections, home services, non-covered
services, temporary and experimental
codes
What is New for 2003?
New Evaluation and Therapeutic Section
in the Otolaryngology Section (92500series)
Cochlear implant codes
Major changes for Speech Pathology
New unlisted ENT service code (92700)
How are CPT Codes Developed?
Developed and copyrighted by AMA
CPT Editorial Panel--16-member panel
meets quarterly to revise, update or
modify CPT codes
Health Care Professionals Advisory
Committee (HCPAC)--14-member nonphysician advisory panel. ASHA represents
Audiology and Speech Pathology with AAA
as an observer
How are CPT Codes Developed?
Resource-based Relative Value System
Update Committee (RUC)--29-member
panel assigns reimbursement value
RUC HCPAC Review Board--recommends
reimbursement for non-physician codes
Practice Expense Advisory Committee
(PEAC)--being phased out
How are CPT Codes Developed?
Application to Editorial Panel--must be
FDA approved, proven benefit in peerreviewed literature, widely used, standard
of care (category I codes)
Application sent to RUC or RUC HCPAC for
review and value determination
CMS generally follows AMA
recommendations
Calculating RVU
Physician work (55%)
Practice expense (42%)
Medical liability insurance (3%)
RUC determines only the physician work
and practice expenses
Global RVU x Medicare conversion
factor=dollar reimbursement value
Practice Expenses
Most Audiology procedures do not involve
physician work.
Resource-based relative values (RBRVU)
include practice expenses (e.g. clinic
labor, equipment, supplies).
Sources of data: Socioeconomic
Monitoring Survey (SMS) and Clinical
Practice Expert Panel (CPEP)
Practice Expenses
SMS data is used to calculate physician
practice expense per hour (PE/HR)
SMS includes clinical staff time but does
not include independent audiologists.
CMS created “zero work pool”, now called
the Non-physician Work Pool (NPWP)
Practice Expense Data
Where do Audiology practice expenses
come from?
All physician PE/HR average (SMS) and
clinical staff time (CPEP) for procedure
CMS calculates an expense pool (e.g.
clinical labor) using “all-physician” PE/HR
and the CPEP average clinical staff time
Data may not be accurate for audiologists.
How Does this Affect
Audiologists?
70% of Audiology codes are in the NPWP
90.6% of Audiology revenue comes from
NPWP, highest of any clinical specialty
NPWP does not accurately reflect true
practice expenses
Options: obtain survey data or continue to
use physician data
Pros and Cons
Are audiologist practice expenses more
than physician expenses?
All-physician average: $69.00 per hour
ENT: $105.70 per hour
Many physician specialties are included in
NPWP (e.g. oncology, radiology, internal
medicine, cardiology)
If some physician groups leave the NPWP,
the remaining groups will be paid less.
Professional & Technical
Codes may not have physician work value
Some codes have technical (TC) and
professional (26) components.
Professional component=physician work
(May be billed by audiologists.)
Technical component=practice expense
Most Audiology codes do not have
physician work.
RVU Example 1--92585-TC
Technical procedure without interpretation
Physician work--0.0
Practice expense--1.18
Malpractice--.10
Non-facility RVU--1.26
Medicare fee (unadjusted)--$44.28
RVU Example 2--92585-26
Professional component
Physician work--0.50
Practice expense--.22
Malpractice--.02
Non-facility RVU--.74
Medicare fee (unadjusted)--$25.60
Notice how small the professional fee is
compared the technical fee.
RVU Example 3--92585 Global
Physician work--.50
Practice expense--2.06
Malpractice--.14
Non-facility RVU--2.70
Medicare fee (unadjusted)--$93.40
Global can be billed by audiologists.
Complexity-based Codes
Unless otherwise specified, procedures
are based on complexity
Enter one code per procedure regardless
of time spent
Most CPT codes are complexity-based.
Time-based Codes
Time period is specified (e.g. 15 minutes)
Enter one code for each time period
Total volume=total time
Example: 2 units=30 minutes for a 15minute procedure
Few Audiology codes are time-based.
Time must be documented.
Audiology Services
CPT codes in the 92500-series
Technical and professional services
Do not require supervision by a physician
Performed by qualified audiologists
Must be ordered by a physician to be
billed.
General Purpose Codes
92506--evaluation of auditory processing
and/or aural rehabilitation status
92507--treatment of auditory processing
disorder (includes aural rehabilitation)
92508--group treatment
Often used (and abused) for hearing
evaluation and treatment, not elsewhere
classified
Audiology Treatment Codes
Audiologists cannot be reimbursed for
treatment services under Medicare
69200--foreign body removal
69210--cerumen management
97112--vestibular rehabilitation
Implant Services
Cochlear implant evaluation: Use
audiological assessment codes
Post-op analysis and fitting:
92601--Diagnostic analysis of CI, <7 yoa
92602--Subsequent programming, < 7 yoa
92603--Diagnostic analysis of CI, >7 yoa
92604--Subsequent programming, > 7 yoa
Billable as diagnostic services
CI Rehab (treatment)--92510 or 92507?
Implant Services
No specific codes for brainstem implants
Use codes for cochlear implant
With diagnosis of vestibular schwannoma
(225.1) or NF-2 (237.72)
Vestibular Function Tests
With electrical recording
92541--spontaneous nystagmus test
92542--positional nystagmus test
92543--caloric vestibular test, each irrigation
92544--optokinetic nystagmus test
92545--oscillating tracking test (pursuit)
92546--sinusoidal vertical axis rotation test
Vestibular Function Tests
92547--use of vertical channel recording
Add-on code--usually limited to 92541
and 92542
No specific code for saccades (use
92700)
Vestibular Function Tests
Observation without electrical recording
No reimbursement value
92531--spontaneous nystagmus
92532--positional nystagmus
92533--caloric vestibular test
92534--optokinetic nystagmus
Audiological Assessment Codes
92551--screening test, air only
92552--pure tone audiometry, air only
92553--pure tone audiometry, air/bone
92555--SRT
92556--SRT and speech recognition
No code for PI/PB (use modifier 22)
Audiological Assessment Codes
92557--comprehensive audiometry
Bundled code (includes 92553 and 92556)
Do not code separately if all component
tests are performed
92559--group audiometric test
Middle-ear Function Tests
92567--acoustic immittance
(tympanometry)
92568--acoustic reflexes
92569--acoustic reflex decay
Site of Lesion Tests
92571--filtered speech test
92572--SSW
92576--SSI (ICM or CCM)
92563--tone decay test
92564--SISI
92565--pure tone Stenger test
92577--speech Stenger test
92589--central auditory function test
Less Commonly Used
Procedures
92573--Lombard test
92575--SAL
92562--loudness balance test (ABLB)
92560--Bekesy screening test
92561--Bekesy diagnostic test
Electrophysiological Tests
92584--electrocochleography
92586--auditory evoked potentials, screening
92585--auditory evoked potentials (ABR, MLR,
late potentials), diagnostic
92587--otoacoustic emissions, screening
92588--otoacoustic emissions, diagnostic
95920--intraoperative monitoring (added on to
primary procedure, e.g. 92585)
Hearing Aid Services
92590--HAE, monaural
92591--HAE, binaural
92592--hearing aid check, monaural
92593--hearing aid check, binaural
V5014--hearing aid repair
92594--electroacoustic test, monaural
92595--electroacoustic test, binaural
Hearing Aid Services
Programming--Use 92594 or 92595
Ear impression--V5275
Real-ear measurement--V5020
Otoscopy is part of examination and is not
coded separately. Video-otoscopy is
diagnostic and is coded as 92700.
Hearing Aid Services
97703 (each 15 min)--hearing aid orientation
92506--outcome measures
92507-aural rehabilitation (except implant)
Considered to be part of fitting*:
device ordering/handling (99002)
special supplies (99070)
patient education materials (99071)
group patient education (99078)
*not billable by audiologists
Evaluation & Management
Level of care determined by complexity
Time determines level only for counseling
and coordination of care
Office visits, inpatient services, consults,
case management, prevention, disability
assessment
Evaluation & Management
Cannot be billed Medicare, Medi-gap, and
many third-party payers but may be billed
to some HMOs
Controversy: use E&M? 99499? 99211?
99211 is allowed but does not describe level
of service. 99499 is unspecified service and
may not pass through billing system. Not
appropriate when more specific codes are
applicable.
Balance Treatment
Audiologists treat vestibular disorders including
BPPV.
Peripheral vestibular rehab (canalith
repositioning) is within the audiologist’s scope of
practice. Code 97112.
PT/OT treats global balance problems (sensory
integration, proprioception).
Dynamic posturography (92548) is within the
PM&R scope of practice.
Global vestibular rehabilitation (97112).
Audiology: HCPCS Codes
V5008-hearing screening
V5010-V5298--hearing aid services
V5299--miscellaneous hearing service
L8614--cochlear implant device/system
L8619--speech processor replacement
L7510--repair of prosthetic device (not
hearing aid)
CPT Modifiers
CPT Modifiers
31 CPT modifiers
6 Anesthesia modifiers
13 Ambulatory Surgery modifiers
Why Use Modifiers?
To indicate that a service was more or less
complex than typical
To indicate that a service was repeated or
discontinued
To add more information regarding the purpose
or anatomic site of the procedure
To help to eliminate the appearance of duplicate
billing
To help to eliminate the appearance of
unbundling (fragmentation).
CPT Modifiers
Not all modifiers are appropriate for use
by audiologists
Modifiers should be used when
appropriate to describe or clarify the
service provided.
Not all modifiers may be applicable to all
codes.
CPT Modifiers
22--unusual procedural service
26--professional component (interpretation)
51--multiple procedures during same encounter
52--reduced service. Example: unilateral
procedure when bilateral is assumed.
CPT Modifiers
53--discontinued procedure
59--distinct procedural service on same day
76--repeat procedure by same provider
77--repeat procedure by other provider
99--multiple modifiers
CPT Modifiers
The following modifiers are restricted:
50--bilateral procedure
76 and 77--not used for quality control or
verification
Other modifiers clearly identified as medical
or surgical (21, 23, 24, 25, 27, 32, 47, 54, 55,
56, 57, 58, 62, 66, 73, 74, 78, 79, 80, 81, 82,
90, 91)
Physical status modifiers (P1, P2, P3, P4,
P5, P6)
HCPCS Modifiers
TC--technical component
CC--procedure code change
RP--repair/replace prosthetic device
RR--rental or lease of DME or prosthetic
device
ICD-9 PCS
Used mainly for inpatient procedures
CPT used exclusively in U.S. for outpatient
procedure coding
Surgical procedures (00.01-86.99)
Diagnostic and therapeutic procedures
(87.01-99.9)
Hearing tests (95.41-95.49)
ICD-10-CM
Replaces ICD-9-CM
Disease and procedure sections
ICD-10 PCS proposed as replacement for
CPT
AMA opposes ICD-10 PCS and is
developing a new system, CPT-5
Disease Coding
Structure of ICD-9-CM
3-, 4-, and 5-digit codes indicating levels
of specificity
Updated annually by working group
Diseases and injuries (001-999)
Factors influencing health status and
contact with health services (V-codes)
External causes of injury or poisoning (Ecodes)
Principles of Disease Coding
General rule: code to the highest degree
of medical certainty.
Use the most specific code possible.
Avoid NOS and NEC codes.
Non-physicians may code symptoms.
Choice of disease code has a great
affect on reimbursement.
NEC and NOS Codes
NEC--not elsewhere classified (xxx.x8)
NOS--not otherwise specified (xxx.x9)
NEC means that no appropriate code was
found in the tabular list based on the
information provided.
NOS means that the condition was not
adequately described by the provider.
NOS codes are usually not accepted
Inpatient Disease Coding
Principal diagnosis (DXLS)--condition
established after study that occasioned
the admission
V-codes are rarely used as principal
diagnoses and rarely stand alone.
Exception: rehab services
Inpatient Disease Coding
“possible”, “probable”, “suspected”, or
“rule out” diagnoses are coded as
confirmed.
“rule out”--diagnosis is possible
“ruled out”--diagnosis is not possible
If condition is ruled out, it is not coded.
Abnormal findings are not coded unless
the clinic significance is indicated.
Inpatient Disease Coding
Conditions that have no bearing on current stay
are not coded.
All conditions observed during evaluation are
coded.
Only conditions treated or that have direct
bearing on the condition being treated are
coded during treatment.
Conditions that are integral to a disease
process are not coded separately.
Outpatient Disease Coding
Condition that is chiefly responsible for the
patient’s visit is the primary diagnosis.
Primary diagnosis may be a disease, condition,
problem, symptom, injury, or reason for
encounter.
Secondary diagnoses may describe co-existing
conditions, symptoms, or reasons
Do not code conditions previously treated and
no longer exist.
Outpatient Disease Coding
Do not code “probable”, “suspected”,
“questionable”, or “rule out” diagnoses.
Code to the highest degree medical
certainty. If unsure, code symptoms or
reasons.
Symptoms may be coded as primary if a
confirmed diagnosed has not been
assigned.
As a general rule, follow outpatient rules
Primary and Secondary
Primary Diagnosis: disease, symptom,
condition or reason that is chiefly
responsible for the visit.
Secondary Diagnosis: other diagnoses
(e.g. relevant chronic conditions),
conditions that have impact on care, or
other conditions found after study.
Primary and Secondary
For treatment services:
Primary Diagnosis: reason that is chiefly
responsible for the visit.
Secondary Diagnosis: Condition treated and
other diagnoses (e.g. relevant chronic
conditions) or other conditions found after
study.
Routine or Administrative Exams
Primary Diagnosis: appropriate V-code to
indicate the reason for the exam
Secondary Diagnosis: any diagnoses,
conditions, or symptoms found after study
Organization of V-codes
Health hazards related to communicable diseases
(V01-V06)
Health hazards related to personal or family history
(V10-V19)
Reproduction and development (V20-V29)
Classification of live births (V30-V39)
Conditions influencing health status (V40-V49)
Specific procedures and after-care (V50-V59)
Other circumstances (V60-V68)
Persons without diagnosis (V70-82)
V-codes
Do not confuse ICD-9-CM V-codes with
HCPCS Level II V-codes.
ICD-9-CM codes are diseases, conditions,
symptoms, or reasons.
HCPCS Level II codes are procedures.
V-codes
Some V-codes must be coded as primary;
others are coded as secondary
Consult your ICD-9-CM guide or your
local registered health information
specialist
Audiology: ICD-9-CM V-codes
V19.2 (family history of hearing loss)
V41.2 (problems with hearing)
V53.2 (fitting/adjustment of hearing aid)
V65.2 (non-organic condition)
V71.8 (observation for suspected condition)
V70.5 (disability exam)
Normal Function
There is no ICD-9-CM code for normal
function. Normal function is not coded as
a disease.
V65.5 when there are no risk factors.
V71.89 when there is clinical reason to
suspect a problem.
Coding and Billing
Caveats
Every insurance carrier has its own rules.
Coding is not the same as billing.
Coding errors may lead to billing errors
Even accurate coding may lead to errors.
Not all billed codes are reimbursable.
Not all encounter codes are appropriate or
billable.
Billing errors, however innocent, may be
viewed insurance fraud.
Coding Rules
Coding must conform to uniform coding
standards.
CMS has the right to audit medical
records, levy fines, and file claims for false
and fraudulent billing.
Insurance carriers may also audit medical
records and file civil claims for fraud and
abuse. May lead to civil and/or criminal
penalties
What is Required to Assure
Accuracy (compliance)?
Billing codes must match documentation.
Documentation must support the scope and
level of service (complexity or time).
CPT codes must match diagnosis.
Services must be appropriate by provider type.
Services must be ordered by a physician (in
writing)
What will Medicare audit?
Eligibility processes, identification and verification of
insurance
Medical record documentation, legibility, and accuracy of
medical terms
Medical record completeness
Consistency of descriptive and decision-making terms in
the medical record
Accuracy of encounter forms
Matching of medical terms in the record with encounter
codes
Accuracy of codes on claim form and bill sent
Reasons for Fraudulent Billing
Inadequate documentation
Improper coding
Services not provided
Fragmentation (unbundling)
Lack of medical necessity
Role of the Provider
Fully document clinical care
Provider is responsible documentation
Use accurate encounter forms
Encounter form is a tool. Documentation
is what is important.
Follow applicable coding and
documentation guidelines
Assist in verifying claims
Coding Dilemma: Data Capture vs. Billing
Data capture: enter codes that
appropriately describe the service
provided.
Purpose: workload reports, costing,
staffing, efficiency, health care trends,
research
Coding Dilemma: Data Capture vs. Billing
Billing: enter codes that is appropriately
describe the service provided
Purpose: revenue generation
Coding Dilemma: Data Capture vs. Billing
Problems: Not all codes entered for data
capture purposes are appropriate for billing.
Exceptions: codes entered into non-billable
clinics, codes without charges
High probability of errors if data capture and
billing systems are linked.
Concerns: Codes may be eliminated if they are
not appropriate by provider type. Problematic
codes may be restricted or removed from
encounter forms or software.
Lesson
Provider must know the reason for
coding:
Data capture (workload, costing, etc.)
Reimbursement (revenue generation)
Define the purpose of coding up front.
Coding rules are different for each
purpose.
What Can Be Done to Improve
Coding?
Coding handbooks and guidelines
Standard encounter forms (super bills)
Education
Good dialogue with coding and billing
officials
Electronic aids (templates, code filters,
prompts, taxonomies, e.g. CHCS-2)
Provider Billing
Providers may bill for services (e.g.
physician services).
Non-providers: Other types of
practitioners may provide services but
procedures are billed as ancillary or facility
charges.
Facility decides who is a provider.
Billing by Non-providers
Audiologists may bill for global (TC + 26
components).
Audiologists may not bill Medicare for
physician (E&M) services.
Technical services may be billed as facility
charges if the procedure has technical
(TC) and professional (26) components.
Technical services are facility charges
regardless of who provides the service.
Professional and Technical Services
Some CPT codes have both technical and
professional components.
Technical component includes the time of the
ancillary staff.
Professional component includes the
physician’s work and expertise.
Technical services are billed as facility charges.
Professional services are billed as physician
services.
Medicare Charges
Hearing aid services are not covered
services.
Routine services are not be covered.
Treatment services by audiologists are not
covered.
All services must be ordered by a
physician.
Medicare Charges
Most procedures are billed as facility charges.
ENG, ABR, and OAE have TC and 26
components.
Cerumen management is a physician charge.
Intraoperative monitoring has TC and 26
components.
Miscellaneous services (99000-99090) are
physician charges.
Case Management Services
Case management services such as team
management (99361-99362) are physician
charges.
These codes are considered as evaluation
& management codes which are not
appropriate for use by audiologists.
Advanced Billing Issues
Physician charges are billed on HCFA
1500.
Facility charges are billed on UB-92.
It is not appropriate to put a physician
charge on a UB-92 and then attach a TC
modifier to indicate it is a “technical” (nonphysician) service.
Medical Necessity
Physicians determine medical necessity.
All orders, consultations, and referrals must be
signed and dated by physician.
All orders, consultations, and referrals must
indicate why the care is medically necessary.
Referrals for evaluation must be medically
necessary and pose a diagnostic question.
Reasonable and Necessary
“reasonable and necessary for the
diagnosis or treatment of an illness, injury,
or to improve the function of a malformed
body member.”
To be reimbursable, all services must be
reasonable and necessary.
Covered Audiology Services
ordered by a physician
reasonable and necessary
used by the physician for evaluating appropriate
medical or surgical treatment
not covered when the diagnosis is known to the
physician
therapeutic services by audiologists are not
covered
Documentation
Principles of Documentation
Documentation must be:
Accurate--describes the care provided
Codable--supports CPT, ICD, DRG codes
Understandable--clear to reader
Timely--written at time patient was seen
Error free--stands alone as a legal document
Principles of Documentation
If ain’t documented, it weren’t done!
All care must be documented.
Anecdotal or historical events (patient not
present) should be documented.
All documentation must be dated and
signed.
Principles of Documentation
Assessments must address:
chief complaint or reason for the visit
pertinent medical, social, and family history
examinations, diagnostic tests
diagnosis or diagnostic impressions
plan of care
Principles of Documentation
Treatment plans are derived from
assessments.
Treatment plans must address:
diagnoses, conditions, or problems
objectives or goals of treatment
expected outcomes
treatment modalities
duration of treatment
Principles of Documentation
To be reimbursable, all treatment services must
be ordered by a physician.
Ongoing treatments (e.g. AR) must be recertified by the referring physician at least every
30 days during and at the termination of
treatment.
All documentation must include:
patient’s name, SSN
referring physician
Principles of Documentation
Progress notes must address:
goals or objectives of treatment
progress toward stated treatment goals
documented, measurable outcomes
alterations to treatment plan
patient and/or family education
Service Agreements
and Referral Guidelines
Service Agreements
Bilateral agreement (contract)
Usually between Audiology and Primary
Care but can be with ENT or any other
referring source.
Service Agreements
Defines scope of services available
Referral criteria (specific, pre-work)
Timeliness agreements
Roles defined for both parties
Criteria for co-management or return
Communication methods
Measuring effectiveness
Referral Guidelines
Operational version of service agreement
Electronic template
Examples: cerumen, sudden hearing loss,
routine repair/adjustment for hearing aid,
disability or fitness exam, non-visit consult
Ensures appropriate, efficient, and timely
referrals
Example: Sudden Hearing Loss
Patient reports sudden hearing loss in one
or both ears. Time of onset and
precipitating factors are important in
diagnosis. Treatment must be started
early to be effective.
Send STAT consult to Audiology and ENT
followed by phone call to Audiology for
appointment
Consult Template
Are ear canals clear of cerumen? Y/N
Does patient have associated dizziness?
Y/N
Is there evidence of middle-ear effusuon
or otitis with exudate? Y/N
Hearing loss in RE, LE, Both ears
Patient Education
What is Patient Education?
Preventive care & wellness programs?
What about...
advance directives
informed consent
objectives, benefits, risks, alternatives to treatment
community resources
test results, health status, medical findings
treatment and discharge plans
patient and/or family responsibilities
JCAHO Requirements
Required patient education:
rehabilitative & compensatory techniques
safe and effective use of medical devices
safe and effective use of medications
food/drug interactions
nutrition, modified diets, food consistency
test results, health status, medical findings
treatment options and alternatives
JCAHO Requirements
risks and benefits of treatment
awareness of community resources
obtaining additional care, entitlements,
access to care issues
informed consent and advanced directives
patient and family responsibilities
self care skills and personal hygiene
Documentation of Patient Education
assess patients ability & readiness to learn
assess motivation
assess barriers and special need
assess preferred mode of learning
document educational content, medium
document educational outcomes and level of
understanding