Transcript Provider Presence #1
Evaluation & Management Services
UCSF Clinical Enterprise Compliance Program
Documentation & Reporting
New Approach to the Same Old Story
UCSF Clinical Enterprise Compliance Program
UCSF Clinical Enterprise Compliance Program
CECP Education Series Wanda T. Ziemba MFA RHIT CPC Medical Center Compliance Manager & CECP Educator
UCSF Clinical Enterprise Compliance Program
MGBS Brown Bag Series
March 17, 2006
UCSF Clinical Enterprise Compliance Program
Agenda
Brief presentation – E&M Issues – Consultation Guidelines – Teaching Physician Guidelines – Questions
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The New, New, New Guidelines
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Documentation Guidelines
1995 E&M Guidelines – Body Areas & Organ Systems – One “Point” for Each BA/OS – Favored Primary Care 1997 E&M Guidelines – “Bullet” System – Discrete Examination Elements – Fair to Specialists
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NHIC
You may use either the 1995 or the 1997 guidelines, whichever provides the most advantage NHIC reviews according to the 1997 guidelines Easier to validate content More difficult to support higher levels
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History
1995/1997-10+
documented ROS
required 1999-proposed 2 of 3 history elements Focused to comprehensive 2002 – menu options for history
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Physical Examination
1995/1997-detailed – Lower extremity exams required for comprehensive – Detailed exam 1999-proposed 200+ list Exact requirements not yet known 2003 – scenario based
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Medical Decision
1995/1997-calculated based on – Problems – Data reviewed/ordered – Risk table 1999-proposed one table encompassing all three areas
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Seven Components of Evaluation & Management Services
The SOAP Note Expanded, Revisited and Beaten Into Submission
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Key Elements
History
as related to the patient’s presentation
Physical Exam
as related to the patient’s presentation
Medical Decision
in managing patient
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New patients, consultations, ED and Admits – 3 of the 3 key elements Established patients, subsequent hospital care – 2 of the 3 key elements Medical Decision is prime
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Contributing Elements
Counseling
with the patient and/or family
Coordination
of care
Nature
of the presenting problem
Time
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Purpose
Remember the primary focus of the medical record Continuity of patient care Legal documentation Legible progress notes Not just for “billing”
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History
Focused – (CC, 1-3 HPI) Expanded – (CC,1-3 HPI, 1 ROS) Detailed – (CC,4+ HPI, 2-9 ROS, 1 PFSHx) Comprehensive – (CC, 4+ HPI, 10+ ROS, 2-3 PFSHx)
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25yo m dilated & hypertrophic CM w/ mild MR, hyperthyroidism Concerns re: STDs; contact 1 wk ago, irritation, burning on urination, OTC tinactin, no Δ No D/C, partner x 1 w/yeast infx, Ǿ IVD/Tattoos – energy level Ǿ Δ Ǿ CP, Ǿ CHF Sx’s, Ǿ palps ↑weight 5 lbs
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CC HPI ROS PFSHx Level Genital irritation Duration; context; assoc. s&s; modifying factors Constitutional; cardiovascular Partner w/yeast infx; Dilated & hypertrophic CM; mild MR; hyperthyroidism 4 HPI 2 ROS 2 PFSHx Detailed
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How specific should the medical record documentation be? Is “negative” or “benign” appropriate when detailing examination findings?
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Physical Examination
Focused – (1-5 bullets, 1 BA/OS) Expanded – (6-11 bullets, 2-7 BA/OS) Detailed – (12 bullets, 2-7 BA/OS) Comprehensive – (18+ bullets, 8+ organ systems)
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The patient is a 25 year old white male, alert & orient x 3, cooperative and in NAD.
VS: 110/70, 60, 5’9”, 179 lbs AT NC PERRLA EOMI Neck Ǿ Ǿ LAD TM PMI ND S1 S2 (↑ A2) HS nml apex CTAB no retractions R shoulder notable >> larger L shoulder?
Ǿ C/C/E nml pulse + foreskin, Ф irritation Ф discharge Ǿ no mass test Ф hernia
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BA/OS Cons Eye Head ENMT CV Resp Ext MS Lymph GU Psych Neuro 1 1 1 1 1 2 1 1 1 1995 1997 Comment 1 1 2 1 GA & VS (when at least 3) Pupils & iris Under MS in 1997 guidelines 1 4 2 TM Auscultation, palpation, edema, pulses Auscultation & effort Not in 1997 guidelines 3 1 3 Inspection/palpation 3 areas Cervical Penis, testicles, hernia 2 1 Mood & affect, orientation
BA/OS Totals 1995 8 OS Comprehensive Totals 3 BA 1997 20 Bullets, 6 systems with 2 or more PE elements Detailed N/A
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The Extreme Extremities
Extremities are obvious in the 1995 guidelines (remember to not count
Body Areas
for the comprehensive level of service) Where do extremities belong in the 1997 guidelines?
Varies with specialty performing service and presenting problem
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The Nebulous Neck
Neck is considered a body area and yet is listed separately in the 1997 guidelines Placement will be determined by the physical examination findings May be Musculoskeletal, Lymphatic, Endocrine
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Problems, Data, Risk
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Medical Decision
Presenting problem – New/established, improving/worse,self limiting Data reviewed – Type, independent review, discussion Risk – Selected from the Morbidity/Mortality Table
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Are You a Psychic
How can you tell if there has been an independent review of source materials or films?
Note the language documented – Personally reviewed; wet reading Consider the level of detail in the medical record
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Medical Necessity/Time
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Time
More than 50% of total face-to-face time Counseling Treatment options, risks & benefits, patient/family education, discussion of results Choose based on total time Document both total and counseling time Only on E&M’s with suggested time
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Consultations
New guidelines require the request as well as the opinion to be documented in the medical record Must be requested by a faculty physician
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Transmittal R788
Deletion of follow-up and confirmatory consultations Revised definitions Updated documentation requirements Second opinion s are assigned Inpatient Consultation codes if the consultation requirements have been met
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Carriers shall instruct physicians and qualified NPPs that a consultation request may be verbal however the verbal interaction identifying the request and reason for a consult shall be documented in the medical record by the requesting physician or qualified NPP, and also by the consulting physician or qualified NPP in the patient’s medical record.
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Teaching Regulations – History
IL372 – initial teaching institution guidelines – Intermediary Letter Outlining the extent of Attending participation required for reporting purposes – Basic guidelines; no address of current technology such as EHR or macros – Medicare only
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Medicare reimburses for clinical activities under Part A and Part B Part A represents hospital services and GME funds (Facility) Part B is attending physician services (Pro-Fee)
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Medicare will reimburse for services predominantly supplied by the House Staff when the faculty physician personally provides direct services and the medical record reflects that face-to face encounter
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Further Refinements to the Medicare regulations
Transmittal 1780 – November 22, 2002 – Developed specific language – Detailed definitions – Additional guidelines for surgical and anesthesia services
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January 13, 2006 Transmittal
Revised Definitions – Resident, Interns & Fellows – Student – faculty Physician – Direct Medical Services – Physically Present
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Three Scenarios
The faculty physician personally performs all the required elements of the E&M service without a resident – The attending documents as if in a non teaching setting
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The resident performs the elements required for the E&M service either jointly with or in the presence of the faculty physician – The faculty physician’s note should reference or “link” to the resident’s note
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The resident performs the required elements in the absence of the faculty physician; the faculty physician independently performs the required elements with or without the resident present and, as appropriate, discusses the case with the resident.
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Acceptable Linkage
“See resident’s note for details; I saw and evaluated the patient and agree with the resident’s findings and plans as written” “I was present with the resident during the history and physical examination; I discussed the case with the resident and agree with the findings and pan as documented in the resident's note.”
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Unacceptable Linkage
“Agree with the above” “Rounded, reviewed, agree” Countersignature only “Seen and agree” “Patient seen and evaluated”
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The resident may not document the presence of the faculty physician The faculty physician should document some pertinent details to satisfy the Medi-Cal requirements Physical presence must be documented by the faculty physician
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However, Medi-Cal will not reimburse for any indirect patient care (22 CA CCR § 51503)
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No reimbursement for services supervising house staff No reimbursement allowed for attending “teaching” time
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When Will Medi-Cal Pay?
(1) They are performed for necessary treatment of the patient; (2) They are not an exercise of
teaching
supervision without direct patient care services being provided; (3) They do not duplicate any medical services billed by any other provider; and
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4) The faculty physician is not on salary or contract to the hospital for the direct patient care services provided.
No professional fees are payable for services provided independently by residents or students in a teaching setting.
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The Medi-Cal program, through its intermediary, will pay allowable Medi Cal rates for direct patient care services in a teaching setting when directly provided by faculty physicians only when such services are provided and billed in accordance with program policies and regulations of the Department of Health Services and when:
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Errors?
What Happens If Our Practice Misunderstands the Regulations?
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Some practices are developing compliance plans; CMS is very interested in how providers code and document.
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Carrier Audits
Just what are the chances that my practice will face a carrier audit? How can I plan for targeted areas?
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Now you know the answers…
UCSF Clinical Enterprise Compliance Program