the chiropractic reimbursement and compliance … 02...osha •occupational safety and health...

www.KMCUniversity.com 12/5/2015

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CA-101: The 4 Things Every CA Must Know

Part 2 Presented by:

Kathy Mills Chang, MCS-P, CCPC, CCCA

Topics Covered

Part 1:

• Chiropractic terminology for CA’s—Managed in Part 1

Part 2:

• Boundaries and Ethics

• Patient Safety

• Documentation

Patient Safety

• Comes down to noticing potential risks in patient interaction and treatment and responding to the unique needs

• All offices have risks

• Having well documented policy and procedures of how your office will handle possible safety issues is key

OSHA

• Occupational Safety and Health Administration (OSHA) governs workplace safety

• Many states have their own version that may have stricter rules and/or resources

• They will do a free onsite audit to help you get to legal

Blood Born Pathogens• Even if your doctor does not do

acupuncture or venipuncture this area must be addressed

• OSHA has direct minimum guidelines

• Your policy should address:• Handling blood or other body fluid

spills• Patient treatment with open wounds

or lacerations• Hepatitis B vaccinations and/or

declination of employees who might come in contact with body fluids (even if your doctor is anti-vaccine)

• How the office will handle the event of a needle stick and/or coming in contact with body fluids for patients and/or team members

• “If it is wet and not yours, DON’T TOUCH IT”

Radiology Considerations

• X-rays do contain risks and contraindications

• CA an alert the doctor so they can weigh the risks of the testing

• Potential risks• Pregnancy or possible

pregnancy• Active or recent radiation

treatment• Metal in the body (MRI)• Possible or confirmed

fracture (positioning)• Others


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Therapies Some therapies have counterindications which could harm the patient:

• Pacemaker for EMS or ultrasound

• Open wounds

• Active Cancer

• Heart conditions with rigorous exercises

• Balance issues

• Pregnancy

• Current flu/cold

• Medications (blood thinners and others)

If the patient has these or others, it does not mean they cannot have the treatment.

Alert your doctor and they will assess the risks of the therapy vs. the rewards of treatment

Responding to Health EmergenciesHow will your office respond to :• Heart Attack/stroke• Patient/team member

fall or injury• Loss of conscience• Active labor • Others

Have policies in place and train annually on how they are to be handled

Ethics/Boundaries/ Managing Risk

• Most Common Causes of Malpractice

• Harassment and Patients

• Cultural Sensitivity and Diversity

• Inappropriate Patient contact

Harassment and the Work Place

No matter the office size, possible harassment must be addressed

• Comments or actions effect the tenor of the workplace

• Does not have to be sexual to cause harm

• Even if team members leaves, they can cause problems with 3rd

party payers and legal authorities

• Lawsuits or audits keep you from treating patients

• Guilty until proven innocent situation – policy can protect!

• Set up:• How potential allegations should

be filed internally• How potential allegations will be

addressed

Cultural Sensitivity and Diversity• Not everybody is the same

religion, race, sexual orientation, and/or gender

• Not treating a patient or patient population is a business decision that should not be taken lightly

• Casual comments can offend or cause the patient more harm than the doctor’s treatment at times

• Be aware of what you say

• Don’t say or write it unless you are willing to pay the consequence!

Inappropriate Patient Contact

Consider:• Proper draping/gown

usage of exposed skin• Comments about

wardrobe or other physical attributes

• Women do this too!• How will the office

handle inappropriate patients

• Ethics of patient/team member dating


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Documentation

Why Is Documentation So Important?• Ensures quality patient

care• Meets licensure

requirements to protect the public

• Guards against malpractice action

• Secures appropriate reimbursement

• Because…if it wasn’t written down, it didn’t happen!

Know your Audience

• Another health care provider

• Your board

• A malpractice attorney

• Third party payer's medical necessity auditor

Good Documentation Tells a Story

CA’s Play a Huge Part in

Documentation• Patients will tell you

things they don’t tell the doctor

• You likely spend more time with the patient than the doctor

• They give you LOTS of subjective data that effects their care

• Write it down!

Help Your Doctor to Be a Good Documentarian

• Elaborate on subtleties

• Dig deeper

• Evaluate all the systems that apply to chiropractic care

• Elaborate on those that may not apply

• Document the “good doctoring”


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Most Important Communication Tool

• Improves communication with other providers

• Records are a legal document

• Inadequate documentation impacts both patient care and outcomes

• The “other” provider can be the “future you”

Comprehensive Notes Tell the Story

Studies have shown that there are many ineffective procedures related to chart documentation. One of the most frequently reported concerns is individual physician practices. It has been found that documentation is used more as a tool to recall events rather than as a means to justify treatment decisions, often leading to a lack of completeness, accuracy and timeliness in completing charts

Documentation in History• Best to record a mechanism of

trauma for every new patient or new episode• Patients may tell you about a

recent injury which they “forgot to tell the doctor”

• Ask leading questions of your patient to elicit a specific incident that precipitated the pain that the patient is experiencing

• Ask about ADL’s • How are they doing in normal life • What can they do now that they

could not before treatment

• Record any incident that the patient can relate that ties to the pain that brought them into the office

Medicare Specifics

• Claims can be denied without documented mechanisms of injury

• Per Medicare: patient can’t just come in with a headache and expect Medicare to pay for the care of that headache

• Some Medicare contractors are even going so far as to say that the injury can’t be incurred during activities of daily living

• For example, patient wakes up in the morning with bad neck pain; denial says that the claim is denied because sleeping is an activity of daily living

Minimum Documentation Standards

• Each state has written or implied documentation rules

• Sometimes one is not aware until it’s too late

• Find out whether your state has specific rules

• Don’t find out the hard way

State Specific Rules


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Good Documentation Protects

• Provides an accurate timeline of treatment

• Confirms compliance

• Ensures consistency of patient care

• Enhances quality of the care given

• Clarifies the actual happenings in the visit

• Is a chronological record of your experiences with the patient

• Should include phone calls and other “orders”

Bad Documentation Disregards

• Altered records

• Missing dates, patient names, provider signatures

• Obliterated entries

• Illegible and many blanks

• Failure to document patient non-compliance

• Lack of documenting phone calls

• Charting only abnormal findings

• Testing without clinical rationale

• Sloppy charting of activities and patient remarks

• Lack of attention to detail to record everything that takes place in a visit

Your Best Defense is a Good Offense

• A well-documented patient record may actually prevent a lawsuit from being filed

• Patient record documentation should accurately reflect the care and treatment provided to a patient and that the standard of care was rendered.

• Objectivity is critical

• Poor documentation or alterations in the patient record can render an otherwise defensible case indefensible

Signature and Patient Name Issues

Why Authenticate?

• To verify provider who treated

• Prove services were provided

• Indicate and verify who provided them

• Validates the entry and legally binds the physician for the included info

Can we Identify Provider?


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Review Signature RequirementsFamiliarize providers and office staff with signature requirements to ensure

more complete compliance with

signature authentication policies

How do we authenticate signatures?

Signature Log

Update Signature Log

• Every year have each provider sign again, even if it hasn’t been a year since the last signature

• Add new providers to the log as they join the group

• Replace previous logs with most recent signatures, however save old copies

• Make sure every log has a start and end date

Patient Identifiers

• Patient name must appear on every item or piece of paper

• Electronic name is ok

• Front and back both

• Especially important when sending records

• Patient number can identify as well

What is Timely Documentation?

Definition:

Describing the events of a patient encounter, supporting the care with subjective and objective clinical rational, assessing the effectiveness of the encounter, and certifying that the services were rendered within the legally mandated medical guidelines

What is Timely Documentation?

In plain English:

• Write down what happen

• Support why your did it

• Sign that it happened

• Do all of the above right away or by the end of the day!


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Why Timely Documentation Matters

• Affects patient care• You might forget clinically important and relevant data if

you wait to write it down

• Affects quality of documentation• Harder to remember the details of the visit if you wait to

document it

• The more patients seen = the more chance for error about who got what service and had what problem

• Not documenting timely directly effects your bottom line

Timely Documentation

What Medicare Says*

• CMS expects the documentation to be generated at the time of service or shortly thereafter

• Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service *Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 12 -Physicians/Nonphysician Practitioners, Section 30.6.1.

What Medicare SaysPlain English:

• Notes should be complete and signed at time of service

• If changes or new info comes up, you have up to 48 hours to amend the record

Not Just Medicare

• Remember all 3rd party payers base their policies on the CMS standard

• Most states have adapted CMS’s guidelines on this as well. So your license may depend on your timely documentation!

Documenting More than a Daily Note

There are situations that need a bit more clarification:

• Day 1.5 Considerations

• Corrections and omissions to already complete records


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Day 1.5 Considerations

• Doctor “Think-time” for diagnosing, reading X-rays, weighing the findings of the exams, and writing a plan of care are near impossible to do while the patient is in the office

• This is a situation where the 48 hours to complete comes into play

• Still expected as close to the time of service as possible

Scribe Use

• Consider using a scribe to speed up data entry during a visit

• Specific guidelines on who can write certain things in the medical file

Amending Completed Records

CMS has direct guidance on amending a patient's record:

• The medical record cannot be altered. Errors must be legibly corrected so that the reviewer can draw an inference as to their origin. These corrections or additions must be dated, preferably timed, and legibly signed or initialed.

Amending Completed Records

To properly execute a medical record addendum, the provider must, at a minimum, write the following details in the medical record:• The date the record is being amended

• The details of the amended information

• A statement that the entry is an addendum to the medical record

• The date of the service being amended

• The signature of the provider writing the addendum

Why did they make these rules?

• Your documentation quality is in question?• Did what happened in the visit really happen?

• Did you make any of the note up after the fact to make it payable when it should not be?

• Are you providing appropriate care if your notes can’t be trusted?

• They don’t want to pay you for incomplete or late work!

So what happens I don’t want to follow the rules?


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What Medicare Says

• A provider can't submit a claim for payment until documentation is completed. • You can’t submit the

claim until the note is fully documented and signed

• In other words – “Until you sign off on your notes all of the work you did is unbillable!”

Ramification if Not Timely

• Charges for services cannot be billed directly after the visit

• Services may not be able to be billed at all because the documentation is questionable

• Services are likely to be deemed medically unnecessary because the documentation is in question

• Some contracts will not allow you to bill the patient

• Your work was all for nothing!!!

Cold Pizza Analogy

Would you want to pay the delivery guy for a cold pizza with the wrong toppings that is hours late? • Would you question when

the pizza was made?• Would you question if they

got your order right? • Would you try to get out of

paying the bill?

When we don’t document timely we are delivering a two day old, cold pizza to the payer, expecting full payment for it, and a huge tip!

Take Away

• Document note at the time of service (or at max 48 hours afterwards)

• Even E/M have a time clock for completion

• Amending the record with new or corrected information is possible but original must be preserved

• Scribes are available to help get documentation done more quickly

Need help? [email protected]

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