Evaluation Management Services UCSF Clinical Enterprise Compliance

Evaluation & Management Services UCSF Clinical Enterprise Compliance Program

Documentation & Reporting New Approach to the Same Old Story UCSF Clinical Enterprise Compliance Program

UCSF Clinical Enterprise Compliance Program CECP Education Series Wanda T. Ziemba MFA RHIT CPC Medical Center Compliance Manager & CECP Educator UCSF Clinical Enterprise Compliance Program

MGBS Brown Bag Series March 17, 2006 UCSF Clinical Enterprise Compliance Program

Agenda l Brief presentation – E&M Issues – Consultation Guidelines – Teaching Physician Guidelines – Questions UCSF Clinical Enterprise Compliance Program

The New, New Guidelines UCSF Clinical Enterprise Compliance Program

Documentation Guidelines l 1995 E&M Guidelines – Body Areas & Organ Systems – One “Point” for Each BA/OS – Favored Primary Care l 1997 E&M Guidelines – “Bullet” System – Discrete Examination Elements – Fair to Specialists UCSF Clinical Enterprise Compliance Program

NHIC l l You may use either the 1995 or the 1997 guidelines, whichever provides the most advantage NHIC reviews according to the 1997 guidelines Easier to validate content More difficult to support higher levels UCSF Clinical Enterprise Compliance Program

History l 1995/1997 -10+ documented ROS required l 1999 -proposed 2 of 3 history elements l Focused to comprehensive l 2002 – menu options for history UCSF Clinical Enterprise Compliance Program

Physical Examination l 1995/1997 -detailed – Lower extremity exams required for comprehensive – Detailed exam 1999 -proposed 200+ list l Exact requirements not yet known l 2003 – scenario based l UCSF Clinical Enterprise Compliance Program

Medical Decision l 1995/1997 -calculated based on – Problems – Data reviewed/ordered – Risk table l 1999 -proposed one table encompassing all three areas UCSF Clinical Enterprise Compliance Program

Seven Components of Evaluation & Management Services The SOAP Note Expanded, Revisited and Beaten Into Submission UCSF Clinical Enterprise Compliance Program

Key Elements l History as related to the patient’s presentation l Physical Exam as related to the patient’s presentation l Medical Decision in managing patient UCSF Clinical Enterprise Compliance Program

l New patients, consultations, ED and Admits – 3 of the 3 key elements l Established patients, subsequent hospital care – 2 of the 3 key elements l Medical Decision is prime UCSF Clinical Enterprise Compliance Program

Contributing Elements l Counseling with the patient and/or family l Coordination of care l Nature of the presenting problem l Time UCSF Clinical Enterprise Compliance Program

Purpose l Remember the primary focus of the medical record l Continuity of patient care l Legal documentation l Legible progress notes l Not just for “billing” UCSF Clinical Enterprise Compliance Program

History l Focused – (CC, 1 -3 HPI) l Expanded – (CC, 1 -3 HPI, 1 ROS) l Detailed – (CC, 4+ HPI, 2 -9 ROS, 1 PFSHx) l Comprehensive – (CC, 4+ HPI, 10+ ROS, 2 -3 PFSHx) UCSF Clinical Enterprise Compliance Program

25 yo m dilated & hypertrophic CM w/ mild MR, hyperthyroidism Concerns re: STDs; contact 1 wk ago, irritation, burning on urination, OTC tinactin, no Δ No D/C, partner x 1 w/yeast infx, Ǿ IVD/Tattoos – energy level Ǿ Δ Ǿ CP, Ǿ CHF Sx’s, Ǿ palps ↑weight 5 lbs UCSF Clinical Enterprise Compliance Program

CC HPI ROS PFSHx Genital irritation Duration; context; assoc. s&s; modifying factors Constitutional; cardiovascular Partner w/yeast infx; Dilated & hypertrophic CM; mild MR; hyperthyroidism 4 HPI 2 ROS 2 PFSHx UCSF Clinical Enterprise Compliance Program Level Detailed

l How specific should the medical record documentation be? Is “negative” or “benign” appropriate when detailing examination findings? UCSF Clinical Enterprise Compliance Program

Physical Examination l Focused – (1 -5 bullets, 1 BA/OS) l Expanded – (6 -11 bullets, 2 -7 BA/OS) l Detailed – (12 bullets, 2 -7 BA/OS) l Comprehensive – (18+ bullets, 8+ organ systems) UCSF Clinical Enterprise Compliance Program

The patient is a 25 year old white male, alert & orient x 3, cooperative and in NAD. VS: 110/70, 60, 5’ 9”, 179 lbs AT NC PERRLA EOMI Neck Ǿ LAD Ǿ TM PMI ND S 1 S 2 (↑ A 2) HS nml apex CTAB no retractions R shoulder notable >> larger L shoulder? Ǿ C/C/E nml pulse + foreskin, Ф irritation Ф discharge Ǿ no mass test Ф hernia UCSF Clinical Enterprise Compliance Program

BA/OS 1995 1997 Comment Cons 1 2 GA & VS (when at least 3) Eye 1 1 Pupils & iris Head 1 ENMT 1 1 TM CV 1 4 Auscultation, palpation, edema, pulses Resp 1 2 Auscultation & effort Ext 2 MS Under MS in 1997 guidelines Not in 1997 guidelines 3 Inspection/palpation 3 areas Lymph 1 1 Cervical GU 1 3 Penis, testicles, hernia Psych 1 2 Mood & affect, orientation Neuro 1 EOMI – Cranial nerves UCSF Clinical Enterprise Compliance Program 1

BA/OS 1995 1997 Totals 8 OS Comprehensive 20 Bullets, 6 systems with 2 or more PE elements Detailed 3 BA N/A Totals UCSF Clinical Enterprise Compliance Program

The Extremities are obvious in the 1995 guidelines (remember to not count Body Areas for the comprehensive level of service) l Where do extremities belong in the 1997 guidelines? l Varies with specialty performing service and presenting problem l UCSF Clinical Enterprise Compliance Program

The Nebulous Neck is considered a body area and yet is listed separately in the 1997 guidelines l Placement will be determined by the physical examination findings l May be Musculoskeletal, Lymphatic, Endocrine l UCSF Clinical Enterprise Compliance Program

Problems, Data, Risk UCSF Clinical Enterprise Compliance Program

Medical Decision l Presenting problem – New/established, improving/worse, selflimiting l Data reviewed – Type, independent review, discussion l Risk – Selected from the Morbidity/Mortality Table UCSF Clinical Enterprise Compliance Program

Are You a Psychic How can you tell if there has been an independent review of source materials or films? l Note the language documented l – Personally reviewed; wet reading l Consider the level of detail in the medical record UCSF Clinical Enterprise Compliance Program

Medical Necessity/Time UCSF Clinical Enterprise Compliance Program

Time l l More than 50% of total face-to-face time Counseling l Treatment options, risks & benefits, patient/family education, discussion of results l Choose based on total time Document both total and counseling time Only on E&M’s with suggested time l l UCSF Clinical Enterprise Compliance Program

UCSF Clinical Enterprise Compliance Program

Consultations l l New guidelines require the request as well as the opinion to be documented in the medical record Must be requested by a faculty physician UCSF Clinical Enterprise Compliance Program

Transmittal R 788 Deletion of follow-up and confirmatory consultations l Revised definitions l Updated documentation requirements l Second opinion s are assigned Inpatient Consultation codes if the consultation requirements have been met l UCSF Clinical Enterprise Compliance Program

l Carriers shall instruct physicians and qualified NPPs that a consultation request may be verbal however the verbal interaction identifying the request and reason for a consult shall be documented in the medical record by the requesting physician or qualified NPP, and also by the consulting physician or qualified NPP in the patient’s medical record. UCSF Clinical Enterprise Compliance Program

Teaching Regulations – History l IL 372 – initial teaching institution guidelines – Intermediary Letter Outlining the extent of Attending participation required for reporting purposes – Basic guidelines; no address of current technology such as EHR or macros – Medicare only UCSF Clinical Enterprise Compliance Program

Medicare reimburses for clinical activities under Part A and Part B l Part A represents hospital services and GME funds (Facility) l Part B is attending physician services (Pro-Fee) l UCSF Clinical Enterprise Compliance Program

l Medicare will reimburse for services predominantly supplied by the House Staff when the faculty physician personally provides direct services and the medical record reflects that face-toface encounter UCSF Clinical Enterprise Compliance Program

Further Refinements to the Medicare regulations l Transmittal 1780 – November 22, 2002 – Developed specific language – Detailed definitions – Additional guidelines for surgical and anesthesia services UCSF Clinical Enterprise Compliance Program

January 13, 2006 Transmittal l Revised Definitions – Resident, Interns & Fellows – Student – faculty Physician – Direct Medical Services – Physically Present UCSF Clinical Enterprise Compliance Program

Three Scenarios l The faculty physician personally performs all the required elements of the E&M service without a resident – The attending documents as if in a nonteaching setting UCSF Clinical Enterprise Compliance Program

l The resident performs the elements required for the E&M service either jointly with or in the presence of the faculty physician – The faculty physician’s note should reference or “link” to the resident’s note UCSF Clinical Enterprise Compliance Program

l The resident performs the required elements in the absence of the faculty physician; the faculty physician independently performs the required elements with or without the resident present and, as appropriate, discusses the case with the resident. UCSF Clinical Enterprise Compliance Program

Acceptable Linkage l l “See resident’s note for details; I saw and evaluated the patient and agree with the resident’s findings and plans as written” “I was present with the resident during the history and physical examination; I discussed the case with the resident and agree with the findings and pan as documented in the resident's note. ” UCSF Clinical Enterprise Compliance Program

Unacceptable Linkage “Agree with the above” l “Rounded, reviewed, agree” l Countersignature only l “Seen and agree” l “Patient seen and evaluated” l UCSF Clinical Enterprise Compliance Program

The resident may not document the presence of the faculty physician l The faculty physician should document some pertinent details to satisfy the Medi-Cal requirements l Physical presence must be documented by the faculty physician l UCSF Clinical Enterprise Compliance Program

l However, Medi-Cal will not reimburse for any indirect patient care (22 CA CCR § 51503) UCSF Clinical Enterprise Compliance Program

l No reimbursement for services supervising house staff l No reimbursement allowed for attending “teaching” time UCSF Clinical Enterprise Compliance Program

When Will Medi-Cal Pay? (1) They are performed for necessary treatment of the patient; (2) They are not an exercise of teaching supervision without direct patient care services being provided; (3) They do not duplicate any medical services billed by any other provider; and UCSF Clinical Enterprise Compliance Program

l 4) The faculty physician is not on salary or contract to the hospital for the direct patient care services provided. No professional fees are payable for services provided independently by residents or students in a teaching setting. UCSF Clinical Enterprise Compliance Program

The Medi-Cal program, through its intermediary, will pay allowable Medi. Cal rates for direct patient care services in a teaching setting when directly provided by faculty physicians only when such services are provided and billed in accordance with program policies and regulations of the Department of Health Services and when: UCSF Clinical Enterprise Compliance Program

Errors? What Happens If Our Practice Misunderstands the Regulations? UCSF Clinical Enterprise Compliance Program

l Some practices are developing compliance plans; CMS is very interested in how providers code and document. UCSF Clinical Enterprise Compliance Program

Carrier Audits l Just what are the chances that my practice will face UCSF Clinical Enterprise Compliance Program

Now you know the answers… UCSF Clinical Enterprise Compliance Program