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Documentation Standards 2008. 2 Agenda Goals of documentation training Iowa Administrative Code SURS & Medical Services Reviews CDAC Service Record Questions.

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Presentation on theme: "Documentation Standards 2008. 2 Agenda Goals of documentation training Iowa Administrative Code SURS & Medical Services Reviews CDAC Service Record Questions."— Presentation transcript:

1 Documentation Standards 2008

2 2 Agenda Goals of documentation training Iowa Administrative Code SURS & Medical Services Reviews CDAC Service Record Questions & answers

3 3 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

4 4 Discussion of Iowa Administrative Code Manual_Documents/Rules/ pdf

5 5 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 providers reimbursement rate (2) Support each item of service. b. A financial record does not constitute a medical record.

6 6 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

7 7 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

8 8 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

9 9 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.

10 10 Medical Records Component- Identification 79.3(2)c(1) Identification Each page or separate electronic document: - Members first and last name Associated within document: - Medical assistance id number - date of birth

11 11 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

12 12 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

13 13 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. Providers assessment, clinical impression, etc 13. Any additional documentation to demonstrate medical necessity

14 14 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

15 15 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

16 16 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 hour care needs documentation, members response, providers name for each shift

17 17 Medical Records Component – Outcome of Service 79.3(2)c(4) Outcome of Service Medical record shall indicate: - members progress in response to services - including: - changes in treatment - alteration of plan of care - revision of diagnosis

18 18 Basis for Service Requirements 79.3(2)d Basis for service requirements for specific services - New as of 4/1/ pages of specific requirements for more than 35 provider types - Outlines documents needed by provider type for SURS review

19 19 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

20 20 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

21 21 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

22 22 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

23 23 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

24 24 SURS and Medical Services Reviews

25 25 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

26 26 Errors in Responding to SURS Review - Failure to submit docs timely per IAC Documentation submitted for wrong dates - Submitted documentation not detailed - Do not submit: Individual Service Plans Individual comprehensive plans CDAC agreements

27 27 Documentation Errors Illegible writing No in/ out times Wrong code vs. service Documentation does not match services Invalid correction No signature or signature sheet

28 28 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

29 29 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/ & other upper GI endo code Sterilization: sterilization consent form Hysterectomy: consent form or doc of prior sterility

30 30 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

31 31 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

32 32 CDAC Service Record

33 33 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

34 34 Medicaid 101

35 35 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

36 36 Contact Information Provider Services (Des Moines area) fax ELVS local to Des Moines

37 37 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

38 38 ELVS Eligibility 24/7 Verify: Monthly eligibility Spend Down TPL insurance Managed Health Care information

39 39 Web Portal Available 24/7 Check eligibility Check claim status Contact EDISS for login ID and password

40 40 Retro Eligibility If 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

41 41 Iowa Administrative Code (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 patients file.

42 42 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

43 43 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

44 44 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

45 45 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

46 46 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

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