DocumentationStandards

2008

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Agenda

●Goals of documentation training

●Iowa Administrative Code

●SURS & Medical Services Reviews

●CDAC Service Record

●Questions & answers

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Documentation Standards Training

Goals

- To discuss IAC as it pertains to documentation

- To emphasize compliance with doc standards in relation to SURS review

- To facilitate awareness that SURS reviews according to code in affect at the time of service

- To educate about requirements, but not to provide specific documentation wording

- To stress that Medical Services review is not equal to SURS review

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Discussion of

Iowa Administrative Code

www.dhs.state.ia.us/PolicyManualPages/Manual_Documents/Rules/441-79.pdf

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Financial Records

79.3(1) Financial (fiscal) records

a. A provider of service shall maintain records as necessary to:

• (1) Support the determination of the provider’s reimbursement rate

• (2) Support each item of service.

b. A financial record does not constitute a medical record.

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Medical (clinical) records

79.3(2) Medical (clinical) records

- Provider shall maintain complete and legible medical records for each service

- Required records will include records required to maintain license in good standing

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Definition of Medical Records

79.3(2)a Definition.

- Medical record means a tangible history that provides evidence of:

(1) The provision of each service and each activity billed to the program

(2) First and last name of the member receiving service

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Purpose of Medical Record

79.3(2)b Purpose

- The Medical record shall provide evidence that the service provided is:

(1) Medically necessary;

(2) Consistent with the diagnosis…

(3) Consistent with professionally recognized standards of care

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Components of Medical Records

79.3(2)c(1-4) Components

(1) Identification

(2) Basis for coverage

(3) Service documentation

(4) Outcome of service

Each will be discussed in greater detail in following slides.

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Medical Records Component- Identification

79.3(2)c(1) Identification

Each page or separate electronic document:

- Member’s first and last name

Associated within document:

- Medical assistance id number

- date of birth

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Medical Records Component – Basis for Service

79.3(2)c(2) Basis for Service

Medical record shall reflect:

- the reason for performing the service

- substantiate medical necessity

- demonstrate level of care

1. Complaint, symptoms, and diagnosis

2. Medical or social history

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Medical Records Component –

Basis for Service

3. Examination finding

4. Diagnostic, lab, X-ray reports

5. Goals or needs identified in Plan of care

6. Physician orders and required PAs

7. Medication & pharmacy records, providers’ orders

8. Professional consultation reports

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Medical Records Component –

Basis for Service

9. Progress or status notes

10. Forms required by the department as condition of payment

11. Treatment plans, care plans, service plans, etc.

12. Provider’s assessment, clinical impression, etc

13. Any additional documentation to demonstrate medical necessity

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Medical Records Component – Service Documentation

79.3(2)c(3) Service documentation

Record shall include information necessary to substantiate the provided service.

1. Specific procedures or treatments

2. Complete date of service with begin and end dates

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Medical Records Component –

Service Documentation

3. Complete time of service with begin and end time

4. Location

5. Name, dosage, and route of medication administration

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Medical Records Component –

Service Documentation

6. Supplies dispensed

7. First name, last name & credential of provider

8. Signature of provider or initials if signature log used

9. 24-hour care needs documentation, member’s response, provider’s name for each shift

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Medical Records Component –

Outcome of Service

79.3(2)c(4) Outcome of Service

Medical record shall indicate:

- member’s progress in response to services

- including:

- changes in treatment

- alteration of plan of care

- revision of diagnosis

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Basis for Service Requirements

79.3(2)d Basis for service requirements for specific services

- New as of 4/1/08

- 5 pages of specific requirements for more than 35 provider types

- Outlines documents needed by provider type for SURS review

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Corrections to Documentation

79.3(2)e Corrections

Provider may correct the medical record before submitting a claim.

(1) Made or authorized by provider of service

(2) No write over; line through and correct

(3) Indicate person making change, and person authorizing change

(4) If change affects paid claim, then amended claim is required

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Maintenance of Documentation

79.3(3) Maintenance requirement

a. During time member is receiving services

b. Minimum of 5 years from claim submission date

c. As required by licensing authority or accrediting body

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Reviews and Audits of Documentation

79.4 Reviews and Audits

Revisions as of 4/1/08.

- Definitions

- SURS can review at any time

- Documentation check list used by SURS

- Review procedures

- Report of findings

- Deadlines and extensions

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Self Assessments

- Quality assurance is in best interest of providers.

- Value to providers of their own QA assessments

Quickly ID narratives that are not adequate Corrections can be made before claim

submission Quickly identify staff who need additional

training

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Summary of IAC Discussion

●Providers can develop a process or system of their own design

●Chosen system must demonstrate that Medicaid rules are met

● IAC does not require 2 sets of documents

●Providers should proactively review their current system to ensure IAC requirements are met

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SURS and Medical Services Reviews

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New Provider Option

●Under old IAC

If received a Findings letter, no opportunity to submit additional information

●Under new IAC

May receive Preliminary Finding of a Tentative Overpayment letter

May request re-evaluation May submit clarifying or supplemental

documentation not previously provided

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Errors in Responding to SURS Review

- Failure to submit docs timely per IAC 79.4

- Documentation submitted for wrong dates

- Submitted documentation not detailed

- Do not submit:

Individual Service Plans Individual comprehensive plans CDAC agreements

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Documentation Errors

● Illegible writing

●No in/ out times

●Wrong code vs. service

●Documentation does not match services

● Invalid correction

●No signature or signature sheet

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More Documentation Errors

●No dates of service

●Failure to use Remittance Advice

●Missing member response to interventions

●Physician orders not followed

●Chiro must indicate area of treatment

●Vision must state replacement reason

●DME use of UE modifier

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Medical Services Documentation Requirements I

Services where required medical documentation frequently missing.

Not a complete list situations where medical documentation is required.

● Endoscopy: op rpt w/ 43450 & other upper GI endo code

● Sterilization: sterilization consent form

● Hysterectomy: consent form or doc of prior sterility

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Medical Services Documentation Requirements II

● Abortions: op rpt, hx & p, fetal ultrasounds. Labs, abortion certificate, progress notes, consult notes

● B9998: description of service/item

● Delivery of multiples: operative report

● Septoplasty: op rpt, hx & p, nasal endoscopy, other imaging or photos, hx of symptoms & prior treatments

● Breast reduction mammoplasty: op rpt, hx & p, pre-op photos, 6 months hx of symtpoms & prior treatments

● Blepharoptosis: op rpt, hx & p, visual field test, pre-op photos

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Medical Services Documentation Requirements III

●Skin tags & keloids: op prt, hx &p, pre-op photos, clinical notes w/ medical necessity

●Botox: for diagnosis of Primary Focal Hyperhidrosis, docs to explain condition interference with ADLs

●Natalizumab: hx of failed trials of preferred meds

●All dump codes: description of billed service, invoice or op report

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CDAC Service Record

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CDAC Service Record

●Required of all CDAC providers

●Must be legible

●Must support the number of units billed

●Must be signed by member

●To be kept for 5 years

●Used as response to SURS for review purposes

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Medicaid 101

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MediPASS & MHC

●MediPASS plus HMOs contracted with DHS

●One of the five provider types that provide primary care services

●Managed Care is mandatory in many counties

●Providers of care must obtain a referral from the Patient Manager

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Contact Information

●Provider Services

800-338-7909

515-725-1004 (Des Moines area)

515-725-1155 fax

●ELVS

800-338-7752

515-323-9639 local to Des Moines

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Medical Assistance Card

●No specific eligibility month or program will be indicated on the card

●Provider must verify eligibility through ELVS or Web Portal

●No change for IowaCare card

●Info Release #632 included additional detail

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ELVSEligibility 24/7

Verify:

●Monthly eligibility

●Spend Down

●TPL insurance

●Managed Health Care information

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Web Portal

●Available 24/7

●Check eligibility

●Check claim status

●Contact EDISS for login ID and password

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Retro EligibilityIf before 12 months from DOS, submit thru regular

channels

● Write words “Retro Eligibility” on form

● Attach copy of retro letter

If after 12 months from DOS, them submit to address in training packet

Must submit claim within 1 year from date of award letter

Copy of letter must be attached to the claim

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Iowa Administrative Code 441

79.9(4) Recipients must be informed before the service is provided that the recipient will be responsible for the bill if a non-covered service is provided.

The member must be informed of the date and procedure that will not be covered by Medicaid. This information should be noted in the patient’s file.

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Timely Filing Guidelines

Initial Filing:

●Must be filed within 12 months of the first date of service

●Medicare crossovers must be filed within 24 months of first date of service

Exceptions:

●Retroactive eligibility

●Third-party related delays

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Timely Filing Guidelines continued

Resubmissions:

● If a claim is filed timely but denied, an additional 365 days from the denial date is allowed

● Claims must be submitted on paper with the a copy of the denial RA

Claim Adjustments:

● Requests for claim adjustments must be made within 12 months of the payment date

● Claim credits are not subject to a time limit

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Claim Submission Issues

●Data outside of box

●Provider #, Member # or DOS missing

●Dollars & cents not noted on form

●Dash used to indicate negative or cents

●Total charge box not completed

●J code drug not in correct location

●Not billing with correct NPI

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Top Denial Reasons●Exact duplicate claim

●Member not eligible

●Missing or invalid MediPASS referral number

●Third-party insurance should have been billed primary

●Medicare should have been billed primary

●Missing or invalid member ID number

●Procedure/treating provider conflict

● Incorrect NPI/Taxonomy combination

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Credit/Adjustment Request

●When to request a credit

●When to request an adjustment

●If crediting, do not send a refund check

●New form has been created to address NPI concerns