2 Agenda Goals of documentation training Iowa Administrative Code SURS & Medical Services ReviewsCDAC Service RecordQuestions & answers.
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 reviewDirection of this training is for discussion of the new 79.3 & 79.4 IAC as related to documentation standards. IAC is not a “training manual” but is a outline of information that would be requested by a SURS review. Changes became effective 4/1/08.During session IME staff will not offer suggestions for format or wording. Nor will staff comment on appropriateness of any provider’s documentation process.A Medical Services review compares medical necessity against the IME criteria for coverage of a service. Medical Services does not review for accuracy of records or of billing procedures.
4 Discussion of Iowa Administrative Code www. dhs. state. ia Discussion of Iowa Administrative Code Manual_Documents/Rules/ pdfIowa Code NOT same as Iowa Administrative Code.Iowa Code are the laws of Iowa.IAC are the administrative rules the outline the daily application of the Iowa Code laws.IAC is used by many different Iowa regulatory agencies, not just DHS or SURS.
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 provider’s reimbursement rate(2) Support each item of service.b. A financial record does not constitute a medical record.Explain IAC header designation.Fiscal records are used by the Fiscal Management when they audit a provider.Medical records are used by SURS when they request a review.Remainder of presentation is about Medical Records. The presentation will paraphrase the IAC.
6 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 standingWhenever you see the words “Medical Record” think “Billing Medicaid.”All services paid by Medicaid are subject to any “Medical record” requirement, therefore all providers that bill the IME must follow the IAC guidelines in chapter 79.Professional organizations may dictate records requirements that are not reflected in the IAC. Providers are responsible for understanding what is required by all applicable governing agencies and the IAC and to have those records available upon request.
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 serviceAlmost direct quote from code
8 Purpose of Medical Record 79.3(2)b PurposeThe 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 careAlmost direct quote from IAC.
9 Components of Medical Records 79.3(2)c(1-4) Components(1) Identification(2) Basis for coverage(3) Service documentation(4) Outcome of serviceEach will be discussed in greater detail in following slides.Each will be discussed in greater detail in following slides.
10 Medical Records Component- Identification 79.3(2)c(1) IdentificationEach page or separate electronic document:- Member’s first and last nameAssociated within document:- Medical assistance id number- date of birthClarification: First and last name on each page; somewhere in the document the SID and DOB must be written in conjunction with the first and last names.Clarification: In the case of electronic documents, names must appear on each screen when viewed electronically and on each page when printed.
11 Medical Records Component – Basis for Service 79.3(2)c(2) Basis for ServiceMedical record shall reflect:- the reason for performing the service- substantiate medical necessity- demonstrate level of care1. Complaint, symptoms, and diagnosis2. Medical or social historyThere are 13 points under Basis for Services; contained in next several slides.Disclaimer found in IAC:“ The medical record shall include the items specified below unless the listed item is not routinely received or created in connection with a particular service or activity and is not required to document the reason for performing the service or activity, the medical necessity of the service or activity , or the level of care associated with the service or activity. “
12 Medical Records Component – Basis for Service 3. Examination finding4. Diagnostic, lab, X-ray reports5. Goals or needs identified in Plan of care6. Physician orders and required PAs7. Medication & pharmacy records, providers’ orders8. Professional consultation reports
13 Medical Records Component – Basis for Service 9. Progress or status notes10. Forms required by the department as condition of payment11. Treatment plans, care plans, service plans, etc.12. Provider’s assessment, clinical impression, etc13. Any additional documentation to demonstrate medical necessity10) Examples would be sterilization consent forms, CDAC log form
14 Medical Records Component – Service Documentation 79.3(2)c(3) Service documentationRecord shall include information necessary to substantiate the provided service.1. Specific procedures or treatments2. Complete date of service with begin and end dates(9 items on 3 pages. )Questions providers can ask themselves:Does the delivered service support the goals identified for this member?Does the narrative clearly identify what the staff did?Does the length and substance of the narrative support the time billed?Does the narrative clearly describe the service provided?Does the narrative clearly identify the progress or lack of progress?Is the narrative legible?
15 Medical Records Component – Service Documentation 3. Complete time of service with begin and end time4. Location5. Name, dosage, and route of medication administration(Page 2- 9 items on 3 pages.)3) Begin and end times must have AM and PM distinction.4) LocationDoes the narrative identify the specific location of the service?Is the location of the service allowed by Chapter 78?Are location changes noted along with begin and end times of each location?5) Medication administration topics to be documented: (prescriptions)Is the name of the medication clearly identified?Is the dosage recorded?Is the dosage the same as ordered by the medical professional?Is the time of dosage recorded, using AM/PM distinction?It the route of administration recorded?Are medication errors noted?
16 Medical Records Component – Service Documentation 6. Supplies dispensed7. First name, last name & credential of provider8. Signature of provider or initials if signature log used9. 24-hour care needs documentation, member’s response, provider’s name for each shift(Page 3) These are not complete lists, just points to consider.6. Supplies dispensed documentation issues to be addressed:- Include over the counter medication purchases such as aspirins, ointments, Depends, catheter bags.- Also includes ancillary services such as chores, financial management, home & vehicle modification, home delivered meals.- Is item clearly identified in the narrative?- Is the name of the staff member who dispensed the item or medication identified?- Is the name of the medication and dosage recorded?- Is the time of medication administration noted? AM/PM distinction?- What is the route of administration?7. Provider name- Is printed name legible?- Is printed credential legible?- Are middle initials used to distinguish two provider with same first and last name?8. Signature- Is the narrative signed?- Is the signature actually of the staff whose printed name appears on the document?- Did staff understand that signing the narrative was making them responsible for accuracy of the content?- Did staff understand that recording data that was not valid/true within the narrative could be considered Medicaid fraud?9. Shift documentation during 24 hour care- not a new requirement as was always required by Survey & Certification-Survey & Certification requirements are greater than SURS requirements
17 Medical Records Component – Outcome of Service 79.3(2)c(4) Outcome of ServiceMedical record shall indicate:- member’s progress in response to services- including:- changes in treatment- alteration of plan of care- revision of diagnosisAlmost direct quote from IACBottom 3 bullets are not corrections, but appropriate provider responses to changes in member’s conditions or symptoms.
18 Basis for Service Requirements 79.3(2)d Basis for service requirements for specific servicesNew as of 4/1/085 pages of specific requirements for more than 35 provider typesOutlines documents needed by provider type for SURS reviewThis sections talks about the types of documents that are required.Quote “The medical record for the following services must include, but is not limited to, the items specified below…..”.New Benefit to providers: These items will be specified on the Documentation Checklist when the SURS unit requests records.For example:-Physician-Service or office notes or narratives- Procedure, laboratory, or test orders and results- Remedial Services provider- Orders for services- Comprehensive treatment or Service plan- Service notes or narratives- Chiropractor- Service or office notes or narratives- X-ray results
19 Corrections to Documentation 79.3(2)e CorrectionsProvider 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 requiredAdditional clarification:Or by person who has first-hand knowledge of the service.No obliteration of the original entry.Must be dated and signed by person making the change. Must be clearly connected with the original entry.
20 Maintenance of Documentation 79.3(3) Maintenance requirementa. During time member is receiving servicesb. Minimum of 5 years from claim submission datec. As required by licensing authority or accrediting bodyAlmost direct quote.Follow the most restrictive requirement.
21 Reviews and Audits of Documentation Revisions as of 4/1/08.DefinitionsSURS can review at any timeDocumentation check list used by SURSReview proceduresReport of findingsDeadlines and extensions- Definitions: 79.4(1) outlines several definitions used during this section of the code.- A provider can be reviewed at any time: applies to financial records as well as medical (clinical records).What is reviewed? (not a complete list)- Did the department correctly pay claims?- Was the service provided as billed?- Do the financial and clinical records substantiate the claims?- Were the goods or services provided in accordance with Medicaid policy?Documentation check list: The IAC contains a copy of the checklist that will be used by the SURS unit to notify a provider of a review.-The unit will specify exactly what documents will be required for the review.- This check list has been included as a courtesy and benefit to providers.- This check list is used by SURS, but not by Fiscal Management.Review procedure:- Upon written request from SURS, provider has 30 calendar days to respond with records.- Requests for extensions must follow the IAC guidelines outlined in IAC 79.4(3).- Department may conduct announced or unannounced on-site reviews or audits.- Reviews and audits may include:- comparing records to claims- interviewing members and employees- examining TPL payment records- comparing Medicaid charges against customary and prevailing chargesReport of findings:- Issuance of a “Preliminary finding of a tentative overpayment.” New benefit that will be discussed more in several slides.- Disagreement with findings- IAC outlines actions that can be taken by the provider.- Once provider re-evaluation is completed, a “Finding and order for payment” will be issued.
22 Self Assessments - Quality assurance is in best interest of providers. - Value to providers of their own QA assessmentsQuickly ID narratives that are not adequateCorrections can be made before claim submissionQuickly identify staff who need additional trainingBest to catch a system issue before claims are submitted or before a review or audit.
23 Summary of IAC Discussion Providers can develop a process or system of their own designChosen system must demonstrate that Medicaid rules are metIAC does not require 2 sets of documentsProviders should proactively review their current system to ensure IAC requirements are met
25 New Provider Option Under old IAC If received a Findings letter, no opportunity to submit additional informationUnder new IACMay receive Preliminary Finding of a Tentative Overpayment letterMay request re-evaluationMay submit clarifying or supplemental documentation not previously providedThis was briefly addressed in last section.Play this up as this was an IME response to provider comment.
26 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 PlansIndividual comprehensive plansCDAC agreementsProviders frequently submit much more than requested. For example by sending the entire patient file when only 1day was requested.
27 Documentation Errors Illegible writing No in/ out times Wrong code vs. serviceDocumentation does not match servicesInvalid correctionNo signature or signature sheetFrom SURS unit.
28 More Documentation Errors No dates of serviceFailure to use Remittance AdviceMissing member response to interventionsPhysician orders not followedChiro must indicate area of treatmentVision must state replacement reasonDME use of UE modifierUE modifier = used equipment
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 codeSterilization: sterilization consent formHysterectomy: consent form or doc of prior sterilityLeaving discussion of IAC and SURS.Medical services has been included in this training session as many times Medical Services must determine whether a claim is payable by the IME. These are services where the specified documentation is required before the claim can be considered for payment.Medical Services review is not the same as a SURS review. Medical Services is looking at medical necessity. These bullets are intended to assist providers in submitting claims with needed documentation.Documentation may be needed by every provider involved in the service: asst surgeon, hospital, anesthesia, etc.
30 Medical Services Documentation Requirements II Abortions: op rpt, hx & p, fetal ultrasounds. Labs, abortion certificate, progress notes, consult notesB9998: description of service/itemDelivery of multiples: operative reportSeptoplasty: op rpt, hx & p, nasal endoscopy, other imaging or photos, hx of symptoms & prior treatmentsBreast reduction mammoplasty: op rpt, hx & p, pre-op photos, 6 months hx of symtpoms & prior treatmentsBlepharoptosis: op rpt, hx & p, visual field test, pre-op photosDeliver of multiples = IME will review claim for possible additional payment.
31 Medical Services Documentation Requirements III Skin tags & keloids: op prt, hx &p, pre-op photos, clinical notes w/ medical necessityBotox: for diagnosis of Primary Focal Hyperhidrosis, docs to explain condition interference with ADLsNatalizumab: hx of failed trials of preferred medsAll dump codes: description of billed service, invoice or op reportSkin tags & Keloids= need medical necessity for removal, not just cosmetic.Just because all documents are submitted with the claims does not guarantee coverage as the situation may not have met the IME coverage criteria.
33 CDAC Service Record Required of all CDAC providers Must be legible Must support the number of units billedMust be signed by memberTo be kept for 5 yearsUsed as response to SURS for review purposesRequired of agency as well as individual CDAC providers.Discuss how times are determined and written.Effective date?
35 MediPASS & MHC MediPASS plus HMOs contracted with DHS One of the five provider types that provide primary care servicesManaged Care is mandatory in many countiesProviders of care must obtain a referral from the Patient Manager5 types: family practicegeneral practicepedsOBIM
36 Contact InformationProvider Services(Des Moines area)faxELVSlocal to Des Moines
37 Medical Assistance Card No specific eligibility month or program will be indicated on the cardProvider must verify eligibility through ELVS or Web PortalNo change for IowaCare cardInfo Release #632 included additional detail
38 ELVS Monthly eligibility Spend Down TPL insurance Verify:Monthly eligibilitySpend DownTPL insuranceManaged Health Care information
39 Web Portal Available 24/7 Check eligibility Check claim status Contact EDISS for login ID and password
40 Retro EligibilityIf before 12 months from DOS, submit thru regular channelsWrite words “Retro Eligibility” on formAttach copy of retro letterIf after 12 months from DOS, them submit to address in training packetMust submit claim within 1 year from date of award letterCopy of letter must be attached to the claim
41 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.
42 Timely Filing Guidelines Initial Filing:Must be filed within 12 months of the first date of serviceMedicare crossovers must be filed within 24 months of first date of serviceExceptions:Retroactive eligibilityThird-party related delays
43 Timely Filing Guidelines continued Resubmissions:If a claim is filed timely but denied, an additional 365 days from the denial date is allowedClaims must be submitted on paper with the a copy of the denial RAClaim Adjustments:Requests for claim adjustments must be made within 12 months of the payment dateClaim credits are not subject to a time limit
44 Claim Submission Issues Data outside of boxProvider #, Member # or DOS missingDollars & cents not noted on formDash used to indicate negative or centsTotal charge box not completedJ code drug not in correct locationNot billing with correct NPI
45 Top Denial Reasons Exact duplicate claim Member not eligible Missing or invalid MediPASS referral numberThird-party insurance should have been billed primaryMedicare should have been billed primaryMissing or invalid member ID numberProcedure/treating provider conflictIncorrect NPI/Taxonomy combination
46 Credit/Adjustment Request When to request a creditWhen to request an adjustmentIf crediting, do not send a refund checkNew form has been created to address NPI concerns