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Do You Feel Like This?
Documentation, and
Compliance: How they Maximize
Profit and Productivity
Dr. Dianne Baynes RN, DC, MCS-P, CPPM
Or This?
Does Your Business Deserve the Same
Focus Your Patients Do?
Learn the Basics to Reduce Your Risk
Who is the OIG?
•Many DCs don’t
know what they
don’t know, when it
comes to
compliance in
healthcare today!
•OIG Compliance is
that rule book that
many don’t know
they must follow
(855) 832-6562
• Office of Inspector
General's (OIG)
mission is to protect
the integrity of
Department of
Health & Human
Services (HHS)
programs as well as
the health and
welfare of program
beneficiaries.
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Under the Magnifying Glass
Work Plan Focus #3-Identify and Address
Trends
Planning Their Work…and Now Working Their Plan
Work Plan Focus #2-Proactive Reviews
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Work Plan Focus #2-Proactive Reviews
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Work Plan Focus #1: Planned Portfolio
Document
Work Plan Focus #1: Planned Portfolio
Document
MACRA Section 514
Pre-Authorization Beyond 12
Improvement Initiative
This Isn’t Going Away Soon
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OIG’s Semi-Annual Report to Congress
Fall 2014
June 2016
Good Documentation Tells a Story
March 2015
What Should You Do Now?
Know your Audience
•Another health care
provider
•Your board
•A malpractice attorney
•Third party payer's
medical necessity
auditor
(855) 832-6562
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Is All Care Medically Necessary?
Clinically Appropriate
Care
• Enhances life
• Relieves symptoms
• Wellness care
• Supportive care
• Maintenance care
Medically Necessary
Care
• Yields a significant
improvement in clinical
findings and patient
functionality
Think Like an Auditor
•Does this care have a beginning – new date of
onset
•Does this care have an end – discharge
•Can I tell by the daily visit notes that this
patient’s case is being managed – or does it
look like the patient comes in whenever
he/she feels like it
•Does the diagnosis match the patient
complaints - and do all of these match the
billing and coding
Medicare Documentation Guidelines
Initial Visit
•History
•Description of
Present Illness
•Physical Exam
•Diagnosis
•Treatment Plan
•Date of initial
treatment
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5 Most Common Errors
• Signatures and Identification of the Doctor and
Patient Not Clear
• No rationale for diagnostics or tests ordered
• Lack of all required elements of a treatment plan
• Initial & Daily Assessment consisting only of
diagnosis
• Performing and billing for full spine adjustments,
without proper documentation of medical
necessity
Know the Documentation Rules!
Subsequent Visits
•History
•Review of chief
complaint
•Physical Exam
•Document daily
treatment
•Progress related to
treatment goals/plan
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State Specific Rules
State Specific Documentation
State Specific Documentation
We Never Know Why the Board Will Get
Involved
The Board Will Determine the Standard
Unprofessional Conduct?
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Good Documentation Protects
• Provides an accurate
timeline of treatment
• Confirms compliance
• Ensures consistency of
patient care
• Enhances quality of the care
given
• Clarifies the actual
happenings in the visit
• Is a chronological record of
your experiences with the
patient
• Should include phone calls
and other “orders”
Bad Documentation Disregards
• Altered records
• Missing dates, patient
names, provider
signatures
• Obliterated entries
• Illegible and many
blanks
• Failure to document
patient noncompliance
• Lack of documenting
phone calls
Episodes of Care
• Charting only abnormal
findings
• Testing without clinical
rationale
• Sloppy charting of
activities and patient
remarks
• Lack of attention to
detail to record
everything that takes
place in a visit
E/M Visit
History
Clinical
Decision
Making
INPUT
OUTPUT
Exam
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Timely Documentation
What Medicare Says*
• CMS expects the documentation to be
generated at the time of service or shortly
thereafter
• Delayed entries within a reasonable time frame
(24 to 48 hours) are acceptable for purposes of
clarification, error correction, the addition of
information not initially available, and if certain
unusual circumstances prevented the generation
of the note at the time of service
*Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual. Chapter 12 - Physicians/Nonphysician
Practitioners, Section 30.6.1.
What Medicare Says
• A provider can't
submit a claim for
payment until
documentation is
completed.
• You can’t submit the
claim until the note
is fully documented
and signed
• In other words –
“Until you sign off on
your notes all of the
work you did is
unbillable!”
Ramification if Not Timely
• Charges for services cannot be billed directly
after the visit
• Services may not be able to be billed at all
because the documentation is questionable
• Services are likely to be deemed medically
unnecessary because the documentation is in
question
• Some contracts will not allow you to bill the
patient
• Your work was all for nothing!!!
Scribe Use
•Consider using a
scribe to speed up
data entry during a
visit
•Specific guidelines
on who can write
certain things in
the medical file
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Day 1.5 Considerations
Manage Your Time
• E/M documentation
takes longer
• Establish times every
day to manage this
important work
• Doctor thinking should
be scheduled
• End of each shift?
• Stay through lunch?
• Come in early or stay
late?
• Doctor “Think-time” for
diagnosing, reading Xrays, weighing the
findings of the exams, and
writing a plan of care are
near impossible to do
while the patient is in the
office
• This is a situation where
the 48 hours to complete
comes into play
• Still expected as close to
the time of service as
possible
Legibility
• Use blue or black
ink
• Never use
correction fluid or
erase
• Correct errors by
putting one line
through it, make
your correction,
and initial and date
the change
Test Yourself
•Signatures legible?
•Identification of
the doctor clear?
•Identification of
the patient clear?
•Date of service
noted?
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Use Standard Abbreviations
• All abbreviations
should be standard
• The easier your charts
are to read, the better
they will perform
under scrutiny
• Supply a legend or
key if you use nonstandard
abbreviations for any
reason
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Amending Completed Records
CMS has direct guidance on amending a
patient's record:
•The medical record cannot be altered. Errors
must be legibly corrected so that the reviewer
can draw an inference as to their origin.
These corrections or additions must be dated,
preferably timed, and legibly signed or
initialed.
The Foundation of Your Foundation
•History is important
every time you begin
a new Incident, Burst,
or Episode of care
•What the patient tells
you isn’t enough
•Weak history = weak
documentation of
medical necessity
Job 1: Doctor Listening
•Patient history, written
and spoken
•Ask thoughtful
questions about
paperwork
•Chief and additional
complaints
•HPI, ROS, and PFSH
•Begin to formulate
thoughts about
examination
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Amending Completed Records
To properly execute a medical record
addendum, the provider must, at a minimum,
write the following details in the medical
record:
• The date the record is being amended
• The details of the amended information
• A statement that the entry is an addendum to the
medical record
• The date of the service being amended
• The signature of the provider writing the addendum
History = Both Input and Output
•Inputs:
• Patient written
history or update
• OATs
• Additional concerns
in ROS
• Pain questionnaires
• Online forms
•Outputs:
• Doctor’s consultation
notes
• Expansion of written
information
• Deep digging beyond
what the patient
wrote and reported
• Expand upon OATs to
identify functional
deficits
Be a Good Doctor
• Elaborate on
subtleties
• Dig deeper
• Evaluate all the
systems that apply
to chiropractic care
• Elaborate on those
that may not apply
• Document your
“good doctoring”
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Most Important Communication Tool
Comprehensive Notes Tell the Story
• Studies related to chart
documentation have shown,
one of the most frequent
concerns is:
• Documentation is used more
as a tool to recall events
• Leading to a lack of
completeness, accuracy and
timeliness in completing
charts
• Rather than as a means to
justify treatment decisions
• Improves
communication with
other providers
• Records are a legal
document
• Inadequate
documentation
impacts both patient
care and outcomes
• The “other”
provider can be the
“future you”
Job 2: Doctor Finding
Job 3: Doctor Thinking
•This is initial
assessment (S+O)
•H + E = D => Tx Plan
•Diagnosis for each
region you plan to
treat
•Treatment plan is
obvious based on DX
•DX and plan for each
component service
• Must be driven by history
• Include tests and
measurements to quantify
history
• Distinguish between
important nuances
• Record everything in the
patient’s record
• Determine whether
additional diagnostic
testing rationale exists
Is All Care Medically Necessary?
Clinically Appropriate
Care
• Maintenance care
• Supportive care
• Palliative care
• Life enhancing and
wellness care
• Symptom relieving only
• Care that doesn’t have as
its goal improved function
and correction
(855) 832-6562
Medically Necessary
Care
• Acute problems
• Care that can provide
measurable functional
improvement
• Chronic care with
expected functional
improvement
• Often defined by the
carrier’s medical policy
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Medical Necessity: Per Medicare
Acute and Chronic Subluxation
The patient must have a significant health problem in
the form of a neuromusculoskeletal condition
necessitating treatment, and the manipulative services
rendered must have a direct therapeutic relationship to
the patient’s condition and provide reasonable
expectation of recovery or improvement of function.
The patient must have a subluxation of the spine as
demonstrated by x-ray or physical examination (PART)
The
Foundational
Visit of the
Episode
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Acute
CMS defines Acute as: "A patient's condition is
considered acute when the patient is being treated for
a new injury, identified by x-ray or physical exam as
specified above. The result of chiropractic manipulation
is expected to be an improvement in, or arrest of
progression of, the patient's condition."
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Acute
Acute
•Examples:
•New injury, identified
by x-ray or physical
exam
•Expected improvement
in or
•Expected arrest of
progression of, the
condition
Chronic
CMS defines Chronic as: "A patient's condition is
considered chronic when it is not expected to significantly
improve or be resolved with further treatment (as is the
case with an acute condition), but where the continued
therapy can be expected to result in some functional
improvement. Once the clinical status has remained stable
for a given condition, without expectation of additional
objective clinical improvements, further manipulative
treatment is considered maintenance therapy and is not
covered"
Chronic
• Slip and Fall at home and
now having neck pain
• Sudden or recent onset
of symptoms – When
lifting a box the patient
started having sciatica
symptoms
Chronic
•Not expected to
significantly improve
or resolve with
treatment
•BUT continued
therapy can result in
some functional
improvement.
Episodes of Care
• Examples:
• Numbness and tingling in
the fingers that has been
going on for years
• Post laminectomy
syndrome
• Decreased ability to sit
due to increased lower
back pain since golfing
• Inability to dress easily
due to neck pain where a
disc has become
unstable
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Maintenance
Offer a Complete and Compliant
Treatment Plan
•Wellness
• Prevent disease
• Promote health
• Prolong/enhance the
quality of life
•Supportive
• Maintain or prevent
deterioration of a
chronic condition
Treatment Plan
• Your treatment plan is
your pre-determined plan
of action.
• It will take into
consideration the tissue
specific issues defined in
your patient work-up and
diagnosis
• Soft-tissue diagnosis and
soft-tissue targeted
treatment
(855) 832-6562
Meet the Requirements
• Frequency and
duration
• Treatment goals for
each
region/treatment to
include long term
goal
• An evaluation of
treatment
effectiveness
measurement
• Date of the plan
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Frequency and Duration
• Indicate initial part of
the treatment
• It’s ok to have an end
game projection
• Don’t be so specific
that you appear
canned or boxed into
a plan
• Each section should
end with an
evaluation
Evaluate the Effectiveness—Measurably!
•OATS make it easy
•Pain is difficult to
track and measure
•Use an accepted
measure that you
can document
simply
•Improvement in
function =
success!!
Treatment Goals
• Treatment goals
need to be
functionally based.
• What functions are
we restoring with
our treatment plan?
• How will we
measure that
corrective change?
• What goals are
outlined for each
type of treatment?
Make it Shine!
•Home care
recommendations
•Prognostic factors
•Inclusion of all
possible treatment
and DME options
What if you treat today?
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Job 4: Doctor Fixing
•Know your functional
deficits so your can
focus your conversation
on how they have
changed.
• Clarify and execute
your plan
• Goals are associated
with the plan
• Medical necessity is
clear, if necessary
• It’s logical to expect
to see the treatment
coded that you
chose
• Better
• Worse
• Same
• Measurable
Daily Documentation Must Include
Patients’ Self-Appraisals
Examples:
Better - Ability to brush hair in the
morning without thumb and index
finger tingling 50% of the time
Worse - Increased difficulty putting
on bra and now requires
assistance from a family member
Same - No change in ability to walk
one block without increased pain
Best Practices for Gathering Functional
Self-Assessment
Example:
“Mrs. Klaus, your walking
really seems improved! I
remember when you first
came in you were only
able to walk about 10
feet without that sharp
knee pain… How far are
you able to walk now
without the pain coming
back?”
(855) 832-6562
Daily Documentation Must Include
Patients’ Self-Appraisals
Master Internal Systems that can
Streamline this Process
•Team member driven
documentation
•They gather relevant
data
•You review out of sight
of the patient then…
•You lead the
conversation
•Save as much as an
hour a day
Best Practices for Gathering Functional
Self-Assessment
Example:
“I get that you feel your
back pain is the same as
when you first came in but
remember how I asked you
keep track of how long you
were able to do the dishes
before it started to spasm
up again? … How long have
you noticed that you can
wash those dishes now? ”
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Best Practices for Gathering Functional
Self-Assessment
Example:
“Remember our staff is like
your pit crew trying to get
you back to driving your car
without pain! We need you
to tell us how long you can
drive now so we can tell if
we need to torque up our
treatment so we can get
you back on the road
quicker!”
Subjective?? NOT!
Good Subjective
Example:
Patient reports cervical pain that is dull and
rated at 3/10. She reports there has been no
change in her overall neck pain since the last
visit but she now is able to sleep 7-8 hours a
night with 3 hours uninterrupted by pain.
(855) 832-6562
Good Subjective
Example:
Since the last visit the patient has decreased
in sharp low back pain from a 4/10 to 2/10.
He says “It didn’t hurt to ride my bike here
today.” When asked how long of a drive that
was, he indicated that it was about a 30
minutes.
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O = ART Data Gathering
O = ART Data Gathering
Medicare wants objective
to be quantifiable and
measurable
• ROM in °’s
• Soft tissue state rated by
severity (minimal to
severe)
• Asymmetry of posture to
cm or mm
• % of impairment or
improvement when
possible
• What do you see,
palpate, and/or
observe about the
patient before
treatment
• Asymmetry (posture,
ortho findings)
• Range-of-motion
(limitations or
mobility)
• Tissue tone (Spasm,
listings, inflammation)
O = ART Gathering
Example
• Cervical Right Lateral
Flexion has improved 10%
since last visit resulting in
an increase in 5°
• Bilateral trapezius spasm
has decreased from
moderate to mild since
last visit. It is no longer
TOP
• Left foot flare decreased
during perambulation by
10° since last visit. Patient
is now 95% of WNL
O = ART Data Gathering
• Use your expertise and
education to describe
how the body is
functioning currently
• “The hips can’t lie!”
• Limits in ROM or spasm
findings indicate a need
for intervention
• Even if patient says
there is no symptoms…
your palpation can show
otherwise.
Objective?? Really?
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Good Objective/ART
Frequency of OATS
•You do not need to
get a new OAT
each visit
•How often should
they be
performed?
Subsequent Visits Documentation Requirements
•
•
History: (29% Documentation Error Rate)
• Review of Chief Complaint
• Changes since last visit
• System review if relevant
Subjective (P)
Location of Symptoms
Quality of Symptoms
Intensity of Symptoms
Physical exam: (43% Documentation Error Rate)
• Exam of area of spine involved in diagnosis – Objective (A, R,
T)
• Assessment of change in patient condition since last
visit (PE, OA, ADL, QVAS) (Same, Better, Worse)
Assessment
• Evaluation of treatment effectiveness (Same, Better,
Worse, How and Why)
•
Daily Treatment Documentation : (15%
Documentation Error Rate)
Best Practices for Defining your Doctor’s
Assessment
•Remember it is all
about Function,
Function, FUNCTION
•Identify HOW the
patient has improved
•Identify WHY they need
continued care
•That is Medical
Necessity by definition!
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PART to Assessment
P + ART = Assessment
or
S (P) + O (ART) = A
Doctor takes subjective and objective findings
and then assesses what they mean to the
effectiveness of their treatment
Plan
Best Practices for Gathering Functional
Self-Assessment
•First, train them that it is
their job to be observant
about their functional
deficits
•Help them understand
that measurable
information helps you to
assist them in faster
improvement
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What We Hope to See
Maintenance
CMS defines Maintenance Therapy as:
"Chiropractic maintenance therapy is not
considered to be medically reasonable or
necessary under the Medicare program, and is
therefore not payable. Maintenance therapy is
defined as a treatment plan that seeks to prevent
disease, promote health, and prolong and
enhance the quality of life; or therapy that is
performed to maintain or prevent deterioration of
a chronic condition. When further clinical
improvement cannot reasonably be expected
from continuous ongoing care, and the
chiropractic treatment becomes supportive rather
than corrective in nature, the treatment is then
considered maintenance therapy."
Episodes of Care
Maintenance
•Wellness
• Prevent disease
• Promote health
• Prolong/enhance the
quality of life
•Supportive
• Maintain or prevent
deterioration of a
chronic condition
Understand the Rules
• Diep ONLY billed AT
modifier, never ever
moving a patient to
maintenance care.
• Even in the details of the
rebuttal from his attorney,
he also argued that he
"never delivered care that
was not AT Modifier
worthy".
(855) 832-6562
GA
Modifier
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What’s Wrong with this Picture?
Voluntary Use = “MAY I?”
ABN for Voluntary Use
Document, Code, and Bill Properly as a Full
Spine Adjuster/Activator Provider
Don’t Stick Out Like a Sore Thumb!
98942-Appearance of Evil
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Why It LOOKS Fishy…
And Recently…
98942 Issues
So? I’m a Full Spine Adjuster!
•Medical necessity
definition dictates that
you must prioritize each
area of complaint
•Every visit:
• S + O (P + ART) for every
region treated
• 2 DX codes for each
region
• Treatment plan for
each/short and long
term goals
Philosophically Driven
• Whether you are
subluxation-based
chiropractor or simply
believe that every patient
requires a full-spine
adjustment, you need
clarity
• Proper coding and case
management for these
technique-specific and
philosophically driven
coding conundrums need
to be defined by you for
your office
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You Define Your Intentions
• Clarify your motivations so
you can describe your
situation and your
intentions
• Create and implement a
policy in order to describe
why it could appear that
your documentation doesn’t
match your coding
• Outline in writing – in
advance of any requests for
records – to help to keep
you and your practice safe
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(855) 832-6562
SOP - Example
How This Looks on Paper
Code This as 98940
Code This as 98941
Code This as 98942
Billing Should Be 98940
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Policy
Code for Subluxations Only
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Sample #1
Sample #1
Sample #6
Sample #6
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Sample #12
Sample #12
Take Action
Put on Your Auditor Hat
•What is
expected/typical
•Look at your CMT coding ratios to evaluate
code usage
•Spot check documentation for 98942 codes
billed to find out if the documentation meets
requirements
•Determine how you can improve
coding/documentation as a full spine
adjuster
Provide Appropriate Rationale
• 98940: 40-60%
• 98941: 40-60%
• 98942: 1-10%
•How would your office
look?
•Run Your Ratios!
Tell Us What You’re Thinking
• Why are the tests
being ordered?
• Why did you decide
to do what you did?
• What’s between
your ears must
appear in the
documentation
• X-rays, labs, other
diagnostic tests,
referrals, and DME
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Your Medical Records Must Tell the Story
Rationale for Films
MD Rationale for CT Scan
Possible X-Ray Rationale
ICD-10 Codes Match Findings/Language
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Who’s Asking??
•Commercial
Insurance Carrier
•Personal Injury
Carrier or Adjuster
•Worker’s
Compensation
Carrier or Adjuster
•Medicare
Administrative
Contractor (MAC)
Why Implement a compliance program?
Integrate policies and
procedures into the
physician’s practice that
are necessary to
promote adherence to
federal and state laws
and statutes and
regulations applicable to
the delivery of
healthcare services
A “Program” is not a “Manual”
•Recovery Audit
Contractor (RAC)
•Comprehensive
Error Rate Testing
(CERT)
•Zone Program
Integrity Contractor
(ZPIC)
•Program Safeguard
Contractor (PSC)
Is it Mandatory?
•Came out of the
sentencing guidelines
•Affordable Care Act:
Mandatory Compliance
Plans Coming Soon
•CMS has NOT finalized
the requirements
•CMS will advance
specific proposals at
some point in the
future
Just Do it! Compliance Program!
• The truth is, we've been
being told that since 2001.
• Get your policies and
procedures and OIG
compliance plan in place.
• It's too easy to do, and if
you don't know how, ask
us! We teach this every
weekend!! Don't delay.
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Review the 7 Steps of the OIG
Compliance Program
Customized Policies
Step 3- Employ Comprehensive
Education and Training
(855) 832-6562
Step 1- Implement Policies and
Procedures
Step 2- Compliance Officer or Contact
Step 4- Enforce Disciplinary Standards
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Step 5- Respond Swiftly to Detected
Offenses
Step 7- Open Lines of Communication
Step 6-Internal Audits and Monitoring
How This Training and
Implementation Will Protect You!
•Stay within the lines
•Eliminate confusion
•Medicare is not to be
trifled with
•Correct financial
inconsistencies
•Risk Management and
Risk Avoidance
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Need Help?
[email protected]
(855) 832-6562
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