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Practices want to use their EHR and practice management (PM) software capabilities in a way that both ensures capturing fee-for-service revenue and doesn't conflict with Office of Inspector General (OIG) warnings about cloning and over-documentation. The OIG has released two reports recently warning healthcare providers about copy/paste, over documentation, and audit functions in their EHRs. Healthcare providers need to balance these warnings with their desire to use software tools and techniques to make coding easier. In this webinar, coding expert Betsy Nicoletti will describe the OIG recommendations and suggest policies and procedures that will allow clinicians to use their EHRs in a way that saves them time and promotes good patient care, but doesn't conflict with those OIG recommendations. At the end of the session participants will: - Have three techniques to help use the coding functions in their software to improve accuracy and efficiency - Know three key audit functions that a practice should use in their EHR programs - Understand the pros and cons of using an E/M calculator and how to assess its accuracy
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PAGE 1 @GoKareo; #KareoTip PAGE 1 KAREO | CONFIDENTIAL
Your Medical Office SoftwareCoding Pitfalls & Promises
PAGE 2 @GoKareo; #KareoTip
Your Hosts Today…
Betsy NicolettiMS, CPC
Lea ChathamContent Marketing Manager, Kareo
PAGE 3 @GoKareo; #KareoTip
Our Schedule for Today…
1 Introduction & Welcome Betsy
2 Your Medical Office Software: Coding Pitfalls & Promises
3 Discover Kareo’s Role
4 Answer Questions
PAGE 4 @GoKareo; #KareoTip
Participate via Social
Facebook.com/GoKareo
Twitter.com/GoKareo
Linkedin.com/company/Kareo
We’ll be live tweeting during today’s webinar!
How to participate:
1. Follow @GoKareo on Twitter
2. Join the conversation using #KareoTip
3. Join Building Best Practices group on LinkedIn
PAGE 5 @GoKareo; #KareoTip
Betsy Nicoletti, MS, CPC
Speaker, writer, and consultant in coding education, billing, and accounts receivable
Author of The Field Guide to Physician Coding
Founder of Codapedia.com
Developer of The Accurate Coding System
MS in organization and management
20 years experience in medical coding
Member of MGMA & the National Speakers Association
Betsy Nicoletti, MS, CPCwww.betsynicoletti.com
@BetsyNicoletti
PAGE 6 @GoKareo; #KareoTip
Our Schedule for Today…
1 Introduction & Welcome Betsy
2 Your Medical Office Software: Coding Pitfalls & Promises
3 Discover Kareo’s Role
4 Answer Questions
PAGE 7 @GoKareo; #KareoTip
Agenda
Use coding functions in software to improve accuracy
Describe key audit functions in EHRs that support compliance
Develop a copy/paste policyDiscuss the pros and cons of Evaluation and
Management calculators in the EHR
PAGE 8 @GoKareo; #KareoTip
Use Software to Improve Accuracy
Complete coding descriptions reduce errors Incomplete CPT code descriptions can lead to
incorrect codes selected
Discourage users from changing descriptions of ICD-9 and CPT codes
ICD-9 codes that are changed are often least specified
PAGE 9 @GoKareo; #KareoTip
Set Coding Edits
Modifier use Edits that remind user when modifier
needed Pre-adjudication edits
Medical necessity editsLinking For vaccines, preventive medicine service
PAGE 10 @GoKareo; #KareoTip
Verify Eligibility, Coverage
Use these functions prior to patient arrivalAllows you to collect patient due amounts,
discuss finances with patient
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Templates for Procedures
Can be very helpful, save typingCan be tied to CPT codesPitfall: can be too generic and non-descriptive “IV was removed and pressure applied for 3-5
minutes or until bleeding stopped”
PAGE 12 @GoKareo; #KareoTip
In the beginning, was the stimulus
PAGE 14 KAREO | CONFIDENTIAL
“Robert Burleigh was overbilled for an emergency-
room visit because the hospital’s electronic records included examinations he
had not been given.”
PAGE 15 @GoKareo; #KareoTip
Letter from HHS and Attorney General
“Troubling indications…game the system… potential cloning”Katherine Sebelius and Eric Holder in a letter
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Protect the Integrity of the Medical Record
Purpose is clinical Other providers must be able to treat from the
recordMisleading, inaccurate entries must not be
tolerated by physician leadersBilling is secondary!
PAGE 17 @GoKareo; #KareoTip
Key Audit Functions
OIG recommendations are described on coming slides as “required” in their report but are not mandates
These are their recommendations, not current requirements
These are suggestions to CMS and the ONC CMS developing guidelines
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OIG report: OEI-01-11-00571
“CMS and its contractors have adopted few program integrity practices to address vulnerability in EHRs”
January 2014
Contractors not looking for this
OIG recommends CMS develop policies
CMS agrees “We will.”
PAGE 19 @GoKareo; #KareoTip
From the New York Times
19
PAGE 20 @GoKareo; #KareoTip
OIG report: OEI-01-11-00570
“Not all fraud recommended safeguards have been implemented in Hospital EHR Technology”
December, 2013
Audit trailCloningOverdocumentation
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OIG Audit Recommendations
Have an audit logMethod of entry should be logged (direct,
copy/paste/import)Track original author when info entered by
someone else (e.g., medical assistant) Changes tracked by addendum, original saved
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OIG User Access Recommendations
Use user IDs and passwordsUse provider National Provider Identifier to
restrict access “Auditor” class user to have read only access
PAGE 23 @GoKareo; #KareoTip
OIG E/M Recommendations
Requires that EHR technology not prompt an EHR user to add documentation but be able to alert a user to inconsistencies between documentation and coding.
“Just add family history and you get a four!”
PAGE 24 @GoKareo; #KareoTip
OIG Patient ID Recommendations
How do you know the patient is really Betsy Nicoletti?
Prior relationship Picture ID Photo then imported into medical record
PAGE 25 KAREO | CONFIDENTIAL
Overdocumentation is the practice of inserting false or irrelevant documentation to create the
appearance of support for billing higher level services. Some EHRs auto-
populate fields when using templates. Other systems generate extensive
documentation on the basis of a click of a checkbox, which if not
appropriately edited, may be inaccurate. Such features can produce information suggesting the practitioner preformed
more comprehensive services than were actually rendered.
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Templates & Copying Notes
Is using a template any different than copying from previous note?
Templates: can encourage documenting elements that aren’t needed
“Sameness” about notes Need enough variety of templates to accommodate
different types of visits and problems
PAGE 27 KAREO | CONFIDENTIAL
Copy-pasting, also known as cloning, allows users to select information from one source and replicate it in another
location. When doctors, nurses, or other clinicians copy-paste information but fail
to update it or ensure accuracy, inaccurate information may enter the
patient's medical record and inappropriate charges may be billed to
patients and third-party health care payers. Furthermore, inappropriate copy-
pasting could facilitate attempts to inflate claims and duplicate or create
fraudulent claims.
PAGE 28 @GoKareo; #KareoTip
Develop a Policy
“Just say no?”Policy: who imports PFSH, how do we know the
clinician reviewed itMedical director input into policyParticularly troubling for inpatient records
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Hospital Visits
This note looks familiar
Entirely copied from previous day, and “edited”
PAGE 30 KAREO | CONFIDENTIAL
With copying and pasting notes in EHRs, the rule is that you should
not document it if you did not ask it, review it, examine it or
consider it. If you copied from a previous note, read your new note and see if it contains any details that do not meet one of those
criteria. If so, delete that element.
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What Makes Sense?
78 y.o. m. w/COPD, pulmonary nodules…
45 y.o. f w/stage 2 breast cancer, tx’ed…
7 y.o. w/ADHD who… Update ages and add
detail as needed
“Since our last visit, he reports feeling increasingly SOB, unrelieved by inhalers,…”
Yes, copy the clinical summary
Always new: “Since last seen”
PAGE 32 KAREO | CONFIDENTIAL
Clinical summary
Pleasant 58-year-old with a past medical history of coronary artery disease,
previous acute coronary syndrome. He had bypass surgery. His last cardiac
catheterization was June 2011. At that time bypass grafts were patent. The third obtuse marginal demonstrated 80 percent
stenosis in the proximal third. The RCA demonstrated 100 percent proximal
stenosis. The mid RCA was supplied by collaterals. There was diffuse coronary
disease. Ejection fraction was 55 percent. There was no intervention at that point in
time.
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“Since last seen…”
Now, the HPI elements that describe patient’s condition
This is the new work and part we will credit for the elements of the HPI
Status of three chronic diseases: yes, if new and updated
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Assessment
Should contain only problems addressed at this visit
Avoid listing all of the patient’s problemsUpdate status of patient’s conditions
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Use or Not Use E/M Calculators?
Do they work?Will they result in coding higher or lower than
note audited by an auditor?Will they result in coding higher or lower than
code selected by the clinician?
Goal: Accurate Coding!
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History in the E/M Calculator
Can only read structured fields: HPI is often free texted
ROS, PFSHMake sure fields have information when clinician
checks “Reviewed, no changes”
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Exam
Easiest part of note for EHR to auditBut, find out which guidelines are used: 1995 or
1997Probably doesn’t have 1997 single specialty
exam in system
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Medical Decision Making
Complexity: hardest part for an auditor, hard for a machine
New or established problem to examiner?May over count dataTable of risk—probably needs physician input
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Check Accuracy
Physician is responsible for coding submitted under his/her provider number
Coder who is experienced auditor should review sampling of notes if using E/M calculator
Should allow for override by physician in both directions: “It just wasn’t that complicated”
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Audit Strategies: New Patients
Select three common conditions for new patients Specialty specific: frequency, headache, shoulder
pain
Select three encounters for this service Review the notes What is the level of template? Does the HPI tell the story? Do they look eerily the same?
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Audit strategy for established visits
Select patients followed multiple times in a year for chronic conditions
Do not include acute visits in this sample Review sequential encounters Look at HPI and A/P for identical documentation
PAGE 42 @GoKareo; #KareoTip
Engaging Physician Leadership
Print out and review both OIG reportsPrint out Documentation Guidelines Research your EHR’s audit functions (who
entered data, time stamp)
PAGE 43 @GoKareo; #KareoTip
Show Results of Audit
Save audit results as part of compliance activities
Celebrate
Review problems with managing physician
Review with clinical staff
Develop a plan that emphasizes patient care
No problems Problems
PAGE 44 @GoKareo; #KareoTip
Our Schedule for Today…
1 Introduction & Welcome Betsy
2 Your Medical Office Software: Coding Pitfalls & Promises
3 Discover Kareo’s Role
4 Answer Questions
PAGE 45 @GoKareo; #KareoTip
Discover Kareo’s Role
Cloud-basedMedical BillingPatient Payment ServicesInsurance Billing & RemittanceScheduling & Practice ManagementElectronic Health RecordsMedical Billing ServicesEducation, Training, & Support Included
20,000 Providers Nationwide
PAGE 46 @GoKareo; #KareoTip
Educational Resources
PAGE 47 @GoKareo; #KareoTip
Discover Kareo’s Role
•Kareo EHR• Built-in templates• Template editing• Set user
permissions• Superbill
PAGE 48 @GoKareo; #KareoTip
Discover Kareo’s Role
•Kareo EHR• Built-in templates• Template editing• Set user
permissions• Superbill
PAGE 49 @GoKareo; #KareoTip
Discover Kareo’s Role
•Kareo EHR• Built-in templates• Template editing• Set user
permissions• Superbill & E/M
Code Assistant
PAGE 50 @GoKareo; #KareoTip
Discover Kareo’s Role
•Kareo EHR• Built-in templates• Template editing• Set user
permissions• Superbill
• Kareo PM• Eligibility
verification• Code scrubbing• Set user
permissions
PAGE 51 @GoKareo; #KareoTip
Discover Kareo’s Role
•Kareo EHR• Built-in templates• Template editing• Set user
permissions• Superbill
• Kareo PM• Eligibility
verification• Code scrubbing• Set user
permissions
PAGE 52 @GoKareo; #KareoTip
Discover Kareo’s Role
PAGE 53 @GoKareo; #KareoTip
Discover Kareo’s Role
PAGE 54 @GoKareo; #KareoTip
Our Schedule for Today…
1 Introduction & Welcome Betsy
2 Your Medical Office Software: Coding Pitfalls & Promises
3 Discover Kareo’s Role
4 Answer Questions
PAGE 55 @GoKareo; #KareoTip
Let’s Answer Your Questions
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