Disclaimer

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Disclaimer

• This presentation is intended only for use by
  Tulane University faculty, staff, and students.
  No copy or use of this presentation should occur
  without the permission of Tulane University.
  Tulane University retains all intellectual
  property interests associated with the
  presentation. Tulane University makes no claim,
  promise, or guarantee of any kind about the
  accuracy, completeness, or adequacy of the
  content of the presentation and expressly
  disclaims liability for errors and omissions in
  such content.

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TUMG Documentation Top 10
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

• It isnt the mountains ahead, its the grain of
  sand in your shoe.

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Read Before Proceeding
Physicians 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
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It is the policy of TUMG to provide healthcare
services that are in compliance with all state
and federal laws governing its operations and
consistent with the highest standards of business
and professional ethics. Education for all TUMG
physicians is an essential step in ensuring the
ongoing success of compliance efforts.
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This education is a General Compliance Education
Presentations available on the Tulane University
Privacy and Contracting websitehttp//tulane.edu
/counsel/upco/billing-ed/
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TUMG Physicians are responsible for documenting
their outpatient visits and selecting the level
of service to be billed to the carrier.
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10 Know what doesnt count when it 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

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10 Know what doesnt count when it 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.

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9 Link to Ancillary staff notes and 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.

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9 Link to Ancillary staff notes and 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 wont look for
  something they dont know exists, and they wont
  count anything they cant find in the record.

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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 physicians note
  alone.

• Example If the resident documents the patients
  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.

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Examples of Linking to Resident 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 residents 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 residents findings and
  plan as documented in the residents note.

Medicare Transmittal 1780 Teaching Physician
Rule provides other examples of linking
statements http//www.med.ufl.edu/complian/Qa/CM
S_Transmittal_R1780B3.pdf
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7 Read Resident Notes 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.

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6 Code Signs and Symptoms if a Definitive
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.

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6 Code Signs and Symptoms if a Definitive
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

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5 Always Code Diagnosis to the Highest
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

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5 Coding to the Highest Specificity Helps to
Avoid 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.

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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
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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 Dont Lose Earned
Reimbursement, Jo Ann Steigerwald, RHIT, ACS GI,
ACS-OH, Teleconference July 25, 2005. (Citing
Cigna Medicare)
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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.

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3 Know How to Document a Time-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

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3 Know How to Document a Time-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

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2 Understand and appropriately apply E/M
Documentation Guidelines

• TUMG physicians are responsible for selecting the
  level of outpatient service billed to the patient
  or the patients insurance.
• To bill for a service, medical necessity must be
  clearly established and
• The documentation must support the level of
  service billed.

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2 Understand and appropriately apply E/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.

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1 WYSI-WYG Principle
What You See Is What You Get

• Corollary
• If it isnt written,
• It didnt happen,
• And it cant be billed

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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.

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Contact Information

• TUMG Business
• ServicesCompliance Reporting Hotline
  504-988-5142

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End of Presentation

• To earn one compliance credit, download the file
  TUMG TOP 10 from the website.
• Complete the quiz and fax to 504-988-7777