The MEAT of Documentation Presented by: Tracy R. Johnson, CPC 2015 Mobile Alabama Chapter Vice-President

Objectives: Introduction on the Importance of Clear Documentation CPT Coding Audits Diagnosis Audits Denial Audits Compliance using 1995/1997 Coding Guidelines What is the difference in Acute and Chronic Conditions? What is CERT? What is Risk Adjustment? The MEAT of the Documentation

The Importance of Clear Detailed Documentation There are multiple types of audits that can be used in a tool today to gauge many different aspects of the coding realm CPT Coding Audits: Audits that strictly take into account the accuracy of the procedural coding on a chart Diagnosis Audits: Audits that strictly take into account the accuracy of the diagnostic coding on the chart. This is also used to establish Hierarchy of Coding (HCC) during an audit. Denial Audits: Audits that are used to gauge the accuracy of a denial from the insurance company as to why the claim was denied

CPT Audits The following rules apply when auditing for Evaluation and Management during a CPT Audit Which set of guidelines are in the “Compliance File”? Are they 1995 guidelines or 1997 guidelines? What are the requirements for both? In the 1995 E/M Coding Guidelines, the Evaluation and Management is based on 3 Key components (History, Examination, and Medical Decision Making) In the 1997 E/M Coding Guidelines, the Evaluation and Management is based on a clear and documented “Extent of the Examination that was performed citing all 14 Review of Systems, and time is more a factor for 1997 Coding Guidelines than in 1995 Coding Guidelines

IMPORTANCE OF THE AUDIT TOOL You may be asking yourself, “Why is an Audit Tool Important”? Here are a few detailed reasons why: To establish compliance of not only the coder but the physician To establish documentation guidelines within the office/hospital setting To establish the need for further education (staff, physicians, etc) To establish a “base-line” as to where all other audits will be based To establish the identify of Medical Necessity in the overall criteria in payment in addition to the specific technical requirements of a CPT code

THE ELEMENTS OF AN AUDIT TOOL There are 5 Basic Elements to an Audit Tool Condition: Statement that describes the results of an audit Criteria: Standards used to measure the activity or performance of the auditee Cause: Explanation of why a problem occurred Effect: The difference between and significance of the condition and the criteria Recommendation: Action that must be taken to correct the course

What is CERT? CERT stands for Comprehensive Error Rate Testing Contractors are to statistically analyze and establish error rates Estimates improper payments Claims are randomly selected for review Not required to notify providers of the intention to start a review

Medicare Appeals Process The Appeals Process contains 5 steps Level 1: Redetermination by a Medicare Contractor Level 2: Reconsideration by a Qualified Independent Contractor Level 3: Hearing before an Administrative Law Judge Level 4: Review by the Appeals Council Level 5: Judicial Review in Federal District Court

Payment Recovery/Recoupment A Medicare Overpayment occurs when a provider receives excess payments due to any of the following: Duplicate Submission of the same service or claim Payment to the incorrect payee Payment for excluded medically unnecessary services A pattern of furnishing and billing for excessive non-covered services (as determined in an audit or review)

Defining “Chronic” versus “Acute” What is the difference between Acute and Chronic Illnesses? Acute Illnesses: Those illnesses that will eventually resolve without any medical supervision (colds, teething) Example: An acute illness will typically run a course regardless of whether or not there is drug intervention; (coughs, colds, teething, PMS, sleeplessness) are all examples of such illnesses. Usually, medicine for acute illnesses are regulated as Over The Counter Drugs Chronic Illnesses: Those that require medical supervision and is often a disease that has formed over a long period of time. Examples: Cancer, AIDS, Kidney Disease and Diabetes. Usually medicines for chronic illnesses are regulated as prescription drugs.

What is Risk Adjustment? Risk Adjustment is the model to adjust capitation payments to private health care plans for the health expenditure risk of their employees CMS measures the disease burden that includes 70 HCC categories, which are correlated to diagnosis codes CMS’ model is accumulative (patient can have more than one HCC category assigned to them) Some categories override other categories There is Hierarchy of Coding Categories (HCC)

HCC’s and How they Affect Payment The following HCCs reflect a few common “chronic” conditions found within the Medicare population, that Medicare Advantage Plans look for to be documented in the patient’s chart: Diabetes without complications Chronic Obstructive Pulmonary Disease Congestive Heart Failure Breast Cancer Ischemic Heart Disease Angina

HCC Guiding Principle The Risk Adjustment diagnosis must be based on clinical medical record documentation from a face-to-face encounter The Diagnosis must be coded according to the ICD-9-CM Guidelines for Coding and Reporting and assigned based on dates of service within the data collection period The Diagnosis must be submitted to the MA organization from an appropriate Risk Adjustment provider type and an appropriate Risk Adjustment physician data source

Understanding Diagnosis Coding: Protect Against Auditor Scrutiny Accurately Report ICD-9-CM Diagnosis Codes Coders cannot assume the past medical history diagnosis has a current affect on the current condition for which the patient is receiving treatment Unless the physician has a “direct statement” that the past medical condition or the medications the patient is taking for the past medical condition has a direct link on the treatment for the current encounter, Coders should not code the past medical history conditions.

Understanding Diagnosis Coding: Protect Against Auditor Scrutiny Capture All Chronic Diseases Coders may report chronic diseases treated on an ongoing basis as many times as the patient is receiving treatment for the condition(s) Code All Documented Conditions that Coexist Code all documented conditions that coexist at the time of the encounter and require or affect the patient treatment or management Do not code conditions that a physician previously treated and no longer exists

Understanding Diagnosis Coding: Protecting against Auditor Scrutiny History Codes V10-V19- Coders may use history codes (V10-V19) as secondary codes when the historical condition or family history has a direct effect on the current care Replacement Codes – Coders may use the replacement codes as secondary codes to show that a patient has had a total knee or other joint replaced. Medication V58 – Medication V codes help to support the use of several different medications like insulin, NSAIDS, or aspirin.

Handle Other Diagnoses and Consider Final Diagnostic Statements For reporting purposes, the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring one of the following: Clinical Evaluation Therapeutic Treatment Diagnostic Procedures Extended Length of Hospital Stay Increased nursing care and/or monitoring

Handle Other Diagnoses and Consider Final Diagnostic Statements If the physician has included a diagnosis in the final diagnostic statement Coders should ordinarily code it However, some physicians include resolved conditions or diagnoses and status- post procedures from previous admissions or evaluations that have no bearing on the current episode in the diagnostic statement Coders should not report these conditions Examples: A patient is a smoker but presents today for a sunburn (Use of tobacco not reported) Parkinson’s disease in a patient with a wart on the finger (Parkinson’s not reported) Depression in a patient who has fallen off a ladder (Depression not reported) History of Acute Myocardial Infarction (AMI) in a patient that has a cold (Old MI not reported)

Now The MEAT

MEAT What is MEAT? M: Monitoring E: Evaluating A: Assessing/Addressing T: Treating

Monitoring “M” Monitoring is the application of all of the below in a medical record: Signs Symptoms Disease Progression Disease Regression

Evaluating “E” Evaluating is the application of all the below in a medical record: Test results Effectiveness of medications Response to treatment

Assessing/Addressing “A” Assessing or Addressing is the application of all of the below in a Medical Record: Ordering Tests Discussion Review of Records Counseling

Treating “T” Treating is the application of all the below in a Medical Record Medications Therapies Other modalities

How Does My Documentation Stand UP? According to CMS an acceptable problem list must show “evaluation and treatment” for EACH condition that relates to an ICD-9-CM code Condition ICD-9-CM Code Documentation Supports CHF 428.0 Symptoms well controlled on Lasix and ACE inhibitor. Will continue to monitor Major Depression 296.20 Despite being on Zoloft 50 mg per day, the patient still feels hopelessness. Will raise to 100 mg for the next two weeks Hypertension 401.9 Stable on medications

Documentation “PitFalls” Providers are not showing all documentation for work performed during the encounter It is acceptable to include “history of” conditions if it directly affects the current treatment plan of the patient Remember, “stating history of” means the patient no longer has that condition

In Summary….. Any and each condition that is addressed at the time of the encounter should be documented in the History and Physical Each condition that relates to an ICD-9 code must show evaluation and/or treatment A list of diagnoses is NOT acceptable as evidence that the diagnosis affected the patient management Using MEAT ensures that documentation is sufficient for CMS’s requirements for validating coding Following the MEAT principle will provide accurate documentation, patient of care quality, and improvement in data management for validating diagnosis codes

Questions?

Thank you for Coming! We hope you enjoyed tonight’s presentation Please take a moment to fill out the Speaker Survey given to you at the start of the presentation The power point will be available on the website www.aapcmobile.com within 24 hours Remember, our next meeting March 17, 2015 6:00 pm Providence Hosptial, DePaul Center