ADVANCED DISCUSSION GROUP—EPIC - … · •ADT/Prelude Registration ......

1

ADVANCED DISCUSSION GROUP EPIC GROUP—EPIC

CATHERINE WAKEFIELDMARK RUPPERTDAVID RICHSTONEDAVID RICHSTONEJILL HATFIELD/VICKY SOTTILE

AHIA 32nd Annual Conference – August 25-28, 2013 – Chicago, Illinois

www.ahia.org

Agendag

Overview of the User Group, Survey Results, 2

p, y ,Webinars and Conference educational offerings

Today’s Topics Data Governance and Reporting (Mark) AHIMA Risk Areas (Catherine)

/ Charge Router/Charging Controls (Jill) Interfaces (Mark) Audit Cycles/Facility Audits (Catherine) Audit Cycles/Facility Audits (Catherine) Examples of 6 month post go-live audits (David)

Summary Summary

Overview

User Group Activities

3

User Group Activities Webinar schedule Conference education Conference education Survey Results

User Group Activitiesp

Epic survey to AHIA members

4

Epic survey to AHIA members Planning 4 webinars in 2013

May 23—Complete; 87 attendees May 23—Complete; 87 attendees July 26—Security and Access Sept—Meaningful Use Sept Meaningful Use Nov—Segregation of Duties

Advanced Discussion Group at Annual Conference Advanced Discussion Group at Annual Conference

Survey Results—71 Responsesy p5

Security and Access 73.2% (webinar) Security and Access 73.2% (webinar)

Meaningful Use 73.2% (webinar)

Cycle Audits 73.2% Cycle Audits 73.2% Examples of 6 mo. post go-live audits 59.2% Charge Router/Charging Controls 56 3% Charge Router/Charging Controls 56.3% Interfaces 56.3% AHIMA Risk Areas 53 5% AHIMA Risk Areas 53.5% Data Governance and Management (Clarity/Cache)

52.1%52.1%

How long has your organization used EPIC?EPIC?

6

Implemented in the past 1 – 5 years

Just Implementing now34 6%

y47.4%

Implemented over 5 years ago17 9%

34.6%

17.9%

Which EPIC systems or applications does your organization use?

• EpicCare Ambulatory EMR • Cadence (Enterprise Scheduling) • MyChart for Patients (Web-based C i i i h P i ) does your organization use?

7

Communication with Patients) • Willow (Pharmacy) •ADT/Prelude Registration (Enterprise Admission/Registration)

• EpicCare Inpatient Clinical Documentation• EpicCare Inpatient Physician Order Entry

90.0%

•ASAP (Emergency Department) • Op Time (Operating Room) • Radiant (Radiology) • HIM Chart Tracking, Release of Information & Deficiency Tracking

• Resolute Hospital Billing 50.0%

60.0%

70.0%

80.0%

• Resolute Professional Fee Billing • Stork (L&D) • Beacon (Oncology) • EpicCare Link (Web-based Communication with External Providers)

• Anesthesia Cardiant (Cardiology) 20.0%

30.0%

40.0%

( gy)• Welcome (Patient Self-Service Kiosk) • Haiku (Hand Held Mobile Device Dictation) • Canto (iPad Dictation) • Beaker (Lab) • Kaleidoscope Ophthalmology• EpicCare Home Health

0.0%

10.0%

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EpicCare Home Health • Tapestry (Managed Care) • Other (please specify)

CUPID; Care Everywhere; Reporting Tools, incl RW and Clarity; ePrescribinginterface; Incoming lab results interface; vaccinations registry interface;

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evaccinations registry interface; outgoing surveillance interface; HIM ROI

• EpicCare Hospice • Rover (Mobile Functionality for Medications)

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What are topics of interest to you?

• Security and Access • Cycle Audits (Order – Documentation – Charge Capture – Coding – Billing) – Ambulatory; Ancillary Services; Specialty Services to you?

8

Response Percent

Ancillary Services; Specialty Services • Meaningful Use • Examples of 6-Months Post Go-Live Audits by Application Rolled Out

• EHR – HIM Aspects – AHIMA Risk Areas • Charge Router/Charging Controls• Interfaces

60.0%

70.0%

80.0%

Response Percent • Interfaces • Data Governance and Management (Clarity/Cache)

• Optimizing Workqueques• Clinical Research Billing Medication• Management - MAR • B k th Gl B k E d PFS

30.0%

40.0%

50.0%• Break the Glass Back End PFS • Pre-implementation Audits • Build Decisions • Project Governance • Conversion Home • Health/Skilled Nursing/Hospice

O h ( l f )

0.0%

10.0%

20.0%

Acc

ess

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Are

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• Other (please specify) :Disaster recovery solution Federal / State regulations that apply to document retention surrounding design, development, implementation, maintenance, upgrading, testing, etc. of an EHR. (Non-ePHI and non-MU documentation which have their own set of regulations)

Secu

rity

and

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IMA

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SOD's for access Charge Master, Contract Management Cash Drawer Utilization and Reconciliation Controls Research charges, charge edits, Research charges, charge/patient reconciliation, and Research Charges Segregation of Duties How to make use of Clarity and Workbench to identify accounts or transactions for audit -

Cyc

le A

udits

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Exam

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continuous audit. Segregation of Duties • Benefit Engine • DAP

Have you performed any audits of EPIC applications? (Select all that apply)applications? (Select all that apply)

9

45.0%

25.0%

30.0%

35.0%

40.0%

5 0%

10.0%

15.0%

20.0%

0.0%

5.0%

Planned audits? 10

Planned Audits

Charges/Revenue

Security/Access

Unsure/trying to determine

Meaningful UseMeaningful Use

Implementation/Post ImplementationBreak the Glass/Physician notes/Make me the AuthorCash/Collections

Interfaces

What ways would you like to receive info regarding auditing Epic applications? regarding auditing Epic applications?

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100.0%

70 0%

80.0%

90.0%

50.0%

60.0%

70.0%

20.0%

30.0%

40.0%

0.0%

10.0%

Webinar/Go-to Meeting

New Perspective “how to” articles

Newsletter E-learning Regional Seminar AHIA Annual Conference Track

User Roundtable AHIA Annual Conference Pre-M g C

or Unique Sessions throughout various

tracks

Cconference

Seminar

What tools would you like to have access to (i.e. through AHIA Audit Library) to support how you approach auditing Epic?

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Tools Audit Programs

Top Risks/Risk Assessments

System System Documation/Workflows/ChartsInternal Control Questionnaires

Data Analytic Ideas/ACL Test ScriptsLessons Learned/Issues Identified f A ditfrom AuditsEpic Reports Auditors Should AccessSecurity IssuesSecurity Issues

Information Exchange/Discussion Thread (not ListServe

Data Governance and Reportingp g13

Data Governance and ReportingB k dBackground

Who owns Data and how is/should reporting of 14

/ p gData Controlled? IT Function versus Operations How much access is afforded:

Operations Personnel, Internal Audit, Corporate Compliance, etc.?

Lack of Epic “support” for data governance and Lack of Epic support for data governance and knowledge outside of IT professionals? Lack of audit specific courses

L k f f di “E i C ifi i ” Lack of support for auditor “Epic Certification” Without this non-IT validation how might quality and

other reporting be impacted?p g p

Data Governance and ReportingE lExamples

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Governance / Reporting Examples/ p g p Traditional / Ideal: IT provides infrastructure, programming, data management

d i l i iand system implementation services.Operations owns the data and uses both IT and in-house

personnel to access source data for validation & reporting Internal Audit has open read access.

Epic Environment: Truly Non-Traditional? IT provides infrastructure programming data management IT provides infrastructure, programming, data management

and system implementation services. IT appears to own the data and the reporting of it.

IT h d IT has open read access.

Data Governance and ReportingB t P tiBest Practices

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Best Practice here is likely found in frameworks like Best Practice here is likely found in frameworks like COCO, ISO, etc. IT is a service provider who maintains the tools to p

generate, manage and report data. IT then owning and actually reporting the data would

not seem ideal, if for not other reason than application of the duty segregation control principal.

Data Governance and ReportingL L dLessons Learned

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Working in this new environment is difficult at best:g Data mining and analytics may be impossible. Application control focus has been an easier path into Epic

d t f f lb it th h h t lid ti i data for us so far, albeit through screen shot validations in many cases for source validation.

Operations personnel are eager to learn Epic but often frustrated if we don’t know more than they do.

The situation gets more difficult and more complex as more and more Epic modules are implemented.p p

Even with EMR and Rev Cycle implemented, we have not yet been able to gain a full data set from registration to dischargedischarge

Data Governance and ReportingQ&AQ&A

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What data governance successes do you have to g yshare?

What data governance challenges are you willing g g y gto share?

What data reporting success do you have to share?p g y What data reporting challenges are you willing to

share?

AHIMA Risk Areas19

Background: AHIMA Risk Areasg

Noridian Administrative Services, LLC20

,Documentation to support services rendered needs to be patient specific and date of service specific. These auto-populated paragraphs provide useful information such as the p p p g p petiology, standards of practice, and general goals of a particular diagnosis. However, they are generalizations and do not support medically necessary information that correlates to h f h l P B MR the management of the particular patient. Part B MR is seeing the same auto-populated paragraphs in the HPIs of different patients. Credit cannot be granted for information that is not patient specific and date of service specific (it li i CW)patient specific and date of service specific. (italics mine—CW)

Source: Source: https://www.noridianmedicare.com/shared/partb/bulletins/2011/271_jul/Evaluation_and_Management_Services_-_Documentation_and_Level_of_Service_.htm

Background: AHIMA Risk Areas g

“For example, electronic health records (EHR) may not only

21

facilitate more accurate billing and increased quality of care, but also fraudulent billing. The very aspects of EHRs that make a physician’s job easier—cut-and-paste features and templates—p y j p pcan also be used to fabricate information that results in improper payments and leaves inaccurate, and therefore potentially dangerous, information in the patient record. And because the g pevidence of such improper behavior may be in entirely electronic form, law enforcement will have to develop new investigation techniques to supplement the traditional methods g q ppused to examine the authenticity and accuracy of paper records. “

http://oig.hhs.gov/testimony/docs/2011/morris_testimony_07122011.pdf

Examples: AHIMA Areas of Risk p

Authorship Integrity Risk

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Authorship Integrity Risk Auditing Integrity Risk Documentation Integrity Risk Documentation Integrity Risk Patient Identification and Demographic Data Risks

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_033097.hcsp

Guidelines for EHR Documentation to Prevent Fraud

Examples: AHIMA Risk Areasp

Authorship 23

p Residency program audits: Students, residents, faculty

documentation Note editing (physician note “edited” by nurse or

resident) Authentication requirements Authentication requirementsAuditing Audit trails in Epic: how many to turn on??? Audit trails in Epic: how many to turn on???

Consider impact on system efficiency What are you going to use?y g g


Documentation integrity

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Documentation integrity Auto inserted data from smart phrases/text Copy/paste; copy forward; cut and paste Copy/paste; copy forward; cut and paste Template All could result in documentation that is not relevant to the

patient on that specific visit

Patient Identification and Demographic data Automated registration data Community provider access to EHR

Examples: Copy and Paste Risksp py

Nurse was updating her resume (using Word) 25

Nurse was updating her resume (using Word) and copied a portion of her resume into a patient chart

ED nurse had two records open. She copied part of Patient A’s record into Patient B’s record—drug use and bi-polar diagnoses showed on Patient B’s medical record and billing informationinformation

Need Error Correction Policy from the start: reporting roles (HIM IS other) customer servicereporting, roles (HIM, IS, other), customer service

Examples: Copy and Paste Risksp py

A note was copied "in total" to include the PREVIOUS

26

A note was copied in total to include the PREVIOUS performing provider's name

NO original documentation by the 'today' provider; just g y y p ; jan electronic signature with 'today's date and time'.

Reviewed 10 visits over a year period for a provider....every exam finding was the same despite current complaints to the contrary. Found to be copying and pasting exam forgot to 'edit' for today's and pasting exam......forgot to edit for today s findings.Plagiarism software download: http://plagiarism.phys.virginia.edu/AHIMA article: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005520.hcsp

Examples: AHIMA Risk Areasp27

Clinical Data (shared)

Demographic Data (shared)Demographic Data (shared)

Service Area X

FinancialData

Service Area X

FinancialData

Service Area X

FinancialData

Service Area X

FinancialData

Service Area X

FinancialData

Service Area X

FinancialData

Service Area X

FinancialDataData Data Data Data DataData Data

Financial Data is segregated by tax ID or billing entity


Structured data (fields/canned text) versus Free

28

Structured data (fields/canned text) versus Free text

“My” 99214/standard template My 99214/standard template Lack of continuous monitoring and feedback to

providers (who owns this?)providers (who owns this?)

Best Practices

Policies—Error Correction, Cut and Paste,

29

Policies Error Correction, Cut and Paste, Documentation

Physician Handbook Physician Handbook Required education and competencies for clinical

usersusers On-going auditing (documentation and coding;

template use; history carry-forwards) with feedback template use; history carry forwards) with feedback to providers

Medical Staff approval on selected policies Medical Staff approval on selected policies

Auditing Suggestionsg gg

Audit for compliance with policies

30

Audit for compliance with policies Include documentation review in coding audits

Cut and Paste Cut and Paste Unique patient visits

Use Plagiarism software Use Plagiarism softwarePlagiarism software download: http://plagiarism.phys.virginia.edu/AHIMA article: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005520.hcsp

AHIMA Risk Areas—Q&A

How are you managing these risks in your

31

How are you managing these risks in your organization?

Charge Router/Charging Controls g / g g32

Revenue Cycle Phase IIy

Phase II: Services, documentation, coding and charge capture.

33

, , g g p


Background:

34

Phase II – Focus on high revenue-producing ancillary departments: Operating Room, Cardiology (Invasive/Noninvasive), Radiology, Lab,

Pharmacy, Respiratory, GI/Endoscopy, Emergency DepartmentW k P f d Work Performed: Interviews with department leadership Process flows within each clinical area R i f l t li i d d Review of relevant policies and procedures Detailed testing Data analytic using ACL data mining tool Findings and Recommendations Findings and Recommendations Interview/Consult:

Mercy Revenue Management Team Charge Description Master (CDM) Team Mercy Compliance Department Central Coding Management


Use of Data Analytics:

35

y Operating Room – presence of pre-op charge/OR level, anesthesia

time, recovery timeMissing Recovery

Total

Location#

Cases% of Total

GrossCharges

# Cases

% of Total

First 30 MIN

ADD 30 MIN

# Cases

GrossCharges

# Cases

FACILITY A 6 0.1% 4,000$ 82 1.1% 4,125$ 9,225$ 0 ‐$ 7,500

Missing Pre Op Missing Anesthesia TimeMissing Recovery

Time

,$ ,$ ,$ $ ,FACILITY B 0 0.0% ‐$ 12 0.9% 600$ 1,356$ 6 2,000$ 1,300FACILITY C 10 0.2% 6,670$ 35 0.7% 1,750$ 3,955$ 0 ‐$ 5,200TOTAL 16 0.1% 10,670$ 129 0.9% 6,475$ 14,536$ 6 2,000$ 14,000

• Opportunities to improve charge capture• Define start and stop times• Enhance reconciliation



36

y GI/Endoscopy – presence of pre-op, Anesthesia time, sedation drug,

recovery time

Total

Location#

Exceptions% of Total

GrossCharges

# Exceptions

% of Total

Gross Charges

# Exceptions

% of Total Gross Charges

# Exceptions

% of Total

Gross Charges

# Cases

FACILITY A 12 0.2% 5,200$ 46 0.8% 25,250$ 99 1.6% 5,200$ 90 1.5% 24,500$ 6,058FACILITY B 63 15 4% 27 279$ 9 2 2% 4 941$ 44 10 8% 2 310$ 11 2 7% 2 992$ 409

Missing Pre Op Missing Anesthesia Time Missing RecoveryMissing Sedation Drug

FACILITY B 63 15.4% 27,279$ 9 2.2% 4,941$ 44 10.8% 2,310$ 11 2.7% 2,992$ 409FACILITY C 175 5.0% 75,775$ 79 2.3% 43,371$ 0 0.0% ‐$ 25 0.7% 6,800$ 3,500TOTAL 250 2.5% 108,254$ 134 5.2% 73,562$ 143 1.4% 7,510$ 126 1.3% 34,292$ 9,967

• Opportunities to improve charge capture• Enhance pharmacy charging• Define start and stop times



37

y Radiology – procedures with or without contrast for contrast media

charge

Location

Missing Contrast Charge

Radiology Procedures with Contrast

% of Missing Contrast Charges

Gross Charges

FACILITY A 24 12,685 0.19% 10,800.00$ FACILITY B 103 5,807 1.77% 46,350.00$ FACILITY C 8 2,477 0.32% 3,600.00$ TOTAL 135 20,969 0.64% 60,750.00$

• Enhance process for capturing charge for contrast media

, ,$



38

y Emergency Department – presence of, or duplication of, facility fee

Missing Duplicate Facility

LocationTotal ED

EncountersMissing

Facility Fee

Facility Fee as a % of Total ED Encounters

Duplicate Facility Fees

Fees as a % of Total ED

EncountersFACILITY A 19,739 9 0.05% 21 0.11%FACILITY B 8,540 890 10.42% 463 5.42%FACILITY C 23,466 13 0.06% 4 0.02%TOTAL 51,745 912 1.76% 488 0.94%

• Opportunities to improve charge capture• Enhance process to eliminate duplicates• Similar analytic for professional fees and suppliesSimilar analytic for professional fees and supplies


Best Practices:

39

Areas with charge auditors embedded in the process have better results

Departments with fully integrated Epic functionality benefit from system controlscontrols

Ability to analyze professional and technical charges across Epic modules

Lessons Learned: Revenue Reconciliation

Current process is manual and time consuming and is not comprehensive

Automation through data analytic is more efficient and accurateg y

Specificity to each area will eliminate false exception hits

Comparison across facilities will expose charge process inconsistencies

Charge Router/Charging Controlsg / g g

How are you addressing revenue risks?

40

How are you addressing revenue risks?

Interfaces41

Interfaces - Backgroundg

Interface Challenges are common in most healthcare

42

Interface Challenges are common in most healthcare Environments: Traditional Best of Breed Approachpp Automated and Manual Interface Situations HL7 Interface Standard Data Integrity Testing Issues Error Identification and Follow-up

Interfaces - Examplesp

What is the status of your Epic environment?

43

What is the status of your Epic environment? All Epic Revenue Cycle Only Revenue Cycle Only EMR Physician Officesy Bolt-ons

Interfaces – Best Practices

Is there an Epic best practice scenario against which

44

Is there an Epic best practice scenario against which to compare your organization? It may be too early to knowy y Not a lot of Epic information sharing yet, at least in the

audit profession Cedars-Sinai Resources and Outcomes Measurement

Function – Focused Data Quality Function – Possible B t P ti f t E i i l t ti d t d Best Practice for post-Epic implementation data and interface error identification and remediation

Interfaces – Lessons Learned

Testing, revalidation and a routine error correction

45

Testing, revalidation and a routine error correction process can be very helpful: Dedicated Data Validation Function Cross-Functional Participation Regular Follow-upg p Prioritization Feedback to Epic?

Interfaces—Q&A

What interface issues have you addressed?

46

What interface issues have you addressed?

Audit Cycles/Facility Auditsy / y47

Audit Cycles/Facility Auditsy / y

Risk Assessment

48

Risk Assessment What are the high risk areas? Revenue Volume Complexity of transactions (e.g., Lab panels) Complexity of regulations (e.g., Pharmacy quantity billing) # of handoffs (e.g., Nursing acuity => room charges) Current audit activity by payers Current audit activity by payersWhat’s in the news/settlements Cycle coverage

Audit Cycles/Facility Auditsy / y

Process components

49

Process components Physician orders, documentation, charging, coding,

billing

Applicable Standards Joint Commission National Patient Safety Goals Policies

MHS Cyclesy

Wanted a three year cycle; have a 4+ year cycle

50

Wanted a three year cycle; have a 4+ year cycle Other

Sedation

Facility Services within the 4 year rotation cylce Orders, Documentation, Billing, Coding

ORs Level Charges, supplies, implants/devicesED Level Charges, supplies, drugs Sedation

Observation Acuity

Pharmacy Billing units, admin fees, 340B, LCD/NCD issuesCT/MRI/PET/Nuc ContrastRad OncLab panels, bundlingRTAIS drug billing admin fees Acuity

OB ED Research

AIS drug billing, admin feesOncology drug billing, admin fees, LCD/NCD issuesEchoTrauma Trauma designationGISleepesea c

And more….p

Rehab Services PT/OT/SpeechInpt Services Acuity charges, supplies, nursing proceduresImaging--General Contrast

Consultant Services CCIA does not have specific expertise in these servicesCath Lab/IRHome HealthHospiceIP Rehab

Example #1p51

Audit Step Chart and Claim AnalysisA dit N Ob ti S iAudit Name: Observation ServicesPurpose: Ensure billing compliance for Observation ServicesSources: EpicPreparer: Staff A

i i dReviewer: Reviewer B and CDate: 11‐JunNote: Fieldwork comments made by the auditor are available on a request‐basis

N‐C:

LegendY ‐ Compliant N ‐ Noncompliant

Noncompliant ‐ Corrected

N/A ‐ No data available to test.

Patient

Final Patient Class (Observation, Inpatient, IP to

Consent form

MRN Account Location / Unit DOS range Obs, Obs to IP) signed?1258816 10591937 GS A WEST CARDIAC UNIT 3/9/11‐3/11/11 IP Y2746387 10603578 GS A WEST CARDIAC UNIT 3/11/11‐3/13/11 IP Y

Example #1p52

CHART DOCUMENTATION

Signed h i i

CHART DOCUMENTATIONOrder UM Review

CMS BM CH15, 290.1 42 CFR 482.30

Original Physician Order

Revised (by CM) Physician

physician Order for final status determination Recomm Evidence of

(Includes date, time, and service requested)

Order Details (Date, time, and service requested)

(IP / Observation) prior to discharge?

Beginning Observation Time (physician order)

Evidence of UM Review?

ended Patient Status per UM?

EHR Review (if applicable)?

Recommended Patient Status per EHR?

Y Y N 2033 Y IP Y IPY Y Y 2220 Y IP Y IP

Example #1p53

Part B Services DischargeBilling

Were Services Performed

Ending Observation

Total Observation Time per chart Revenue

Code 44 on claim

Code 44 education

Part B Services DischargeCMS BM CH15, 290.5.1

Performed that are Covered under Part B Insurance?

Total time Part B service was performed?

Observation Time (Last patient care service rendered)

Time per chart documentation (Beginning : Ending : Part B Services)

Patient Class Appropriate?

Type of Bill Appropriate?

Observation HCPCS (G3078) Appropriate?

Revenue Code Appropriate for Observation?

Attending phys ID appropriate?

claim appropriate (Inpatient to Outpatient ‐ Medicare)?

education given to patient (per MHS Code 44 Policy)?

Other phys ID

Y 7 1241 33 Y Y Y Y Y Y Y YN/A N/A 1644 18 Y Y Y Y Y N/A N/A YN/A N/A 1644 18 Y Y Y Y Y N/A N/A Y

Example #1p54

HoursHours

Number of Number ofBilled Hours Equal ChartNumber of

Observation Hours Billed

Number of hours for Chart Documentation

Equal Chart Supported Hours?

43 33 N43 33 N18 18 Y

Example #2p55

√

Tickmark Legend Chart and Claim ReviewOB Hospitalist Program: Facility E/M Services Testwork performed without exception.

X

X1

X2

To determine compliance to CMS requirements and EMTALA requirements.Testwork performed with exception. Services provided, with order, but not coded or billed.Testwork performed with exception. Services provided, billed and coded but no order.

Testwork performed with exception. Facility Evaluation and Management (E/M) under billed or over billed.

N/A

MultiCare Connect

X3

X4

NA

Testwork performed with exception. 2 Ob ED visits in same calendar day.

Attribute is not applicable to the sample item.

Testwork performed with exception. Ob ED not a distinct service.

Issues were identified.Inpatient

Auditors A and B

Reviewers C and D

10/1/2012

ITEM NUMBER

MEDICAL Demographics -

Pt's name, Site

(Patient Discharge

(D) or

PATIENT IDENTIFICATION INFORMATION

RECORD NUMBER

middle initial, DOB, Address, DOS

Came From)

Admitted (L&D)

NPSG 01.01.01: NPSG 01.01.01:

NPSG 01.01.01:

For Auditor

Use OnlyFor Auditor Use Onlyy y

1 2987777 √ 8/12/2012 Unknown Discharged2 52791 √ 8/16/2012 Unknown Discharged3 164652 √ 8/4/2012 Unknown Discharged

Example #2p56

CONSENTSQUALITY ASSURANCE CONSENTS

Chief Compliant

QUALITY ASSURANCE

Orders

pdocumented by

physician or non-physician

practitioner (NPP)

Medical Screening

Exam

Facility ED Evaluation/

Management Service Billed

AMA - Signed

AMA form by Patient

Supporting Documentation

for Services (Nurses' Notes)

Procedures Performed & Documented

Physician Supervision Present

Consent for Treatment/Financial Agreement

Signed

CMS EMTALA Current

MHS Policy and Procedure Informed

Consent and Patient

Competency onCMS Requirements,

JC Requirements, and CoP; MHS

Policy

CMS Requirements,

JC Requirements,

and CoP

EMTALA, GS Policy "Pregnant Patient,

Imminent Delivery"

Current Procedural

Terminology 2012 Book;

CMS Requirements EMTALA

CMS Requirements

and JC Requirements

CMS Requirements, 1995 and 1997 Documentation

Guidelines

CMS Requirem

ents

Competency on pages 5 & 6 J-6; CMS 482.13 (b)

(2); & Wa. Health Law

ManualX 1 √ √ X3 N/A √ X 1 √ √X 1 √ √ X3 N/A √ X 1 √ √√ √ √ X3 N/A √ √ √ √√ √ √ X3 N/A √ √ √ √

Example #2p57

BILLING/CODING/MODIFIERS - ASSOCIATED WITH THE OB ED FACILITY E/M LEVEL OF SERVICE

Claim information available for

review

Claim dates - match

MR

Revenue code

reported on Claim

Facility ED E/M Code/

Procedure Code

Procedures Performed

HCPCS/CPT4 Appropriate

Modifier appropriate

Services Billed and Submitted

Principal diagnosis - appropriate

ICD 9 Codes (Not including

Principal Diagnosis)

Attending phys ID appropriate

BILLING/CODING/MODIFIERS - ASSOCIATED WITH THE OB ED FACILITY E/M LEVEL OF SERVICE

review MR on Claim Code Performed Appropriate appropriate Submitted appropriate Diagnosis) ID appropriate

Identify procedures performed

from

CMS Claim Requirement

s

CMS Claim

Requirements

CMS Claim

Requirements

CMS Requirem

ents

documentation. Did we bill for all

procedures?CMS Claim

RequirementsCMS Claim





Requirements√ √ √ X3 X 1 X 1 √ √ √ N/A √√ √ √ X3 √ √ √ √ √ N/A √√ √ √ X3 √ √ √ √ √ N/A √√ √ √ X3 X X √ √ √ √ √

Cycle Audits/Facility Auditsy / y58

What audits are you doing? What audits are you doing? What can you share about your processes?

Examples of 6 month post go-live ditaudits

59


Security

60

Security Make sure Epic personnel are restricted out of Chronicles

within some reasonable post go-live timeframe p g Check the number and nature of staff with this highest

level of access How robust is your IS Change Management Process? Changes to your Master files should all be well

documented and tested prior to moving into production


Work Queues61

Run Data on all work queues

Month Charges Payments Adjustments To Bad Debt A/R Changey j / ------ --------- ----------- ------------ ------------ ------------- Dec 12 352,995,988 -110,900,476 -231,438,801 -11,491,678 -834,967 Jan 13 401,525,218 -111,009,833 -228,570,958 -9,681,954 52,262,473

F b 13 362 519 766 104 894 503 245 179 536 10 115 864 2 329 863 Feb 13 362,519,766 -104,894,503 -245,179,536 -10,115,864 2,329,863 Mar 13 391,861,426 -117,325,575 -259,957,523 -8,726,359 5,851,968 Apr 13 382,445,431 -109,290,101 -253,892,195 -7,762,792 11,500,343 May 13 404,110,980 -122,765,406 -273,680,790 -11,394,735 -3,729,952y , , , , , , , , , , Jun 13 289,837,460 -78,959,626 -206,785,985 -6,598,541 -10,908,545

Look for Anomalies


Work Queues62

Top 10 Inpatient DNBs/Stop Bills Error ID Owning Area Count Amount

---------------------------------------------- -------- -------- ----- ----------

1. SB Resp Charges To Be Reviewed 1018 CLIN FIN 34 2,790,216

2 DNB HIM CODING STATUS NOT COMP 4146501 HIM 42 2 744 357 2. DNB HIM CODING STATUS NOT COMP 4146501 HIM 42 2,744,357

3. DNB HIM PRIMARY DX CHECK 4140005 HIM 41 2,723,963

4. DNB HIM DRG CHECK 4142002 HIM 41 2,723,963

5. SB Late Charges 11 BILLING 40 2,131,904

6. SB Rehab IP Hipps Review 1027 REHAB 25 1,266,041

7. DNB COD DRG CHECK 4142001 HOSP CODING 14 993,416

8. SB MEDASSETS EXCEPTION 1023 CHARGE CAPTU 14 982,823

9. DNB COD PRIMARY DX CHECK 4140004 HOSP CODING 13 971,919

10. DNB COD CODING STATUS NOT COMP 4146502 HOSP CODING 13 971,919


Work Queues63

Q Denials Trending Summary as of: 6/30/13 Denial Reason Amount Count --------------------- ---------- ----- 23-23-PAYMENT ADJUSTED BECAUSE 9,308,677 1459 16-CLAIM/SERVICE LACKS INFO 2,167,803 451 18-18-DUPLICATE CLAIM/SERVICE 1 785 572 203 18-18-DUPLICATE CLAIM/SERVICE. 1,785,572 203 96-96-NON-COVERED CHARGE(S). 1,138,071 393 15-15-PAYMENT ADJUSTED BECAUSE 743,995 50 A1-A1-CLAIM DENIED CHARGES. 561,222 128 97-97-PAYMENT IS INCLUDED IN T 439,025 5 22-22-PAYMENT ADJUSTED BECAUSE 309,472 97 29-29-THE TIME LIMIT FOR FILING 281,615 28


Interfaces

64

Interfaces Identify non-Epic systems that require interface into Epic Obtain data output from these systems Obtain data output from these systems Ensure Epic is receiving all data from these systems For Ex., If Lab system says they are interfacing 1,500 For Ex., If Lab system says they are interfacing 1,500

accounts and $2,500,000 over to Epic, are all of these coming in to Epic?

How does IS manage the nightly interface process?


Outbound Data Sets

65

Outbound Data Sets Contracted Physicians should be getting ADT info to do

their own billingg Check to make sure they are getting minimum necessary

info, but also ALL the patients they have seen If there are gaps in the data pull, you could end up owing

your group $$ that they didn’t bill for due to the i l t i t f !incomplete interface!


Statistics66

Test the accuracy of your post go-live statistics Are admissions and discharges counted correctly? Are you pulling from all the right sources? For example,

OpTime accumulates admissions. You need to add these to the ADT admits for a totalthe ADT admits for a total.

How are Observation patient conversions to/from IP status handled?

When you pull admit data based on UB or 837 claim files, you may miss Self Pay accts which don’t get UB’s but get statementsget statements

Summaryy

Epic has many modules, features and functionality

67

Epic has many modules, features and functionality Auditors need to know how to use Epic fully

Many roles Many roles Many views Audit trails Audit trails

Learn from each other Have fun with it (that which doesn’t kill you makes Have fun with it (that which doesn t kill you, makes

you stronger)!

Summaryy

Epic has many modules, features and functionality

68

Epic has many modules, features and functionality Auditors need to know how to use Epic fully

Many roles Many roles Many views Audit trails Audit trails

Learn from each other Have fun with it (that which doesn’t kill you makes Have fun with it (that which doesn t kill you, makes

you stronger)!

Save the DateSeptember 21 24 2014September 21-24, 2014

33rd Annual Conference Austin, Texas

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