Presented by

Brenda Edwards, CPC, CPB, CPMA, CPC-I, CEMC, CRC

Senior Consulting Manager of Risk Adjustment

BULLET PROOF DOCUMENTATION

Disclaimer

The speaker has no financial relationship to any products or services referenced in this program. The program is intended to be informational only. The speaker is not an authoritative source by law. Attendees are advised to reference payer specific provider manuals, on-line or otherwise, for verification prior to making changes to their coding, documentation and/or billing practices.

Agenda

Physician Documentation

Complete Compliance in EMR

Effective Physician Communication and Education

Questions to Ponder

How do we achieve “bulletproof E/M documentation?

Would another provider be able to

step in?

Would documentation be

specific and legible?

Would another provider understand

the rationale for treatment?

In the worst case scenario, if a

provider is in a court of law, would they be able to defend

their documentation?

E/M Code Selection & Medical Necessity

Together equal E/M Code Selection

History

Exam

Is equal to the sum of:

Medical Decision Making (MDM)

History Problem

Focused

Expanded Detailed Comprehensive

Exam Problem

Focused

Expanded Detailed Comprehensive

MDM Straight

Forward

Low

99213

Moderate

99214

High

99215

History Problem

Focused

Expanded Detailed Comprehensive

Exam Problem

Focused

Expanded Detailed Comprehensive

MDM Straight

Forward

Low

99221

Moderate

99222

High

99223

E/M Code Selection

http://www.cms.gov/manuals/downloads/clm104c12.pdf

Medical necessity

• “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code”

Volume

• Should not be the primary factor to select the level of service billed

Documentation

• Accurately support the level of service reported

Make the chief complaint a real complaint

In the patient’s own words

Chief complaint is not

3 month follow up

Here for check up

Doing well

Ankle

Bulletproofing E/M Documentation

HPI-Answer the Questions

Who is the patient?

What is the problem?

When did it begin-set date or chronic?

Where is the location of the problem?

Why is the patient here?

How are you going to treat them?

Don’t Ignore the Review of Systems (ROS)

Avoid pitfalls

Providers should identify each system reviewed

Avoid vague language

ROS as above

ROS within normal limits

ROS negative

All others negative

Use the Exam Guidelines That Work Best For Your Provider

Use either 95 or 97 guidelines

• Cannot combine on one visit

Know your payers

• What are the guidelines for your MAC?

• Body area and/or organ systems?

• 4 X 4?

• 2-4, 5-7?

• Limited or extended exam?

Physician’s are not limited by specialty on

97 exam templates

Incorporate the Language of MDM into the Documentation

Use language that paints the picture, give rich details of the encounter

Details, Details, Details!

Bulletproofing

Legible signature on every entry or a signature log

No signature stamps

Have an electronic signature policy for EMR

Send all related documentation

Define unusual abbreviations

Use a cover letter, if necessary, to explain the content and layout of the documentation

Complete Compliance in EMR

Golden Rule of Coding

• If it is not documented, it is not done and therefore not billable!

Golden Rule of EMR

• If it’s documented, was it really done or simply carried forward?

EMR

Reduced staff/paper

Template driven

Minimal free text

”Note bloat”

Buried detailsInadequate training

Immediate access to records

Drop down list errors

Time & date stamps

Signatures Lack of standardization

Scanned chartsAudit trail –

meta data

ProductivityCloned notes

Authentication

SecureSharedScribeAudit trailBilling rulesPrint metadata

Cloning

“It would not be expected that every patient had the same exact problem, symptoms, and required the exact same treatment. Cloned

documentation does not meet medical necessity requirements…”

Palmetto GBA Medicare

Cloning Two consecutive visits Chief complaint on both visits is

“follow-up for osteoporosis.”

2010 2011

Next visit

Templates

Customization

Limitations

Modifications

Template Summary

InconsistenciesFamily history notes on initial visit…

...when patient is seen one year later, the date of parents’ deaths have changed by one year

Electronic TemplateConflicting Information

Physical ExaminationConstitutional

well nourished, seems more confused today, alert, oriented to person, place and time, no acute distressEyes

conjunctiva normal, sclerae nonictericNeck

no masses or tendernessRespiratory

breathing unlabored, clear to auscultationCardiovascular

regular rate and rhythm, no murmurs presentSkin and subcutaneous tissue

no rashes or lesions presentNeurologic

cranial nerves II-XII grossly intactPsychiatric

judgement and insight intact, normal mood and appropriate affect

Review of Systems

Constitutional

Denies: fatigue, malaise, excessive weight change

Eyes

Denies: double vision, blurred vision, vision loss, floaters

Cardiovascular

Denies: chest pain, palpitations, irregular heart beats, syncope, dyspnea on exertion

Respiratory

Denies: shortness of breath, wheezing, cough

Neurologic

Denies: tingling, memory difficulties, seizures, tremors, loss of balance

Endocrine

Denies: polyuria, polydipsia, significant hypoglycemia, significant hyperglycemia

Mapping/Behind the Scenes

Thoughts on EMRIrrelevant information makes you search for pertinent findings

• Does this save time over dictating?

Providers will think in categories instead of personal opinion

• Clicking boxes instead of writing what they think and feel based on observations

What does this do to providers from a medical-legal standpoint?

• Nearly identical documentation on large numbers of patient records

•Tells the story (great detail)

•No data elements captured

•Visit may be “under coded” by computer

Free text narrative

•Avoid “auto-authentication” (click without reading)

Review orders prior to electronic signature

•Appointments

•Receipt of report

•Prompt call to lab, x-ray, consultant

•Review of report

•Communicate results to patient

•Arrange follow up services

Tracking mechanism

Scanned documents stored in correct files

Prescription medications

Does note stand alone?

•Who has vs. who needs access?

•Provider authentication

•Patient encounters locked immediately after visit?

•May find signature in electronic audit trail, is it apparent in note?

Passwords, authentication & electronic signature

•Is the entire note being dictated in the impression?

•Is information being carried forward from previous visit?

•“New patient with warts” used as chief complaint in 8 consecutive notes!

•Is the EMR being used correctly?

Use

•Is the E/M code recommended based on 1995/1997 guidelines?

•Does the provider have the ability to override the recommended code?

•How is MDM calculated?

Code Selection

•Clearly identified with current date

•Reference date being amended

•Reason for late entry

•Electronic signature

Amended Records

EFFECTIVE PHYSICIAN EDUCATION

AND COMMUNICATION

Top Coding and Documentation Errors

• Documentation does not support level of service billed

• Chief complaint missing

• Assessment not clearly documented

• Documentation not signed

• No record of tests ordered in documentation but were billed

• Medications not clearly documented or missing

• Diagnosis not correctly referenced

• Missing documentation

• Lost dictation

• Incomplete documentation

• Legibility

Areas of Risk

Understanding Your Provider

Providers maintain a busy and stressful scheduleBe respectful of his or her time

Providers want to care for patientsExplain that you are looking at from an objective

point of view to help reduce risk and protect the provider

Understanding the ProviderUnclear Documentation

Example: Physician documents an excisional biopsy of forearm

Physician was trained to refer to “excisional biopsy” or “shave excision”

CPT has a code for:

Excision

Biopsy

Shave

BUT NOT ONE FOR ALL OF IT!

Common FearsWhat if I mispronounce a medical term?

What if he/she erupts and I sit there speechless?

What if he/she doesn’t find me credible?

What if I am asked a question and don’t know the answer?

What if I am unable to get my point across?

The answer is COMMUNICATION!

Don’t Panic! It’s OK!

Talk to your provider

•Look at CPT®, CDR and other resources together

•Explain

•“CPT®

descriptions are not the same as what you are telling me”

•“Help me to understand what you did or what you meant”

Use medical dictionaries and references

Use internet search for unfamiliar terms

•Credible sources

Communication

7% happens in spoken words

38% happens through voice tone

55% happens through body language

Body LanguageYour Gesture Body Language

Arms crossed Defensive

Constant eye contact Aggressive

Fidgeting Bored/impatient

Hunched posture Lack confidence

Little eye contact Low interest/lack confidence

Rubbing nose or mouth

Lying

Tapping Impatient or nervous

Touching face/hair Timid

Watching timeAnxious to move on to something else

• Always use facts

• Show source documents on rules

• Use rationales

• Remain organized, detached and calm

• Professionally impersonal

• State facts concisely

• Be genuine

• Be personable

• Be pleasant

• Create calm environment

• Listen with care/concern

Communication Tips

Initiating a Difficult Conversation

Ask Is this a good time to talk?

Be Direct Short statement that gets to the point

Use Active Listening Allow physician to respond completely, even if defensive

Sympathize Understand their perspective and make the effort to show it

Empathize Express you realize how hard it is, it’s hard for you, too

Assess•Tell me more•Are you ready to expand on this?

Detailed conversationExplain rationale, reward, and risk

Remember…You don’t need to know the answer to every question…

BUT, you do need to know where to find the information!

The end goal is documentation that promotes proper payment for all services rendered!

In Parting

“The promise of EMR is a more accurate, legible and comprehensive medical record, available to physicians at

the touch of a button”

The problem is finding a way to get there!

Findlay D. Authenticating the electronic medical record. Healthcare Risk Manager. Volume 12. Number 30. 2006. Available at www.magmutual.com/risk/newsletters.html

Be Empowered!

Thank YOU!

CEU #