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Sickness billing format for client for Legal

is this on okay so we can go to the next slide okay so a long time ago in an academic center far far away rogue faculty members roam the hall and our first faculty member is dr. baldemar aka C who must be named [Music] their stress balls so fatal flaws include field patients seen by his peers as new patients failed to document time and counseling when billing by time billed consults for a patient who was self referred and billed 99205 for all patients when medical decision-making did not meet that high level if we move to the next slide so a new patient is a patient that hasn't been seen by you or someone in your specialty for the last three years I think a common scenario is that one of your peers may see a patient in the hospital setting and then they come to see you for a follow-up visit in the office that would still be considered an established patient not a new patient there are there is an alternate way to code your level of service I think everyone received an E&M card in their packet this morning it's an outpatient card and if you wish to code your E&M service based on time over 50% of the visit needs to be devoted to counseling and coordination of care there are associated times located in the blue column next to the CPT code for instance 99214 requires 25 minutes so if you wanted to build that service based on counseling and coordination of care you would document the total time you spent with the patient 25 minutes and perhaps 15 minutes was spent counseling the patient you would include those details on the flipside of this card you have a the consult services and the new patient visits those require three of the three key components history exam and medical decision making if you wish to bill a consult service 992 for one through four five you need to ensure that you have the requesting provider's name in your medical record and you send that report back to that requesting provider it's not necessary to do so in the inpatient setting since it's a shared record in epic as long as the documentation includes consulate requested by so-and-so for such-and-such reason when we wanted to quickly take a look at medical decision-making yes I'm sorry yes yes whoever we yes correct no patient well you can also take over their care too so they've sent them the sent the patient to you for your advice and opinion and in your recommendations you want to continue to treat this patient you're sending the RIC consult report back to that referring physician and you're taking over the management of the care you can still build that as a consult it's different than if I'm in the community and I have a problem and I come to you directly say I want you to give me an opinion my doctor isn't sending me I'm coming I would be a new patient to you yes new patient right if they're kind of wiping their hands of the patient and saying here you take care of this problem that's a new patient yes as a physician that's probably difficult for you sometimes because of the information you're provided you get a patient's chart when they come in right and and you're not quite sure right so yeah right whether a physician has referred the patient or I came in on my own you're still gonna send a letter back to whoever I see the billing is different right that is that is problematic I'm not sure if there's anybody in your department that is involved in the process that could help here I mean one would hope that a patient would say when they present that you know I see so-and-so in the community but I really wanted a second opinion from you but that's another way it sounds like there aren't apartment workflows that I'm aware of I don't know of one specific for urology but departments do have a workflow where the phone call comes in and they're there to document that in the scheduling component so perhaps that's helpful 99205 that dr. Voldemort was billing all the time correct so again to bill in 99205 if you're not quoting the service based on time if you take a look at your E&M card a 990 205 requires a comprehensive history a comprehensive exam and high medical decision making as opposed to a 990 to 1/5 which is an established patient you're required to hit two out of the three key components which is a comprehensive history comprehensive exam and high medical decision making so the point being for a new patient or a consult you need to hit all three key components I'm given the EMR s ability to capture the history and the exam components a lot of the focus from a carrier perspective and insurer perspective is the medical decision making so we're going to walk through that process for a level five you're required to have comprehensive high medical decision making medical decision making is broken down into three components first how many diagnoses or problems am i dealing with are they getting better or they new to me the second is how much data am i reviewing and the third is overall risk and we'll break it down and you actually have the form in your handout that breaks it down in a similar fashion the first category is how many diagnosis is so if you're seeing a patient for the first time you will get the most credit that you can obtain in this category which is four points a new problem with additional workup so that would give you four there thank you and if we move and that would that would equate to high in that category but again we have three categories and you need to achieve two out of those three categories for the level selected the next category is how much data am i reviewing so I'm not sure how much data you do review for a typical patient but the first bullet is bloodwork so if you look at one blood test or multiple blood tests you get one point the second one is radiology scans it doesn't matter how many radiology scans you're looking at you get one point then we have a medicine test but I do like to point out that any direct visualization or independent review would heighten your medical decision making with this component with two points if you decide that you're going to obtain a history from outside of the epic system or or outside of the patient that would give you additional points and if you're receiving in an additional history from a family member or a caretaker so that would heighten your medical decision-making in that category but for these purposes we'll check off one lab and one radiology which would give you low in this category and we'll move on to the third category which is the actual risk to the patient and you can select the level of risk based on any of those three categories if you move on to the next slide I think we have a risk table there so if you take note under moderate for presenting problems an undiagnosed new problem is identified there so perhaps that's the case for your new patient they would fall under moderate risk in this category I just want to point out prescription drug management also falls under moderate risk under management options surgery with some acute risk factors on would fall under hi in the last column and an individual with a chronic illness with severe exacerbation likely going to be hospitalized would fall under high risk there so for cases of this new patient that you're seeing we have four under the first category a which gives us a high we've looked at two points of data which gives us a low under the second category and our medical risk was moderate so therefore we would use the one in the middle which is moderate medical decision making so that's just an example of what that looks like I don't I don't believe that you're going to remember this point system this is really an audit point system but really just the premise on how someone would look at your medical record from a medical decision-making perspective premise is you've got somebody presenting to you that's not getting any worse they're stable kind of holding their own typically your medical decision making is going to be less versus somebody coming into you that's getting worse or has an undiagnosed new problem that you've got it got to really do some work upon that would equate to a higher level versus your patient who stable [Music] so dr. Norman Bates fatal flaws included attested to advanced practice provider notes failed to indicate medical necessity of m.d. participation in an a PP visit and utilize non leased or employed Yale medicine a PP notes so basically we're addressing shared visit rules in this slide so if if you wish to work with an advanced practice provider and render an E&M collaborative services there's a few criteria that needs to be met first it needs to be medically necessary to have you participate in the visit and in addition to that medical necessity that needs to be documented there needs to be a substantial component of the enm that's performed by you as the MD in those cases if that criteria is met you can combine the documentation of the AP P and the MD and Bill at whatever level generally a higher level under the MD again the a PP must be a Yale medicine employee which means they must be employed or least and credentialed by Yale medicine if you're not clear on that and you're working with an advanced practice provider you really need to reach out to someone in your department to verify that I think for the most part the majority of a PP s from the hospital have been leased over to Yale medicine recently and pas must have a delegation agreement that's updated annually which they're aware of that's part of their credentialing process I'm not sure if anyone here is utilizing shared visits when they render E&M services the biggest thing I see when I look at documentation is the physician and the document as they would with a resident all right so you're gonna put your teaching position I've seen and evaluated the patient and you personalize that to the plan that does not work with an AP RN or a PA because they are billing providers in their own right and the insurance company would much rather pay them at the 85 90 % rates than 100% the physician fee schedule so you're both independent billing practitioners you need to document exactly what you've done for the visit an application doesn't work so a PRN perhaps listens to the heart here's something doesn't quite like and you repeat that exam of the heart and then you need to document what you I know it's not inherent and how you know you kind of work clinically the same with everyone but unfortunately with a drn's RPAs your two independent practice tears and they each need to document what you've done Kevin's in the corner so dark dr. dark Vader's fatal flaws include no original documentation cloned copied pasted all records of service cloning errors continue to be propagated so just to touch base on a few practices that are out there Yale medicine practice standards indicate that the copy forward the copy paste feature cannot be utilized for history of present illness exam and medical decision making and these were practice standards that were published by dr. bender as part of the Yale Medicine protocols if you do forward documentation from a previous visit you want to make sure that you update that documentation based on the visit at hand you want to update any exam components any history components based on what the patient is telling you that day again due to the copy and paste functionality medical decision making is really the main main course for selecting your level of service in the ambulatory setting there is a functionality called make me the author which is really a misnomer that was developed by epic initially to help residents and fellows forward their documentation to a teaching physician there is a clear audit trail that's maintained in epic you cannot make yourself the author of anyone's documentation you can clearly see every iteration of that note within epic through the hover feature through the previous version features so when an auditor sitting with at a computer they can see that there's been multiple contributors to that note so just I just wanted to bring that to everyone's attention I think that make me the author is really very misleading and led to a lot of problems when epic was first implemented so I think the key piece here is that you don't want to bring any documentation forward that doesn't belong to you you should be the initial author of that documentation if you wish to edit that documentation for the visit at hand we see a lot of that a lot of sharing of notes between an advanced practice provider in an MD you want to make sure you're the original author on whatever you're bringing forward [Music] King Herod's fatal flaws include one more one more back yes so we're talking about scribes in this slide and basically scribe policy there we actually have two major projects that have been launched for scribe services and what's required of the provider that's rendering the service is that you need to ensure that you attest that the scribes documentation is accurate and sign that documentation and within that attestation it must be clear that you saw the patient this is not something that the scribe can document for you you as the billable provider need to insert that attestation we've sent out multiple emails multiple educational blasts regarding this and we've worked closely with the scribe there we go we've worked closely with the scribe contractor so that is a requirement that the physician or the provider that's rendering the service must meet you must document your own attestation indicating that the documentation is accurate and that you saw the patient the scribe has their own requirements they must document that they've scribed for which provider and sign the note as well on what we're finding upon review of a few records not just in urology but throughout the university is that the scribe is inserting that statement so again I'm utilizing failure to document verification of a scribes work and failure to document your presence you need to make sure that you insert that smart phrase and personalize it what we like to remind folks of is in the hospital setting and that's the majority of our work is done in the outpatient or the inpatient hospital setting you cannot utilize an RN a resident or a fellow since they participate in the care Joint Commission prohibits the use of providers that participate in the care as scribes and I think we went through all of this earlier you must affirm that your personal perform the service you must document that you reviewed it for accuracy and you as the MD must sign the note I know that there's a virtual scribe and you need to be the one putting in your and this is a sample practitioner attestation that you're required to insert the scribe cannot insert this attestation for you [Music] [Music] so dr. Corelli de villes fatal flaws including applying general attestations to resident E&M notes merely co-signing a procedure and diagnostic test reports and didn't verify resident or medical student documentation so generally this is an overview of teaching physician guidance when working with a resident and a fellow basically if you're working with a resident or a fellow and you're providing an E&M service you're required to document that you saw the patient you evaluated the patient and what your participation was in the plan your personalization should be around that plan component generic attestations that simply state that without any personalization are not acceptable or available for procedures that take less than five minutes and generally have a zero to ten day global you need to document that you were there for the entire procedure if you wish to bill for a service that was rendered by a resident or fellow for a procedure that takes greater than five minutes and those are usually the 90 day Global's if you wish to build for that service that was performed by a resident or a fellow you need to document the key components and your presence during the key components i'm diagnostic tests you need to review and agree or make edits to the residents interpretation and sign that now in order to build for that service we didn't put any additional information on here about medical students but most of you may have heard that the Center for Medicare and Medicaid Services email with a bulletin that said that teaching positions can now use medical student documentation in the past the only thing you were able to use from a medical student would be the review of systems and past family social history so you know the balloons went up in the air everybody's all excited about this change and in compliance we had come up with a couple of smart phrases for you to use and then as we discussed this further with the Association of American Medical Colleges there's ground work that needs to be done before we can just slip the switch and implement this alright so for example we need to figure out who needs to be involved in this process as the how does the hospital have policies that allow the medical student document in the medical record they don't they have to amend their policy we need to check with epoch what kind of access to our medical students have do they have the ability to forward a note to you you know are you going to let any medical student document a history and exam and a plan in the medical record or do you just want to confine that the third or fourth year medical students which is something that that you all need to consider have the medical students been taught to write good notes and then for us how do we get the information out to you as teaching positions how do we educate residents and it's important for us to do that because in order for you to use a medical students know either the resident has to be physically present for the medical student or you need to be physically present with the medical student and you need to either perform or repr form the exam so there's a lot of questions that we have about this the double AMC we've submitted our questions to them and they are approaching EMS about it and we're expecting an answer back from them hopefully sooner than later so you will be hearing more information from us about that doctor papel who's our medical director for compliance and I are coming up with an email to send out to all of you to sort of fill in where we're at with that so I would kind of discourage you from changing practices at this point and so we have some further information that really solidifies how we can put this change in full effect just a reminder that teaching physician guidance only applies to physicians it does not apply to advanced practice providers you couldn't utilize an advanced practice provider a resident an AP P could not utilize a residents note and treat it as a teaching position utilize a teaching position at a station filling out of our you you and he'd build modifier 25 bill for a visit right here okay so Freddy Krueger's fatal flaws are he allowed any urine use ID and password he modifier all right so that IDs and passwords should never be shared now this is something I I'm getting complaints about in the compliance department which kind of a new trends part of it has to do with the Medicaid guidelines that require when you're working with a PA or a PRN that you the position have to document I Ithaca Lea necessary for you to get involved why couldn't the APR enter PA handle it I've had several cases reported where physicians have logged in under their ID and password and let the PA do the documentation or a PRN these folks are not scribes they are medical practitioners you should never share your ID or password I'm had another case where a physician gave their ID and password to an RN to answer their in basket messages again complete violation of the law and of our policies here at Yale medicine these resulted in written warnings to the practitioners and our policy says do not give out your password to anyone including IT staff or your supervisor don't share your account with anyone or let anyone use your account and then misuse of this will be regarded with the utmost seriousness alleged violations will be pursued and can lead up to sanctions up to an including dismissal or expulsion will be imposed this is serious also have malpractice or you if you're letting up do that that's a great question it leads right into what I'm going to talk about my example was a patient is coming back for a scheduled urodynamic test and/or the test and a visit right but when we looked at the documentation there wasn't significant separately identifiable information to support the visit the documentation all supported what you would typically see you right before you did the procedure and the comments you would typically make after the procedure but there wasn't anything separately we could carve out in order to give credit or both yes yes so but you have to make sure so it's a returned patient visit so you have to hit two out of the three key components for any nm right so history exam er plan 2 out of 3 plan of course so you're talking about different human options that we could perhaps pursue after this there you go with your plan so you'd have to meet something a little different about history or exam in order to build for the EMM that that sounds more like something that you probably could bill Annie and them with because you're gonna probably document a lot more than you normally would if you hit this patience established and they're coming in or a scheduled visit that sounds more like an example where usability and app and of course if you're addressing that problem yes a separate problem with that's really the problem I see is when it's a scheduled event you know the patient's coming in and you're managing their medications based on the diagnostic test results so it's not there's nothing there outside of what you would routinely do post the procedure pre the procedure but that sounds to me like it could support an E&M and I'd be happy to look at an example if you send me the MRN number and date of service I can leave a card [Music] [Music] so for patients that are in research studies if the services rendered you know solely for eligibility purposes it's not billable or if the service or Spri services wouldn't be billable for insurance we have on foreign rule to help us get the filling right for these patients an encore we build and build the study calendar so we need to know all the services of the patients that are received which are standard of care we know those go out to insurance which are research only we know those oh none of them and then an epic will build the calendar for the patients as they're enrolled but none of that can be and most being possibly right unless you make sure that the contract budget economics that are really clear as to what are just to study related procedures we don't have we find inconsistencies many times when we look between these documents and they're not really clear about the services where there's so if you could please just keep that in mind when you're doing research studies that you get that part right we have a great shot of getting the billing right okay villain is dr. Vito Corleone II he's a graduate of the broken leg of lamb University extensive experience mental health Personality Disorder from what movie I heard it way back there we said Godfather over there obviously we're gonna have to fix our music with these things doctor Corleone II violated her fines under the False Claims Act you know and in every other industry it's really acceptable to reward customers that reverb services to your business do but in health care is not and the fines are pretty steep as you can see so the government feels that it could lead to corruption of medical decision making to over utilization of the program and it can also lead to patients tearing and unfair competition so for Stark referring patients to his wife's oxygen company right just know that under an academic medical center setting there are a lot of exceptions Stark Law so any questions you have about that are really best directed the False Claims Act can be provided for billing for services not rendered we had a case recently where it was somebody build for the E&M visit with a procedure and there was no if you misrepresent so if you're always up coding your E&M there's definitely fines associated with that dude that's also known as the whistleblower law so if somebody's disgruntled and they go to the feds then at the 30 percent of whatever the government recovers so it's kind of strong if you have disgruntled folks around you're right you're right so under the False Claims Act the government doesn't have to prove intent but they have to prove that you know you had information knowing that it was incorrect kind of deliberate ignorance of the law I mean this doesn't happen on your routine this is a systemic issue right all right so I think we're on villain [Music] you know we hope that if you have compliance concerns that you could take the normal route by bringing your concerns department what if you can't we have a hotline really something new for compliance now on our website we have a form that you can fill out for questions that you want to ask us both they're really for routine inquiries you know you can pick up the phone and call us any time this is used primarily by our new central billing team and it's providing us with really good data about what types of questions are out there what department we can use it to make sure we're timely and I would use the information for tracking and training you know that that's out there I did want to talk a little bit about excluded too if you are convicted you have a healthcare fraud conviction if you fails to pay back a federal school loan or if you lost your life alcohol addiction and you can end up on Medicare and Medicaid looted lists meaning you cannot paramedic a patient which would not be very beneficial for us as an academic so that concludes our presentation on your medical billing compliance or 2018 you'd be happy to take any questions you right so we would definitely let you know if we did an audit and we found some things that we wanted to talk to you about we would certainly send you a letter meet with you if they ended up meeting with you it meets your training requirements um I do have eight audit staff in the department and so there's currently about 2,400 physicians practitioners so you know we can't audit anybody but we always get phone calls from physicians saying can you take a look at this note and they give us their mrn in the data service you look at it and provide feedback our office is recently going over some structural changes because we faced them 10 mil a draft 10 million dollar overpayment or Medicaid for six audits recently and that of course got the attention of higher up we did get that down to 2.7 million dollars but that's a lot of money so the office of general counsel is helping us restructure compliance so that we can do more proactive audits of your billing we've been in a reactive mode since epic has gone into place because the central billing folks or the folks in your department we're so nervous that we went on the EMR and the billing system at the same time they were really looking at your notes and your billing more so than they ever did and as a result we were flooded with and you look at this then it turned into audits and whatever but we're refining how we do these types of audits where we have a systemic issue we're having a much smaller statistically valid random sample it's really dropping the number of services and we're allocating much more time to doing proactive audits oh yeah receiving letters from us but again we're here to help you know billing is not building a documentation is not not an easy thing it takes a village you know if you have any questions we're half we're happy to help I just want to interject that the billers and coders are looking at your services on a regular basis and we do get quite a few inquiries from them can you take a look at this before we let the charge go out and we will contact if you there's a problem we don't want you to do that you need to get paid for what you do so you know the central billing office are really the boots on the ground at this point and if they do think that's something you're not billing something correctly even if it's under billing or over billing they're sending enquiries to us we've provided the central billing team with a grid of every situation we could possibly think of and you know for most of them they can contact you directly right and for some of them they need to refer it to us so that we can make sure you get the correct information because it's a little more complicated and we would definitely give your feedback if you were under billing as well as over billing yeah no I don't know there's nobody here for the central billing specifically they're mostly looking at the bills you're dropping versus the documentation that you hands on the department depends on the risk associated with particular procedures it depends if something about the billing looks kind of odd to them they're gonna go back and look at your documentation or if you feel like a modifier 25 they want to make sure you have enough documentation in there for the enm one thing I strongly encourage you to do because I get this this complaint quite a bit is that the coders have a process that if they need your feedback in order to have this bill go out please I know you get a lot of stuff in your inbox but the charges can't go out unless you give them some information do that with so they're not trying to harass you they're trying to get your bill out the door and they will often forward those types of inquiries where they've reached out to you several times if someone's not responding so we can get the claim out the door correctly so two things I know about one is we do monitor things like that you know anthem was sending our faculty modifier 25 letters saying you know faculty members Billy modifier 25 too often and we would take a look at that you look good we're not gonna do anything about it and an initiative I just learned about recently is a clinical initiative optimization that dr. Taheri has instituted and that team is looking at your utilization so within neurology they're gonna they're looking at your how you bill EMM levels and if you look like you're billing Level 5's more than anybody else in the department they're asking them to look at it and generally that will come to us and we will compare you to academic data not just here in neurology but neurologists that are in academic packages across the country if you look okay with that or good you know the commercial payers of Medicare Medicaid compare you to Doc's in the community or ologist in the community which is not really representative a good comparison for you because generally the community Doc's are referring the patients to you so you're seeing more complicated paid cases I mean that being said we still that's what the government and the commercial payers would audit you by they don't have the academic data so we look at a broad spectrum of data look at your documentation it would be an issue we would contact they definitely look at enm utilization they also have a time assigned to each CPT code so they're looking at who might have a medically unbelievable day right I mean it happens and again and again I don't think their data is all that accurate for academic medical centers because we've got residents and you're working with a MPAs so I actually have some compliance risk software that I'm using now and I've identified or if identified some positions that have medically unbelievable days so we're going in and looking at that yeah it looks at your enm it looks all kinds of thing you yeah the hours in the day it's kind of unbelievable that you could have done all that in one day yeah yeah but I'm happy that we finally have some software that that's comparing everybody to that and and whoever is kicking out at the top you know we're gonna check it out and if everything's fine then we feel very comfortable we can defend this yeah we never we don't do random audits we've never done random bodies right absolutely more of that and I yep I know always I wish I wish I had yeah right oh definitely and I wish I had the resources to audit every physician that came in for the practice cuz I think you know if somebody maybe somebody's just not doing something as silly as the review of systems isn't documented correctly when you're billing your higher levels I mean it's a simple thing I would love to be able to do that but we don't have the resources we did offer like 13 or 14 sessions it was really not very well attended so you know that either tells me I'm not offering it at a good time or maybe we need to look at it some other way so we love to do that we love to take like one of your E&M visits right and we'll give you the medical record and we'll audit it in front of your eyes exactly how an outside auditor would look at it definitely we have to help out all right well thank you very much everybody I walk in my office you're not just the young operate I would think that you're getting a letter back whoever sent you saying I agree this person needs surgery I mean you need to think about the line is drawn in the sand it's in black and white I need surgery and my doctor says you go to Yale and have