1)Patient's chart - records are an indispensable part of modern health care.
2) Accurate medical records are indication that good care was delivered.
3) Legal function - accurate, neat record symbolizes quality care and well-informed physician.
The physician's office must take care what is written in the chart, how it is written and by whom it is written.
Medical Record Users
Patient, Clinical researchers, Peer reviewers, Reimbursement technicians, Professional licensing and accreditation agencies.
Document that requires an individual (Custodian of Records) to appear in court on a specified date.
Electronic Medical Records
EMR's or CPR's - computerized medical records.
1) Increase the availablity of the PT medical history and perserve accuracy
2) Facilitate clinical research by providing comprehensive views of health care delivery
3) Provide diagnostic and therapeutic problem-solving support
4) Increase efficiency by reducing time spent retrieving information
5) Eliminate overhead and administrative costs associated with paper transfer and storage
6) Maintain a comprehensive legal record of patient care
7) Ensure confidentiality of patient data through the use of passwords and other security measures
Staff member should put a line throught the mistake in ink, write in the correction near it, initial it, and date it.
An intentional deception or misrepresentation made by an individual who know tha the false infor reported could result in a benefit to herself/himself.
An incident or a practice that is not consistent with sound medical, business, or fiscal practices.
1. Is the service or supply necessary?
2. Is the service or supply appropriate according to professionally recognized standards?
3. Has a fair price been charged?
Fraud & Abuse Control Program
Established by the federal government shared by OIG, FBI, and DOJ to prosecute and investigate the suspected fraud and abuse.
OIG = Office of Inspector General, FBI = Federal Bureau of Investigation, DOJ = Department of Justice
The OIG and CMS warn physicians of suspected fraudulent practices by issuing fraud alerts.
Office of Inspector General
1) Investigates suspected fraud and abuse, and audits and inspects CMS programs and contractors.
2) Conducts investigations of specific providers that may be suspected of fraud, waste, or abuse to determine whether criminal, civil, or administrative actions are warranted.
Employees who report illegal or wrongful activities of the employer or fellow employees.
Identified Risk Areas - OIG
1. Billing for Services not documented
2. Duplicate Billing
5. Improper use of provider numbers
6. Misuse of Billing & Coding software
7. Billing companies with questionable practices
8. Focus on certain E& M codes 99214, 99233, 99244
9. Credit Balances
10. Waiver of co-pays and deductibles
11. Professional courtesy, discounted services
12. Code steering
Focus on Certain E&M Codes
99214 Est PT, OV L4
99233 Subsequent HV L3
99244 Outpatient Consultations L4
All levels of E&M codes should be listed on the superbill... if not it is code steering.
Stark Law / Self-referral Prohibitions
OBRA - The Omnibus Budget Reconciliation Act of 1989 included Stark I provisions, which banned physicians from referring laboratory speciments to any entity with which the physician has a financial relationship.
Compliance Plans by OIG
An effective plan reduces the risk of civil and criminal action and provides a safety net in the event of an audit. Accomplishes the following:
1. Review all billing procedures, 2. Correct any weaknesses or errors, 3. Establish controls, NOT mandatory.
Seven Basic Components of Compliance Plan
1. Auditing & Monitoring
2. Establish Practice standards & procedures
3. DESIGNATING A COMPLIANCE OFFICER
4. Conducting appropriate training & education
5. Responsing to detected offenses & developing corrective action initiatives
6. Developing open lines of communication
7. Enforcing Disciplinary standards by adhering to well-publicized guidelines
Compliance Officer Duties
1. Overseeing & monitoring the implementation of the compliance program
2. Establish methods, such as audits, to improve the practice's efficiency and quality of services and to reduce the practice's vulnerability to fraud and abuse.
3. Periodically revising the compliance program in light of changes in the needs of the practice or changes in the law, standards, and procedures of government and private payer health plans.
4. Developing, coordinating, and participating in a traing program that focuses on the components of the compliance program and seeks to ensure that training materials are appropriate.
5. Esuring that the DHHS-OIG's "list of Excluded Individuals and entities" and the General Services Administration's "List of Parties Debarred from Federal Programs" have been checked with respect to all employees, medical staff, and independent contractors.
6. Investigating any report or allegation concerning possible unethical or improper business practices and monitoring subsequent corrective action and compliance.
Principles of Documentation
1. Medical record should be complete and legible.
2. The documentation of each patient encounter should include the date;
3. The reason for the encounter;
4. Appropriate history and physical examination;
5. Review of lab results, x-ray data, and other ancillary services (physical therapy), where appropriate;
7. Plan for care (including discharge service, if appropriate.
E&M Seven Factors
3. Medical Decision Making (MDM)
5. Coordination of Care
6. Presentation of the problem
3 of 3 Rule
Must have all 3 components of history, examination and MDM documented
All consultations (except follow-up)
Initial hospital care
Comprehensive nursing facility care
Emergency department services
Observation services/inpatient hospital
Domiciliary care, new pt
Home services, new pt
Office visit, new pt
2 of 3 Rule
Only 2 of 3 components of history, examination and MDM documented.
Subsequent hospital care
Subsequent nursing facility care
Domiciliary care, established pt
Home services, established pt
Office visit, established pt
Elements of History
1. Chief complaint
2. History of present illness
3. Review of systems
4. Past, Family, & Social History
Insufficient documentation of medical necessity is the number one reason for denial of Medicare claims nationwide.
Any patient who has not been seen by the physician or anyone in his or her group in the past 3 years.
A patient who has been seen by the physician or one of the members of his or her group during the past 3 years.
Most used code
99213 Established pt, Hx - expanded problem focused, Exam - expanded problem focused, MDM - low
Teaching Physician Services
Teaching physician: A physician who involves residents in the care of patients. (attending physician)
Resident: A (GME) graduate medical education person can be a resident, a fellow, or an intern. Medical students do not fall into this category.
Moonlighting fellow: Provide services outside the scope of the GME program usually found in ER and office settings.
S Subjective view of the case (pt telling you)
O Objective data (doctors sees)
A Assessment )prognosis and/or
differential dx for pt (ex. BP)
P Plan for treatment