reaching full potential - cardea services€¦ · reaching full potential: quality assurance and...

5/9/2014

1

Reaching Full Potential:

Quality Assurance and Improvement with Visit Documentation

Beatriz ReyesTraining Manager, Cardea-Oakland, CA

Karen Shiu, MPHData/Training Manager, Cardea-Oakland, CA

Ann FinnOwner/Healthcare Consultant, Ann Finn Consulting-Niskayuna, NY

1

Cardea

Our Services

Training – Organizational Development – Research and Evaluation

Our Mission

Improve organizations’ abilities to deliver accessible, high quality, culturally proficient, and compassionate services to their clients.

2

STD-related Reproductive Health

Training & Technical Assistance Center

Funded by a cooperative agreement by the Office of Population Affairs, within the Office of the Assistant Secretary for Health in collaboration with the Division of STD Prevention within the Centers for Disease Control and Prevention,

National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention.

3

5/9/2014

2

Setting Up for Success: Integrating Revenue Cycle Management

Tuesday, February 25, 2014 Recording available now!

Reaching Full Potential: Quality Assurance and Improvement with Visit Documentation

Wednesday, April 30, 2014

Bringing It All Together: Sustaining and Enhancing Billing and Reimbursement Efforts

Thursday, June 26, 2014

Billing & Sustainability Series:Implementation and Improvement Strategies

for STD and Other Public Health Programs

4

Disclaimer

The content provided in this presentation is intended for educational purposes only. It is not intended to serve as medical, health, legal or financial advice, or as a substitute for professional advice of a medical coding professional, health care consultant, physician or medical professional, legal counsel, accountant or financial advisor.

Cardea encourages providers to contact third-party payors for specific information on their coding, coverage, and payment policies.

5

Learning Objectives

By the end of this webinar, participants will be able to:

• Discuss the importance of QI/QA in billing forSTI and other related services.

• Identify strategies for improving and assuring the quality of billing-related activities such as client visit documentation.

6

5/9/2014

3

Revenue Cycle Management Continuum

Cardea adapted the Transtheoretical Model of behavior change, or Stages of Change, developed by Drs. Prochaska and DiClemente, to identify benchmarks of organizational capacity building for revenue cycle management.

7

What is the Revenue Cycle?

A. The billing of third-party payors to collect patient service revenues.

B. The administrative and clinical functions that contribute to the capturing, management, and collection of patient service revenues.

C. The managing of claims and payments to/from third-party payors for patient services.

Participant Poll

8

What is the Revenue Cycle?

A. The billing of third-party payors to collect patient service revenues.

B. Administrative and clinical functions that contribute to the capturing, management, and collection of patient service revenues.

C. The managing of claims and payments to/from third-party payors for patient services.

Participant Poll

9

5/9/2014

4

Revenue Cycle

Front End

Pre-Visit

Intermediate

Visit

Back End

Post-Visit

10

Revenue Cycle

Front End

Pre-Visit

Intermediate

Visit

Back End

Post-Visit

Front EndPre-Visit

Steps to collect client info, determine fees, and communicate payment policies prior to the provision of services.

11

Revenue Cycle

Front End

Pre-Visit

Intermediate

Visit

Back End

Post-Visit

IntermediateVisit

Documentation and coding of services provided

12

5/9/2014

5

Revenue Cycle

Front End

Pre-Visit

Intermediate

Visit

Back End

Post-Visit

Back EndPost-Visit

Steps to bill, collect, and track payments for services

13

Quality Improvement v. Assurance

14


15

Quality Improvement

• A philosophy or approach• Focuses on systems and processes

• Assumes the system, and not the individual, is the root of most problems

• Driven by staff and clients

5/9/2014

6


16

Quality Improvement

• A philosophy or approach• Focuses on systems and processes

• Assumes the system, and not the individual, is the root of most problems

• Driven by staff and clients

Quality Assurance

• A specific activity• Focuses on policies, procedures, tasks, and compliance checks

• Seeks to identify problems and make corrections

• Driven by management

This Webinar Will Cover…

• Compliance in documenting and coding for STIs and other related services

• Integrating QI/QA

• Review of codes, functions, and resources

• Review of the most common errors and best practices

17

Revenue Cycle

Front End

Pre-Visit

Intermediate

Visit

Back End

Post-Visit

18

5/9/2014

7

Intermediate Processes

Adapted from the Elements for Successful Immunization Billing Practice at New York State’s Local Health Departments, June 2012

Data Capture

19



Data Capture

ProvidersProviders, Back office staff-coders, Billing

agency, etc.

20



Documentation of Medical Services

(Charge Data Capture)

Medical services recorded

Data Capture


agency, etc.

21

5/9/2014

8



Documentation of Medical Services

(Charge Data Capture)

Medical Service Coding

(Charge Data Entry)

Medical services recorded

Services translated to diagnosis and procedures codes

Data Capture


agency, etc.

22

KEY PIECES TO ENSURE COMPLIANCEQA/QI

Teamwork

Forms & data capture

Documentation & appropriate coding

23

Compliance and QI/QA

Compliance Requirements

Quality Improvement

Quality Assurance

Changes

24

Ex: Performance Evaluation

5/9/2014

9

Who is the OIG?

Office of Inspector General (OIG)

• Mission to protect the integrity of Department of Health & Human Services.

• At the forefront of the Nation's efforts to fight waste, fraud, and abuse; and to promote economy, efficiency, and effectiveness in Medicare, Medicaid, CDC, NIH, and the FDA.

25

What is a Compliance Program?

Why Should I Create One?

A set of internal policies and procedures that you put in place to help your organization comply with the law.

- Office of Inspector General

An effective compliance program:• Enhances an organization's operations• Improves quality of care• Reduces overall costs• Helps identify and address problems before they become

systemic and costly

26

1. Foster a culture of compliance:• Support with sufficient resources and commitment

o Bring up compliance issues in staff meetingso Reward staff that have brought up compliance issueso Create a compliance team or hire a compliance officer

8 Tips For Implementing Effective

Compliance Programs

27

5/9/2014

10


Compliance Programs

2. Create written policies, procedures and standards of conduct:

• Policies should be specific to each job type• Policies should be current and updates – USE THEM!• Send policies via email, or leave in common areas• Create a policy on the query process

o A query is a question posed to a provider to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record1

28

2. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_040394.hcsp?dDocName-bok1_040394


Compliance Programs

3. Conduct effective training and education• Stay current• Be creative on how trainings are delivered• Learn from your mistakes

4. Promote Communication• Be visible• Be approachable

29


Compliance Programs

5. Take appropriate corrective actions; investigate promptly

• Involve staff that understands the issues at hand

6. Track resolutions of complaints• What were the corrective actions taken?• What were the outcomes?

30

5/9/2014

11


Compliance Programs

7. Conduct regular internal audits (QA)• Identify risk areas to pay attention to during audits

o For example: coding

• Define the scope of the audit, whether it’s scheduled or a surprise

8. Review compliance program (QA)• Are benchmarks and goals being met?

o Are benchmarks and goals updated to reflect changes in payment reforms and quality standards?

• Are corrective actions sufficient?

31

Staff must be able to communicate in order to ensure complete and compliant billing…but how?

Articulate connections across job functions

Billing is a Team Effort

Adapted from Kern County Department of Public Health Services

Provider Provide servicesRecord services

provided: Documentation

Cashier Charge captureCollect fees, copays

BillerBill third-party

payorsMonitor receivables, follow-up on denials

Make corrections,resubmit bills

Bill Paid

Coder

Apply codes to the services in the medical

record

Apply codes to the services documented in the medical record

32









Bill Paid

Coder


record


Questions about documentation

33

5/9/2014

12









Bill PaidCoder


record


Questions about codes; Additional Information

34









Bill PaidCoder


record


Questions about codes; Additional Information

35

Questions

36

5/9/2014

13

Participant Poll

Does your agency have a compliance plan for client visit documentation?

A. Yes, we have a compliance plan specifically on client visit documentation.

B. Kind of, we have a compliance plan for billing that includes client visit documentation.

C. No, we do not have a compliance plan on client visit documentation.

D. I don’t know.

37

FORMS, DOCUMENTATION, AND

CODINGForms and data collection

Documentation

Types of Codes

38

Encounter Form

Encounter Forms, Super bills, or Charge Slips serve as a method of communication between providers, office staff, and payors.

Encounter form components:• Time of appointment• Reason for visit• Findings, diagnosis• Treatment, diagnostic tests, counseling• Resources and Referrals • Supplies• Drugs and injections (with lot # and units)• Interpreter/language lines

39

5/9/2014

14

Forms, Forms, Forms

Encounter forms should be:• User friendly – clinical and billing • Comprehensive• Easy to prioritize diagnoses• Accurate American Medical Association(AMA) code

descriptions• Space for modifiers, quantity & special instructions

40

Electronic Medical Record

Concerns:

• Copying and pasting documentation• Auto assigned codes• Drop down list edits• Over-clicking of check boxes• Missing documentation • Electronic signature and authentication• Vendor response to updates

41

Methods for Documentation

and Their Definitions

42

5/9/2014

15

Why is Proper Documentation

Important?

Proper Documentation…• Improves compliance • Improves patient care • Improves clinical data for research and education • Protects the legal interest of the patient, facility and

clinician• Enables proper reimbursement for services performed

Providers fill out the encounter form, coders/billers shouldn’t change the encounter form!

43

ICD-9-CM Diagnosis Codes – “Why”

• International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9 CM)

• Set of codes defining diseases, signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease

• Supports medical necessity of services/procedures provided

• Supported by documentation in patient’s medical record

• Only the licensed provider determines the diagnosis

44

Procedure Codes – “What”

Current Procedural Terminology (CPT) 4th edition is a set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care professionals, or entities.

• Maintained by the American Medical Association (AMA)• Each procedure or service is identified with a five-digit

code• Every service provided relates to a CPT code including

E/M’s, device implants, lesion removals, lab tests, immunizations, etc.

45

45

5/9/2014

16

Procedure Codes – “What” Continued

Healthcare Common Procedural Code System (HCPCS)

• All CPT codes are HCPCs codes, but not all HCPCS codes are CPT codes….say what?o Level 1 HCPCS – Based on and identical to CPT codeso Level II HCPCS – Identify products, supplies, materials and

services which are not included in CPT-4 codes� Devices, drugs

46

Modifiers

Two digit codes that accompany a CPT code in order to further describe a situation that may impact or modify reporting and reimbursement of services

• Some modifiers are assigned by the clinician during thevisit and some may be added during billing

• Only certain modifiers impact payment • Payers may treat modifiers differently

47

Our Codes Tell The Story

• To establish medical necessity, for every what there must be a why.

• Unusual circumstances explained with modifier.

Encounter Content Code Book

Why • Diagnoses • ICD-CM

What • Services Performed• Drugs, Supplies

provided

• CPT• HCPCS

o level I – Serviceso level II - Drugs/Supplies

AdditionalExplanation

• Modifiers • CPT

48

5/9/2014

17

Evalua<on and Management―E/M

• E/M is when provider evaluates a client’s condition and decides on a course of treatment to manage it

• Requires selection of CPT code that best represents:o Patient typeo Setting of service

(Office, Outpatient, Inpatient, Emergency department)o Level of service

49

Patient Type

New Patient• “One who has not received any professional services from

the physician, or other qualified healthcare professionals or another physician of the exact same specialty and sub-specialty who belongs to the same group practice, within the past 3 years”

Established Patient• Within 3 years

50

Types of E/M Visits

• Preventive Medicine Services• Consultations• Preventive Medicine Counseling• Problem-Focused Visits

51

5/9/2014

18

E/M: Problem-Focused Visits

Services to evaluate patients with a problem or chief

complaint in the outpatient clinic setting• New patients 99201-99205

• Established patients 99211-99215

• Examples: Routine contraceptive surveillance, family

planning counseling and education, contraceptive problems,

suspicion of pregnancy, STI testing and treatment, and

evaluation of other reproductive system symptoms

Lisa, a return patient, meets with the NP to be

evaluated and tested for STIs including an exam

and counseling. Her visit might be reported as

99213…

52

Documenting Problem-Focused

Medical Visits

• Composite of Three Key Components Method

• Time Counseling

53

“Composite of 3 Key Components” Method

History

• Chief Complaint• History of the present illness (HPI) – e.g., severity, duration, etc.• Review of body systems (ROS) – e.g., respiratory, constitutional• Past, family, social history (PFSH) – e.g., previous illness, hereditary diseases, and physical activities, alcohol and drug use

Physical Exam

• Multiple organ system examination

Medical Decision Making

• Number of possible diagnosis and management options• Amount and complexity of medical record, lab work/diagnostic tests, etc.• Amount and complexity of disease(s)

54

54

5/9/2014

19

About the Chief Complaint…

Concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the patient encounter, usually stated in the patient’s own words

• Should be clearly reflected in the medical record• Front desk should not be filling this in prior to visit

Required for problem-focused visits!

5555

“Time Counseling” Method

Time can be used when:

• At least 50% of clinician’s total Face-to-Face (FTF) time with patient is spent on counseling / coordination of care

• Criteria of an E/M must still be met

MUST document in the Medical Record:

• Total duration of encounter

• At least 50% of time is spent counseling

• Nature and extent of the issues discussed, client questions and physician response, and recommendations or next steps

56

56

Summary: Problem-Focused E/M

• Choose E/M based on scores of 3 key componentso History, Physical exam, MDM

• Compute counseling time as a percentage of total

FTF timeo If >50%, find E/M based on documented time factor

• Select the E/M code that is greater: 3 key

components or face-to-face time

57

5/9/2014

20

KEY POINTS FOR ACCURATE

DOCUMENTATION AND CODING

58

Common Errors

1) Missed charges / inaccurate and outdated codes2) E/M code not supported in documentation –

template driven3) Documentation specificity lacking4) Improper modifier usage5) Time not captured for related codes6) Diagnosis coding – specificity and sequencing7) Medical necessity not supported8) Patient need vs. Provider level not matched9) Team work – accountability not fostered

59

1 – Missed Charges / Inaccurate Codes

Missing, inaccurate and outdated codes reduce reimbursement

QI/QA:

• Ensure every service is matched to a CPT code• Correct codes to describe acuity and site• Descriptions should be accurate and not abbreviated and

misleading• Internal chart to bill audits

60

5/9/2014

21

QI/QA: Outdated Codes

• Assign updates - Review committee or staff role

• Periodically review client encounter forms/templates to ensure ICD/CPT codes are up-to-date and complete to reflect all services provided

• ICD updated (Oct 1 by WHO), CPT (Jan 1 by AMA)

o Summaries of updates in Appendix B of the CPT manual and at the front of the ICD manual

• Delete the clutter

• Have space for clinicians to write in additional codes as needed

61

QI/QA: Missed Charges

• Capture all services in addition to the main service:o Ancillary Lab Tests / Radiology – In-house vs. Send-out

o Expanded Hours Access – Nights and Weekends

o Interpreter Services

o Smoking Cessation Counseling

o Screening, Brief Intervention, and Referral to Treatment (SBIRT)

o Vaccines / Immunizations

• Understand services provided and what payors will reimburse

• Negotiate payment for relevant services when setting up contracts

62

QI/QA: Code Specificity

• Procedures have different CPT codes than E/M services

• Lesion removals - document location and intensity

• An E/M is not always billed when performing a procedure – only if separate and distinct

CPT Description – Partial listing

17110 / 17111 Molluscum Destruction 1-14 / 15+

46900 / 46924 Destruction of anal lesion(s); Simple / Extensive

54050 / 54065 Destruction of penis lesion(s); Simple / Extensive

56501 / 56515 Destruction of lesion(s), vulva; Simple / Extensive

57061 / 57065 Destruction of vaginal lesion(s); Simple / Extensive

63

5/9/2014

22

2 – E/M Coding Not Supported

• E/M level billed is not supported in the medical record documentation

• Clinician does not fully grasp E/M coding guidelines and assignment

• Multiple distinct issues addressed but not documented or billed – “oh by the way…”

• Templates drive E/M assignment vs. documentation

64

QI/QA: E/M Coding

• Can an outside reviewer get to the same E/M code by following your documentation?

o Risk for audit is higher when distribution of codes within a practice doesn't look reasonable

o If a single code is predominant in a clinician’s profile, assumption may be clinician isn't really coding for individual encounters

• Review templates-ensure key components and time are addressed

• Internal audits on regular basis

65

QI/QA: E/M Profiling

• Compare clinician / service type coding and volumes internally and with relevant benchmarks to identify vulnerabilities and potential revenue leakage

• Discuss findings with team

• Reinforce with education

66

5/9/2014

23

3 – Documentation Specificity Lacking

Documentation drives compliant coding

If it isn’t documented (and readable) – it can’t be coded and billed

QI/QA:

• ALWAYS follow coding guidelines

• Revise forms to ensure key documentation elements of services are included and in sequential order of the visit

• Look for cut and paste trends

• Internal audits - education

67

QI/QA: Documentation

• AutomateAllows clinicians to quickly capture all charges, promoting timely, accurate reimbursement

• Speech Recognition Software Allows clinicians to dictate directly into patients’ charts, enabling them to include all pertinent information while it is fresh

• Rules-based EditsAlert staff of where errors may exist, allowing organizations to audit all accounts and avoid inaccurate or missed charges

• Late ChargesTrack by department - resolve root causes

• Clinical Documentation SpecialistsEmploy to serve as liaisons to coders and clinical staff, improving communication, completeness and specificity of documentation

68

10 Principles of Documentation

1) Medical record (MR) should be complete and legible

2) Documentation of each patient encounter should include:

• Date

• Reason for encounter

• Appropriate history and physical exam in relationship to the patient’s chief complaint

• Review of lab, x-ray data and other ancillary services, where appropriate; assessment

• Plan for care

3) Past and present diagnoses should be accessible to the treating and/or consulting physician

69

5/9/2014

24

10 Principles of Documentation con’t

4) Reasons for and results of x-rays, lab tests and other ancillary services should be documented or included in the MR

5) Relevant health risk factors should be identified

6) Patient’s progress, including response to treatment, change in treatment, change in diagnosis, and patient non-compliance, should be documented

7) Written plan for care should include, when appropriate:

• Treatments and medications, specifying frequency and dosage;

• Any referrals and consultations;

• Patient/family education; and

• Specific instructions for follow-up

70

10 Principles of Documentation con’t

8) Documentation should support the intensity of the patient evaluation and/or the treatment, including through processes and the complexity of medical decision-making as it relates to the patient’s chief complaint for the encounter

9) All entries to the medical record should be dated and authenticated

10) CPT/ICD codes billed should reflect the MR documentation

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

71

4 – Improper Modifier Usage

Modifiers can mean the difference between full

reimbursement and reduced reimbursement – or denial

QI/QA:

• Anytime you provide more than one service at a single

encounter, you must consider whether a modifier is needed

• Update forms / templates to prompt for modifiers

• Review NCCI edits and codes that require modifiers

• Review modifiers and applicable usages as a team

72

5/9/2014

25

5 – Time Not Captured

Certain CPT codes require time to be documented

• Problem-focused E/M level

• Preventive / behavior change counseling (99401-99409) (i.e. Smoking cessation, HIV counseling)

• Interpreter, evening hours

QI/QA:

• Review forms and ensure an easy method to capture elements needed – form should prompt clinician

• Should be part of the notes; encounter form/ superbill may not be included during audits

73

6 – Diagnosis Coding

Specificity and Sequencing

• Is the primary reason for the visit your first-listed (primary) diagnosis code billed?

• Coding HIV and other STD diagnoses that have not been not confirmed by a screening test

• High risk sexual behavior with / without risk factors noted

74

QI/QA: Diagnosis Coding

• Only the licensed Provider determines the diagnosis

• Ensure forms allow clinicians to sequence and mark diagnosis codes are co-equal – no circling!

• Ask site of exposure and document

• Hire certified or trained coders and billing staff

75

5/9/2014

26

QI/QA: Diagnosis Coding con’t

• Code is invalid if it has not been coded to the full

number of digits required for that code (5th digit if

possible)

• If diagnosis is not established, code the symptom

• Don’t code for:

o “Rule-out” diagnoses

o Conditions that were treated and no longer exist

o Diagnosis that doesn’t apply to the visit

• AIDS / HIV coding have specific ICD guideline rules

76

Be Careful Assigning Codes …

Codes follow the patient long after the visit

77

7777

7 - Medical Necessity Not Supported

• Payors increasingly concerned about medicalnecessity

• Coding for services not provided is considered fraud

• Site of exposure not asked / documented for ordering appropriate screening tests – medical necessity

• May cause denials or future financial recoupment

78

5/9/2014

27

QI/QA: Medical Necessity

• Match each CPT code to a corresponding diagnosis before submitting

• Order ancillary tests keeping in mind risk factors and current guidelines

• Query clinician for incomplete codes – team work

• Billers should not be changing MR, need review process

79

8 – Patient Need vs. Provider Level

Do your patients meet with the correct level of

provider to ensure clinic efficiency and accurate

reimbursement?

Nurse visits inappropriately billed

Lab tests for new patient with no FTF encounter

QI/QA:• Review services / provider type – staff assessment

• Reassign tasks where possible

• Scheduling and clinic flow analysis

80

Nurse Visits – Often Overbilled

E/M 99211 if state and payor allow for it

• Documentation supports medical necessity

• Must be an established patient

• Must be a face-to-face encounter

• Nature of presenting problem with diagnosis from prior MD visit

• Brief history of the problem

• Documentation of vital signs (sole reason for visit should not be Blood Pressure check or Blood Draw)

• Plan of care

• Date/signature of the nurse or other provider

81

5/9/2014

28

9 - Team work & Accountability

Successful organizations work together as a team

All roles from front end staff to billing are essential part of the revenue cycle

QI/QA:• If questions on documentation of services billed, coders

and billers should be encouraged to query the clinician• Clinician must be accessible to answer questions timely• Encourage meetings and opportunities to explore

questions and potential issues together• Encourage mentoring• Time and space to do your job well

82

QI/QA Best Practices

Documentation:

• Complete and accurate

• Orders dated and signed?

• Required times captured?

• Charts reviewed on a regular basis?

• Clinicians available to clarify / answer questions?

• Easy access to valid codes which reflect actual services provided

Coding:

• Patient new or established?

• Type of E/M provided?

• Any surgical procedures?

• Labs and image studies ordered?

• Drugs administered or ordered?

• Supplies or devices used?

• Any modifiers needed?

• Appropriate diagnosis assigned and prioritized?

83

QI/QA Best Practices

• Current coding guides• In-service training • Job aides or other

reference guides • “Lunch and Learn” sessions• External courses and

seminars, if available • Department meetings• Accessible bulletin board • Peer–to-peer learning• Job shadowing

• Use your data - create helpful reports

• Monitor / periodic reviews• Review / update internal

compliance plans• Provide feedback • Improve communication

84

5/9/2014

29

Questions?

85

Resources by Cardea

• Billing and coding guide• Case studies on public health programs’ experiences

with third-party billing • Webinar recordings• Online learning tools• Request custom training and technical assistance

Visit our STDRHTTAC page: www.cardeaservices.org/ourwork/projects/stdrhttac

86

Online Learning Community

Building Sustainability for Public Health ProgramsA project of Cardea’s STD-Related Reproductive Health Training & Technical Assistance Centers

www.cardeastdrh.groupsite.com

Community Foundation• Shared interest in strengthening revenue management

strategies and billing practices• Open to agencies at all stages of billing implementation• Sharing of experience, knowledge, and resources

87

5/9/2014

30

Online Learning Community Features

• Resource Library• Peer-to-peer discussion• Continued / follow-up learning from training and

technical assistance activities, including webinars• Access to exclusive training and learning

opportunities

88

Setting Up for Success: Integrating Revenue Cycle Management

Tuesday, February 25, 2014

Reaching Full Potential: Quality Assurance and Improvement with Visit Documentation

Wednesday, April 30, 2014

Bringing It All Together: Sustaining and Enhancing Billing and Reimbursement Efforts

Thursday, June 26, 2014

Billing & Sustainability Series:Implementation and Improvement Strategies

for STD and Other Public Health Programs

Thank you!

Thank you!

89

Contact Information

Beatriz ReyesTraining Manager, Cardea – OaklandEmail: [email protected]: 510-835-3700

Ann FinnOwner/Healthcare Consultant, Ann Finn Consulting LLCEmail: [email protected]: 518-522-8159

Karen Shiu, MPHData/Training Manager, Cardea – OaklandEmail: [email protected]: 510-835-3700

90

Resource Page

Cardea Resources

• An online learning community to help you connect with peers and access resources

https://cardeastdrh.groupsite.com/login

• Webinars and other online learning tools (STDRH webpage) http://www.cardeaservices.org/ourwork/projects/stdrhttac

ICD- 10 Resources

• National Center for Health Statistics (NCHS)

http://www.cdc.gov/nchs/icd/icd10cm.htm

• Center for Medicare and Medicaid Services (CMS)

http://www.cms.hhs.gov/ICD10/01_overview.asp

• World Health Organization (WHO)

http://www.who.int/classifications/icd/en/

Office of Inspector General Resources

• Short and informative Podcasts

http://oig.hhs.gov/newsroom/video/2011/heat_modules.asp

• A variety of useful compliance tools and resources

http://oig.hhs.gov/compliance/

Topics include:

• RAT-STATS- a free statistical software package that providers can download to assist in a

claims review. The package, created by OIG in the late 1970s, is also the primary

statistical tool for OIG's Office of Audit Services. Among other tasks, the software assists

the user in selecting random samples and estimating improper payments.

• Compliance 101 and Provider Education

• Compliance Guidance

Centers for Medicare and Medicaid Services (CMS) Resources

• HCPCS general information

http://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/index.html?redirect=/MedHCPCS

Geninfo/

• Clinical Laboratory Improvement Amendments (CLIA)

http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html

• The Medicare Learning Network® (MLN) Educational Web Guides Documentation Guidelines for

Evaluation and Management (E/M) Services page offers health care professionals E/M services

information and resources.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNEdWebGuide/EMDOC.html

• Medicare Coverage Center

http://www.cms.gov/center/coverage.asp

American Health Information Management Association (AHIMA)

• Best Practices for EHR Documentation

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050286.hcsp?dDocN

ame=bok1_050286

• Health Information Management (HIM) Trends and Topics

http://www.ahima.org/resources/default.aspx

Food and Drug Administration (FDA)

• Clinical Laboratory Improvement Amendments (CLIA)

http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/IVDRegulatoryAssistanc

e/ucm124105.htm

American Medical Association (AMA)

• Current Procedural Terminology (CPT)

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-

practice/coding-billing-insurance/cpt.page

Centers for Disease Control (CDC) • STD-related Reproductive Health, Prevention, Training, and Technical Assistance Centers

(STDRHPTTACs) overview

http://www.cdc.gov/std/stdrhpttac/default.htm

American Academy of Professional Coders (AAPC)

• Resource page from AAPC

http://www.aapc.com/resources/index.aspx

The American Academy of Family Physicians (AAFP)

• Information on Coding from the AAFP

www.aafp.org/online/en/home/practicemgt/codingresources.html

American Hospital Association (AHA)

• Coding Advice and Resources

http://www.aha.org/advocacy-issues/medicare/ipps/coding.shtml

National Association of County & City Health Officials (NACCHO) Toolbox

• Searchable, free, online collection of local public health tools produced by members of the

public health community on billing issues. http://www.naccho.org/toolbox/index.cfm?v=4&id=243&topicname=Billing

Other Resources • http://journals.lww.com/stdjournal/Abstract/2014/04000/Insurance_Among_Patients_Seeki

ng_Care_at_a.2.aspx

• HealthHIV's National Center for Healthcare Capacity Building is conducting a four part webinar

series for the enhancement of third-party billing systems to maximize revenues. This series is

intended for administrators and medical billing specialists.

http://www.healthhiv.org/modules/info/maximizing_third_party_reimbursement.html

Q&A Follow‐up Part 1—Setting Up for Success: Integrating Revenue Cycle Management

Cardea Page 1 of 3 2014

The questions listed below were submitted by participants during the February 25, 2014, webinar Setting Up for Success: Integrating Revenue Cycle Management. Time constraints prevented our team from addressing these questions during the event. The answers below were provided by the Multnomah County Health Department’s STD Clinic. They reflect the experience of that clinic and are not intended as medical, health, legal or financial advice.

Policies and Procedures Q: If a DIS client is brought back for retesting 3 months later (or even later than that), do you charge

the $20 flat fee again during that visit?

A: If the client returns for only a three month retest, then there is no charge. However, most clients end up receiving a full screen, and then are charged on the sliding fee scale.

Q: How do you manage fee collection with clients using Family Planning services through Title X if

they slide to $0?

A: The Multnomah County STD Clinic does not receive Title X funding. Q: How is it that you can decide to eliminate part of services based on ability to pay and risk level?

A: The process that we went through to allow us to require payment for low risk clients was to read the relevant Program Element (programmatic/ service deliverable) and interpret the Local Public Health Agreements (LPHA), review local epidemiology and CDC guidelines, review costs, and reach an understanding both within the county and with the State of what we will charge per client. We also continue to review expenditures and revenue to assess the ongoing impact of client charges. In Oregon, in consultation with the State, we were allowed to bill insurance and charge clients a nominal fee that does not cover all of our costs without changing the Program Element/LPHA. In some states, local health departments may need to change the LPHA prior to implementation.

Q: Why wouldn't you be billing the $20 charge to clients who have private insurance as well? What

happens if the insurance does not reimburse you?

A: Clients that agree to bill their private insurance will receive an explanation of benefits from their insurer. If the claim is denied or only partial payment is received, then the client will be charged on a sliding fee scale based on their Federal Poverty Level (FPL).

Q: Would a DIS client be the same as an STD client? Can you please share what is involved in a DIS

visit, for both the positive CT/NG/SPH, and for a contact?

A: A DIS client is defined as a case or contact to chlamydia, gonorrhea, syphilis, and/or HIV. DIS clients are charged a flat fee of $20, which includes the office visit, screening for CT/GC, RPR, and HIV, and treatment. DIS clients are not refused testing and treatment due to inability to pay. For more information on DIS, see the CDC website http://www.learnpartnerservices.org/.

Q: What are the qualifications of a DIS? Is a DIS a public health nurse, or an epi, or a hybrid of the

two? Are they MAs or Health Educators…?

A: Multnomah County employs five Disease Investigation Specialists (DIS) that receive training from the CDC. The majority of our DIS have a Bachelor’s degree, however that is not a requirement. For more information on DIS, see the CDC website http://www.learnpartnerservices.org/.



Clinic Flow and Systems Q: How much more time does the expanded scheduling take? Have you experienced patients being

upset or resistant to process?

A: The average phone call takes 2‐5 minutes. We have options for non‐priority populations, such as our “Just Checking” (asymptomatic STD screening) or non‐priority clients can come in as a “stand‐by” to wait for someone to no‐show his or her scheduled appointment. Since there are options for all clients we have not had upset clients.

Q: Is the Epic system unique to Oregon?

A: No, EPIC is not unique to Oregon. For more information on EPIC Practice Management and EHR see http://www.epic.com/. Multnomah County participates in a collaborative called OCHIN which allows us to share in the cost of EPIC with other Local Health Departments and other safety net clinics. For more information on the collaborative see their website: https://ochin.org/.

Third‐Party Payer Relationships Q: Are you billing Medicaid and are there any circumstances that you would not bill Medicaid for

eligible clients?

A: Yes, we bill Medicaid. If a client does not want us to bill Medicaid then we ask that the client sign an Advance Beneficiary Notice informing the client that he or she will be charged on the sliding fee scale.

Q: Medicare does not reimburse for STD screens, only by the PCP. How do you bill and do you get

reimbursed by Medicare?

A: We bill Medicare and we receive some payment from them. I do not have a breakdown of what they have covered.

Q: Are you an in‐network provider when you bill the private insurance companies?

A: Our Mid‐Level Providers (NPs and PA‐Cs) are credentialed with Regence Blue Cross/Blue Shield and Pacific Source. We bill all other private insurances even if we are not listed as “in‐network.”

Q: Are you contracted with any insurances? If yes, how does that work with your DIS visits? My

understanding is that if you are contracted, you must bill the insurance for any visit.

A: Our Mid‐Level Providers (NPs and PA‐Cs) are credentialed with Regence Blue Cross/Blue Shield and Pacific Source. We bill all other private insurances even if we are not listed as “in‐network.” We will bill insurance for a DIS visit, if the client agrees.

Q: What are some of the major commercial payers available for pre‐verification on PH Tech?

A: For more information on PH Tech, see their website http://www.phtech.com/.



Cost‐Effectiveness Q: It seems like you are billing $20 for every client. How is that cost effective?

A: Multnomah County STD Clinic benefits from being part of a larger infrastructure, within Multnomah County Health Department (MCHD). MCHD provides medical billing staff and supports EPIC Practice Management.

Clients seen at the STD Clinic by a Mid‐Level Provider (MLP) are charged on a sliding fee scale based on the Federal Poverty Level, so not all clients will be charged the minimum fee of $20. We bill insurance if a client agrees and is seen by a MLP. MLP priority populations are:

Symptomatic, e.g. abnormal discharge, dysuria, abdominal pain, etc.

Cases and contacts to CT, GC, syphilis, and HIV (DIS referrals)

Men who have sex with men (MSM)

Men and women under 25 years of age

DIS clients, cases or contacts to chlamydia, gonorrhea, syphilis, and/or HIV are charged the flat fee of $20 (no one is refused service due to inability to pay).

Our “Just Checking” visits (asymptomatic STD screening) completed by a Community Health Worker or DIS, are a flat fee of $20 for priority populations (MSM and men and women under 25 years of age) and $40 for non‐priority clients.

reaching full potential - cardea services€¦ · reaching full potential: quality assurance and...

Documents