Physician Education and CDI 2017 Iowa Coding Project Workshops 1 Presented by: James Dunnick, MD, FACC, CHCQM, CPC, CMDP The Dunnick Group, LLC [email protected]Project: Coding Physician Education and CDI: A Collaborative Approach from a Physician’s Perspective Learning Outcome Standard: This program is based on general federal, state, and compliance guidelines. Disclosure of Proprietary Interest Project: Coding The Dunnick Group, LLC does not have any proprietary interest in any product, instrument, device, service, or material discussed during this learning event. The Dunnick Group, LLC uses physician led teaching to reduce cost of care, improve outcomes, and reduce audit risk exposure The education offered by ICAHN in this program is compensated by the HRSA Small Hospital Improvement Program (SHIP) grant, Iowa FY17-18, Contract #5888SH01. Learning Outcomes Project: Coding By the end of this session, attendees should be able to: • Identify reasons for payer scrutiny • Describe the cost of non compliance • Describe physician resistance • Identify ways to create physician buy-in • Identify a plan to place a CDI program
Transcript
Physician Education and CDI 2017 Iowa Coding Project Workshops
Physician Education and CDI 2017 Iowa Coding Project Workshops
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What is E/M? Three key E/M parts
A. History
1. History present illness
2. Past medical family social history
3. Review of systems
B. Physical Exam
1. 1995-Body areas or organ systems
2. 1997- General or specialty specific
C. Medical Decision Making
1. Problem points
2. Data points
3. Risk 19
What is E/M HPI?
History of Present Illness
Has components called elements.
8 Elements:
Location Timing
Severity Duration
Quality Modifying Factors
Context Assoc. Symptoms or Signs
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What is E/M?
Level of HPI
Problem focused Brief ( 1-3 )
Expanded PF Brief ( 1-3 )
Detailed Extended ( 4-8 )
Comprehensive Extended ( 4-8 )
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MAGIC WORDSHPI:
• John is a 55 year old Hispanic male who has noticed chest pain. His wife saw him grimacing and rubbing his chest and wanted him seen. Her brother died of a heart attack last summer. John does not seem to know his family well but his father may have had some cardiac problems. I don’t have the feeling we have reliable details with this.
• He felt the discomfort was quite severe and this further caused alarm. He has been putting off being seen due to a new job and not wanting to miss days of work.
• At work the company nurse gave him antacids and told him he may have an ulcer. She sent him home and told him to obtain medical clearance prior to returning to work.
• He felt the antacids may have helped and is hoping this means his heart is all right. 22
Auditor Sees
chest pain
severe
antacids may have helped.
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Auditor Grades
HPI Elements:
• Severity- Yes. Severe
• Quality- no
• Location- Yes. Chest
• Duration- no
• Associated sx’s and sym’s- no
• Modifying factors- Yes. Antacids may have helped
• Timing- no
• Context- no
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E/M
Level HPI
• PF Brief (1-3)
• EPF Brief
• Det Ext (4-8)
• Comp Ext
New Patient Payouts
Level HX EX MDM Time $
• 99201 PF PF SF 10 43.00
• 99202 EPF EPF SF 20 43.00
• 99203 DET DET LOW 30 72.00
• 99204 COMP COMP MOD 45 107.00
• 99205 COMP COMP HIGH 60 144.00
MAGIC WORDS
HPI: John presents with 3 weeks of severe dull chest pain.
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Auditor Sees
3 weeks severe dull
chest
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Auditor Grades
HPI Elements:
• Severity- yes. severe
• Quality- yes. dull
• Location- yes. chest
• Duration- yes. 3 weeks
• Associated sx’s and sym’s- no
• Modifying factors- no
• Timing- no
• Context- no
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What is E/M?
Level of HPI
Problem focused Brief ( 1-3 )
Expanded PF Brief ( 1-3 )
Detailed Extended ( 4-8 )
Comprehensive Extended ( 4-8 )
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New Patient PayoutsLevel HX EX MDM Time $
• 99201 PF PF SF 10 43.00
• 99202 EPF EPF SF 20 43.00
• 99203 DET DET LOW 30 72.00
• 99204 COMP COMP MOD 45 107.00
• 99205 COMP COMP HIGH 60 144.00
4 paragraphs of 146 words audits more poorly (fewer dollars) than 1 sentence of 10 words.
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E/M HPI New Patient
• John presents today with chest pain. He had a CABG three years ago and unfortunately has started back with his smoking. He is now at 1 pack per day. He remains overweight.
• His older brother and his father died of heart disease and this pain re occurrence is further causing him concern.
• He is compliant with his beta blocker and aspirin.
• He does not have palpitations, shortness of breath, nor syncopal spells.
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Auditor Sees
John presents today with chest pain. CC
He had a CABG three years ago PMH
Unfortunately has started back with his smoking. He is now at 1 pack per day. SH
He remains overweight. PE, SH
His older brother and father died of heart disease FH
He is compliant with his beta blocker and aspirin. PMH
He does not have palpitations, shortness of breath, nor syncopal spells.ROS
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The Auditor Grades
No Elements
Non Billable note
E/M HPI
John presents today with chest pain. CC
He had a CABG three years ago PMH
Unfortunately has started back with his smoking. He is now at 1 pack per day. SH
He remains overweight. PE, SH
His older brother and father died of heart disease FH
He is compliant with his beta blocker and aspirin. PMH
He does not have palpitations, shortness of breath, nor syncopal spells. ROS HPI
Document Bill OK?
99203 99204 NO
99204 99203 NO
Audit Exposure
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3.20% 3.79%
46.60%43.32%
3.09%
0%
20%
40%
60%
80%
100%
99211 99212 99213 99214 99215
Pe
rce
nt
of
En
cou
nte
rs
Established Patient Encounters
CMS Part B Established Patient Evaluation & Management Services
Family Practice
Family Practice Established Patient Evaluation & Management Services
Document Bill OK?
99203 99204 NO
99204 99203 NO
99204 99204 YES/NO
Audit Exposure
CC: Chest pain
HPI: 62 yo wm with severe crushing cp off/on for three days.
MDM: 1. Unstable angina pectoris. Cath this afternoon.
Medical Necessity
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CC: Chest pain
HPI: 62 yo wm with severe crushing cp off/on for three days.
He feels the longest episode was just 30 seconds.
Medical Necessity
CC: Chest pain
HPI: 62 yo wm with severe crushing cp off/on for three days. The longest episode was just 30 seconds he feels. It seems to occur when he walks up the hill to his barn and then seems to resolve at the top when he rests.
Medical Necessity
CC: Chest pain
HPI: 62 yo wm with severe crushing cp off/on for three days. The longest episode was just 30 seconds he feels. It seems to occur when he walks up the hill to his barn and then seems to resolve at the top when he rests. Yesterday he had to stop half way up the hill due to the pain.
MDM: 1. Unstable angina pectoris. Cath this afternoon.
Medical Necessity
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MDM: 1. Unstable Angina.
The description is very consistent with unstable angina and in fact crescendo or pre infarct angina. I do not want to risk an event occurring in testing delay or while trying to do a non invasive study. I will bring him in to the hospital now, keep him at bed rest, start antiplatelet agents and beta blockers, and plan for a LHC this afternoon. Intervention will be based on the results.
Medical Necessity
• 27 yo wm presents with chest pain. Worse when he moves his arms to lift objects. He raked two acres of leaves yesterday.
• Exam ; NL
• MDM: Musculoskeletal chest pain
Example
ICD 10 CM
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ICD 10 CM
• 27 yo wm presents with chest pain. Worse when he moves his arms to lift objects. He raked two acres of leaves yesterday.
• Exam ; NL
• MDM: Musculoskeletal chest pain
� R07.89
Example
Chest Pain
The patient is admitted through the ER with a complaint of chest pain. The EKG and laboratory tests completed in the ER are inconclusive, but an acute myocardial infarction is ruled out. During the hospital stay, the cardiovascular workup did not reveal any coronary artery disease. The patient is known to have a gastroesophageal reflux disease. I feel the patient has atypical chest pain due to GERD.
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Chest PainThe patient is admitted through the ER with a complaint of chest pain. The EKG and laboratory tests completed in the ER are inconclusive, but an acute myocardial infarction is ruled out. During the hospital stay, the cardiovascular workup did not reveal any coronary artery disease. The patient is known to have a gastroesophageal reflux disease. I feel the patient has atypical chest pain due to GERD.
MDM: 1. Atypical chest pain R07.89
2. Gastro-esophageal reflux disease K21
K21
Chest Pain
The patient is admitted through the ER with a complaint of chest pain. The EKG and laboratory tests completed in the ER are inconclusive, but an acute myocardial infarction is ruled out. During the hospital stay, the cardiovascular workup did not reveal any coronary artery disease. The patient is known to have a gastroesophageal reflux disease. I feel the patient has atypical chest pain due to GERD with esophagitis.
MDM: 1. Gastro-esophageal reflux disease with esophagitis. K21.0
MDM: 2. Atypical Chest Pain
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Clinical Example
HPI: 73 yo WM presents with the sudden onset of LUE/LLE weakness and slurred speech.
PE: Marked weakness of the LUE. Weakness, though less severe, of the LLE. Speech is very slurred.
MDM: Left sided CVA.
Clinical Example
HPI: 73 yo WM presents with the sudden onset of LUE/LLE weakness and slurred speech.
PE: Marked weakness of the LUE. Weakness, though less severe, of the LLE. Speech is very slurred.
MDM: Left sided CVA.
1. Cerebral infarction. Right internal carotid artery
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Clinical Example
HPI: 73 yo WM presents with the sudden onset of LUE/LLE weakness and slurred speech.
PE: Marked weakness of the LUE. Weakness, though less severe, of the LLE. Speech is very slurred.
MDM: Left sided CVA.
1. Cerebral infarction. Embolization of the right internal carotid artery. I63.131
Clinical Example
MDM: Left sided CVA.
1. Cerebral infarction. Embolization of the right internal carotid artery. We will consult neurology for their thoughts on medical vssurgical treatment.
We will keep her on telemetry to evaluate for the potential of a dysrhythmia being an etiology.
2. L side hemiplegia. I will ask PT/OT to evaluate for mobility, balance, gait, and strength improvement.
3. Slurred speech. I am concerned about aspiration and she will require a swallow study and speech therapy.
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Clinical Example
MDM: Left sided CVA.
1. Cerebral infarction. Embolization of the right internal carotid artery. We will consult neurology for their thoughts on medical vs surgical treatment. We will keep her on telemetry to evaluate for the potential of a dysrhythmia being an etiology.
2. L side hemiplegia. I will ask PT/OT to evaluate for mobility, balance, gait, and strength improvement.
3. Speech deficit. Aphasia. I am concerned about aspiration and she will require a swallow study and speech therapy.
ICD 10 CM
Does it Match?
• J00…… 99214
• I25.10…..99215
Be prepared to defend this.
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Waste Abuse Fraud
Waste:
• To use unnecessary Medicare health care benefits or spend Medicare
health care dollars without real need.
Abuse:
Excessive or improper use of services…. resulting in unnecessary costs
to Medicare.
Fraud:
• An intentional and willful act of deception…..
Cost of Non Compliance
• “A 16-count indictment was unsealed in federal court charging a cardiologist with performing unnecessary catheterizations, tests, stent insertions and causing unnecessary coronary artery bypass surgeries as part of a scheme to overbill Medicare.”
• On August 21, 2014, U.S. Attorney for the Northern District of Ohio Steven M.
Dettelbach
The hospital risk
• XX hospital faces
• 15 lawsuits over improper heart procedures
• subject of a federal investigation
• Securities and Exchange Commission filing Written by Ayla Ellison (Twitter | Google+) | February 13, 2015
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Cost of Non Compliance
A Massachusetts family practitioner agreed to pay $162,676.94
The physician submitted claims under his billing number for services provided by nurse practitioners.
Cost of Non-Compliance
Hospital Fined
• $13 Million Dollars for incentives for productivity and providing care not supported by documentation.
Cost of Non-Compliance
The XXX of Indiana, agreed to pay $121,855.01.
The OIG alleged that they submitted claims to Medicare for physical therapy services that were improperly documented by a physical therapist.
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Cost of Non-Compliance
• Nursing Home agreed to pay $1,139,789.65.
• OIG alleged they billed for post hospital extended care services furnished at the nursing home using certifications and re-certifications that did not meet applicable Medicare criteria.
Changing Responsibility
• Provider
• Coder/Biller
• Compliance Officer
• CFO
• CEO
Cost of Compliance
"We have a number of physician practices, and I am concerned…..“
Senior vice president and CFO XX Hospital
Written by Ayla Ellison (Twitter | Google+)
December 03, 2014 Beckers
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The Changing CFO Role
The hospital CFO role is becoming more strategic.
Value Based PurchasingImprove quality of care
Lower cost of care
CFOs concerns
• They are branching out into unfamiliar territory
• Just beginning to realize their personal risk
Written by Ayla Ellison (Twitter | Google+) | December 03, 2014 Beckers
The Changing CFO Role
Responsibility for Billing Errors
• The C Suite
• The Board
• The Employees
• The Patients
HOW DO WE FIX THE PROBLEM?
COMPLY
DOCUMENT CORRECTLY
PLAY BY THE RULES
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Good news• There are E/M techniques to create a better note• There are EHR techniques to be accurate• Medical necessity can be explained when you construct a note• There is a fine line between efficient use and misuse• We can take the time to learn how to make the entire process match• Providers can be taught these rules• The rules must be practiced
Compliance Documentation
THE PLANYou must involve the C suite
• Show them how hard it is to code from poor physician documentation
• Show them bill delays when charts cause questions
• Keep track of query sends and receives
• Explain that RAC losses do not have to be a “normal cost of doing business”
• Be sure they understand audits are increasing
THE PLANYou must create provider buy in
• Show them you are on their side
• Make sure they understand you are trying to help not suggesting poor care
• Give them specific examples
• Answer their question: “What’s in it for me?”
• Start an education plan
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THE PLANBuild a Team
• Physician Champion
• Lead coder must be experienced and with excellent communication skills
• Add the CFO, explain their personal exposure
• Detailed and experienced CDI team
• Audit; internal and external
Learning Outcomes
Project: Coding
By the end of this session, attendees should be able to:
• Identify reasons for payer scrutiny
• Describe the cost of non compliance
• Describe physician resistance
• Identify ways to create physician buy-in
• Identify a plan to place a CDI program
QUESTIONS?
If you have questions about this education, please contact:
