Clinical Documentation Improvement Boot Camp - PowerPoint Presentation

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Clinical Documentation Improvement Boot CampRCPA ConferenceOctober 8, 2014Slide2

Agenda Behavioral Health Services Cultural OverviewCurrent Regulatory Environment – New Compliance Challenges

Function of the Progress NoteDefensive Maneuvers – Audit Proof DocumentationTechnical BasicsMedical NecessityStandard of Care

Offensive Maneuvers – Moving Forward

EMR Issues

DSM-5/ICD-10-CM TransitionField Training Exercise - Mock Audits

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Boot Camp BeginsSlide4

Cultural OVERVIEWBehavioral Health ServicesSlide5

Cultural OverviewHistorically, behavioral health services have been

isolated and managed separately from other medical disciplines;Behavioral health services are “carved

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from medical health insurance plans and most often managed by a separate company with different rules.

Long-standing differences in coverage between behavioral health and medical benefits.Behavioral health services are less understood than other medical specialties and often viewed as a “little different” and medicine’s “stepchild

.”Neglect by parent organizations of their behavioral health programs;Audit and Compliance programs have traditionally not looked “under the hood” until a governmental audit occurs.

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Cultural OverviewHistorical lack of evidence based treatment interventions with measurable outcomes; traditional treatment focused on the patient-provider relationship.Translates into poorly worded, overgeneralized and un-measurable treatment goals for patients.

Difficulty measuring progress and defending medical necessity.

High emphasis on confidentiality results in suboptimal documentation to support services rendered:

How much to document?

Where to document?What can be shared under HIPAA?

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Cultural OverviewPractitioner independence to practice in their own way:Lack

of consistency among practitioners translated into variable documentation styles and language.Difficulty for third party entities to

interpret/understand

treatment rendered and

assess if medical necessity met.Behavioral health providers have largely not been targeted by major governmental entities resulting in complacency in documentation

.Providers not being held accountable for documentation.

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Cultural OverviewPractitioner resistance to financial implications, “but we’re here to help people.”

Not understanding documentation’s link to reimbursement.Liability issues may not be as heightened as in a medical model.

Decreased lack of attention to documentation

and continuity of the overall patient medical record.

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Cultural OverviewSeparation between mental health and substance abuse services;Differences in licensing and accreditation standards.Differing approaches to treatment.

Differing standards for staff qualifications.

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Cultural OverviewImpact on Medical NecessityWhile medical necessity is not new for inpatient/Partial Hospitalization Programs (“PHP”), it is a relatively new concept for outpatient services.

In the 80’s, services were available to whomever could access and wanted them; patient/client/consumer motivation was key criteria.Challenge of providing services for those who may not understand need for services, i.e., documenting medical necessity for involuntary treatment.

Mental health services have served a protective function for patients who may have not met traditional criteria for medical necessity;

challenge of defending through documentation , role of social issues as safety issues.

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Current Regulatory Environment:A Changing LandscapeSlide12

New Compliance ChallengesOverhaul of CPT psychiatric codes;

Effective January 1, 2013Roll-out of DSM-5; Introduced May 2013

Transition to ICD-10;

October 1, 2015

Transition to the Electronic Health Record

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Overhaul of CPT Psychiatry CodesMost significant change is physician shift to Evaluation & Management (“E&M”) codes;Elimination of the long standing pharmacologic management

CPT code 90862 which contained general documentation requirements.E&M codes requires specific documentation requirements, for which psychiatrists in outpatient settings in particular are not accustomed to utilizing.

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Office of Inspector General - 2014 Work Plan“We will determine the extent to which selected payments for evaluation and management (E/M) services were inappropriate. We will also review multiple E/M services

associated with the same providers and beneficiaries to determine the extent to which electronic or paper medical records had documentation vulnerabilities. Context—Medicare contractors have noted an increased frequency of medical records with identical documentation across services.

Medicare

requires providers to select the billing code for the service on the basis of the content of

the service and to have documentation to support the level of service reported. “

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Getting Down to Basics:

The Progress Note

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Function of the Progress NoteInvoice for Services RenderedIs the only “proof” of what occurred in treatment and what services were delivered; to whom, by whom, why, for how long, whether it was effective and whether it should be reimbursed.

Justifies the purpose of the service; supports medical necessity.

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Function of the Progress NoteCommunication Tool

 Documentation needs to be sufficiently clear and detailed to enable another practitioner to take over the case for any number of reasons.Documentation needs to be readily understood by a third party entity who may/may not have knowledge of behavioral health. 

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Function of the Progress NoteStandard of Care In the event of negligence, Standards of Care (“SOC”) will be the measuring tool for determining whether a practitioner was negligent.A SOC holds a person of exceptional skill or knowledge to a duty of acting as would a reasonable and prudent person possessing the same or similar skills or knowledge under the same or similar circumstances.

 SOC include Practice Acts, state and federal laws, accreditation agencies, professional associations, scientific literature and/or specific organizational standards. 

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Defensive Maneuvers for Compliant Documentation:Making Your Progress Notes Audit-Proof

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Defensive Maneuvers

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Defensive Maneuvers Strategic TacticsTechnical BasicsSupport medical necessityStandard of Care

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Strategic Tactic #1 Technical Basics

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Technical BasicsCompliance is not an optionKnow regulatory and organizational policies for documentation and billing:

Timed codes; includes “rounding” rulesUnit limitsNon-reimbursable services

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Technical BasicsWrite legibly and ensure legible, written signature with credentials. Alternatively, ensure timely, electronic signature authentication of documentation.Do not attempt to alter the record. Ensure that the original and the correction/addition are clearly and correctly marked.

 Small errors – single line drawn through the error with initial and date.Correction of previous entry – begin a new entry with corrected content with current date and time.Appropriate process to correct entries in the EMR

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Technical BasicsBe concise and “smart” in documenting; more is not necessarily better.Use lay language and ensure acronyms are spelled out; records may be reviewed by others with little/no behavioral health background and will need to readily understand the content.

Using templates for progress notes may increase efficiency but inherently contribute to compliance risks to include lack of patient specificity, boxes/lines left blank and /or inadequate documentation.

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Technical BasicsRemain mindful of content that becomes standard/pre-populated on each progress note; always read your note and edit appropriately.Consider the potential reader audiences of your notes; other clinicians, supervisory staff, utilization reviewers, insurance companies, the client and/or client family, significant other(s), plaintiff attorneys and/or exhibit in a court proceeding.

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Strategic Tactic #2

Support Medical Necessity

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Medical NecessityInitial EvaluationSupport for medical necessity begins with the initial evaluation resulting in a diagnoses as the primary focus of treatment and the individual’s capacity to participate in treatment, development of an individualized treatment plan, progress notes that address the patient/client progress relative to the treatment goals and establishing a discharge plan from day one. There must be continuity between these components; disjointed record conveys lack of direction in treatment and invites questions about medical necessity.

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Medical NecessityTreatment PlanDiagnostic formulation from the initial evaluation drives treatment direction articulated in the individualized treatment plan.Practitioners often view negatively and underestimate the significance of the treatment plan.

Behavioral health providers will be held increasingly accountable for measurable outcomes; incorporating evidence based practices when possible and articulating them in the treatment plan will support medical necessity.

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Medical NecessityTreatment PlanEstablish long and short term goals that are easily understood, concrete, measurable and obtainable so that progress can be demonstrated. Unrealistic goals set patient/client up to appear as having failed and medical necessity of intervention(s) more likely questioned.Avoid use of stock, repetitive goals from client to client; i.e. “stabilization of mood,” “improved social functioning,” “absence of risk,” “normalization of functioning.”

Update goals regularly or when interventions appear ineffective.

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Medical NecessityProgress NotesClinical notes for therapy sessions serve to document not only the patient’s clinical status and progress, but also serve to ensure that quality of care is adequate and payment is made for services provided. Progress notes should include:Date and length of the therapy sessions; start/stop times.

Patient's current clinical status as it relates to diagnosis; current symptoms and functional status.

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Medical NecessityProgress NotesContent of the therapy session, i.e., note of the major themes discussed.Summary of the therapeutic intervention of the session; be specific.

Summary assessment of the patient's progress or lack of progress toward the treatment goals. KNOW THE TREATMENT PLAN. Plan for the immediate future; connect back to the treatment plan.

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Medical NecessityHIPAA and Psychotherapy NotesPsychotherapy notes are notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or

family counseling session and that are separated from the rest of the individual’s medical record.Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

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Strategic Tactic #3Standard of Care

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Standard of CareDocumentation needs to reflect that your actions were similar to what reasonable clinicians would do under the same or similar circumstances; what would a comparable peer social worker, psychologist, licensed counselor, nurse have done.More important to document details of decisions that increase risk rather than those that decrease risk; i.e. documenting a decision to hospitalize may not require as lengthy an assessment versus allowing the patient to return to an unsupervised, unmonitored setting which required more comprehensive evaluation.

Health care providers have a duty to be familiar with SOCs – ignorance is not a defense.

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Standard of CareMedical record will be the only defense regarding whether professional specialty specific standards of care were followed.Mistake in judgment does not necessarily violate SOCs. Important to document a reasonable and complete thought process and clinical considerations, in addition to the final decision.

Include both positive and negative, verbatim responses from the client.

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Offensive Maneuvers

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Moving Forward – EMR DesignEnsure EMR documentation templates will capture required regulatory information.All entries into the medical record must be unambiguously identified and authenticated by their author.

Be aware of default information in templates and/or cut and paste functions.Failure to appropriately edit records, challenges documentation integrity and credibility of the information.

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Moving Forward – DSM-5/ICD-10DSM-5 maps to ICD-9 & ICD-10.Full use of DSM-5 projected by October 1, 2015 when ICD-10-CM is adopted as our standard coding system.

Dates when DSM-IV may no longer be used will be determined by the American Psychiatric Association.Handout “DSM-5/ICD-10 Overview for Behavioral Health Providers”

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Field Training Exercises - FTXBreak – Out Groups for Mock Documentation Audits

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ResourcesAmerican Psychiatric Associationhttp://www.psych.org/American Academy of Child and Adolescent Psychiatryhttp://www.aacap.org/

American Psychological Associationhttp://www.apa.org/National Association of Social Workershttp://www.naswdc.org/American Association for Marriage and Family Therapists

http://www.aamft.org/iMIS15/AAMFT/

American Counseling Association

http://www.counseling.org/Judge David L. Bazelon Center for Mental Health Lawhttp://csmh.umaryland.edu/

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Boot Camp InstructorsGeorgia Rackley, MSN, RN, CPC, CLNC, Senior Clinical Specialist georgiarackley@sunstoneconsulting.com717-574 -1947Laura Ehrlich, RN, BSN, CCM, Senior Consultant

lauraehrlich@sunstoneconsulting.com717-968 – 5035www.sunstoneconsulting.com

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