CSI- Claim Scene Investigators

…Finding the Clues in your Health Information

Dawn Crump

Vice President Audit Management Solutions - CIOX Health

Overview

• Health Information and its role in denial prevention

• Determining what documentation is required

• Practical pointers on reducing documentation denials

Request for Health Information Drivers

Increased scrutiny of health

information:

• More covered lives

• ACO Growth

• Health Information Exchange

• Health Care Reform

• Value Based Payment

• Legal

• Billing/ Quality Compliance/ Audits

More audits are on the rise:

• Health Plan Requests

• HEDIS

• Medicare Risk Adjustment

• Commercial Risk Adjustment

• Government Audits

• MAC

• RAC

• CERT

• OIG

• QIO

Release of Information (ROI) - more complicated then ever

• EMR-Electronic Medical Record

– Archive systems

• Paper Records

• Hybrid- Combination of EMR and Paper

Where to look?

• Multiple sources of information- Bolt on systems

• Radiology

• Operating rooms

• Rehab facilities or units

• Pharmacy

• Other providers of services

Timelines & Submission Methods

• Changing timelines for submissions to auditors

• Methods:

– Fax

– Paper

– CD

– ESMD

Reading between the lines- Understanding the top reasons for audit denials

• Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

• Does documentation support medical decision?

Medically Necessary

• Specific documentation or documents required to support services billed per LCD or health plan requirements

Insufficient Documentation

• Codes assigned per coding guidelines based on documentation provided in health information

Incorrect Coding

What are the cost associated with improper payments?

• Medicare auditors are after all improper payments

from all providers - Medicare Modernization Act and Affordable Care Act have components to

reduce fraud, waste, and abuse to preserve the Medicare Trust Fund

- Though some auditors may focus more on hospitals, the reviews can lead to

physician provider reviews

- If the inpatient procedure was deemed medically unnecessary then so are

corresponding Part B claims.

• CERT programs cites insufficient documentation for

high percentage of errors

• Medicare fee for services estimates for FY 2014 12.7% of claims valued at $45.8 Billion in improper payments

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/index.html?redirect=/CERT

4/4/2016

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CERT Error Rate Information • WPS CERT “insufficient

documentation continues to have a large impact on error rates for WPS Medicare and on a national level. Medical record documentation must support the services billed according to Medicare guidelines, the medical necessity of the services, and be legible in order?”

http://www.wpsmedicare.com/j5macpartb/departments/cert/document-tips.shtml

4/4/2016 9

Service Type Improper Payment Rate

Improper Payment Amount (2)

Inpatient Hospitals

9.2% $10.4B

Durable Medical Equipment

53.1% $5.1B

Physician/Lab/Ambulance

12.1% $11.0B

Non-Inpatient Hospital Facilities

13.1% $19.2B

Overall 12.7% $45.8B

What are auditors looking for?

• Complete documentation

• Diagnostic test results supporting medical decisions

(admission, procedures, therapy)

• Previous treatment options

• Orders/ Appropriate Signatures

• Certification Statement

• Review records for completeness prior to submitting

Insufficient Documentation

Claims are placed into this category when:

Medical documentation submitted is inadequate to support payment for

the services billed

Evidence that allowed services were actually

provided, were provided at the level billed,

and/or were medically necessary

Specific documentation element that is required

as a condition of payment is missing, such as a physician

signature on an order, or a form that is required to be

completed in its entirety

How to know what to include?

• All requests are not the same! • Create checklist for high volume/high dollar services • Know your auditors and what they are auditing

• Use the following to develop your lists: • LCD/NCD Requirements

- Know the LCD’s (local coverage determination) and NCD’s (national coverage determination)-

**review annually for changes on high volume procedures • CERT tips guidelines • Medicare Billing Manuals • Recovery Auditor websites

Best Practice

• View and approve prior to submission of health information

• Randomly audit compiled health information

Inpatient Rehab Example

• Inpatient Rehab Facility Patient Assessment instrument (IRF-PAI)

– Must be submitted in a specific timeframe

– Must be included in the health information

When reviewing the record in the EMR for appeal, IRF-PAI was present and time stamped…

Example from CGI website

Documentation needed for Chemotherapy drugs: 1. Administration Record including start and stop times 2. Signed and dated physician order for chemo 3. Infusion start and stop times 4. Drug order including dose and route Supplemental Medical Review Contractor (SMRC) project - Herceptin http://www.strategichs.com/wpcms/project-y2p25-herceptin-multiuse-vials/

Service Types with Highest Improper Payments: Part A Inpatient Hospital PPS

2014 CERT Results

Improper Payment Rates CERT 2014 Error Report

Part A Inpatient Hospital PPS Services (MS-DRGs)

Projected Improper Payments

Improper payment

rate

Insufficient Document

ation Medical

Necessity

Major Joint Replacement Or Reattachment Of Lower Extremity (469 , 470)

$345,709,650 5.90% 68.40% 21.20%

Spinal Fusion Except Cervical (459 , 460)

$200,530,719 10.30% 46.60% 37.60%

WPS CERT Denial : Procedure, total hip replacement, and thus inpatient admission, not reasonable and necessary: little information about prior conservative treatment; no specific information about X-rays.

Total Joint Replacement Surgery – Medically Necessary

4 key criteria:

- Radiologic - Therapy Treatment - Pharmacological Treatment - History of pain and impact on ADL

Examples: • Example of a medical record that may result in a DENIED claim

– Mrs. Smith is a female, age 70, with chronic right knee pain. She states she is unable to walk without pain and pain meds do not work. Therefore, she needs a total right knee replacement.

• MLN Link : http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se1236.pdf

• http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33050&ContrId=225&ver=22&ContrVer=1&DocType=All&bc=AgIAAAAAAAAAAA%3d%3d&

TJR Example of a Medically Substantiated Note

History: Mrs. Smith is a 70-year-old female who is suffering from end-stage Osteoarthritis (OA) of her right

knee, worsening gradually over the past 10 years. Treatment has included NSAIDs which have not effectively relieved her pain/inflammation and which have recently begun to cause her gastric distress. She has also participated in an exercise program/physical therapy for the past 3 months without functional improvement. Sometimes the pain keeps her awake at night. She is using a cane and is no longer able to climb the five steps to her front door. Personal safety is compromised as she had falls x 3 in attempting the stairs to her home entrance. Her knee pain and stiffness limit her ability to perform ADLs. She cannot walk from her bedroom to her kitchen without stopping to rest.

Physical exam: Bilateral varus knee deformity consistent with severe osteoarthritis. Right knee extension reduced to

minus 15 degrees and flexion to less than 100 degrees. Unable to rise from chair unassisted. Full motion of the right hip, no calf tenderness or ankle edema. Antalgic gait noted.

Investigations: X-ray (7/2/11): right knee shows joint space narrowing along with marginal osteophytes.

Impression:

Total Knee Arthroplasty (TKA) indicated.

Service Types with Highest Improper Payments: Part A

Excluding Inpatient Hospital PPS

2014 CERT Results

Home Health Documentation

• Required Documentation:

• Physician certification/recertification of “confined to home” status and the need for home health services

- Why confined to home in narrative?

- Why intermittent skilled nursing services are needed?

- PT, OT, SLP services must be reasonable and necessary to the restoration or maintenance of function

• Face-to-face encounter documentation

• Therapy notes

• Comprehensive assessment of the home care recipient

Home Health – Insufficient Documentation Denial

• The devil is in the details: ask the why’s? • A home health agency submitted a claim for home PT, OT and home

health aide services. • Documentation was submitted

- Physician’s signed plan of care - Face-to-face encounter documents - Comprehensive assessment of the beneficiary - Copies of all therapy and home health aide notes

• The submitted face-to-face encounter documentation stated only “unsteady gait” and “taxing effort.”

• Acceptable Narrative: • Ambulates limited distance of 125’ with assistance of a walker due to

acute stroke; • Frequent seizure activity, requires supervision/assistance of another

person

SNF – 2013 CERT Report

• The improper payment rate for SNF services was:

• 2014 - 7.0% error rate; projected improper payment amount was $2.45 billion

• Majority of improper payments for SNF services were due to insufficient documentation Include:

• Certification that daily skilled care that could only be provided in a SNF setting;

• Plan of care

• Time (in minutes) for each therapy service provided

Don’t forget about your large volume services?

• EKG’s:

• Missing 12-Lead Electrocardiogram (EKG) tracings to support the 12-Lead EKGs billed during the emergency room encounter and observation admission on billed dates of service. Submitted documentation includes the physician's testing orders and the physician's EKG interpretations.

• http://www.wpsmedicare.com/j5macparta/departments/cert/j5mac-2nd-qtr-2014-error-summary.shtml

4/4/2016 25

Denials will happen:

• Be prepared for denials

• Review record submitted against denial reason – EMRs can be tricky to review

– Has the information changed?

– Ensure health information included supports minimum LCD/NCD requirements

• Direct denials to appropriate personnel and be sure they have all the information available for an appeal

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Best practice tips

Identify your top denial reasons

Create checklist/ templates to educate clinicians in understanding specific required documentation

Identify additional documentation needed for different service lines and specialties

Educate clinicians to answer the why’s

Best practice tips

Make sure all signatures are present and legible and meet requirements

Ensure EMR print templates are inclusive of all key information and review annually

Review records for completeness/specific documentation needs prior to submitting

Questions

• Contact - Dawn.Crump@CIOXHealth.com