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The MEAT of Documentation The MEAT of Documentation

The MEAT of Documentation - PowerPoint Presentation

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The MEAT of Documentation - PPT Presentation

Presented by Tracy R Johnson CPC 2015 Mobile Alabama Chapter VicePresident Objectives Introduction on the Importance of Clear Documentation CPT Coding Audits Diagnosis Audits Denial Audits ID: 674014

patient coding medical diagnosis coding patient diagnosis medical audits documentation condition codes guidelines history conditions code disease audit treatment

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Slide1

The MEAT of Documentation

Presented by:

Tracy R. Johnson, CPC

2015 Mobile Alabama Chapter Vice-PresidentSlide2

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 DocumentationSlide3

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 deniedSlide4

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 GuidelinesSlide5

IMPORTANCE OF THE AUDIT TOOL

You may be asking yourself, “Why is an Audit Tool Important”?

Here are a few detailed reasons why:

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 codeSlide6

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 courseSlide7

What is CERT?

CERT stands for

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 reviewSlide8

Medicare Appeals Process

The Appeals Process contains 5 steps

Level 1: Redetermination by a Medicare Contractor

Level 2: Reconsideration by a Qualified Independent Contractor

Level 3: Hearing before an Administrative Law Judge

Level 4: Review by the Appeals Council

Level 5: Judicial Review in Federal District CourtSlide9

Payment Recovery/Recoupment

A Medicare Overpayment occurs when a provider receives excess payments due to any of the following:

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)Slide10

Defining “Chronic” versus “Acute”

What is the difference between Acute and Chronic Illnesses?

Acute Illnesses: Those illnesses that will eventually resolve without any medical supervision (colds, teething)

Example: 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

Chronic Illnesses: Those that require medical supervision and is often a disease that has formed over a long period of time.

Examples: Cancer, AIDS, Kidney Disease and Diabetes. Usually medicines for chronic illnesses are regulated as prescription drugs.Slide11

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)Slide12

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:

Diabetes without complications

Chronic Obstructive Pulmonary Disease

Congestive Heart Failure

Breast Cancer

Ischemic Heart Disease

AnginaSlide13

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 sourceSlide14

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.Slide15

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 existsSlide16

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. Slide17

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:

Clinical Evaluation

Therapeutic Treatment

Diagnostic Procedures

Extended Length of Hospital Stay

Increased nursing care and/or monitoringSlide18

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 status-post 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:

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)Slide19

Now The MEATSlide20

MEAT

What is MEAT?

M: Monitoring

E: Evaluating

A: Assessing/Addressing

T: TreatingSlide21

Monitoring “M”

Monitoring is the application of all of the below in a medical record:

Signs

Symptoms

Disease Progression

Disease RegressionSlide22

Evaluating “E”

Evaluating is the application of all the below in a medical record:

Test results

Effectiveness of medications

Response to treatmentSlide23

Assessing/Addressing “A”

Assessing or Addressing is the application of all of the below in a Medical Record:

Ordering Tests

Discussion

Review of Records

CounselingSlide24

Treating “T”

Treating is the application of all the below in a Medical Record

Medications

Therapies

Other modalitiesSlide25

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 medicationsSlide26

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 conditionSlide27

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 codesSlide28

Questions?Slide29

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