Lori-Lynne A. Webb
December 10, 2015
As we prepare for
2016 New Year, there are some challenges left over from 2015 that may need to
be reviewed and met. CMS and some of the
"big payers" have identified a few of the issues in 2015 post ICD-10
that need some improvement. As we are
well aware, documentation continues to be a challenge. Below outlines some of the "risks"
that were identified and then the opportunity to implement some of the
que/review plans and ideas. The review
can bring to light problematic areas and some possible solutions for not only
coders, but for your physicians, providers, clinical and office staff.
Risk: The record(s) does not contain a legible
signature with credential.
Que/Review: Per CMS' requirements in the Medicare
Program Integrity Manual ; Chapter 3 – (3.3.2.4. Verifying Potential Errors and
Taking Corrective Actions) Signature Requirements that was just updated and
implemented 08/25/2015, "For medical review purposes,
Medicare requires that services provided/ordered be authenticated by the
author. The method used shall be a handwritten or electronic signature. Stamped
signatures are not acceptable." The instructions from CMS are specifically
for CMS, however, these instructions from CMS can easily be put into place as a
valid process for all signature authentications for a "best practice"
in your office.
In
addition, providers should not add late signatures to the medical record,
(beyond the short delay that occurs during the transcription process) but
instead should make use of the signature authentication process. The signature
authentication process described below should also be used for illegible
signatures.
A.
Handwritten Signature
A handwritten signature is a mark or sign by an individual on a
document signifying knowledge, approval, acceptance or obligation.
B.
Signature Log
Providers will sometimes include a signature log in the
documentation they submit that lists the typed or printed name of the author
associated with initials or illegible signature. The signature log might be
included on the actual page where the initials or illegible signature are used
or might be a separate document. Reviewers should encourage providers to list
their credentials in the log. However, reviewers shall not deny a claim for a
signature log that is missing credentials. Reviewers shall consider all
submitted signature logs regardless of the date they were created. Reviewers
are encouraged to file signature logs in an easily accessible manner to
minimize the cost of future reviews where the signature log may be needed
again.
C.
Signature Attestation Statement
Providers will sometimes include an attestation statement in the
documentation they submit. In order to be considered valid for Medicare medical
review purposes, an attestation statement must be signed and dated by the
author of the medical record entry and must contain sufficient information to
identify the beneficiary.
Should a provider choose to submit an attestation statement, they
may choose to use the following statement:
“I, _____[print full name of the physician/practitioner]___,
hereby attest that the medical record entry for _____[date of service]___
accurately reflects signatures/notations that I made in my capacity as
_____[insert provider credentials, e.g., M.D.]__when I treated/diagnosed the
above listed Medicare beneficiary. I do hereby attest that this information is
true, accurate and complete to the best of my knowledge and I understand that
any falsification, omission, or concealment of material fact may subject me to
administrative, civil, or criminal liability.”
D. Signature Guidelines
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Meets
Requirements
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1.
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Legible
full Signature
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X
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2.
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Legible
first initial and last name
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X
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3.
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Illegible
signature over a typed or printed name
(example)
John Doe Smith, MD
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X
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4.
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Illegible
signature where the letterhead, addressograph, or other information on the
page indicates the identity of the signatory. Eg: illegible signature appears on a
prescription. The letterhead of the
prescriptions lists (3) physicians' names, one of the names is circled.
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X
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5.
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Illegible
signature NOT over a typed/printed name and NOT on letterhead, but the
submitted documentation is accompanied by a signature log, or an attestation
statement.
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X
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6.
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Initials
over a typed or printed name
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X
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7.
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Initial
NOT over a typed/printed name but accompanied by a signature log, or an
attestation statement.
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X
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8.
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Unsigned
handwritten note where other entries on the same page in the same handwriting
are signed
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X
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Does
NOT meet Requirements
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1.
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Illegible
signature NOT over a typed or printed name, NOT on letterhead and the
documentation is unaccompanied by a signature log or attestation
statement. (example)
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X
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2.
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Initials
NOT over a typed/printed name unaccompanied by a signature log or attestation
statement.
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X
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3.
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Unsigned
typed note with providers typed name
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X
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4.
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Unsigned
typed note without providers typed/printed name.
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X
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5.
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Unsigned
handwritten note, the only entry on the page
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X
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6.
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"Signature
on file"
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X
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E.
Electronic Signatures
Providers
using electronic systems need to recognize that there is a potential for misuse
or abuse with alternate signature methods. For example, providers need a system
and software products that are protected against modification, etc., and should
apply adequate administrative procedures that correspond to recognized
standards and laws. The individual whose name is on the alternate signature
method and the provider bear the responsibility for the authenticity of the
information for which an attestation has been provided. Physicians are
encouraged to check with their attorneys and malpractice insurers concerning
the use of alternative signature methods.
Risk: The Electronic Health Recod was not signed
electronically
Que/Review: With
some EMRs, it is possible that the provider did not sign off the record or log
out within the prescribed time or protocol.
If a claim is billed, and the authentication was not done in a timely
manner, the 3rd party may request a refund if such a medical record
is submitted during an audit. It is
critically important that the electronic record have accurate time/date stamp
authentication. In addition to
signature authentication, the system should ensure that the electronic record
system correctly documents who is
accessing and writing/authenticating the medical records/chart. If a signature has been missed, when the
provider goes back in, the time-date stamp needs to accurately reflect when the
"signature" was performed. As
a best practice, it is advisable to print out the medical records/notes and
review that all notes, and authentications from all parties are correctly
reflected.
Risk: The highest
degree of specificity was not assigned to the most precise ICD-10 diagnosis
code
Que/Review: At this time, Post implementation that it is
imperative that the provider or coder review the notes and apply the most
specific ICD-10 diagnosis code. If the
codes are input electronically by the provider, then the coder should have the
option to suggest a correction, or make the appropriate corrections prior to
the claim being submitted. The ICD-10cm
guidelines require us to use the most specific code as per the
documentation. However, some 3rd
party payers will still pay the claim if your code is within the same
"family". However, it is of
best practice to review and implement coding per the current ICD-10cm codeset
guidelines regarding specificity and unspecified codes.
I.A. 9.b. “Unspecified” codes Codes titled
“unspecified” are for use when the information in the medical record is
insufficient to assign a more specific code. For those categories for which an
unspecified code is not provided, the “other specified” code may represent both
other and unspecified. See Section
I.B.18 Use of Signs/Symptom/Unspecified Codes
If you do not have a
"specific" diagnosis, but have signs and or symptoms, it is
appropriate to report those on the claim according to the ICD-10cm guidelines
Section
1B.18. Use of Sign/Symptom/Unspecified
Codes
Sign/symptom and “unspecified”
codes have acceptable, even necessary, uses. While specific diagnosis codes
should be reported when they are supported by the available medical record
documentation and clinical knowledge of the patient’s health condition, there
are instances when signs/symptoms or unspecified codes are the best choices for
accurately reflecting the healthcare encounter. Each healthcare encounter
should be coded to the level of certainty known for that encounter. If a definitive diagnosis has not been
established by the end of the encounter, it is appropriate to report codes for
sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient
clinical information isn’t known or available about a particular health
condition to assign a more specific code, it is acceptable to report the
appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been
determined, but not the specific type). Unspecified codes should be reported
when they are the codes that most accurately reflect what is known about the
patient’s condition at the time of that particular encounter. It would be
inappropriate to select a specific code that is not supported by the medical
record documentation or conduct medically unnecessary diagnostic testing in order
to determine a more specific code. (ref ICD-10-CM
Official Guidelines for Coding and Reporting FY 2016 Page 16/17 of 115)
Risk: Discrepancies exist between the diagnoses billed and
the diagnoses in the medical record
Que/Review:
Having a different diagnosis billed on the insurance claim, not match
that which was in the medical record documentation can set the stage for an
audit by your 3rd party payer.
These discrepancies can happen as a simple "fumble-finger"
error upon data entry. If this is the
case, then a correction of the diagnosis should be made and the claim
re-processed and the medical records submitted to the carrier for verification
of correct and complete documentation and coding.
As a best
practice, the coder/biller should be the ones charged with conducting auditing
pre and post claims on a regular basis to avoid this issue. If insurance claims are generated solely upon
the physicians' billing via an electronic medical record interface to a patient
management/billing system, an audit or review system should be in place prior
to the claim being generated to avoid this type of claim error. Many billing companies now hold or suspend
claims until the charges have been reviewed.
This activity can alter or slow down your accounts receivable. Continued ICD-10 education and audit of
clinical and coded information should be a required part of the physician or
hospital based billing practices.
Risk: Information is missing regarding diabetic
complications, or notations if patient is type 1, type 2 or gestational
diabetes. (eg diet
controlled/Medication controlled/insulin controlled) ISSUE!
Que/Review: In ICD-9, physicians could
simply document Diabetes Mellitus – 250.00 – without specifying whether it was
Type 1 or Type 2 and whether it was controlled or had complications.
The guidelines for ICD-10cm,
require a much higher degree of specificity and more clearly defined clinical
documentation.
As coders and
providers, chronic condition documentation needs to correlate the complexity of
the diagnosis status into hospital and office based care. The element of good documentation must
clearly show that the care is delivered, documented and the
patient response to that care delivery and/or treatment. If these critical pieces are not coded, the
data analysis and statistics will be lost and/or skewed. Currently ICDd10 allows us these area too
review for correct coding.
·
E08
Diabetes mellitus due to underlying condition
·
E09 Drug
or chemical induced diabetes mellitus
·
E10 Type
1 diabetes mellitus
·
E11 Type
2 diabetes mellitus
·
E13 Other
specified diabetes mellitus
The Diabetes codes
in ICD-10-CM can have up to six characters. The first three characters
represent the
category, the fourth character identifies the presence of manifestations or
complications, and the fifth and sixth characters identify specific types of
manifestation.
·
Physicians need to first document whether
diabetes is primary or secondary to a (separate) diagnosis, or gestational
diabetes.
·
Documentation should also include the body
system affected, and the diabetic complications affecting that body system.
·
ICD-10 separates Type 1, Type 2 and Gestational diabetes, along with the
system that is impacted.
·
If multiple systems are impacted, each must be
separately coded.
·
ICD-10 requires the provider/physician to document
with Gestational Diabetes if it is "diet" controlled,
"insulin" controlled or "unspecified" control. This has been an area of concern for MD's to
choose the correct code if the patients' gestational diabetes is controlled via
" oral medication". ACOG has
stepped forward and acknowledged that the provider should code these type of
patients as "diet" controlled.
Risk: Clinical documentation does not say if the patient's
diagnoses are being "monitored, evaluated assessed or treated".
Que/Review: Upon
review, the coder or biller should review and determine if the patient's
diagnoses noted in the chief complaint match and be correlated back to the care
treatment plans within the chart. If
these plans are not being supported by the clinical documentation and medical
necessity, this could be a risk area when billing E&M and operative
procedures. In the table below, it
outlines what the "minimum" documentation requirements should be for
"monitoring, evaluation, assessments and on-going treatment plans.
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The Care/Treatment plan in each patient chart should reflects
the patient's assessed needs and has been updated at each patient visit or
hospital stay to include the status of the disease or care process. This documentation is to include all
progress (good or bad, and changing needs.)
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There is documented evidence of changes in or re-evaluation of
treatment needs and/or services during periods of sudden changes in
functioning or symptoms at each patient visit or hospital stay.
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All treatment needs should be identified in the medical record,
and documented if those diagnoses are/are not being addressed, and are
prioritized based on importance/severity as determined by the physician or
healthcare provider .
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There is documented support that the primary care coordination
and integrated care is occurring with the primary physical health care
provider and any specialty health care providers and/or ancillary services
requested, and provided.
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In 2016 we can
only guess what the payers will want to review, but these issues identified
above, were targeted issues in both clinical documentation and in
billing/claims from payers in 2015 as areas of interest and non-compliance. Communication, education, awareness, and
improvement will always help ensure the most complete information held in the
medical and billing records.
