Documentation Strategies (2015)

10/24/2019 Disclaimer • I wish I could guarantee that your work will “Bullet Proof” Documentation never be audited, reviewed, or denied after taking this course! Strategies (2019) • What I can promise is that you will leave here Steven G. Yeomans, DC, FACO with a better understanding of the methods of 404 Eureka St. documentation, the needed elements to Ripon, WI 54971-0263 920-748-3644 create a quality note, and various options [email protected] from which you can choose. 1 2 The “Mission” of Documentation Bullet-Proof Documentation Strategies • To “tell a story” about the patient presentation • Overview • To present in an efficient, concise, practical approach – Your documentation is a reflection of your quality the salient / important clinical features – SOAP Notes (Subjective/Objective/Assessment/Plan) • Utilize evidence based approaches when possible • Legibility • Utilize an outcomes based management system • “Tell a story” that is patient specific and concise • Efficient – short & sweet • To share with others when properly requested • Exam notes are longer / daily notes are short • SIGN YOUR NOTES! 3 4 Documentation General Rules of Documentation • Why bother? Who benefits? • Use only blue or black ink – DC • Never use correction fluid or erase – Patient • Only use standard abbreviations – Insurer • Write legibly – Malpractice buffer • Patient’s name on all notes – Outcomes based research • Correct errors by putting one line through it & – Interdisciplinary communication & marketing initial/date it (discuss recent challenge) – Chiropractic (our reputation is at stake!) • Sign or electronic: provider name & date 5 6 1 10/24/2019 Error Correction Consideration Error Correction Consideration From Dr. Stephen Perle, DC, MS U. of Bridgeport (2-11-10) From Dr. Stephen Perle, DC, MS U. of Bridgeport (2-11-10) • The old “line through, date, sign” method may be • Word docs are not “encoded” and can be used against the Dr. altered = risk management issue – “Dr. I see that you have corrected errors in the chart. How – Encoded records includes a date stamp and many? How do we know the chart isn’t full of errors that haven’t been corrected yet?” includes the ability for an audit trail including – NEW Approach: put a single line through date/sign and appropriate changes to the record. notate the entry “void” and then write the correction – The attorney has a greater challenge with a void vs. the “old” error correction only method. 7 8 Creating “Bullet-Proof” Notes So what do your notes look like??? • Evidence-based • Medical necessity • Chiropractic necessity • Quantitative versus Qualitative – Outcome-based • Tell the patient’s “story” 9 10 Example 2 Example 1 11 12 2 10/24/2019 ….or, this? Example 3 SIGN YOUR NOTE! 13 14 Documentation: Need For Change Insurance Audits • Professionalism • Many insurers – not just Medicare – are • Public Image (our patients notice!) auditing our records – Cultural Authority • Penalties and / or refunds are being requested • Interdisciplinary Respect • DON’T IGNORE THESE FACTS! • 3rd Party Payer Demands • Malpractice Buffer IGNORANCE IS NOT BLISS!!!! • Medicare Audits**** 15 16 Historical Review of Chiropractic Documentation (2008-2016) • Office of the Inspector General (OIG) report 17 18 3 10/24/2019 OIG Report Facts (2008) • 94% were missing required elements – Treatment goals and treatment plan: 2 most common (Susan McClelland) • 83% had an insufficient treatment plan • 67% did not show medical necessity or were miscoded • 47% of the claims should not have been paid 2008 2008 19 20 5/2009 OIG Report 10/2016 OIG Report • Treatment Plan (TP) – one of the key elements Hundreds of Millions in Medicare Payments for to prove medical necessity to Medicare. Chiropractic Services Did Not Comply With – TP documentation was “insufficient” Medicare Requirements – TP is needed to track specific goal changes (to Source: OIG 10/18/2016 prove treatment was “active/corrective”) • Most Medicare payments for chiropractic services did not comply with – TP was found in 76%, BUT… Medicare requirements. • On the basis of our sample results, we estimated that $358.8 million, or • 43% lacked treatment goals approximately 82% of the $438.1 million paid by Medicare for • 17% lacked objective measures chiropractic services was unallowable. • 15% lacked the recommended level of care • These overpayments occurred because CMS's controls were not effective – Overall, only 11% of DC’s had “acceptable” TP’s in preventing payments for medically unnecessary chiropractic services. 2016 2009 https://oig.hhs.gov/oas/reports/region9/91402033.asp 21 22 10/2016 OIG Report 10/2016 OIG Report Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply With Medicare Requirements Hundreds of Millions in Medicare Payments for (continued)… Chiropractic Services Did Not Comply With Source: OIG 10/18/2016 • We recommended that CMS do the following, which could have saved Medicare Medicare Requirements (continued)… an estimated $358.8 million for 2013: Source: OIG 10/18/2016 – (1) determine a reasonable number of chiropractic services that are necessary to actively treat spinal subluxation and implement a system edit to • Strong controls to prevent improper payments for chiropractic services are identify services for review in excess of that number; important to program integrity. – (2) determine a reasonable limit for the number of chiropractic services that • For example, CMS could consider taking appropriate action to limit the Medicare will reimburse, take appropriate action to put that limit into effect, number of chiropractic services that Medicare will reimburse to a specified and implement a system edit to disallow services in excess of that limit; maximum (e.g., 30 per beneficiary per year). – (3) improve education of chiropractors on Medicare coverage requirements for chiropractic services and the proper use of the AT modifier to ensure that • If such a limit had been in place during our audit period, it would have only medically necessary chiropractic services are billed to Medicare; and prevented chiropractors from billing a high number of medically unnecessary – (4) specifically identify significant obstacles to developing a more reliable services. control for identifying maintenance therapy and work to establish such a • Unless CMS implements strong controls, it is likely to continue to make control. improper payments to chiropractors. https://oig.hhs.gov/oas/reports/region9/91402033.asp https://oig.hhs.gov/oas/reports/region9/91402033.asp 23 24 4 10/24/2019 10/2016 OIG Report 10/2016 OIG Report OIG Auditor’s report: Summary of findings on DC payments (continued)… OIG Auditor’s report: Summary of findings on DC Source: Chiropractic Economics 10/24/2016 Specific problems identified by the Medicare administrative contractors (MACs), who process Part B claims for payments CMS, fell mostly into the following categories: • 1. Maintenance therapy. CMS guidelines state that acute subluxations of the spine may Source: Chiropractic Economics 10/24/2016 require up to three months of active treatment. Treatments beyond this time period are considered maintenance therapy, which is not a service covered by Medicare Part B. • Kathy Mills Chang, a certified medical compliance specialist and certified According to Chang, these are called “screens,” whereby Medicare sets internal professional chiropractic coder (MCS-P and CPCC), says, parameters for certain diagnosis codes to identify when most cases should be complete. “This alerts them that any care beyond that might be approaching – “The challenge is not the AT modifier or the updating of ‘box 14’ with the new maintenance care, and therefore, the provider may receive a request to justify initial treatment date of an episode. with additional documentation why this case requires more care than another,” Chang – The real problem is the DC understanding which care is ‘medically necessary’ says. • 2. Failure to document medical necessity. Even though patient records were submitted according to Medicare’s definition and which care would be defined as with the AT (acute treatment) modifier, upon investigation it was determined that the ‘maintenance care’ per Medicare’s definition. treatments provided did not warrant this coding. “This is truly the No. 1 problem with – The care is actually not ‘unnecessary’ but perhaps better defined as ‘not documentation and Medicare in our profession. It’s that the doctor may consider care ‘medically necessary’ and therefore coverable, so they bill Medicare with an AT medically necessary’ and therefore, doesn’t qualify for reimbursement from modifier indicating active treatment. However, the notes do not warrant active Medicare but rather is the patient’s financial responsibility.” treatment and fail to establish why the care meets Medicare’s definition.” https://www.chiroeco.com/oig-report-summary-of-findings/ https://www.chiroeco.com/oig-report-summary-of-findings/ 25 26 10/2016 OIG Report 10/2016 OIG Report OIG Auditor’s report: Summary of findings on DC OIG Auditor’s report: Summary of findings on DC payments (continued)… payments (continued)… Source: Chiropractic Economics 10/24/2016 Specific problems identified by the Medicare administrative contractors (MACs), who process Part B claims for Source: Chiropractic Economics 10/24/2016 CMS, fell mostly into the following categories: • Possible remediation of OIG report – The Office of Audit Services (OAS), which prepared the report, recommends • 3. Excessive treatments. A 2005 OIG report

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