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TUMG Documentation Top 10TUMG Documentation Top 10

It isn’t the mountains ahead, it’s the grain of sand in your shoe.

A countdown of important issues that affect documentation, coding, and reimbursement for physician services.

Before Viewing: print the handout/quiz for TUMG Documentation Top Ten

Read Before ProceedingRead Before ProceedingPhysicians and Staff may earn one compliance

credit by viewing this presentation, completing the assessment, and faxing the assessment to the

University Privacy and Contracting Office: 504-988-7777

This presentation may be viewed for compliance credit only once in a fiscal year

(July 1 - June 30).

To check how many compliance credits you have and to see which training sessions you have

completed, contact the University Privacy and Contracting Office at

504-988-7739

It is the policy of TUMG to provide healthcare It is the policy of TUMG to provide healthcare services that are in compliance with all state services that are in compliance with all state

and federal laws governing its operations and and federal laws governing its operations and consistent with the highest standards of consistent with the highest standards of

business and professional ethics. Education business and professional ethics. Education for all TUMG physicians is an essential step in for all TUMG physicians is an essential step in ensuring the ongoing success of compliance ensuring the ongoing success of compliance

efforts.efforts.

This education is a General Compliance Education This education is a General Compliance Education Presentations available on the Tulane University Presentations available on the Tulane University

Privacy and Contracting website:Privacy and Contracting website:http://tulane.edu/counsel/upco/billing-ed/http://tulane.edu/counsel/upco/billing-ed/

04/22/2304/22/23 TUMG Compliance TUMG Compliance 66

TUMG Physicians are responsible TUMG Physicians are responsible for documenting their outpatient for documenting their outpatient visits and selecting the level of visits and selecting the level of

service to be billed to the carrier.service to be billed to the carrier.

#10 Know what #10 Know what doesn’tdoesn’t count when count when it comes to documenting a serviceit comes to documenting a service

• “No change in history or exam since…” • “No change since last visit…” • “Findings same as last visit…”• Illegible notes• Undocumented work

#10 Know what #10 Know what doesn’tdoesn’t count when count when it comes to documenting a serviceit comes to documenting a service

• Outpatient visit documentation must “stand alone.” Physicians cannot link to other visits for chief complaint, HPI or exam. Only information documented in the visit note will count as support for a level of service.

• Reimbursement guideline: payors base reimbursement on what is documented for a particular date of service, not on information contained in other visit notes.

#9 Link to Ancillary staff notes and #9 Link to Ancillary staff notes and patient questionnaires patient questionnaires

• Patient questionnaires and staff notes can provide documentation to support a level of service, but physicians must link to them in the visit note.

• “Positive for cough and fever. Per 6/15/05 patient questionnaire, all other systems negative”

• “Per 8/1/05 questionnaire, family history non-contributory”

• Note: Physicians may link to ancillary staff notes and patient questionnaires for two elements of History: Review of Systems and Past/Family/Social History. A link to a measurement of Vital Signs can be used as an Exam element.

#9 Link to Ancillary staff notes and #9 Link to Ancillary staff notes and patient questionnaires patient questionnaires

• If using a patient questionnaire to support a service, physicians should review, sign, and date the form.

• If using a patient questionnaire from a previous visit, physicians should include the date the questionnaire was completed.

• Be sure the questionnaire is put in the medical chart. Auditors/Reviewers won’t look for something they don’t know exists, and they won’t count anything they can’t find in the record.

#8 Link to Resident Notes#8 Link to Resident Notes• Linking to resident notes means that the

level of service and reimbursement can be determined and supported by the combination of both notes.

• Not linking to a resident note will result in the level of service and reimbursement being determined by the teaching physician’s note alone.

–Example: If the resident documents the patient’s history for a new patient, unless the physician links to the resident note OR re-documents the history, a new patient or consult code cannot be billed.

Examples of Linking to Examples of Linking to Resident NotesResident Notes

• Physician sees patient with the resident:– New Patient, Consult/or

Follow-up visit: “I was present with the resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”

• Physician sees patient after the resident– New Patient, Consult/or

Follow-up visit: “I saw and evaluated the patient. Discussed with resident and agree with resident’s findings and plan as documented in the resident’s note.”

Medicare Transmittal 1780 – Teaching Physician Rule provides other examples of linking statements: http://www.med.ufl.edu/complian/Q&a/CMS_Transmittal_R1780B3.pdf

#7 Read Resident Notes #7 Read Resident Notes Before Linking!Before Linking!

• When physicians link to resident notes, they attest that they have “reviewed” the documentation. The combined notes will determine the level of service.

#6 Code Signs and Symptoms if a #6 Code Signs and Symptoms if a Definitive Diagnosis cannot be madeDefinitive Diagnosis cannot be made

• ICD-9 Coding Guidelines note– Diagnoses are often not established at the time of

the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.

– Codes that describe symptoms and signs, as opposed to diagnoses, are accepted for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the physician.

#6 Code Signs and Symptoms if a #6 Code Signs and Symptoms if a Definitive Diagnosis cannot be madeDefinitive Diagnosis cannot be made

Rule out and possible conditions should not be coded. They may, however, be mentioned in the documentation as support for the complexity of the medical decision making.

– Source: ICD-9 CM, Volumes 1 & 2, INGENIX, 2005

#5 Always Code Diagnosis to the #5 Always Code Diagnosis to the Highest SpecificityHighest Specificity

• A diagnosis code is INVALID if it has not been coded to the full number of digits required for that code.

• ICD-9 CM, INGENIX, 2005

#5 Coding to the Highest Specificity Helps to #5 Coding to the Highest Specificity Helps to Avoid Workfile Edits and DenialsAvoid Workfile Edits and Denials

• When a code requires a 4th or 5th digit, IDX is set up to stop charges and drop them into workfiles for follow-up with the physician. Until the additional digit(s) are added, the bill remains suspended in the IDX system.

#5 Coding to the Highest Specificity#5 Coding to the Highest Specificity

• To avoid coding specificity errors:– Be sure your billing encounter form

contains up-to-date codes and that the codes indicate whether a 4th or 5th digit is required.

Source: ICD-9 CM, INGENIX, 2005

#4 Avoid “Cloned” Notes#4 Avoid “Cloned” Notes

• Cloned notes or notes that have little or no change from visit to visit and patient to patient raise both documentation and reimbursement issues:

– These type of notes do not support Medical Necessity. In some cases, they may not support that a visit actually occurred.

– Cloned notes may be construed as an attempt to defraud the Medicare program.

Source: E/M Undercoding: Don’t Lose Earned Reimbursement, Jo Ann Steigerwald, RHIT, ACS GI, ACS-OH, Teleconference July 25, 2005. (Citing Cigna Medicare)

#4 Avoid “Cloned” Notes#4 Avoid “Cloned” Notes

• Visit notes must be patient-specific– If using templates or EMRs (Electronic

Medical Records), they should be detailed and specific enough to accurately reflect the patient service.

#3 Know How to Document a #3 Know How to Document a Time-Based CodeTime-Based Code

• Time-Based codes require two elements of documentation:– Time Element – two ‘times’ must be documented:

• Total time of the visit • Amount of time face-to-face counseling with the patient

and/or family, which must represent of more than 50% of the total time

– Content of counseling:• Record must reflect what topic(s) were discussed during the

counseling portion of the visit• Documentation of counseling must be patient-specific; use of

generic “canned” notes is discouraged

#3 Know How to Document a #3 Know How to Document a Time-Based CodeTime-Based Code

• To learn more about time-based codes, visit the Tulane School of Medicine Compliance Training Website: – http://www.som.tulane.edu/fpp/billing_new/

– View the PowerPoint Presentation and Download the file on “Time-Based Codes”

#2 Understand and appropriately apply #2 Understand and appropriately apply E/M Documentation GuidelinesE/M Documentation Guidelines

• TUMG physicians are responsible for selecting the level of outpatient service billed to the patient or the patient’s insurance.

• To bill for a service, medical necessity must be clearly established and

• The documentation must support the level of service billed.

#2 Understand and appropriately apply #2 Understand and appropriately apply E/M Documentation GuidelinesE/M Documentation Guidelines

• For more information on E/M Documentation Guidelines, visit the Tulane School of Medicine Compliance Training Website:

• http://tulane.edu/counsel/upco/billing-ed/

– The website has a 9-part “Documenting an Outpatient Visit” module. Physicians and Staff may view and/or print any or all of the presentations.

#1 WYSI-WYG Principle#1 WYSI-WYG Principle

Corollary:If it isn’t written,It didn’t happen,

And it can’t be billed

What You See Is What You Get

#1 WYSI-WYG Principle#1 WYSI-WYG Principle• If medical record documentation

does not support medical necessity, or does not support the level of service billed, reimbursement may be denied.

• In the case of an audit, payors may request a refund of reimbursement or impose penalties.

Contact InformationContact Information

–TUMG Business –ServicesCompliance Reporting

Hotline: 504-988-5142

End of PresentationEnd of PresentationTo earn one compliance credit, download the To earn one compliance credit, download the

file: “TUMG TOP 10” from the website.file: “TUMG TOP 10” from the website.

Complete the quiz and fax to 504-988-7777Complete the quiz and fax to 504-988-7777