Reducing the Burden of Clinical Documentation

QUESTION: 

What are the CMS documentation guidelines for who may elicit and document the patient’s history, including ROS, HPI and PFSH? Is it acceptable for my medical assistant to document the ROS, HPI and PFSH if I review the information?

ANSWER: 

Yes, as of 1/1/2019, CMS has modified previous rules relative to history discussion and documentation. As per CMS MLN11063, effective on 1/1/2019:

“For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary and indicate in the medical record that they have done so.

CMS is clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.” 

The physician must still personally perform the physical exam and medical decision-making activities

Work Smarter, Not harder...

The single most common complaint when educating physicians on proper documentation for HCCs is the amount of time it takes to document a complete ROS and HPI. Up-training medical assistants and nurses to take and document the history components can significantly reduce the time physicians spend documenting and increase the time they spend taking care of patients. 

Visit ERM365 to learn more. 

Top 5 Reasons to Attend

  Have you registered for a workshop in 2020? 

   If not, here are the top 5 reasons to attend:

      #5 - I am a coder who needs CEUs from the AAPC

     #4 - I am a physician who needs CMEs from the AMA and/or AAFP

      

     #3 - I want to learn how HCCs impact value-based contracts.

      

     #2 - I want to learn more about HCC coding and clinical documentation. 

     #1 - I am looking for the best HCC tools available.

     Download the agenda to learn more. 

        OR... register your team using the links below. 

Advanced Risk Management - Improve the accuracy of your risk scores!

 Are you looking for the best education available in risk adjustment, value-based payments and/or CDI?

Good News - You have found it!

Join us for a day of risk adjustment, catch up with colleagues over lunch, and get the best tools in the industry for FREE!

Do you need CMEs or CEUs? We have that too!

All Workshops are approved by the American Medical Association, American Academy of Family Practice and the American Academy of Professional Coders.

Register your team ( 3 or more) today to save 10% on any 2020 Workshop!

Take advantage of Early Bird pricing and Save $100!

Overview:

Vast changes are coming to risk adjustment in 2020. What should your team be doing now to prepare? What are the potential impacts to revenue?

Discuss the importance of managing HCCs year over year. What resources are available from CMS to help? 

Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims?

Take a deep dive into HCC Coding and Documentation.

Review NEW HCCs for 2020 and see what documentation is needed to validate payment.

Learn how to leverage frontline staff to be successful in the world of risk adjustment and value-based payments.

Download the Agenda Here

Who Should Attend?

-Providers - MDs, DOs, PAs, and NPs

-Medical Directors - Medicare Advantage, ACOs, CPC+ and Medicaid

-Hospitals and Academic Medical Centers

-Medical Coders, Billers and CDI Specialists

-Executive Leaders, Administrators, Directors and Managers

-MSO and IPA Teams

-Rural Health Centers, FQHCs and Community Health Centers

-Health Alliance Members and Medical Society Members

-Medicare, Medicare Advantage, Medicaid and Commercial Plans

  

REGISTER BELOW:

Jacksonville on 2/13/2020

Tampa on 3/12/2020

Orlando on 5/9/2020

Each Attendee will Receive ($130):

 - Color copy of the presentation

 - 2020 CMS-HCC Quick Coder

 - Laminated HCC and CDI Tools

 - CME from AAFP and AMA

 - CEU from AAPC

To SPONSOR an EVENT

Please email Kameron Gifford

Early Bird Pricing and Group Discounts

Register NOW to save $100 with Early Bird Pricing!

Bring the WHOLE TEAM!
 Register 3 and save 10% on your order!
 Register 4 and use the code TEAM4 to save 20% on your order!

Chicago Podiatrist Sentenced to 7 Years for False Documentation

A Chicago podiatrist has been sentenced to more than seven years in prison and ordered to pay nearly $7 million in restitution following his conviction for health care fraud.

Dr. Yev Gray was sentenced to 90 months in prison and ordered to pay $6,974,895.00 in restitution related to the submission of false reimbursement claims for non-rendered podiatric services.

According to court records, Dr. Yev Gray was the owner and president of Aggeus Healthcare, headquartered in Chicago, Illinois, which provided podiatry services to residents of long- term care facilities. As of September 2015, Aggeus was operating in at least 16 states. In Missouri, Aggeus contracted with podiatrists to provide services in eleven facilities, with seven of the facilities located in the cities of Bourbon, Hannibal, Maryland Heights and Poplar Bluff, Missouri.

According to court records, Dr. Gray created an electronic medical record (EMR) system, which automatically inserted into patient records, diseases and symptoms that the patients did not have. Dr. Gray also pressured Aggeus podiatrists to provide unneeded services, such as Doppler studies, the incision and drainage of abscesses, and the removal of calluses. Some of the podiatrists complied, provided the unneeded services, and signed the false treatment notes; others refused. Despite repeated complaints from patients, nursing homes, and some of their podiatrists, Dr. Gray and his co-defendants continued to create false patient records and to bill for medically unnecessary services. From 2009 to September 2015, Medicare paid Aggeus Healthcare millions of dollars based on the false reimbursement claims submitted by Aggeus.

Yev Gray, 49, Chicago, IL, pled guilty on May 12, 2017 to one felony count of conspiracy to commit healthcare fraud and one felony count of making false statements relating to health care matters.

Natalie Gray, a lawyer and the wife of Dr. Gray, is currently serving a one-year prison term for her role in the health care fraud conspiracy. The CEO of Aggeus and four Aggeus podiatrists are awaiting sentencing.

Read More

Published on FierceHealthPayer (http://www.fiercehealthpayer.com)

OIG: Cigna overbilled Medicare Advantage for $28M in 2007

May 8, 2013 | By Dina Overland

Cigna Healthcare of Arizona, a subsidiary of national insurer Cigna providing Medicare Advantage plans, overbilled Medicare by about $28 million in 2007, according to a new report released last week from the U.S. Department of Health & Human Services Office of Inspector General.
The OIG determined that Cigna submitted diagnoses to HHS for its risk score calculations that didn't always comply with federal requirements. Of the 100 beneficiaries in the sample OIG analyzed for the report, 40 had invalid risk scores because either the documentation didn't support the associated diagnosis or the diagnosis was unconfirmed.
Because Cigna's contracts require its providers submit accurate claims, the insurer assumed all providers were submitting accurate diagnoses as well. But the OIG said providers often report incorrect diagnoses or report diagnoses for conditions that didn't exist when providers treated the beneficiaries.
Based on its investigation, the OIG said Cigna must repay at least $151,000 in improper charges. The federal auditor also recommended that HHS conduct a more in-depth review of the disputed payments. Also, CIGNA needs to bring its "significant error rate" into compliance with federal rules, the report said.
"For one beneficiary, Cigna submitted the diagnosis code for 'congestive heart failure, unspecified,' " the report said. "However, the documentation that Cigna provided indicated that the beneficiary visited the physician because of knee pain. The documentation did not support the diagnosis of congestive heart failure."
Cigna, however, disagreed with the OIG's findings. In a written response to the report, Cigna said the OIG didn't properly account for frequent disparities in charges shown in claims data and in medical records. What's more, the OIG should have analyzed more medical records in its sample and taken a different statistical approach, both of which would have resulted in Cigna owing a total of just $440,000.
HHS will review the report and decide whether to implement the OIG's recommendations or take separate action. Cigna can appeal the report's findings.
To learn more:
- here's the OIG report

Survey: Hospitals are not ready for ICD-10

More than 50% of hospitals have not started training for coding staff

Topics: Information Technology, Clinical Documentation

April 26, 2013

Almost half of small- and mid-sized hospitals are lagging behind official CMS timelines for the transition to ICD-10 code sets, according to a survey.
Is your hospital ready for ICD-10? Evaluate your preparedness across six areas using our Readiness Diagnostic. U.S. health care organizations are working to transition from ICD-9 to ICD-10 code sets to accommodate codes for new diseases and procedures. The switch from ICD-9 to ICD-10 code sets is slated for Oct. 1, 2014 and will require health care providers and insurers to change out about 14,000 codes for about 69,000 codes.
For the survey, Health Revenue Assurance Holdings polled more than 120 hospitals with fewer than 400 beds. The survey aimed to determine whether the facilities were following official CMS timelines for ICD-10 preparation.
About 20% of the surveyed hospitals said they have not begun education or training for the ICD-10 transition, according to the survey. HRAA also found that 55% of surveyed hospitals have not started training their coding staff on the ICD-10 procedure coding system, known as ICD-10-PCS.

How the Advisory Board can help your organization build an ICD-10 transition plan

Moreover, despite CMS recommendations that hospitals begin ICD-10 testing in 2013, 25% of surveyed hospitals said they plan to start testing in January 2014, and 24% said they plan to begin testing in April 2014 (Walsh, Clinical Innovation & Technology, 4/24; McCann, Healthcare IT News, 4/24).