Transcript Documentation Standards 2009

Agenda
 Goals of documentation training
 Iowa Administrative Code
 SURS Reviews
 Questions & answers
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Documentation Standards Training
Goals:
 To discuss IAC as it pertains to documentation
 To emphasize compliance with doc standards in
relation to SURS review
 To educate providers about requirements, but not to
provide specific documentation wording
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Iowa Administrative Code
http://www.dhs.state.ia.us/policyanalysis/PolicyMa
nualPages/Manual_Documents/Rules/441-79.pdf
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441- 79.3(249A)
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441- 79.3(249A) Maintenance of
records by providers of service
 Providers shall maintain complete and legible records as
required in this rule.
 Failure to maintain records or to make records available
to the department or its representative may result in
claim denial or recoupment.
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Medical (clinical) records
79.3(2) 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
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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
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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
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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.
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Medical Records Component
#1- Identification
79.3(2)c(1) Identification
 Each page or separate electronic document:
- Member’s first and last name
 Associated within the medical record:
- Medical assistance id number
- Date of birth
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Medical Records Component
#2– 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
13 Bullets to follow on several slides
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Basis for Service
1. Complaint, symptoms, and diagnosis
2. Medical or social history
3. Examination finding
4. Diagnostic, lab, X-ray reports
5. Goals or needs identified in Plan of Care
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Basis for Service
6. Physician orders and required Prior Authorizations
7. Medication & pharmacy records, provider’s orders
8. Professional consultation reports
9. Progress or status notes
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Basis for Service
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
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Medical Records Component
#3 –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
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Service Documentation
3. Complete time of service with begin and end time
(unless time-defined CPT code is used)
4. Location
5. Name, dosage, and route of medication administration
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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
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Medical Records Component
#4 – Outcome of Service
79.3(2)c(4) Outcome of Service
Medical record shall indicate:
 member’s progress in response to services including:
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
changes in treatment

alteration of plan of care

revision of diagnosis
Basis for Service Requirements
79.3(2)d Basis for service requirements for
specific services
 New as of 4/1/08
 specific requirements for more than 40 provider types
 Outlines documents needed by provider type for SURS
review
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Corrections to Documentation
79.3(2)e Corrections
(1) Correction made or authorized by provider of service
(2) No write over or obliteration; line through and correct
(3) Indicate person making change, and person
authorizing change (if applicable)
(4) If change affects paid claim, then amended claim is
required
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Maintenance of Documentation
79.3(3) Maintenance requirement
a. During time member is receiving services
b. Minimum of 5 years from claim submission date (rolling
5 year retention)
c. As required by licensing authority or accrediting body
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441-79.4(249A)
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Audit or review at any time
79.4(2)a Audit or review of clinical & fiscal
records by the department
Review/ audit to determine:
 If the department has correctly paid
 If the provider has furnished billed services
 If records substantiate submitted claims
 If provided services were in accordance with policy
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Documentation Checklist
79.4(2)b Audit or review of clinical & fiscal
records by the department
 Form 470-4479 Documentation Checklist
 Lists specific documents to be requested for SURS review
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Audit/Review Procedures
79.4(3) Audit or review procedures
a. Records must be submitted within 30 days of
written notification
b. Extension of time limits:
(1) for up to 15 days when:
 Established good cause
 Request received before deadline
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Audit/Review Procedures
(2) For another 15 days when:
 Established exceptional circumstances
 Received before 15 day extension deadline
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Audit/Review Procedures
c. Announced or unannounced on-site reviews or audits
are possible
d. Procedures
 Comparing clinical record against claim
 Interviewing members & staff
 Examining TPL records
 Comparing usual & customary fees
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Preliminary Report of findings
79.4(4) Preliminary report of audit or review
findings
 If overpayment has occurred, a preliminary finding of a
tentative overpayment letter is issued
 Provider has opportunity to request reevaluation.
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Disagreement with Findings
79.4(5) Disagreement with review findings.
 Written reevaluation request received within 15 calendar
days of notice date
 Provider can submit clarifying information or
supplemental documentation within 30 days
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Order for Repayment
79.4(6) Finding and order for repayment.
 When reevaluation or expiration of deadlines has passed
 Order for repayment of over payment
 IME may withhold payments from other claims.
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Errors in Responding to Reviews
- Failure to submit docs timely per IAC 79.4
- Documentation submitted for wrong dates
- Submitted documentation not detailed
- Failure to submit:
 Individual Service Plans
 Individual comprehensive plans
 CDAC agreements
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Documentation Errors
 Illegible writing
 No in/ out times (where required)
 Wrong code vs. service
 Documentation does not match services
 Invalid correction
 No signature or signature sheet
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More Documentation Errors
 No dates of service
 Missing member response to interventions
 Physician orders not followed
 Chiro not indicating area of treatment
 Vision not stating replacement reason
 DME incorrectly using UE modifier
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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
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Summary of IAC Discussion
 Providers can develop a process or system of their own
design
 Chosen system must demonstrate that Medicaid rules
are met
 Providers should proactively review their current system
to ensure IAC requirements are met
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