© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Chapter 3 Freestanding Ambulatory Care

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Learning Objectives List the types of freestanding ambulatory centers and differentiate among them regarding the kinds of programs and services they offer. Define basic terms related to freestanding ambulatory care facilities. 2 (continues)

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Learning Objectives (continued) List the major agencies or organizations that set standards for the facility and interpret their standards. Discuss pertinent record completion, filing, quality assessment, coding and indexing, and computer systems for freestanding ambulatory care facilities. Discuss payment systems for ambulatory care. 3

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Care Settings Public health departments Community health centers Rural health clinic Industrial or occupational health centers Ambulatory surgery centers (ASCs) Urgent care centers Physician private practices University health centers Birth centers 4

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Types of Patients Not critically ill Wellness care Minor acute problems Chronic conditions Sometimes specific types of patients cared for in certain settings (e.g., pediatric clinic) 5

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Types of Caregivers Physician Nurse practitioner (NP) Certified nurse midwife (CNM) Physician’s assistant (PA) Dentist Nutritionist Counselor/therapist Psychologist Social worker Chiropractor Podiatrist 6

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Regulatory Issues: Licensure Laws vary from state to state Licensure does not usually apply to physician offices Licensure does usually apply to ambulatory surgery centers and birth centers 7

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Regulatory Issues: Medicare Certification Conditions of Participation or Conditions of Coverage exist for some settings Ambulatory surgical services, rural health clinics, and federally qualified health centers must meet Conditions to qualify for Medicare and/or Medicaid reimbursement 8

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Regulatory Issues: Accreditation 9

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Other Regulations: Compliance Office of the Inspector General (OIG) issued compliance guidance for development of compliance programs Areas to monitor: coding and billing; reasonable and necessary services; documentation; improper inducements, kickbacks, and self-referrals Medicaid Integrity Program (MIP): Medicaid Integrity Contractors (MICs) audit providers 10

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Documentation Registration/demographic information History and physical, reason for visit Laboratory and X-ray reports Progress notes Encounter form (superbill) Copies of hospital records Problem list 11

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Special Requirements 12

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Record Format Source oriented: Arranged according to source (e.g., laboratory, nursing, etc.) Integrated: Chronological order Problem oriented (POMR): Problem list with other documentation keyed to problem number. Electronic health record (EHR) 13

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Patient Identifier/ Filing Methods 14

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Reimbursement Fee for Service Medicare Physician Fee Schedule (PFS) based on resource-based relative value scale (RBRVS) –Payments for “incident to” services by MLP –Payments under locum tenens arrangements Ambulatory Surgery Centers Capitation Medicaid and EPSDT 15

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Reimbursement Resources Program manuals Program transmittals Local coverage determinations (LCDs) National coverage determinations (NCDs) 16

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Coding and Classification 17

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Data and Information Flow Visit is basis of workflow Appointment methods –Standard scheduling –Block appointment method –Modification of standard and block 18 (continues)

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Data and Information Flow (continued) 19

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Data and Information Flow (continued) 20

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Filing Identifier impact on filing method (e.g., alphabetical identifier=alphabetical filing) Numerical filing –Straight numerical order –Terminal digit order Color coded file folders available for both alphabetical and numerical filing systems Equipment: cabinets, open-shelves Late reports 21

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Record Linkage to Other Sites Electronic health records allow multiple user access from various sites simultaneously Paper-based systems designate home base for record –patient-selected site –last site seen Transporting records: courier, fax, security considerations 22

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Computer Systems 23

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Incentives for Electronic Systems Electronic Health Records E-prescribing 24

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Uniform Ambulatory Minimum Data Set Patient data Provider data Encounter Data 25

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Quality Assessment and Performance Improvement Select problem or process, collect data, assess data, develop improvement Patient compliance affects quality Patient satisfaction Quality of data within patient record Physician quality reporting system (PQRI) 26

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Utilization Management (UM) Appropriateness of services and treatment Examine high cost or high volume services Two approaches to UM –Prospective review/precertification –Retrospective review 27

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Risk Management & Legal Issues 28

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Role of the Health Information Manager Information management Supervision of personnel Knowledge of regulations Knowledge of electronic information systems Training and education Non-traditional roles 29

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Trends Shifting of care from inpatient to ambulatory settings Integration of freestanding facilities into networks of providers Increased scrutiny of documentation for support of reimbursement requested Medical home Increased use of electronic health records 30

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Summary Types of facilities and caregivers Accreditation and licensing standards Reimbursement Information Management Performance Improvement and Utilization Management Risk Management and Legal Issues 31

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Web Activity Review LCDs and NCDs in the Medicare Coverage Database at the CMS Web site. Follow instructions to locate and review the LCD or NCD of your choice. What type of information does the LCD or NCD document contain? How might this information be useful to a freestanding ambulatory care provider? 32