payors do not prescribe clinicians to perform audits, it is a very helpful practice to use. It can also reinforce the value that your company provides to your clients. audits should have some statistical significance to them, but you can perform a “mini” audit on an annual or two-year basis. audits should cover all medical practitioners in the office, including nonphysician providers and a variety of clinical support staff, to ensure complete medical record taking from the onset of the encounter. as noted earlier, longitudinal samples should review records for the same patients for more than one period. For example, a sample could be structured for ten patients per billing provider for all encounters in the last two years. It is only when samples are taken in this fashion that cloned records become clearly identifiable. another best practice is to use an outside auditor for claims audits no less than every three years. RECOMMENDATION: Work with your clients to include a cycle with your billing service contract. BEST PRACTICE: FRESH PRIOR HISTORY OF PRESENT ILLNESSES FOR EACH ENCOUNTER many medical record systems allow the prior history of present illness (HPI) to be pulled forward from the last encounter or a similar encounter. In certain instances, the medical group has clinical support staff pull forward information as part of their work to prep the patient for the physician. Often times, this cloned HPI includes diagnoses and treatment that will not be covered during that visit. For multispecialty groups, emrs that allow for all work-ups seen by the practice to be included in the next encounter by any physician in the group are especially difficult for billers and auditors. It leaves you wondering: For which diagnosis do you code, and what drove the medical encounter, treatment, and follow-up? To solve for both of these issues, preferred systems allow for each encounter to use a diagnosis-based template for unique completion specific to that encounter. RECOMMENDATION: Work with your clients to clarify how their emr is used by medical staff and clinicians. Work with them to enact policies and system functions that discourage cloned records. This may include recommendations to switch to a different emr. BEST PRACTICE: STAY AWAY FROM DEFAULT LANGUAGE language built into templates or used in time-saving macros is ripe for audit failure and recoupments. rarely do these defaults fit the actual patient encounter, and they must be customized. RECOMMENDATION: either turn off all default functionality or educate clinicians to edit any default language entered on each 10 HBma BIllINg • NOVemBer.DeCemBer.2014 encounter. Clinicians should proof the entire record, and the electronic signature process should require that the entire record be reviewed. Best Practices Tomorrow a 2013 study discussed in the Critical Care Medicine journal found that the younger generation of physicians coming through training often use cloning to complete their charts. Compared to their attending physicians, residents copied partial notes 82 percent of the time, but for fewer components (55 percent) than their attending physicians (61 percent).5 This is especially true after residents in the study returned from vacation. The most troubling part of the study was that it was limited to intensive care unit patients; in this instance, cloned notes could easily drive inappropriate care because the record failed to reflect the latest changes in the patient’s status. Cloned notes are a significant issue that require deliberate changes to IT infrastructure, processes, protocols, and culture. Billing companies can play a big part in reinforcing and facilitating this change. Jennifer Searfoss has been the CEO of the Searfoss Consulting Group, LLC, since its founding in 2011 and is focused on revenue cycle management and strategic planning in this post-health-reform world. From 2007 to April 2011, she established and led the Provider Communications and Advocacy unit for UnitedHealthcare. Prior to that, Jennifer served as the external relations liaison for the Washington, DC– based Government Affairs Department of the Medical Group Management Association. Scott Kraft has more than 12 years of experience analyzing healthcare policy and delivering common sense solutions for physician practices. Scott is a certified coder and medical practice auditor. He has published hundreds of articles with detailed information about Medicare payment policy, collections, fee schedule analysis, administrative best practices, and how-to coding advice. Resources 1. “Cloned Documentation Could result In medicare Denials For Payment,” National government services, last modified january 13, 2014, bit.ly/1uga2uD. 2. albelson, reed, and Creswell, julie, “us Warning to Hospitals on medicare Bill abuses,” New York Times, september 24, 2014. 3. Ibid. 4. Ibid. 5. Thornton, jD, schold, jD, Venkateshaiah, l, and lander, B,
Billing_NovDec14
To see the actual publication please follow the link above