1. Documentation Standards
2008
Intro remarks

2. Agenda Goals of documentation training Iowa Administrative Code
SURS & Medical Services Reviews
CDAC Service Record
Questions & 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 review
Direction 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/ pdf
Iowa 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 standing
Whenever 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 service
Almost direct quote from code

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
Almost 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 service
Each 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) Identification
Each page or separate electronic document:
- Member’s first and last name
Associated within document:
- Medical assistance id number
- date of birth
Clarification: 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 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
There 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 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. 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. Provider’s assessment, clinical impression, etc
13. Any additional documentation to demonstrate medical necessity
10) Examples would be sterilization consent forms, CDAC log form

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
(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 time
4. Location
5. 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) Location
Does 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 dispensed
7. First name, last name & credential of provider
8. Signature of provider or initials if signature log used
9. 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 Service
Medical record shall indicate:
- member’s progress in response to services
- including:
- changes in treatment
- alteration of plan of care
- revision of diagnosis
Almost direct quote from IAC
Bottom 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 services
New as of 4/1/08
5 pages of specific requirements for more than 35 provider types
Outlines documents needed by provider type for SURS review
This 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 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
Additional 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 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
Almost direct quote.
Follow the most restrictive requirement.

21. Reviews and Audits of Documentation
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
- 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 charges
Report 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 assessments
Quickly ID narratives that are not adequate
Corrections can be made before claim submission
Quickly identify staff who need additional training
Best 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 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. SURS and Medical Services Reviews

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
This 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 Plans
Individual comprehensive plans
CDAC agreements
Providers 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. service
Documentation does not match services
Invalid correction
No signature or signature sheet
From SURS unit.

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
UE 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 code
Sterilization: sterilization consent form
Hysterectomy: consent form or doc of prior sterility
Leaving 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 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
Deliver 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 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
Skin 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.

32. CDAC Service Record

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
Required of agency as well as individual CDAC providers.
Discuss how times are determined and written.
Effective date?

34. Medicaid 101

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
5 types: family practice
general practice
peds OB IM

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

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. ELVS Monthly eligibility Spend Down TPL insurance
Verify:
Monthly eligibility
Spend Down
TPL insurance
Managed Health Care information

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

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. 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 service
Medicare crossovers must be filed within 24 months of first date of service
Exceptions:
Retroactive eligibility
Third-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 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. 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. 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. 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