Transcript The MEAT of Documentation

The MEAT of
Documentation
Presented by:
Tracy R. Johnson, CPC
2015 Mobile Alabama Chapter Vice-President
Objectives:
• Introduction on the Importance of Clear Documentation
• CPT Coding Audits
• Diagnosis Audits
• Denial Audits
• Compliance using 1995/1997 Coding Guidelines
• What is the difference in Acute and Chronic Conditions?
• What is CERT?
• What is Risk Adjustment?
• The MEAT of the Documentation
The Importance of Clear Detailed Documentation
• There are multiple types of audits that can be used in a tool today to gauge
many different aspects of the coding realm
• CPT Coding Audits:
Audits that strictly take into account the
accuracy of the procedural coding on a chart
• Diagnosis Audits:
Audits that strictly take into account the
accuracy of the diagnostic coding on the
chart. This is also used to establish Hierarchy
of Coding (HCC) during an audit.
• Denial Audits:
Audits that are used to gauge the accuracy of
a denial from the insurance company as to why
the claim was denied
CPT Audits
• The following rules apply when auditing for Evaluation and Management
during a CPT Audit
Which set of guidelines are in the “Compliance File”? Are they
1995 guidelines or 1997 guidelines?
• What are the requirements for both?
In the 1995 E/M Coding Guidelines, the Evaluation and
Management is based on 3 Key components (History, Examination,
and Medical Decision Making)
In the 1997 E/M Coding Guidelines, the Evaluation and Management
is based on a clear and documented “Extent of the Examination that
was performed citing all 14 Review of Systems, and time is more a
factor for 1997 Coding Guidelines than in 1995 Coding Guidelines
IMPORTANCE OF THE AUDIT TOOL
• You may be asking yourself, “Why is an Audit Tool Important”?
• Here are a few detailed reasons why:
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To establish compliance of not only the coder but the physician
To establish documentation guidelines within the office/hospital setting
To establish the need for further education (staff, physicians, etc)
To establish a “base-line” as to where all other audits will be based
To establish the identify of Medical Necessity in the overall criteria in payment
in addition to the specific technical requirements of a CPT code
THE ELEMENTS OF AN AUDIT TOOL
• There are 5 Basic Elements to an Audit Tool
• Condition:
Statement that describes the results of an audit
• Criteria:
Standards used to measure the activity or performance
of the auditee
• Cause:
Explanation of why a problem occurred
• Effect:
The difference between and significance of the
condition and the criteria
• Recommendation:
Action that must be taken to correct the course
What is CERT?
• CERT stands for
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Comprehensive Error Rate Testing
Contractors are to statistically analyze and establish error rates
Estimates improper payments
Claims are randomly selected for review
Not required to notify providers of the intention to start a review
Medicare Appeals Process
• The Appeals Process contains 5 steps
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Level 1:
Level 2:
Level 3:
Level 4:
Level 5:
Redetermination by a Medicare Contractor
Reconsideration by a Qualified Independent Contractor
Hearing before an Administrative Law Judge
Review by the Appeals Council
Judicial Review in Federal District Court
Payment Recovery/Recoupment
• A Medicare Overpayment occurs when a provider receives excess
payments due to any of the following:
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Duplicate Submission of the same service or claim
Payment to the incorrect payee
Payment for excluded medically unnecessary services
A pattern of furnishing and billing for excessive non-covered services (as
determined in an audit or review)
Defining “Chronic” versus “Acute”
• What is the difference between Acute and Chronic Illnesses?
• Acute Illnesses:
• Example:
• Chronic Illnesses:
• Examples:
Those illnesses that will eventually resolve without any
medical supervision (colds, teething)
An acute illness will typically run a course regardless of
whether or not there is drug intervention; (coughs,
colds, teething, PMS, sleeplessness) are all examples of
such illnesses. Usually, medicine for acute illnesses are
regulated as Over The Counter Drugs
Those that require medical supervision and is often a
disease that has formed over a long period of time.
Cancer, AIDS, Kidney Disease and Diabetes. Usually
medicines for chronic illnesses are regulated as
prescription drugs.
What is Risk Adjustment?
• Risk Adjustment is the model to adjust capitation payments to private
health care plans for the health expenditure risk of their employees
• CMS measures the disease burden that includes 70 HCC categories,
which are correlated to diagnosis codes
• CMS’ model is accumulative (patient can have more than one HCC
category assigned to them)
• Some categories override other categories
• There is Hierarchy of Coding Categories (HCC)
HCC’s and How they Affect Payment
• The following HCCs reflect a few common “chronic” conditions found
within the Medicare population, that Medicare Advantage Plans look for to
be documented in the patient’s chart:
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Diabetes without complications
Chronic Obstructive Pulmonary Disease
Congestive Heart Failure
Breast Cancer
Ischemic Heart Disease
Angina
HCC Guiding Principle
• The Risk Adjustment diagnosis must be based on clinical medical
record documentation from a face-to-face encounter
• The Diagnosis must be coded according to the ICD-9-CM Guidelines
for Coding and Reporting and assigned based on dates of service within
the data collection period
• The Diagnosis must be submitted to the MA organization from an
appropriate Risk Adjustment provider type and an appropriate Risk
Adjustment physician data source
Understanding Diagnosis Coding: Protect
Against Auditor Scrutiny
• Accurately Report ICD-9-CM Diagnosis Codes
Coders cannot assume the past medical history diagnosis has a
current affect on the current condition for which the patient is
receiving treatment
Unless the physician has a “direct statement” that the past medical
condition or the medications the patient is taking for the past
medical condition has a direct link on the treatment for the current
encounter, Coders should not code the past medical history
conditions.
Understanding Diagnosis Coding: Protect
Against Auditor Scrutiny
• Capture All Chronic Diseases
Coders may report chronic diseases treated on an ongoing basis as
many times as the patient is receiving treatment for the condition(s)
• Code All Documented Conditions that Coexist
Code all documented conditions that coexist at the time of the
encounter and require or affect the patient treatment or
management
Do not code conditions that a physician previously treated and no
longer exists
Understanding Diagnosis Coding: Protecting
against Auditor Scrutiny
• History Codes V10-V19- Coders may use history codes (V10-V19) as
secondary codes when the historical condition or family history has a
direct effect on the current care
• Replacement Codes – Coders may use the replacement codes as
secondary codes to show that a patient has had a total knee or other
joint replaced.
• Medication V58 – Medication V codes help to support the use of
several different medications like insulin, NSAIDS, or aspirin.
Handle Other Diagnoses and Consider Final
Diagnostic Statements
• For reporting purposes, the definition for other diagnoses is interpreted
as additional conditions that affect patient care in terms of requiring one
of the following:
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Clinical Evaluation
Therapeutic Treatment
Diagnostic Procedures
Extended Length of Hospital Stay
Increased nursing care and/or monitoring
Handle Other Diagnoses and Consider Final
Diagnostic Statements
• Consider Final Diagnostic Statements
• If the physician has included a diagnosis in the final diagnostic statement
• Coders should ordinarily code it
• However, some physicians include resolved conditions or diagnoses and statuspost procedures from previous admissions or evaluations that have no bearing
on the current episode in the diagnostic statement
• Coders should not report these conditions
• Examples:
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A patient is a smoker but presents today for a sunburn (Use of tobacco not reported)
Parkinson’s disease in a patient with a wart on the finger (Parkinson’s not reported)
Depression in a patient who has fallen off a ladder (Depression not reported)
History of Acute Myocardial Infarction (AMI) in a patient that has a cold (Old MI not
reported)
Now The MEAT
MEAT
• What is MEAT?
• M:
• E:
• A:
• T:
Monitoring
Evaluating
Assessing/Addressing
Treating
Monitoring “M”
• Monitoring is the application of all of the below in a
medical record:
• Signs
• Symptoms
• Disease Progression
• Disease Regression
Evaluating “E”
• Evaluating is the application of all the below in a
medical record:
• Test results
• Effectiveness of medications
• Response to treatment
Assessing/Addressing “A”
• Assessing or Addressing is the application of all of
the below in a Medical Record:
• Ordering Tests
• Discussion
• Review of Records
• Counseling
Treating “T”
• Treating is the application of all the below in a
Medical Record
• Medications
• Therapies
• Other modalities
How Does My Documentation Stand UP?
• According to CMS an acceptable problem list must show
“evaluation and treatment” for EACH condition that relates to an
ICD-9-CM code
Condition
ICD-9-CM Code
Documentation Supports
CHF
428.0
Symptoms well controlled
on Lasix and ACE inhibitor.
Will continue to monitor
Major Depression
296.20
Despite being on Zoloft 50
mg per day, the patient
still feels hopelessness.
Will raise to 100 mg for the
next two weeks
Hypertension
401.9
Stable on medications
Documentation “PitFalls”
• Providers are not showing all documentation for work performed
during the encounter
• It is acceptable to include “history of” conditions if it directly affects the
current treatment plan of the patient
• Remember, “stating history of” means the patient no longer has that
condition
In Summary…..
• Any and each condition that is addressed at the time of the encounter should
be documented in the History and Physical
• Each condition that relates to an ICD-9 code must show evaluation and/or
treatment
• A list of diagnoses is NOT acceptable as evidence that the diagnosis affected
the patient management
• Using MEAT ensures that documentation is sufficient for CMS’s
requirements for validating coding
• Following the MEAT principle will provide accurate documentation, patient
of care quality, and improvement in data management for validating diagnosis
codes
Questions?
Thank you for Coming!
• We hope you enjoyed tonight’s presentation
• Please take a moment to fill out the Speaker Survey given to you at the
start of the presentation
• The power point will be available on the website www.aapcmobile.com
within 24 hours
• Remember, our next meeting
• March 17, 2015
6:00 pm
Providence Hosptial, DePaul Center