A Belt and Suspenders Approach to Chart Audit and Coding by Carol Olson

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A Belt and Suspenders Approach to Chart Audit and Coding by Carol Olson

  1. 1.         A  Belt  &  Suspenders  Approach           to  Chart  Audit  &  Coding   March  19,  2014  
  2. 2. BUCKLE  UP…  ARE  YOU  READY  FOR  THE  RIDE?   2   One  foot  on  the  brake  and  one  on  the  gas,  hey   Well,  there's  too  much  traffic,  I  can't  pass,  no   So  I  tried  my  best  illegal  move   A  big  black  and  white  come  and  crushed  my  groove  again   Go  on  and  write  me  up  for  125  …Post  my  face,  wanted  dead  or  alive   Take  my  license,  all  that  jive  ...I  can't  drive  55,  oh  no,  uh  
  3. 3. ACCURATE  RISK  SCORES  BEGIN  WITH  DOCUMENTATION   Accurate   DocumentaNon   &  Coding   Complete  &   Timely    Data   Submission   Accurate  Risk   Score  &   Resources   3  
  4. 4. !   Management  Challenge  6:   •  PrevenNng  Improper  Payments  and  Fraud  in  Medicare                                   Advantage   •  CMS's  reported  error  rate  for  MA  decreased  from  11.4  percent  for     •  FY  2012  to  9.5  percent  for  FY  2013   •  In  2008  the  announced  error  rate  was  30%  in  large  part  due  to  signature   issues   •  CMS  implemented  RADV  to  reduce  the  errors  in  risk-­‐adjustment  data  and   resulNng  improper  payments  .  RADV  verifies  the  accuracy  of  plan-­‐reported   diagnoses  through  medical  record  review  and  recouping  improper   payments  idenNfied  by  these  audits.     •  CMS  plans  to  audit  about  30  MA  contracts  per  year   •  hZp://oig.hhs.gov/reports-­‐and-­‐publicaNons/top-­‐challenges/2013/   FY  2013  OIG  REPORT   4  
  5. 5. DOCUMENTATION  IMPROVEMENT  STEPS   !   Explain   •  Communicate  the  changes  within  the  industry  and  provide  adequate   educaNon  to  the  providers  and  staff   !   Evaluate   •  Look  at  opNons  to  improve  the  clinical  documentaNon     •  Analyze  or  review  to  idenNfy  potenNal  problems   !   Select   •  Methods  for  documentaNon  improvement  that  work  for  your  unique  office   and  staff   •  Be  sensiNve  to  the  provider’s  Nme.  Make  it  worthwhile  for  providers  to   take  Nme  out  of  their  busy  day  to  discuss  a  case  or  go  over  a  review     !   Analyze   •  Analyze  methodologies  and  the  effecNveness  of  your  programs  to  ensure   the  program  structure  is  effecNve   5  
  6. 6. CHANGES  TO  THE  RULES  OF  THE  ROAD   !   Analyze  the  2014  PY  (25%/75%)  blended  model.               Train  coders  and  providers  accordingly   •  What  codes  are  new?   •  What  codes  dropped  off?   •  Changes  in  Hierarchies   !   Audit  to  ensure  documenta^on  is  complete  and  accurate  for   code  capture  in  the  revised  model   •  Are  there  different  documentaNon  requirements?   •  Look  for  areas  of  improvement   •  Specificity   !   U^lize  analy^cs  to  assist  with  loca^ng  poten^al  coding  and   documenta^on  errors   •  Incorrect    documentaNon/coding  paZerns   •  InpaNent  condiNons  coded  in  the  outpaNent  seeng   6  
  7. 7. 7   !   The  rules  of  the  road  change,  we  must  shib  gears  and                     communicate  the  changes.  Let’s  offer  the  providers  the                           opportunity  to  be  successful   •  Provider  and  Coder  Training-­‐Who  will  be  your  audience?   •  Primary  Care/Specialty  Care   •  Coders/  Billers   •  Office  Managers/Cooperate  Staff   •  Large  Group  versus  Small  Group   !   Be  crea^ve  in  the  planning  stages   •  Don’t    rush  the  process.  Plan,  Plan,  Plan  you  want  to  drive  the  message  to  as  many   vehicles  as  possible   •  Involve  Provider  RelaNons,  possible  making  it  a  contest   •  Quarterly  Provider  meeNngs  are  a  good  venue   •  Breakfast,  Lunch  or  Dinner  meeNngs  most  aZended.     Ø  Feed  them  and  they  will  come   •  Offer  CME’s  for  the  Providers  and  CEU’s  for  the  Coders   •  Requirement  to  aZend  in  order  to  parNcipate  in  incenNve  programs   !   The  right  planning  and  training  will  drive  higher  performance   HOW  DO  WE  DRIVE  THE  MESSAGE  
  8. 8. CHALLENGES  FOR  VALIDATION  FOR  2013/2014   ICD-­‐9-­‐CM   2013  HCC  Model   PY  2014   2014  HCC  Model   PY  2015   Status   Diabetes   Unspecified   250.00   19   19   No  change     DiabeNc  Renal   250.40   16   18   Category  Change  2014   Morbid  Obesity   278.01   0   22   Added  Code  2014   CKD-­‐Stage  1   585.1   131   0   Deleted  Code  2014   8   Some  codes  that  exist  in  both  models  had  category  changes      
  9. 9. BUCKLE  UP  AND  LET’S  WORK  TOGETHER   9   CMS requests organizations’ best efforts to assist in correcting and improving payment error
  10. 10. ECONOMICS  OF  HEALTHCARE   !   The  Big  Picture   •  Resources  are  being  spent  each  and  every  day  regardless  if                           the  condiNons  were  documented  appropriately   •  What  steps  are  you  taking  to  ensure  medical  record                   documentaNon  support  chronic  condiNons?         •  We  must  teach  our  providers  the  basic  requirements,  acceptable  verbiage,   the  differences  between  provider  documentaNon  and  the  official  coding   guidelines   •  Direct  Feedback  to  the  coder  and  provider  should  be  provided   •  Physicians    are  overwhelmed  and  just  want  to  treat  their  paNents,   however  Nme  constraints  someNmes  lead  to  minimal  documentaNon,  poor   specificity,  unsigned  records  and  missed  status  codes…   •  Let’s  demonstrate  this  doesn’t  need  to  be  an  added  burden   •  Provide  soluNons  and  tools   10  
  11. 11. THE  COMPLETE  PICTURE  OF  HEALTH   !   Documen^ng  and  coding  the  pa^ent’s  diagnosis  to  the  highest   specificity  in  the  medical  record   •  Affects  the  accuracy  of  your  paNent’s  health  status  and  is  reflected  in   measures  of  paNent  outcomes  and  potenNally  reimbursement   •  Drives  the  development  of  care  management  strategies  and  idenNfies   paNents  most  in  need  of  resources   •  Shapes  the  coordinaNon  of  care  in  both  the  inpaNent  and  outpaNent   seengs   •  Reflects  CMS’s  assessment  of  quality  of  care  delivered   •  Drives  government  and  state  distribuNon  of  funding  to  support  enriched   paNent  services   •  Under  coding  skews  the  cost  data  and  possibly  the  outcomes  as  well     11  
  12. 12. IMPORTANCE  OF  MEDICAL  RECORD  DOCUMENTATION   !   Accurate    documenta^on  and  coding  is  the  key  to  prompt  and  en^tled   reimbursement,  prac^ce  profiling  and  contract  nego^a^ons.  It  is  cri^cal  for   both  legal  and  financial  reasons     •  The  medical  record  chronologically  documents  the  care  of  the  paNent  and  is  an  important   element  contribuNng  to  high-­‐quality  care     •  The  progress  note  updates  the  paNent’s  clinical  course  of  treatment  and  summarizes  the   assessment  and  plan  of  care     !   But,  the  role  of  documenta^on  has  expanded…     •  TradiNonally,  documentaNon  was  used  mainly  by  the  provider  as  a  source  of   informaNon  to  assist  memory  of  paNent  care  from  one  episode  to  the  next  and   support  conNnuity  of  care.     •  Today,  documentaNon    is  also  the  primary  means  of  communicaNon  among  an   extended  care  team  and  externally  to  health  plans  and  other  agencies  monitoring   health  care  quality   12   The  spoken  word  perishes…the  wri0en  word  remains  
  13. 13. 2012  DIABETIC  FACT  SHEET-­‐UPDATED  3/2013   13   hZp://professional.diabetes.org/admin/UserFiles/0%20-­‐%20Sean/FastFacts%20March%202013.pdf     !   Nearly  26  million  children  and  adults  in  the   United  States  have  diabetes   !   79  million  Americans  have  pre-­‐diabetes   !   1.9  million  Americans  are  diagnosed  with   diabetes  every  year   !   Nearly  10%  of  the  en^re  U.S.  popula^on  has   diabetes,  including  over  25%  of  seniors     !   As  many  as  1  in  3  American  adults  will  have   diabetes  in  2050  if  present  trends  con^nue   !   The  economic  cost  of  diagnosed  diabetes  in   the  U.S.  is  $245  billion  per  year  
  14. 14. RAF  SCORES   !   Plans  should  not  assume  that  the  RAF  scores  assigned  to  their  members  are   accurate.  Even  if  your  RAF  score  seems  good,  that  score  may  not  truly   represent  the  actual  prevalence  of  chronic  diseases  in  the  MA  popula^on   you  manage.  You  could  be  missing  a  significant  opportunity  to  have  the   appropriate  financial  resources  necessary  to  manage  the  popula^on   !   Members  are  not  always  seen  on  a  regular  basis,  which  will  result  in  low   RAF  scores   !   Reality  is  the  providers  are  strapped  for  ^me  and  see  mul^ple  pa^ents   each  day.  Some^mes  the  importance  of  iden^fying  the  burden  of  disease  in   the  popula^on  they  are  managing  can  be  lost.     !   Physicians  need  to  examine  popula^on  data  about  chronic  condi^ons,   which  will  help  them  focus  not  only  on  individual  member  screenings,  but   also  on  the  en^re  popula^on  they  manage.  By  doing  so,  they  can  bejer   understand  the  true  burden  of  disease  in  this  popula^on  of  oben   chronically  ill  members   14  
  15. 15. DATA  VALIDATION  AUDIT   !   DVA  –  Data  Valida^on  Audit   !   Data  valida^on  involves  retrospec^ve  comparison  of               diagnos^c  data  (ICD-­‐9-­‐CM)  reported  to  the  actual           documenta^on  within  the  medical  record   !   DVA’s    should  be  performed  for  compliance  ,  educa^onal   purposes  and  to  monitor  and  assess  the  quality  of  coding.   During  the  review  the  auditor  specifically  verifies  the  following   •  Dates  of  service  are  within  the  data  collecNon  period   •  Provider  signature/credenNals  are  present  on  the  note  for  each  DOS  submiZed   •  The  service  was  provided  by  an  acceptable  provider  type  and  place  of  service   •  The  diagnoses  are  properly  supported  by  the  medical  record  documentaNon  and   official  coding  guidelines  were  followed   •  Billing  codes  without  appropriate  supporNng  documentaNon  is  a  compliance  issue   and  creates  risk  for  invesNgaNon  as  fraud   15  
  16. 16. COMMON  DOCUMENTATION  &  CODING  ISSUES   !  Lack  of  suppor^ve  documenta^on  for   acute    and  chronic  condi^ons                      (No   MEAT)   ! Diabe^c  complica^ons,  manifesta^ons   and  specificity  missing  or  lacking     Example:    Diabe^c  CKD,  Stage  CKD   ! Incorrect  specificity  when  selec^ng  the   ICD-­‐9  code,    the  documenta^on  should   match  the  ICD-­‐9  selected   ! Coding  resolved    or  history  of  diagnoses  as   ac^ve,  may  code  resolving  diagnosis   ! Coding  acute/current  cancers  without    the   status  or  ac^ve  treatment  documented   16   ! Metasta^c  Cancer/  site  not  documented  or   coded  (one  of  the  highest  HCCs)   ! Acute  stroke  coded  in  the  outpa^ent  semng   when  most  likely  the  residual  or  history  of   stroke  should  have  been  coded   ! Fracture  codes  reported  when  the  fracture   isn’t  in  the  acute  phase   ! Unconfirmed  diagnoses  coded  example:   probable,  suspected,  consistent  with,  rule   out,    rather  code  signs  and  symptoms  un^l   defini^ve   !  Not  documen^ng    status  codes  yearly   •  Ostomy  Status  Morbid  Obesity   •  AmputaNon  Quadriplegia/Paraplegia   •  Dialysis  Status  Non  Compliance  with  Dialysis  
  17. 17. ICD-­‐10-­‐CM  DOCUMENTATION  IMPROVEMENT   !   ICD-­‐10-­‐CM  does  not  require  an  increase  in  quan^ty  of   documenta^on,  however  high  quality  documenta^on  will   increase  benefits  of  the  new  coding  system  which  is   increasingly  being  demanded  by  other  ini^a^ves   !   Analyze  ICD-­‐9-­‐CM  frequency  data  and  focus  educa^onal   efforts  on  most  frequently-­‐coded  condi^ons   !   Preliminary  ICD-­‐10-­‐CM  CMS-­‐HCC  &  Rx-­‐HCC  Model   •  hZp://www.cms.gov/Medicare/Health-­‐Plans/ MedicareAdvtgSpecRateStats/Risk-­‐Adjustors.html   17  
  18. 18. ICD-­‐10-­‐CM  –  LET’S  HAVE  SOME  FUN!   !   Spacecrab  Collision  Injuring  Occupant   V95.43XA   !   Dependence  on  other  enabling  machines   and  devices  Z9989   •  Do  they  mean  Crackberry  or  Smartphone?   !   Burn  due  to  water-­‐skis  on  fire  V91.07S   !   Swimming  pool  of  prison  as  the  place  of   occurrence  of  the  external  cause  Y92.146   18  
  19. 19. FINISH  LINE…  QUESTIONS,    THANK  YOU!   19   Next phase has to focus on compliance, education and systemic change.
  20. 20. AltegraHealth.com   (310)  874-­‐0539   Carol  Olson,     CCS,  CCS-­‐P,  CPC-­‐I,  CPC-­‐H,  CEMC,  CCDS,     AHIMA  Ambassador  ICD-­‐10-­‐CM   PCS  Approved  Trainer   Vice  President  of  Educa=on  &  Consul=ng      Carol.Olson@AltegraHealth.com  

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