Compliant RA Coding and the EHRaapcperfect.s3.amazonaws.com/a3c7c3fe-6fa1-4d67... · Sheri Poe...

3/28/2016

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Compliant

RA Coding

and the EHRSheri Poe Bernard, CCS-P, CPC, COC, CPC-I

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Consider factors that brought us to the EHRs we are

coding from today, and what a “compliant” EHR is

Explore benefits of taking a proactive approach to EHR

compliance issues and policies in the RA workplace

Learn to discern difference between good and bad data

within an EHR

Discuss impact of EHRs on diagnosis support and

reporting

Today’s goals

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Office of the National Coordinator for Health

Information Technology (ONC):

EHR goals: Improve quality, safety, efficiency, and reduce health disparities

Engage patients and family

Improve care coordination, and population and public health

Maintain privacy and security of PHI

Ultimately, it is hoped it will result in:

• Better clinical outcomes

• Improved population health outcomes

• Increased transparency and efficiency

• Empowered individuals

• More robust research data on health systems

Meaningful use

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CMS: Pressured for implementation of certified plans with $$$

Certifiers: Standards ignored coding/documentation compliance

HHS and Office of National Coordinator of HIT: Did not publish

coding/documentation guidance for EHRs

Med Schools: Clinical documentation addressed without any focus on

EHR platforms, compliance and coding is barely mentioned

Software vendors: Promised time and personnel cutting, advised to

omit coders from selection process

Providers and facilities: Drank the Kool-Aid, often did NOT involve

coding staff in purchase decisions

Group practices and facilities: Impose productivity standards

RA auditors: Usually do not have access to providers and bounce

between many different EHR platforms

A Perfect Storm

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Electronic health records

Feature-by-feature review

What is CMS’ position

Affect on RA compliance

Unintended consequences

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EHR may not include all elements of eSignature

requirements

Name, credential, date, “electronically signed by”

eSignature at beginning of record

Identifying author doesn’t “authenticate” record

CMS’ position

Most of what CMS has to say about electronic signatures is

regarding safeguards of access to the electronic record, and

identification of authorship. An e-signature should be dated and the

author’s credentials should be included.

RA compliance

Communicate to clients any system-wide shortcomings

eSignature issues

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Differentiating between authorship and approval

eSignature issues

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EHR doesn’t differentiate among documentation

authors, line by line or entry by entry

CMS’ position

“Abuse” describes incidents or practices that may not be fraudulent

but are not consistent with accepted medical or business practices or

may result in unnecessary costs. Some such incidents directly relate

to EHR software features, such as allowing multiple providers to

add text to the same progress note but not allowing each provider to

sign, making it impossible to verify the actual service provider or

the amount of work performed by each provider.

RA compliance

Policy to ensure authorship issues are flagged

Policy to alert clients when EHRs have faulty software features

Authorship errors

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/ehr-provider-booklet-overview.pdf

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EHR doesn’t date problem list or med list

CMS’ position

Defaulting or copying and pasting clinical information with previous

existing documentation from other patient encounters in a different

health record facilitates billing at a higher level of service than was

actually provided.

RA compliance

Policy to accept only dated or referenced med lists

Policy to omit all problem lists, or accept only dated or referenced

problem lists

Authorship errors


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Check boxes instead of free text

Templates: Using predefined text and text options to document the

patient visit within a note

Macros: Expanding text associated with abbreviations or specific

keystrokes

Populating via Default: Generating content without positive action

or selection by author

CMS’ position

Some EHR systems use templates that complete forms by checking a

box, macros that fill in information by typing a key word, or auto-

population of text when it is not entered. Problems can occur if the

structure of the note is not a good clinical fit and does not

accurately reflect the patient’s condition and services. These

features may encourage over-documentation even when services are

not medically necessary or are never delivered.

Moving to Documentation…


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CMS’ position

Policy should require providers to modify templates so that

documentation clearly reflects specific conditions and observations

unique to the service, and to clearly identify the services provided.

Policy should also require the physician to provide additional

information to describe the patient in the specific episode of illness.

Data-entry shortcuts

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/ehr-decision-table.pdf

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Sample

Checked BoxesIn a “template,”

the boxes are

blank.

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keystrokes. Macros allow users to generate a lot of documentation

with one click. This practice is also referred to as charting by

exception



CMS’ position

Policy should require the provider to verify the validity of

information on entry.

Providers should incorporate policies and control structures that

require the addition of free text when auto-population methods are

used.



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keystrokes



RA compliance

Create policies addressing “good clinical fit” and “accurately reflect

patient’s condition”

Train coders to understand auto-generation of text and macros so

they can interpret documentation better

Do not use anything populated by default as support (if you can

detect the methodology)



Policy should require the provider to modify copied information to be patient-specific and related to the current visit.


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Click boxes to complete system reviews

Designed after old templates like those produced by T Systems

Templates do not reflect the complexity of the diagnosis or

medical decision making

Qualitative data missing:

Chest pain (intermittent, with exercise, constant, debilitating)

Cough (at night, productive, dry, reactive, crouplike)

Type 2 diabetes (affecting daily living, managed with diet, with oral

meds, in a confident or unconfident patient)

RESULT: Support often missing when ROS/PE is templated list

Unintended consequences: template

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Patient presents with nausea, vomiting and abdominal pain

Before EHRPHYSICAL EXAM: VITALS; BP 136/82, P 76, R 16, afebrile. W 178, RBS 96. HEART: regular rate and rhythm

without murmur or gallops. LUNGS: clear to auscultation all fields without rales, rhonchi or wheezing. ABDOMEN:

soft with active bowel sounds, no muscle guarding, lower left abdominal tenderness noted, no palpable mass or

organomegaly noted. EXTREMITIES: no edema

After EHRPHYSICAL EXAM: This is a well-developed, well-nourished male in no acute distress. VITALS: BP 138/74, P 62, W

164, P02 95 R 16 RBS 99 BMI 32. TEMP 98.6 HEAD: Normocephalic, atraumatic, no visible or palpable masses,

depressions or scaring. PERRLA. TMs translucent and mobile. Remainder of the ENT exam is unremarkable. NECK:

Supple. Euthyroid with no lymphadenopathy and nontender. Carotid pulses equal bilaterally. No bruits noted. LUNGS:

Clear to auscultation and percussion. HEART: Regular rate and rhythm. There are no murmurs or gallops noted. No

cardiomegaly or thrills. ABDOMEN: soft, lower left abdominal tenderness noted. There are no masses noted. There is

no hepatosplenomegaly noted. Active bowel sounds. EXTREMITIES: There is no edema, clubbing or cyanosis noted.

Peripheral pulses are +2 bilaterally. NEUROLOGIC: CN 2-12 normal. Deep tendon reflexes are +2 bilaterally.

Strength 5/5 and symmetrical. Babinski negative, no clonus, gait normal. PSYCHIATRIC: oriented x3, judgment and

insight good, normal mood and affect. Recent and remote memory intact.

Unintended consequences: template

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CMS’ position

Some EHR systems use templates that complete forms by checking a

box, macros that fill in information by typing a key word, or auto-

population of text when it is not entered. Problems can occur if the

structure of the note is not a good clinical fit and does not

accurately reflect the patient’s condition and services. These

features may encourage over-documentation even when services are

not medically necessary or are never delivered.

RA compliance

Seek support of any checked diagnosis boxes elsewhere in the

documentation

Identify those documents in which free text is permitted with

checked boxes. This may provide support.


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Automated narrative function (template translated

into documentation narrative)


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Sample

Automated

narrative

functionChecked boxes like

Headache, cough,

sputum production

and negative

findings translate

into a narrative in

the electronic

record’s ROS.

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Automated narrative function (template translated

into documentation narrative)

CMS’ position

Problems can occur if the structure of the note is not a good clinical

fit and does not accurately reflect the patient’s condition and

services.

Templates may encourage over-documentation to meet

reimbursement requirements even when services are not medically

necessary or are never delivered

RA compliance

Be aware it is difficult to determine whether documentation is cloned

from another visit, or a template narrative as for some patients, the

ROS is unchanged over time.



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Auto-forward of clinical data

System pulls details of last visit (H&P, med list, past medical history,

etc.) into today’s encounter to streamline documentation

CMS’ position

This can affect the quality of care and can cause improper payments

due to:

• Potentially false impression of services provided to the patient

• Coding from old or outdated information that may lead to “upcoding”

Policy should require the provider to modify copied information to

be patient-specific and related to the current visit.

RA compliance

Internal policies should address how to handle pull-forward

information and when it can be reported with support, or used as

support



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Auto-forward of clinical data


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Cloning

Copy and Paste: Selecting data from one location and reproducing it

in another; also called “cloning,” “cookie cutter,” “copy forward,”

and “cut and paste.” Clinical plagiarism occurs when a physician

copies and pastes information from another provider and calls it his

or her own

CMS’ position

Policy should require the provider to modify copied information to

be patient-specific and related to the current visit.

Copied information should include proper notation and clear

attribution.

Best Practices: Providers must recognize each encounter as a stand-

alone record, and ensure the documentation for that encounter

reflects the level of service actually provided and meets payer

requirements for billing and reimbursement.



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Code drop-down lists for providers

Often list unspecified first

May have truncated definitions

Don’t include guidance

CMS’ position

Begin in the Index. Then access the code in the

Tabular section and read all guidance there.

RA compliance

Display may not include narrative diagnosis, only code

Display may include code and truncated description


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No links between etiology and manifestation


Code drop-down lists for providers

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Note bloat , meaningless repetition

Provider ability to “think in ink” impaired

Lack of detailed, narrative descriptions of the

progress – qualitative details -- of the disorder


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UTI

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Incomplete pulldown menus of diagnoses

Otitis media in ICD-10

OM

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Incomplete pulldown menus of diagnoses

Otitis media in ICD-10

OM

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ICD-10-CM instructions

Use additional code for any associated perforated tympanic

membrane (H72.-)

Use additional code to identify exposure to environmental tobacco, to

tobacco smoke in perinatal period, history of tobacco use,

occupational exposure to tobacco, tobacco dependence, tobacco use

Excludes1 otitic barotrauma, otitis media (acute) NOS

OM

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OIG

“ICD–9–CM codes reported on the health insurance claims form

should be supported by documentation.” … “In addition to facilitating

high quality patient care, a properly documented medical record

verifies and documents precisely what services were actually

provided. The medical record may be used to validate: (a) The site of

the service; (b) the appropriateness of the services provided; (c) the

accuracy of the billing; and (d) the identity of the care giver (service

provider)”

-- The OIG Compliance Program for Individuals and

Small Group Physician Practices (Federal

Register, Oct 5 2000, Page 59440)

Coding from codes

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Guidelines

“The importance of consistent, complete documentation in the

medical record cannot be overemphasized. Without such

documentation accurate coding cannot be achieved.”

-- ICD Official Guidelines for Coding and Reporting

Coding from codes

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Actual example of provider coding

“30-week multigravida seen today for an uncomplicated

OB office visit. Diagnoses: V22.2 Intrauterine pregnancy

and V45.89 History of cesarean section.”

V22.2 Pregnant state, incidental

V45.89 Other postprocedural status

Correct code:

654.23 Previous cesarean delivery, antepartum

Unintended consequences: Codes

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Written policy for when the system goes down

And what happens when the system goes back up to

recreate the documentation?

Written policy on what is considered the legal medical

record.

Once was all the paper in the chart. Now, it could have

wider scope. What will you exclude from a request for a

medical record?

• Audio dictation files; audio patient telephone files

• Nursing reports

• Videorecordings of procedures

• Recorded telemedicine consults

Other issues to consider

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https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/electronic-health-records.html

Or Google:

CMS EHR toolkit program integrity 2015

EHR Toolkit from CMS


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Decision Table

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Monitoring and Auditing

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Expand your policies and procedures

Keep vigil on evolving compliance requirements

Consider clinical as well as coding implications of EHR flaws

Download CMS EHR Toolkit athttps://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/electronic-health-records.html

Your takeaway


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Thank you

Contact information

Sheri Poe Bernard, CPC, CPC-I, CCS-P

Phone 801-582-7000

Email [email protected]

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