1
ADVANCED DISCUSSION GROUP EPIC GROUP—EPIC
CATHERINE WAKEFIELDMARK RUPPERTDAVID RICHSTONEDAVID RICHSTONEJILL HATFIELD/VICKY SOTTILE
AHIA 32nd Annual Conference – August 25-28, 2013 – Chicago, Illinois
www.ahia.org
Agendag
Overview of the User Group, Survey Results, 2
p, y ,Webinars and Conference educational offerings
Today’s Topics Data Governance and Reporting (Mark) AHIMA Risk Areas (Catherine)
/ Charge Router/Charging Controls (Jill) Interfaces (Mark) Audit Cycles/Facility Audits (Catherine) Audit Cycles/Facility Audits (Catherine) Examples of 6 month post go-live audits (David)
Summary Summary
Overview
User Group Activities
3
User Group Activities Webinar schedule Conference education Conference education Survey Results
User Group Activitiesp
Epic survey to AHIA members
4
Epic survey to AHIA members Planning 4 webinars in 2013
May 23—Complete; 87 attendees May 23—Complete; 87 attendees July 26—Security and Access Sept—Meaningful Use Sept Meaningful Use Nov—Segregation of Duties
Advanced Discussion Group at Annual Conference Advanced Discussion Group at Annual Conference
Survey Results—71 Responsesy p5
Security and Access 73.2% (webinar) Security and Access 73.2% (webinar)
Meaningful Use 73.2% (webinar)
Cycle Audits 73.2% Cycle Audits 73.2% Examples of 6 mo. post go-live audits 59.2% Charge Router/Charging Controls 56 3% Charge Router/Charging Controls 56.3% Interfaces 56.3% AHIMA Risk Areas 53 5% AHIMA Risk Areas 53.5% Data Governance and Management (Clarity/Cache)
52.1%52.1%
How long has your organization used EPIC?EPIC?
6
Implemented in the past 1 – 5 years
Just Implementing now34 6%
y47.4%
Implemented over 5 years ago17 9%
34.6%
17.9%
Which EPIC systems or applications does your organization use?
• EpicCare Ambulatory EMR • Cadence (Enterprise Scheduling) • MyChart for Patients (Web-based C i i i h P i ) does your organization use?
7
Communication with Patients) • Willow (Pharmacy) •ADT/Prelude Registration (Enterprise Admission/Registration)
• EpicCare Inpatient Clinical Documentation• EpicCare Inpatient Physician Order Entry
90.0%
•ASAP (Emergency Department) • Op Time (Operating Room) • Radiant (Radiology) • HIM Chart Tracking, Release of Information & Deficiency Tracking
• Resolute Hospital Billing 50.0%
60.0%
70.0%
80.0%
• Resolute Professional Fee Billing • Stork (L&D) • Beacon (Oncology) • EpicCare Link (Web-based Communication with External Providers)
• Anesthesia Cardiant (Cardiology) 20.0%
30.0%
40.0%
( gy)• Welcome (Patient Self-Service Kiosk) • Haiku (Hand Held Mobile Device Dictation) • Canto (iPad Dictation) • Beaker (Lab) • Kaleidoscope Ophthalmology• EpicCare Home Health
0.0%
10.0%
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What are topics of interest to you?
• Security and Access • Cycle Audits (Order – Documentation – Charge Capture – Coding – Billing) – Ambulatory; Ancillary Services; Specialty Services to you?
8
Response Percent
Ancillary Services; Specialty Services • Meaningful Use • Examples of 6-Months Post Go-Live Audits by Application Rolled Out
• EHR – HIM Aspects – AHIMA Risk Areas • Charge Router/Charging Controls• Interfaces
60.0%
70.0%
80.0%
Response Percent • Interfaces • Data Governance and Management (Clarity/Cache)
• Optimizing Workqueques• Clinical Research Billing Medication• Management - MAR • B k th Gl B k E d PFS
30.0%
40.0%
50.0%• Break the Glass Back End PFS • Pre-implementation Audits • Build Decisions • Project Governance • Conversion Home • Health/Skilled Nursing/Hospice
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0.0%
10.0%
20.0%
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• Other (please specify) :Disaster recovery solution Federal / State regulations that apply to document retention surrounding design, development, implementation, maintenance, upgrading, testing, etc. of an EHR. (Non-ePHI and non-MU documentation which have their own set of regulations)
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SOD's for access Charge Master, Contract Management Cash Drawer Utilization and Reconciliation Controls Research charges, charge edits, Research charges, charge/patient reconciliation, and Research Charges Segregation of Duties How to make use of Clarity and Workbench to identify accounts or transactions for audit -
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continuous audit. Segregation of Duties • Benefit Engine • DAP
Have you performed any audits of EPIC applications? (Select all that apply)applications? (Select all that apply)
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45.0%
25.0%
30.0%
35.0%
40.0%
5 0%
10.0%
15.0%
20.0%
0.0%
5.0%
Planned audits? 10
Planned Audits
Charges/Revenue
Security/Access
Unsure/trying to determine
Meaningful UseMeaningful Use
Implementation/Post ImplementationBreak the Glass/Physician notes/Make me the AuthorCash/Collections
Interfaces
What ways would you like to receive info regarding auditing Epic applications? regarding auditing Epic applications?
11
100.0%
70 0%
80.0%
90.0%
50.0%
60.0%
70.0%
20.0%
30.0%
40.0%
0.0%
10.0%
Webinar/Go-to Meeting
New Perspective “how to” articles
Newsletter E-learning Regional Seminar AHIA Annual Conference Track
User Roundtable AHIA Annual Conference Pre-M g C
or Unique Sessions throughout various
tracks
Cconference
Seminar
What tools would you like to have access to (i.e. through AHIA Audit Library) to support how you approach auditing Epic?
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Tools Audit Programs
Top Risks/Risk Assessments
System System Documation/Workflows/ChartsInternal Control Questionnaires
Data Analytic Ideas/ACL Test ScriptsLessons Learned/Issues Identified f A ditfrom AuditsEpic Reports Auditors Should AccessSecurity IssuesSecurity Issues
Information Exchange/Discussion Thread (not ListServe
Data Governance and Reportingp g13
Data Governance and ReportingB k dBackground
Who owns Data and how is/should reporting of 14
/ p gData Controlled? IT Function versus Operations How much access is afforded:
Operations Personnel, Internal Audit, Corporate Compliance, etc.?
Lack of Epic “support” for data governance and Lack of Epic support for data governance and knowledge outside of IT professionals? Lack of audit specific courses
L k f f di “E i C ifi i ” Lack of support for auditor “Epic Certification” Without this non-IT validation how might quality and
other reporting be impacted?p g p
Data Governance and ReportingE lExamples
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Governance / Reporting Examples/ p g p Traditional / Ideal: IT provides infrastructure, programming, data management
d i l i iand system implementation services.Operations owns the data and uses both IT and in-house
personnel to access source data for validation & reporting Internal Audit has open read access.
Epic Environment: Truly Non-Traditional? IT provides infrastructure programming data management IT provides infrastructure, programming, data management
and system implementation services. IT appears to own the data and the reporting of it.
IT h d IT has open read access.
Data Governance and ReportingB t P tiBest Practices
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Best Practice here is likely found in frameworks like Best Practice here is likely found in frameworks like COCO, ISO, etc. IT is a service provider who maintains the tools to p
generate, manage and report data. IT then owning and actually reporting the data would
not seem ideal, if for not other reason than application of the duty segregation control principal.
Data Governance and ReportingL L dLessons Learned
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Working in this new environment is difficult at best:g Data mining and analytics may be impossible. Application control focus has been an easier path into Epic
d t f f lb it th h h t lid ti i data for us so far, albeit through screen shot validations in many cases for source validation.
Operations personnel are eager to learn Epic but often frustrated if we don’t know more than they do.
The situation gets more difficult and more complex as more and more Epic modules are implemented.p p
Even with EMR and Rev Cycle implemented, we have not yet been able to gain a full data set from registration to dischargedischarge
Data Governance and ReportingQ&AQ&A
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What data governance successes do you have to g yshare?
What data governance challenges are you willing g g y gto share?
What data reporting success do you have to share?p g y What data reporting challenges are you willing to
share?
AHIMA Risk Areas19
Background: AHIMA Risk Areasg
Noridian Administrative Services, LLC20
,Documentation to support services rendered needs to be patient specific and date of service specific. These auto-populated paragraphs provide useful information such as the p p p g p petiology, standards of practice, and general goals of a particular diagnosis. However, they are generalizations and do not support medically necessary information that correlates to h f h l P B MR the management of the particular patient. Part B MR is seeing the same auto-populated paragraphs in the HPIs of different patients. Credit cannot be granted for information that is not patient specific and date of service specific (it li i CW)patient specific and date of service specific. (italics mine—CW)
Source: Source: https://www.noridianmedicare.com/shared/partb/bulletins/2011/271_jul/Evaluation_and_Management_Services_-_Documentation_and_Level_of_Service_.htm
Background: AHIMA Risk Areas g
“For example, electronic health records (EHR) may not only
21
facilitate more accurate billing and increased quality of care, but also fraudulent billing. The very aspects of EHRs that make a physician’s job easier—cut-and-paste features and templates—p y j p pcan also be used to fabricate information that results in improper payments and leaves inaccurate, and therefore potentially dangerous, information in the patient record. And because the g pevidence of such improper behavior may be in entirely electronic form, law enforcement will have to develop new investigation techniques to supplement the traditional methods g q ppused to examine the authenticity and accuracy of paper records. “
http://oig.hhs.gov/testimony/docs/2011/morris_testimony_07122011.pdf
Examples: AHIMA Areas of Risk p
Authorship Integrity Risk
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Authorship Integrity Risk Auditing Integrity Risk Documentation Integrity Risk Documentation Integrity Risk Patient Identification and Demographic Data Risks
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_033097.hcsp
Guidelines for EHR Documentation to Prevent Fraud
Examples: AHIMA Risk Areasp
Authorship 23
p Residency program audits: Students, residents, faculty
documentation Note editing (physician note “edited” by nurse or
resident) Authentication requirements Authentication requirementsAuditing Audit trails in Epic: how many to turn on??? Audit trails in Epic: how many to turn on???
Consider impact on system efficiency What are you going to use?y g g
Examples: AHIMA Risk Areasp
Documentation integrity
24
Documentation integrity Auto inserted data from smart phrases/text Copy/paste; copy forward; cut and paste Copy/paste; copy forward; cut and paste Template All could result in documentation that is not relevant to the
patient on that specific visit
Patient Identification and Demographic data Automated registration data Community provider access to EHR
Examples: Copy and Paste Risksp py
Nurse was updating her resume (using Word) 25
Nurse was updating her resume (using Word) and copied a portion of her resume into a patient chart
ED nurse had two records open. She copied part of Patient A’s record into Patient B’s record—drug use and bi-polar diagnoses showed on Patient B’s medical record and billing informationinformation
Need Error Correction Policy from the start: reporting roles (HIM IS other) customer servicereporting, roles (HIM, IS, other), customer service
Examples: Copy and Paste Risksp py
A note was copied "in total" to include the PREVIOUS
26
A note was copied in total to include the PREVIOUS performing provider's name
NO original documentation by the 'today' provider; just g y y p ; jan electronic signature with 'today's date and time'.
Reviewed 10 visits over a year period for a provider....every exam finding was the same despite current complaints to the contrary. Found to be copying and pasting exam forgot to 'edit' for today's and pasting exam......forgot to edit for today s findings.Plagiarism software download: http://plagiarism.phys.virginia.edu/AHIMA article: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005520.hcsp
Examples: AHIMA Risk Areasp27
Clinical Data (shared)
Demographic Data (shared)Demographic Data (shared)
Service Area X
FinancialData
Service Area X
FinancialData
Service Area X
FinancialData
Service Area X
FinancialData
Service Area X
FinancialData
Service Area X
FinancialData
Service Area X
FinancialDataData Data Data Data DataData Data
Financial Data is segregated by tax ID or billing entity
Examples: AHIMA Risk Areasp
Structured data (fields/canned text) versus Free
28
Structured data (fields/canned text) versus Free text
“My” 99214/standard template My 99214/standard template Lack of continuous monitoring and feedback to
providers (who owns this?)providers (who owns this?)
Best Practices
Policies—Error Correction, Cut and Paste,
29
Policies Error Correction, Cut and Paste, Documentation
Physician Handbook Physician Handbook Required education and competencies for clinical
usersusers On-going auditing (documentation and coding;
template use; history carry-forwards) with feedback template use; history carry forwards) with feedback to providers
Medical Staff approval on selected policies Medical Staff approval on selected policies
Auditing Suggestionsg gg
Audit for compliance with policies
30
Audit for compliance with policies Include documentation review in coding audits
Cut and Paste Cut and Paste Unique patient visits
Use Plagiarism software Use Plagiarism softwarePlagiarism software download: http://plagiarism.phys.virginia.edu/AHIMA article: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005520.hcsp
AHIMA Risk Areas—Q&A
How are you managing these risks in your
31
How are you managing these risks in your organization?
Charge Router/Charging Controls g / g g32
Revenue Cycle Phase IIy
Phase II: Services, documentation, coding and charge capture.
33
, , g g p
Revenue Cycle Phase IIy
Background:
34
Phase II – Focus on high revenue-producing ancillary departments: Operating Room, Cardiology (Invasive/Noninvasive), Radiology, Lab,
Pharmacy, Respiratory, GI/Endoscopy, Emergency DepartmentW k P f d Work Performed: Interviews with department leadership Process flows within each clinical area R i f l t li i d d Review of relevant policies and procedures Detailed testing Data analytic using ACL data mining tool Findings and Recommendations Findings and Recommendations Interview/Consult:
Mercy Revenue Management Team Charge Description Master (CDM) Team Mercy Compliance Department Central Coding Management
Revenue Cycle Phase IIy
Use of Data Analytics:
35
y Operating Room – presence of pre-op charge/OR level, anesthesia
time, recovery timeMissing Recovery
Total
Location#
Cases% of Total
GrossCharges
# Cases
% of Total
First 30 MIN
ADD 30 MIN
# Cases
GrossCharges
# Cases
FACILITY A 6 0.1% 4,000$ 82 1.1% 4,125$ 9,225$ 0 ‐$ 7,500
Missing Pre Op Missing Anesthesia TimeMissing Recovery
Time
,$ ,$ ,$ $ ,FACILITY B 0 0.0% ‐$ 12 0.9% 600$ 1,356$ 6 2,000$ 1,300FACILITY C 10 0.2% 6,670$ 35 0.7% 1,750$ 3,955$ 0 ‐$ 5,200TOTAL 16 0.1% 10,670$ 129 0.9% 6,475$ 14,536$ 6 2,000$ 14,000
• Opportunities to improve charge capture• Define start and stop times• Enhance reconciliation
Revenue Cycle Phase IIy
Use of Data Analytics:
36
y GI/Endoscopy – presence of pre-op, Anesthesia time, sedation drug,
recovery time
Total
Location#
Exceptions% of Total
GrossCharges
# Exceptions
% of Total
Gross Charges
# Exceptions
% of Total Gross Charges
# Exceptions
% of Total
Gross Charges
# Cases
FACILITY A 12 0.2% 5,200$ 46 0.8% 25,250$ 99 1.6% 5,200$ 90 1.5% 24,500$ 6,058FACILITY B 63 15 4% 27 279$ 9 2 2% 4 941$ 44 10 8% 2 310$ 11 2 7% 2 992$ 409
Missing Pre Op Missing Anesthesia Time Missing RecoveryMissing Sedation Drug
FACILITY B 63 15.4% 27,279$ 9 2.2% 4,941$ 44 10.8% 2,310$ 11 2.7% 2,992$ 409FACILITY C 175 5.0% 75,775$ 79 2.3% 43,371$ 0 0.0% ‐$ 25 0.7% 6,800$ 3,500TOTAL 250 2.5% 108,254$ 134 5.2% 73,562$ 143 1.4% 7,510$ 126 1.3% 34,292$ 9,967
• Opportunities to improve charge capture• Enhance pharmacy charging• Define start and stop times
Revenue Cycle Phase IIy
Use of Data Analytics:
37
y Radiology – procedures with or without contrast for contrast media
charge
Location
Missing Contrast Charge
Radiology Procedures with Contrast
% of Missing Contrast Charges
Gross Charges
FACILITY A 24 12,685 0.19% 10,800.00$ FACILITY B 103 5,807 1.77% 46,350.00$ FACILITY C 8 2,477 0.32% 3,600.00$ TOTAL 135 20,969 0.64% 60,750.00$
• Enhance process for capturing charge for contrast media
, ,$
Revenue Cycle Phase IIy
Use of Data Analytics:
38
y Emergency Department – presence of, or duplication of, facility fee
Missing Duplicate Facility
LocationTotal ED
EncountersMissing
Facility Fee
Facility Fee as a % of Total ED Encounters
Duplicate Facility Fees
Fees as a % of Total ED
EncountersFACILITY A 19,739 9 0.05% 21 0.11%FACILITY B 8,540 890 10.42% 463 5.42%FACILITY C 23,466 13 0.06% 4 0.02%TOTAL 51,745 912 1.76% 488 0.94%
• Opportunities to improve charge capture• Enhance process to eliminate duplicates• Similar analytic for professional fees and suppliesSimilar analytic for professional fees and supplies
Revenue Cycle Phase IIy
Best Practices:
39
Areas with charge auditors embedded in the process have better results
Departments with fully integrated Epic functionality benefit from system controlscontrols
Ability to analyze professional and technical charges across Epic modules
Lessons Learned: Revenue Reconciliation
Current process is manual and time consuming and is not comprehensive
Automation through data analytic is more efficient and accurateg y
Specificity to each area will eliminate false exception hits
Comparison across facilities will expose charge process inconsistencies
Charge Router/Charging Controlsg / g g
How are you addressing revenue risks?
40
How are you addressing revenue risks?
Interfaces41
Interfaces - Backgroundg
Interface Challenges are common in most healthcare
42
Interface Challenges are common in most healthcare Environments: Traditional Best of Breed Approachpp Automated and Manual Interface Situations HL7 Interface Standard Data Integrity Testing Issues Error Identification and Follow-up
Interfaces - Examplesp
What is the status of your Epic environment?
43
What is the status of your Epic environment? All Epic Revenue Cycle Only Revenue Cycle Only EMR Physician Officesy Bolt-ons
Interfaces – Best Practices
Is there an Epic best practice scenario against which
44
Is there an Epic best practice scenario against which to compare your organization? It may be too early to knowy y Not a lot of Epic information sharing yet, at least in the
audit profession Cedars-Sinai Resources and Outcomes Measurement
Function – Focused Data Quality Function – Possible B t P ti f t E i i l t ti d t d Best Practice for post-Epic implementation data and interface error identification and remediation
Interfaces – Lessons Learned
Testing, revalidation and a routine error correction
45
Testing, revalidation and a routine error correction process can be very helpful: Dedicated Data Validation Function Cross-Functional Participation Regular Follow-upg p Prioritization Feedback to Epic?
Interfaces—Q&A
What interface issues have you addressed?
46
What interface issues have you addressed?
Audit Cycles/Facility Auditsy / y47
Audit Cycles/Facility Auditsy / y
Risk Assessment
48
Risk Assessment What are the high risk areas? Revenue Volume Complexity of transactions (e.g., Lab panels) Complexity of regulations (e.g., Pharmacy quantity billing) # of handoffs (e.g., Nursing acuity => room charges) Current audit activity by payers Current audit activity by payersWhat’s in the news/settlements Cycle coverage
Audit Cycles/Facility Auditsy / y
Process components
49
Process components Physician orders, documentation, charging, coding,
billing
Applicable Standards Joint Commission National Patient Safety Goals Policies
MHS Cyclesy
Wanted a three year cycle; have a 4+ year cycle
50
Wanted a three year cycle; have a 4+ year cycle Other
Sedation
Facility Services within the 4 year rotation cylce Orders, Documentation, Billing, Coding
ORs Level Charges, supplies, implants/devicesED Level Charges, supplies, drugs Sedation
Observation Acuity
Pharmacy Billing units, admin fees, 340B, LCD/NCD issuesCT/MRI/PET/Nuc ContrastRad OncLab panels, bundlingRTAIS drug billing admin fees Acuity
OB ED Research
AIS drug billing, admin feesOncology drug billing, admin fees, LCD/NCD issuesEchoTrauma Trauma designationGISleepesea c
And more….p
Rehab Services PT/OT/SpeechInpt Services Acuity charges, supplies, nursing proceduresImaging--General Contrast
Consultant Services CCIA does not have specific expertise in these servicesCath Lab/IRHome HealthHospiceIP Rehab
Example #1p51
Audit Step Chart and Claim AnalysisA dit N Ob ti S iAudit Name: Observation ServicesPurpose: Ensure billing compliance for Observation ServicesSources: EpicPreparer: Staff A
i i dReviewer: Reviewer B and CDate: 11‐JunNote: Fieldwork comments made by the auditor are available on a request‐basis
N‐C:
LegendY ‐ Compliant N ‐ Noncompliant
Noncompliant ‐ Corrected
N/A ‐ No data available to test.
Patient
Final Patient Class (Observation, Inpatient, IP to
Consent form
MRN Account Location / Unit DOS range Obs, Obs to IP) signed?1258816 10591937 GS A WEST CARDIAC UNIT 3/9/11‐3/11/11 IP Y2746387 10603578 GS A WEST CARDIAC UNIT 3/11/11‐3/13/11 IP Y
Example #1p52
CHART DOCUMENTATION
Signed h i i
CHART DOCUMENTATIONOrder UM Review
CMS BM CH15, 290.1 42 CFR 482.30
Original Physician Order
Revised (by CM) Physician
physician Order for final status determination Recomm Evidence of
(Includes date, time, and service requested)
Order Details (Date, time, and service requested)
(IP / Observation) prior to discharge?
Beginning Observation Time (physician order)
Evidence of UM Review?
ended Patient Status per UM?
EHR Review (if applicable)?
Recommended Patient Status per EHR?
Y Y N 2033 Y IP Y IPY Y Y 2220 Y IP Y IP
Example #1p53
Part B Services DischargeBilling
Were Services Performed
Ending Observation
Total Observation Time per chart Revenue
Code 44 on claim
Code 44 education
Part B Services DischargeCMS BM CH15, 290.5.1
Performed that are Covered under Part B Insurance?
Total time Part B service was performed?
Observation Time (Last patient care service rendered)
Time per chart documentation (Beginning : Ending : Part B Services)
Patient Class Appropriate?
Type of Bill Appropriate?
Observation HCPCS (G3078) Appropriate?
Revenue Code Appropriate for Observation?
Attending phys ID appropriate?
claim appropriate (Inpatient to Outpatient ‐ Medicare)?
education given to patient (per MHS Code 44 Policy)?
Other phys ID
Y 7 1241 33 Y Y Y Y Y Y Y YN/A N/A 1644 18 Y Y Y Y Y N/A N/A YN/A N/A 1644 18 Y Y Y Y Y N/A N/A Y
Example #1p54
HoursHours
Number of Number ofBilled Hours Equal ChartNumber of
Observation Hours Billed
Number of hours for Chart Documentation
Equal Chart Supported Hours?
43 33 N43 33 N18 18 Y
Example #2p55
√
Tickmark Legend Chart and Claim ReviewOB Hospitalist Program: Facility E/M Services Testwork performed without exception.
X
X1
X2
To determine compliance to CMS requirements and EMTALA requirements.Testwork performed with exception. Services provided, with order, but not coded or billed.Testwork performed with exception. Services provided, billed and coded but no order.
Testwork performed with exception. Facility Evaluation and Management (E/M) under billed or over billed.
N/A
MultiCare Connect
X3
X4
NA
Testwork performed with exception. 2 Ob ED visits in same calendar day.
Attribute is not applicable to the sample item.
Testwork performed with exception. Ob ED not a distinct service.
Issues were identified.Inpatient
Auditors A and B
Reviewers C and D
10/1/2012
ITEM NUMBER
MEDICAL Demographics -
Pt's name, Site
(Patient Discharge
(D) or
PATIENT IDENTIFICATION INFORMATION
RECORD NUMBER
middle initial, DOB, Address, DOS
Came From)
Admitted (L&D)
NPSG 01.01.01: NPSG 01.01.01:
NPSG 01.01.01:
For Auditor
Use OnlyFor Auditor Use Onlyy y
1 2987777 √ 8/12/2012 Unknown Discharged2 52791 √ 8/16/2012 Unknown Discharged3 164652 √ 8/4/2012 Unknown Discharged
Example #2p56
CONSENTSQUALITY ASSURANCE CONSENTS
Chief Compliant
QUALITY ASSURANCE
Orders
pdocumented by
physician or non-physician
practitioner (NPP)
Medical Screening
Exam
Facility ED Evaluation/
Management Service Billed
AMA - Signed
AMA form by Patient
Supporting Documentation
for Services (Nurses' Notes)
Procedures Performed & Documented
Physician Supervision Present
Consent for Treatment/Financial Agreement
Signed
CMS EMTALA Current
MHS Policy and Procedure Informed
Consent and Patient
Competency onCMS Requirements,
JC Requirements, and CoP; MHS
Policy
CMS Requirements,
JC Requirements,
and CoP
EMTALA, GS Policy "Pregnant Patient,
Imminent Delivery"
Current Procedural
Terminology 2012 Book;
CMS Requirements EMTALA
CMS Requirements
and JC Requirements
CMS Requirements, 1995 and 1997 Documentation
Guidelines
CMS Requirem
ents
Competency on pages 5 & 6 J-6; CMS 482.13 (b)
(2); & Wa. Health Law
ManualX 1 √ √ X3 N/A √ X 1 √ √X 1 √ √ X3 N/A √ X 1 √ √√ √ √ X3 N/A √ √ √ √√ √ √ X3 N/A √ √ √ √
Example #2p57
BILLING/CODING/MODIFIERS - ASSOCIATED WITH THE OB ED FACILITY E/M LEVEL OF SERVICE
Claim information available for
review
Claim dates - match
MR
Revenue code
reported on Claim
Facility ED E/M Code/
Procedure Code
Procedures Performed
HCPCS/CPT4 Appropriate
Modifier appropriate
Services Billed and Submitted
Principal diagnosis - appropriate
ICD 9 Codes (Not including
Principal Diagnosis)
Attending phys ID appropriate
BILLING/CODING/MODIFIERS - ASSOCIATED WITH THE OB ED FACILITY E/M LEVEL OF SERVICE
review MR on Claim Code Performed Appropriate appropriate Submitted appropriate Diagnosis) ID appropriate
Identify procedures performed
from
CMS Claim Requirement
s
CMS Claim
Requirements
CMS Claim
Requirements
CMS Requirem
ents
documentation. Did we bill for all
procedures?CMS Claim
RequirementsCMS Claim
RequirementsCMS Claim
RequirementsCMS Claim
RequirementsCMS Claim
RequirementsCMS Claim
Requirements√ √ √ X3 X 1 X 1 √ √ √ N/A √√ √ √ X3 √ √ √ √ √ N/A √√ √ √ X3 √ √ √ √ √ N/A √√ √ √ X3 X X √ √ √ √ √
Cycle Audits/Facility Auditsy / y58
What audits are you doing? What audits are you doing? What can you share about your processes?
Examples of 6 month post go-live ditaudits
59
Examples of 6 month post go-live ditaudits
Security
60
Security Make sure Epic personnel are restricted out of Chronicles
within some reasonable post go-live timeframe p g Check the number and nature of staff with this highest
level of access How robust is your IS Change Management Process? Changes to your Master files should all be well
documented and tested prior to moving into production
Examples of 6 month post go-live ditaudits
Work Queues61
Run Data on all work queues
Month Charges Payments Adjustments To Bad Debt A/R Changey j / ------ --------- ----------- ------------ ------------ ------------- Dec 12 352,995,988 -110,900,476 -231,438,801 -11,491,678 -834,967 Jan 13 401,525,218 -111,009,833 -228,570,958 -9,681,954 52,262,473
F b 13 362 519 766 104 894 503 245 179 536 10 115 864 2 329 863 Feb 13 362,519,766 -104,894,503 -245,179,536 -10,115,864 2,329,863 Mar 13 391,861,426 -117,325,575 -259,957,523 -8,726,359 5,851,968 Apr 13 382,445,431 -109,290,101 -253,892,195 -7,762,792 11,500,343 May 13 404,110,980 -122,765,406 -273,680,790 -11,394,735 -3,729,952y , , , , , , , , , , Jun 13 289,837,460 -78,959,626 -206,785,985 -6,598,541 -10,908,545
Look for Anomalies
Examples of 6 month post go-live ditaudits
Work Queues62
Top 10 Inpatient DNBs/Stop Bills Error ID Owning Area Count Amount
---------------------------------------------- -------- -------- ----- ----------
1. SB Resp Charges To Be Reviewed 1018 CLIN FIN 34 2,790,216
2 DNB HIM CODING STATUS NOT COMP 4146501 HIM 42 2 744 357 2. DNB HIM CODING STATUS NOT COMP 4146501 HIM 42 2,744,357
3. DNB HIM PRIMARY DX CHECK 4140005 HIM 41 2,723,963
4. DNB HIM DRG CHECK 4142002 HIM 41 2,723,963
5. SB Late Charges 11 BILLING 40 2,131,904
6. SB Rehab IP Hipps Review 1027 REHAB 25 1,266,041
7. DNB COD DRG CHECK 4142001 HOSP CODING 14 993,416
8. SB MEDASSETS EXCEPTION 1023 CHARGE CAPTU 14 982,823
9. DNB COD PRIMARY DX CHECK 4140004 HOSP CODING 13 971,919
10. DNB COD CODING STATUS NOT COMP 4146502 HOSP CODING 13 971,919
Examples of 6 month post go-live ditaudits
Work Queues63
Q Denials Trending Summary as of: 6/30/13 Denial Reason Amount Count --------------------- ---------- ----- 23-23-PAYMENT ADJUSTED BECAUSE 9,308,677 1459 16-CLAIM/SERVICE LACKS INFO 2,167,803 451 18-18-DUPLICATE CLAIM/SERVICE 1 785 572 203 18-18-DUPLICATE CLAIM/SERVICE. 1,785,572 203 96-96-NON-COVERED CHARGE(S). 1,138,071 393 15-15-PAYMENT ADJUSTED BECAUSE 743,995 50 A1-A1-CLAIM DENIED CHARGES. 561,222 128 97-97-PAYMENT IS INCLUDED IN T 439,025 5 22-22-PAYMENT ADJUSTED BECAUSE 309,472 97 29-29-THE TIME LIMIT FOR FILING 281,615 28
Examples of 6 month post go-live ditaudits
Interfaces
64
Interfaces Identify non-Epic systems that require interface into Epic Obtain data output from these systems Obtain data output from these systems Ensure Epic is receiving all data from these systems For Ex., If Lab system says they are interfacing 1,500 For Ex., If Lab system says they are interfacing 1,500
accounts and $2,500,000 over to Epic, are all of these coming in to Epic?
How does IS manage the nightly interface process?
Examples of 6 month post go-live ditaudits
Outbound Data Sets
65
Outbound Data Sets Contracted Physicians should be getting ADT info to do
their own billingg Check to make sure they are getting minimum necessary
info, but also ALL the patients they have seen If there are gaps in the data pull, you could end up owing
your group $$ that they didn’t bill for due to the i l t i t f !incomplete interface!
Examples of 6 month post go-live ditaudits
Statistics66
Test the accuracy of your post go-live statistics Are admissions and discharges counted correctly? Are you pulling from all the right sources? For example,
OpTime accumulates admissions. You need to add these to the ADT admits for a totalthe ADT admits for a total.
How are Observation patient conversions to/from IP status handled?
When you pull admit data based on UB or 837 claim files, you may miss Self Pay accts which don’t get UB’s but get statementsget statements
Summaryy
Epic has many modules, features and functionality
67
Epic has many modules, features and functionality Auditors need to know how to use Epic fully
Many roles Many roles Many views Audit trails Audit trails
Learn from each other Have fun with it (that which doesn’t kill you makes Have fun with it (that which doesn t kill you, makes
you stronger)!
Summaryy
Epic has many modules, features and functionality
68
Epic has many modules, features and functionality Auditors need to know how to use Epic fully
Many roles Many roles Many views Audit trails Audit trails
Learn from each other Have fun with it (that which doesn’t kill you makes Have fun with it (that which doesn t kill you, makes
you stronger)!
Save the DateSeptember 21 24 2014September 21-24, 2014
33rd Annual Conference Austin, Texas
69