2 ObjectivesReceive an update on the NC Medicaid Recovery Audit Contractor programUnderstand the chosen “basics” of the NC RAC programLearn likely areas of NC RAC focusAppreciate clinical documentation tips and strategies to reduce RAC financial exposure
3 Medicaid RAC Provisions Section 6411 Affordable Care Act, Expansion of the RAC Program, required States to establish programs to contract with RACs by December 31,2010Delay in implementation by April 2011Implementation of program when Final Rule published
4 State Medicaid RAC Plan Section 1902 (a)(42)(B)(i) SSA-Title XIX of the SSA, NC Medicaid established RAC programState will make RAC payments contingencyContingency payments will not exceed highest rate paid under Medicare RAC$30 fee paid per underpayment identifiedEfforts of the Medicaid RAC(s) will be coordinated with other contractors or entities performing audits of entities receiving payments under the State plan or wavier in the State, and/or State and Federal law enforcement entities and the CMS Medicaid Integrity Program
12 Hospital Documentation Medical RecordERH & PConsultProgress NotesAncillary StaffDischarge Summary
13 Medical NecessitySection 1862 (a)(1)(a) Social Security Act Title XVII“No payment can be made that is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve functioning of a malformed body member”Medical Necessity“Responsibility of the Physician”Medicare and other 3rd party payer guidelinesScreening criteria
14 Commercial Screening Criteria “CMS considers use screening criteria as only one tool that should be utilized by contractors “Medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at anytime during the stay(Chapter 6, Section 6.5.2, of the Medicare Program Integrity Manual)Reviewer applies clinical judgment
15 Additional Criteria Admission criteria; Invasive procedure criteria; CMS coverage guidelines;Published CMS criteria;DRG validation guidelines;Coding guidelines;Other screens, criteria, and guidelines (e.g., practice guidelines that are well excepted by the medical community)
16 Signs & SymptomsBeneficiary must demonstrate signs and symptoms to warrant need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basisConsider any pre-existing medical problems or extenuating circumstances that make admission of the beneficiary medically necessaryInpatient care rather than outpatient is required only if the beneficiary’s medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting
17 Physician’s Responsibility The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting. (Medicare Benefit Policy Manual Chapter 1 Section 10)
18 Factors to be Considered Factors to be considered when making the decision to admit include such things as:The severity of the signs and symptoms exhibited by the patient;The medical predictability of something adverse happening to the patient;The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; andThe availability of diagnostic procedures at the time when and at the location where the patient presents.
19 Lack of Focus Medical record documentation Severity signs and symptoms Portrayal of patient acuityRisk of morbidity and mortalityPredictability of adverse outcomesProvisional diagnoses
20 Typical CaseMrs. Jones, a 78 year old woman presented to the Emergency Room in acute respiratory distress, with difficulty breathing that started about two hours prior to presentation to the ER. She has known COPD and continues to smoke, now requiring supplemental oxygen 2 liters round the clock.PMH: COPD, CHF, lung cancer status post lobectomy and chemo, hypertension.Vital signs: HR 120, RR 34, Temperature 99 F, oxygen sats 85%, appears in no respiratory distress, A & O x 3
21 Medical Necessity Physician lack of appreciation and understanding “This patient does not meet medical necessity criteria”“Please change the patient status to outpatient”“Please document for medical necessity”
22 Severity Clinical Impression Clinical Impression Plan-admit and treat Acute COPDHypoxemiaMorbidly obeseTobacco addictionPlan-admit and treatAcute exacerbation of COPDAcute on chronic respiratory failureMorbid obesityTobacco addiction-continues to smokePlan- will need to admit patient and improve patient’s oxygenation, currently she is on a 100% non-rebreather in the hopes of avoiding the vent. Last admission she was on the vent and had to be discharged to LTAC to wean her off the vent
23 Severity of Illness SOI Extent of organ system derangement or physiologic decompensation for a patientGives medical classification:MinorModerateMajorExtremeServes as basis for evaluating hospital resource useAssigned SOI based upon specific diagnoses and procedures performed
24 Severity of Illness Clinical Screening criteria Dyspnea and >= one: Respiratory rate >= 24/minStridorHeart rate >=100/minChange in mental statusSputum smear/culture (+) for bacteria/fungi/protozoa
25 Medical Necessity Hospital Clinical DocumentationHospitalSeverity of IllnessRisk of MortalityPhysicianPhysician JudgmentMedical Decision Making/Medical Necessity
26 Physician Documentation DisconnectClinical indicatorsPhysician DocumentationSeverity of Illness
27 Different Perspective Clinical DocumentationMedical NecessityHospital/Physician admission and continued staySeverity of IllnessScreening criteriaPhysician clinical judgment, medical decision making, admission & dischargeRevenue CycleDenials avoidance and appealsStrategy to minimize denials/financial exposure
28 Clinical Documentation Today Required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomesChronologically, documents the care of the patient and is an important element contributing to high quality care
29 The “Great Facilitator Medical record facilitates:the ability of the physician and other healthcare professionals to evaluate and plan the patient's immediate treatment, and to monitor his/her healthcare over time;communication and continuity of care among physicians and other healthcare professionals involved in the patient's care;
30 The “Great Facilitator accurate and timely claims review and payment;appropriate utilization review and quality of care evaluations; andcollection of data that may be useful for research and education
32 Reducing that “Hassle Factor” An appropriately documented medical record can reduce many of the "hassles"Associated with claims processing and may serve as a legal document to verify the care provided, if necessary.Associated with retrospective queries from Health Information Management coding
33 “Clinical Documentation-Why the Fuss” Providing services consistent with standards of medical care, evidenced based medicine, and insurance coverageSite of serviceMedical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/orServices provided have been accurately reported
34 Documentation Purposes Outlines and highlights patient’s clinical presentationHistory of Present Illness and contextConstellation of signs and symptomsRecording of physical findingsAssimilating historical data and physical findings in into clinical contextFormulation of Working Hypotheses
35 Documentation Purposes Justification for diagnostic workupDevelopment and documentation of clinical diagnosesDevelopment and implementation of care planAdherence to best practice, evidence based medicineQuality measurement
36 Documentation Purposes Support of outcome studiesRisk of mortality and morbidity, severity of illnessRisk adjusted readmissionsPromotes continuity of careMeasurement of efficiency/valueRepresents clinical judgment and medical decision-making in support of medical necessity depiction for hospital and physicianProvisions of clinical data for research and educationSupports and justifies resource consumption and research
37 Measurement of Efficiency “Providing and ordering a level of services that is sufficient to meet a patient’s health care needs but is not excessive, given the patient’s health status”GAO Report to Congress-Focus on Physician Practice Patterns Can Lead to Greater Program Efficiency, April 2007
38 Documentation Deficiencies Result of Documentation DeficienciesAppearance of unnecessary use of resourcesAppearance of inefficient practice of medicineNon-support of medical necessityReporting of nonspecific diagnoses/symptoms versus definitive diagnosesInaccurate reporting of patient outcomesPoor, inadequate communication between providersIncreased risk of hospital readmissions
39 Principles of Medical Record Documentation Medical should be complete and legibleDocumentation of each patient encounter should include:Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
40 Principles of Medical Record Documentation The documentation of each patient encounter should include:assessment, clinical impression, or diagnosis;plan for care; anddate and legible identity of the observerDocumentation should support intensity of patient evaluation and/or treatment, including thought processes and the complexity of medical decision-making as it relates to the patient’s chief complaint for the encounter
41 Principles of Medical Record Documentation Past and present diagnoses should be accessible to the treating and/or consulting physician.Appropriate health risk factors should be identified.
42 Principles of Documentation The documentation should support the intensity of the patient evaluation and/or the treatment, including thought processes and the complexity of medical decision-making as it relates to the patient's chief complaint for the encounter.
43 Principles of Documentation The patient's progress, including response to treatment, change in treatment, change in diagnosis, and patient non-compliance should be documented
44 Nature of Presenting Problem Ensure the nature of the patient’s presentation corresponds to CPT’s contributory factors of the nature of the presenting problem and/or patient’s status descriptions for the code reported.
45 Nature of Presenting Problem For instance:99231 – “Usually the patient is stable, recovering or improving.”99232 – “Usually the patient is responding inadequately to therapy or has developed a minor complication.”99233 – “Usually the patient is unstable or has developed a significant complication or a significant new problem.”
46 Importance of Proper and Accurate Documentation Services billed to the Medicare program are the sole responsibility of the Medicare provider.Documentation needs to be unique, specific, and should accurately reflect the services you are billing.
47 Importance of Proper and Accurate Documentation Documentation not only must reflect necessity and the services provided but also must be consistent among the providers involved in an episode of care.Medicare payment for services may be denied if the supporting documentation is not thorough.
48 Clinical Case Study H & P Assessment HD #3 Right Lower Lobe Infiltrate- start IV Zosyn and LevaquinPulmonary edema- diureseH & H decreased- watch closely and transfuse if necessaryCardiac arrhythmia- continue Rythmol and CoumadinWhat level do we have here, minimal, limited, multiple, extensive
49 Clinical Case Study Cont. H & P Assessment HD #3Right Lower Lobe Infiltrate- start IV Zosyn and LevaquinPulmonary edema- diureseH & H decreased- watch closely and transfuse if necessaryCardiac arrhythmia- continue Rythmol and Coumadin
50 New & Improved H & P Assessment HD #3 Aspiration pneumonia-continue IV Zosyn and Levaquin, patient’s respiratory status improving but still somewhat short of breath, chest X-ray still shows some consolidation, slowly improving, may need a few days more of IV antibioticsAcute on chronic systolic CHF- diuresing nicely, will consider step down therapy to PO tomorrowChronic blood loss anemia due to slowly bleeding AV malformation- H & H decreased- watch closely and transfuse if necessary. Will have to transfuse judiciously if necessary given the patient’s precarious CHF with tendency to fluid overload
52 Widespread Probe Review Trailblazer widespread review MS-DRG 690- Urinary Tract InfectionPost-payment sample of 100 claimsPaid claims error rate percentRecords reviewed for:Verification of Medicare coverage for billed servicesDetermination of medical necessityDetermination of appropriateness of care settingValidation of the MS-DRG
53 Lack of Medical Necessity Examples lack of medical necessity denials:Physicians writing admission orders for acute inpatient care for a patient documented as stable, receiving oral medications, without fever, and with normal laboratory valuesAdmission orders are written for acute inpatient care for a condition or complication not substantiated by supporting documentation from members of the interdisciplinary team
54 Lack of Medical Necessity The documentation of admission assessment was insufficientThe documentation did not support an inpatient level of care
55 Key Elements of Medical Record Documentation “Reasonable and Medically Necessary” and “Supporting Documentation” are key elements of medical record documentationInterdisciplinary team documentation of assessment, intervention, and outcomes provides a picture of patient’s clinical condition and response to treatment
56 The Sum of the Components Each component is useful in determining “reasonable and medically necessary” services are provided and billed to the contractor for reimbursementObjective clinical documentation solidifies admission/continued stay medical necessity
57 RAC Related Denials Lack of consistency in entry in medical record Assessments, treatment plans, physician orders, nursing notes, medication and treatment records, etc., and other facility documents such as admission and discharge data, pharmacy records, etc.Provider’s failed to adequately document significant changes in the patient’s condition or care issues that in some instances impacted the review determinationSE 1027 article
58 Added ValueAncillary Provider Documentation supports and facilitates provider patient status decisions:The severity of signs and symptoms exhibited by the patient;The medical predictability of something adverse happening to the patient ;The need for diagnostic studies;The availability of diagnostic procedures at the time when and at the location where the patient presentsChapter one section 10 of the medicare benefit policy manual
59 A “Few” More WordsDuring medical review, the medical reviewer considers any pre-existing medical problems or extenuating circumstances that make the admission of the beneficiary medically necessary.Inpatient care rather than outpatient care is required only if the beneficiary's medical condition, safety or health would be significantly and directly threatened if care was provided in a less intensive setting.
60 The “Last Word”Inpatient care rather than outpatient care is required only if the beneficiary's medical condition, safety or health would be significantly and directly threatened if care was provided in a less intensive setting.Objective account of assessment, interventions, and outcomes, response to treatment.
61 Medical Necessity & Diagnosis For a service to be considered medically necessary, it must be all of the following:Appropriate in duration and frequencyMeets but does not exceed patient’s medical needsProvided in accordance with accepted standards of medical practiceNot experimental or investigationalPerformed by qualified personnel in an appropriate setting
62 Relevant NoteMedicare requires the informational content (the facts about the patient’s condition) in the medical record to demonstrate all of the above.The facts, not just conclusory statements, must demonstrate that the patient has the diagnosis reported on the claim and that the patient’s condition fulfills all coverage provisions of all Medicare rules and policies.
63 Evaluation and Management HistoryHPIROSPFSHPhysical ExamMedical Decision MakingNumber of Diagnoses and Management OptionsAmount and Complexity of DataTable of Risk
64 Elements of E & M Six Major Elements History Physical Exam Medical Decision MakingCounselingCoordination of CareNature of Presenting Problem
65 Key vs. Contributing Components HistoryPhysical ExamMedical Decision MakingContributingNature of Presenting ProblemCounselingCoordination of CareTime is a factor in average times for E/M, critical care and add on codes for extended, complex cases
66 Documentation Requirements Documentation must meet following criteriaMust be legibleClearly identify patient, date of service, and who performed the serviceAccurately report all pertinent facts, findings, and observationsInclude appropriate diagnosis for the service providedDocumentation must have hand written or an electronic signature
67 What are the Payers Looking For ? Require reasonable documentation that services consistent with the insurance coverage providedMay request record to validate:The site of service;The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/orThat services provided have been accurately reportedOIG report July 28,2010 indicated Medicare paid an estimated $13.8 million for incorrectly coded services provided during the calendar year 2007 by physicians billing for the wrong place of service, billing using nonfacility POS was hospital outpatient department
68 Documentation 101Documentation for each patient encounter should include:reason for encounter and relevant history, physical examination findings, and prior diagnostictest results;assessment, clinical impression, or diagnosis;plan for care; anddate and legible identity of the observer.If not documented, the rationale for ordering diagnostic and other ancillary services should beeasily inferred
69 Documentation 101Past and present diagnoses should be accessible to the treating and/or consulting physicianAppropriate health risk factors should be identified.The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.The CPT and International Classification of Diseases 9th Revision Clinical Modification (ICD-9- CM) codes reported on the health insurance claim form should be supported by the documentation in the medical record.Last point is vital to billing and coding compliance as coding and billing for diagnoses supported by clinical documentation is considered a billing/coding error, subjecting you to possible more focused review
70 E & MEvaluation of patient with exchange of clinically reasonable and necessary informationUse of the clinical information in the management of the patientCardinal Rule of E & M codingNo evidence of face-to-face visit→→ NO E & MNo diagnosis documented →→ No E & MSpecific, Accurate and Detailed Documentation fundamental to E & M
71 Basics of E & M Assignment Chief Complaint (CC)CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter.Every progress note must have clearly documented CCHPI- chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.
72 HPI HPI consists of following: Location Quality Severity Duration TimingContextModifying factors; andAssociated signs and symptomsHPI sets the tone and stage for medical necessity by providing support for extent and completeness of ROS and physical exam
73 Take NoteThe extent of HPI, ROS and PFSH that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem (Chief Complaint)Two levels HPIBrief HPI consists of 1 -3 elementsExtended HPI consists of 4 or more elementsH & P- strive for 4 or more elements HPIImperative to paint an accurate and clear picture of the patient’s chief complaint and HPI, more on this in a minute
74 Role of HPIHPI drives:Extent of PFSH, ROS and physical exam performedMedical necessity for amount work performed and documentedMedical necessity for E & M assignmentMedical necessity of an Evaluation and Management (E/M) encounter is often visualized only when viewed through the prism of its characteristics captured in specific History of Present Illness (HPI) elements
75 Speaking of Medical Necessity Federal law requires that all expenses paid by Medicare, including expenses for Evaluation and Management services, are medically reasonable and necessary
76 Medical NecessityMedical necessity of E/M services is generally expressed in two ways: frequency of services and intensity of service (CPT level).Medicare’s determination of medical necessity is separate from its determination that the E/M service was rendered as billed.
77 Medical NecessityMedicare determines medical necessity largely through the experience and judgment of clinician coders along with the limited tools provided in CPT and by CMS.At audit, Medicare will deny or downcode E/M services that, in its judgment, exceed the patient’s documented needs
78 Elements of Medical Necessity Medical necessity of E/M services is based on the following attributes of the service that affected the physician’s documented work:Number, acuity and severity/duration of diagnoses/ problems addressed through history, physical and medical decision-making.
79 Elements of Medical Necessity The context of the encounter among all other services previously rendered for the same problemComplexity of documented comorbidities that clearly influenced physician work.Physical scope encompassed by the problems (number of physical systems affected by the problems).
80 Medical Necessity & Diagnosis For medical necessity, services must meet the following:Appropriate in duration and frequencyMeet but does not exceed patient’s medical needsProvided in accordance with accepted standard of medical practiceNot experimental or investigationalPerformed by qualified personnel in appropriate setting
81 Qualifying FactorMedicare requires the informational content (the facts about the patient’s condition) in the medical record to demonstrate all of the above.The facts, not just conclusory statements, must demonstrate that the patient has the diagnosis reported on the claim and that the patient’s condition fulfills all coverage provisions of all Medicare rules and policies.
82 Case Study “Demonstrating Medical Necessity” The patient s a 61-year old male with a history of peripheral vascular disease, who has had multiple vascular surgeries on his right lower extremity, which included an aortobifemoral, a right profunda to politeal bypass, a jump graft from the common femroal to the profunda, and a redo fem below knee popliteal bypass. The patient presented to Ziosville approximately 5 PM the day prior to presentation, complaining of increased right lower extremity pain that started below his knee. The patient does have a significant history of claudicating, however, this pain was at rest.
83 Case Study ContinuedShe described it as crampy, has been increasing in intensity since its onset, and he also reports that his foot is cold. Currently the patient does not have any sensation below the mid calf on his right lower extremity and has decreased strength at his ankle, and little to no motor function in his toes. Pain is rated at 9 out of 10 pain scale, took some Motrin this morning with no improvement, can’t hardly walk due to the pain.
84 Case Study Continued PMH: Hypertension-labile and not well controlled Coronary artery disease with episodes of unstable angina relieved with nitro for the most part. CABG x 5Diabetes Type II uncontrolled. Patient noncompliant with diet and medication regimen
85 Case Study Continued Assessment & Plan The patient is a 61-year old male with a history of peripheral vascular disease who presents with acute on chronic limb ischemiaAdmit the patient to the peripheral vascular service under Dr DenialWe will schedule the patient for an emergent right lower extremity thrombectomy and possible femoral to tibia bypass and possible fasciotomiesWe will need to reverse the patient’s Coumadin with fresh frozen plasmaWe will make appropriate plans for the OR including chest x-ray, electrocardiogram, type and cross, and preoperative antibiotics
86 What’s the Big DealWhy the focus upon specific, accurate and detailed clinical documentation?CERT ProgramRAC ProgramMedicare Administrative Contractor reviewsMedicaid Integrity ContractorGoal to reduce Medicare paid claims error rate by 50% by 2012
88 Looking Ahead Once Again Clear, concise, and complete clinical documentation essential for business successPhysician Feedback ProgramPhysician Quality Reporting SystemPay-for-PerformanceBundled Payments (ACE Project)Accountable Care OrganizationsShared savings, Gain sharingICD-10 October 2013Alternate Care Contracts
89 Healthcare Quality Reporting Healthgrades.comWhynotthebest.orgHospitalCompare.govMedicare.govNew feature Physician Compare allows physician look-upIndicates participation in PQRSIndicates participation in prescribing medicines electronically
90 Modifier JW Palmetto requires use of modifier JW HCPS Modifier JW-drug/biological amount discarded/not administered to any patientNot used when actual drug dose administered less than billing unitBilling unit 10 mg, if administer 7 mg, bill one unit w/o JW modifierCoverage limited to single use vials.Multiple use vials not subject to payment
91 Modifier JWDrug wastage must be documented in the patient’s medical record with date, time, amount wasted and reason for wastage.Upon review, any discrepancy between amount administered to the patient and amount billed will be denied as non-rendered unless the wastage is clearly and acceptably documented.The amount billed as “wasted” must not be administered to another patient or billed again to Medicare.
92 Documentation Requirements All doses must be drawn by a licensed professional whose scope of practice includes administration of parenteral medications and knowledge of aseptic technique.All doses from a given vial should be drawn and administered within the time period specified on the package insert.Only one vial of a given concentration of the medication should be opened and used by the administering professional at any given time. A second vial of the same medication must not be opened until the previous vial is discarded.
93 Documentation Requirements Any opened vials or filled syringes must be discarded if not used within the specified time frame of the first puncture of the vial. Vials must be labeled to document the time of first entry and maintained at a temperature specified on the package insert during non-use.Residual amounts of these medications (either in the vial or syringes) must never be pooled with medication from another vial or syringe. If a patient requires more medication than is in a single, drawn syringe, then medication from a separate vial should be drawn into a separate syringe for administration
94 Quality AssuranceEach facility should have in place a process-monitoring (quality assurance) program, which ensures compliance with these policies and procedures. This program should include:Recording data on infections in treated patients.Unannounced practice audits involving quality assurance staff observing performance of reuse techniques.
95 Of NoteModifier JW not used when billing unit already includes amount administered as well as amount wasted.Example- J1275- meperidine hydrochloride, per 100 mg. If 75 mg injected, bill one unit J1275J mg includes administered amount as well as wastage. Do not use modifier “JW”