Getting Started with OIG Compliance - KMC University · •Pathway for electrochemical nerve impulses •Made of mostly Fats (Omega 3’s) Physiology Physiology is the study of movement

www.KMCUniversity.com 12/5/2015

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CA-101: The 4 Things Every CA Must Know

Part 1

Presented by:

Becky Walter, MCS-P, CMQP, CCCA

Our Plan!

Part 1:

•Chiropractic terminology for CA’s

Part 2:

•Boundaries and Ethics

•Patient Safety

•Documentation

Prep for the CCCA Exam on Saturday

•Not taking the test? No problem!• Still want to take the test?…please advise•Use this as a refresher for some of the questions about terminology

Chiropractic Terminology

•Anatomy

•Physiology

•Therapies and Modalities

•Conditions

Anatomy BasicsSkeletal System: 206 bones, cartilage and ligaments

Axial Division: Trunk

Appendicular Division: Appendages

Condyle: Rounded end of bone

Tendons: Anchor Muscle to Bone

Ligaments: Anchor Bones to Bones

Understanding the Roots

• It’s Greek to me! Or Latin!

• Terminology

• Root Words

• Suffixes

• Prefixes

• There’s a method to the madness


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Core Chiro Terms

• -algia = pain

• -itis = inflammation

• -pathy – disease of, usually non-inflammatory

• -osis = state or condition of

• Cervicalgia

• Lumbalgia

• Scoliosis

• Cephalgia

• Myalgia

• Myofascitis

• Spondylopathy

Very Common Prefix/Combining Forms for DX

Basic Anatomy-Directional TermsAnterior: In front of, front

Posterior: After, behind, following, toward the rearDistal: Away from, farther from the originProximal: Near, closer to the originDorsal: Near the upper surface, toward the backVentral: Toward the bottom, toward the bellySuperior: Above, overInferior: Below, underLateral: Toward the side, away from the mid-lineMedial: Toward the mid-line, middle, away from the side

Common Anatomical Terms

•Prone: Lying face down

•Supine: Lying on the back, face up (also dorsal)

•Antalgic: Any physical attitude assumed to gain relief of pain

Spinal Anatomy Cervical Spine

• 7 vertebra: C1-C7

• Occiput

• Atlas = C1

• Axis = C2

• Atlanto-Axial = C1-C2

• Cervical Lordosis: refers to the curve of the spinal: could be hypo or hyper


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Thoracic Spine

• 12 Vertebra: T1-T12

• Also called the dorsal spine

• Kyphotic Curve• From the Greek: hump•AKA hunchback

Lumbar Spine

• 5 Lumbar Vertebra: L1-L5• Pelvic• Sacrum• Coccyx• Lumbar lordodic curve• Many areas to understand below the belt

Extra-Spinal Joint Anatomy

Joints outside of the spine:• Mostly Synovial (filled

with Synovial Fluid)• Have different functional

limitation and pathologies based on body’s use

• Are ALL adjustable (98943)

• Dysfunction effects function of the spine

Muscles

Different types of muscle•Skeletal (moves bone and other structure)•Smooth (organs)•Cardiac (Heart)

Chiropractors mostly treat Skeletal Muscles

Muscle NamesMuscle Anatomy

• Like Rope:•Made of multiple strands of myofibrils that are bound together to form the muscle• Each myofibril has multiple sarcomeres that are bound together as well


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Fascia •All muscles and organs are wrapped in fascia

•Injury or repetitive activities cause binding up of tissue

•Causes groups of muscles to be effected

Nerves

•Cable-like bundle of nerve fibers

•Pathway for electrochemical nerve impulses

•Made of mostly Fats (Omega 3’s)

Physiology

Physiology is the study of movement of the body

Terms of Motion

•Flexion: The joint angle becomes smaller•Cervical flexion is when the head is bowed forward•Lateral flexion is ear to shoulder

•Hyper/hypo-flexion: Too Much/Too Little Flexion

Terms of Motion

•Extension: The joint angle becomes larger•Cervical extension-head goes backward

•Hyper/Hypo-Extension: Too far, as in hyperextended knee

Terms of Motion

•AB-duction: Moving farther away from the mid-line

•AD-duction: Moving toward the midline


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Lordosis/Kyphosis

•Lordis – Bent to front

•Osis – state of

•Kypho – bent to back

•Hypo- not enough

•Hyper – too much

Cervicothoracic Junction

•Sit at a desk much?

•Text much?

•Look at your phone much?

•Patients have more and more challenges with forward head carriage

Upper Cross Syndrome

Subluxation/Segmental Dysfunction DX

A vertebral subluxation is the result of spinal bones with improper motion or position affecting nerve communications between your brain and your body.sub = less than | luxation = dislocation

Facet Joint Syndrome•The zygapophysial

joints account for between 5% and 15% of cases of chronic, axial low back pain•Facetogenic pain is the result of repetitive stress and or cumulative low-level trauma leading to inflammation and stretching of the joint capsule


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Facet Syndrome

•Well- localized LBP with some hip/buttock or leg pain above the knee

•Sudden onset often movement

•Facet or capsule is the source of pain

•Lumbar paravertebral tenderness is indicative of facetogenic pain.

Disc Conditions

Changes to the disc space or condition effect:

•Nerve communication•Organ dysfunction•Muscle spasms•Burning/numbness feeling•Muscle atrophy

•Normal joint function•Recruiting of muscles• Increase wear on adjacent

joints

Disc ConditionsDegeneration

• Spinal arthritis• Three phases (increasing in severity)• Chronic

Bulging disc• Part of the disc presses on the nerve root• Can cause radicular symptoms• Commonly caused by trauma

Herniated disc• More severe version of bulging disc• MRI often needed to confirm• Very severe can require surgery

Thinning disc• Dehydration/desiccation of the disc

Osteophyte formation• Sandpaper-like bone spurs where the body

naturally starts to fuse vertebrae together• Wolfe’s Law (Bones grows according to imposed

demand)• Compresses and limits the discs’ normal ROM

Muscle Spasm

Commonly called a “charley horse” but it can occur in any muscle

Spasms of skeletal muscles are often due to:• Overuse • Dehydration• Electrolyte abnormalities

Presents:• Abruptly• Painful• Usually short-lived• Often the pain comes and goes• Secondary to larger condition

Trigger points (“muscle knots”) are found in spastic muscles – these may cause radicular symptoms

Arthritic Conditions

• Over 100 types of arthritis• Common arthritis joint symptoms include

swelling, pain, stiffness and decreased range of motion

• Can cause permanent joint changes• Osteoarthritis is the most common type of

arthritis• When the cartilage – the slick, cushioning

surface on the ends of bones – wears away, bone rubs against bone, causing pain, swelling and stiffness

• Over time, joints can lose strength and pain may become chronic

• Risk factors include excess weight, family history, age and previous injury

Osteoporosis

•The bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D•Becoming very common in youth due to poor diet

Large amounts of soda cause the body to build bone from phosphorus instead of calcium Contraindicated for some chiropractic techniques


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Therapies and ModalitiesSupervised Modalities

• 97010-97028 DO NOT require one-on-one contact by the provider

• Billed only once per encounter

• Are not time based for billing purposes

• However documentation should include where it was delivered and time

Use of Ice-Cold Therapy

•Causes vasoconstriction (shrinkage of blood vessels), decreasing blood flow to an area, and slowing the body’s metabolism and its demand for oxygen. • The therapeutic goals

include reducing edema, easing inflammation, and blocking pain receptors.•Cold vs heat within the

first 48 hours after injury.

Use of Heat

•Heat causes vasodilation increasing blood flow to a specific area. • Increases the oxygen,

nutrients, and various blood cells delivered to body tissues•Relieve local pain,

stiffness, or aching, particularly of muscles and joints

97012 Mechanical Traction

• Force used to create tension of soft tissue or to separate joints•Untimed & billed only

once a visit• Intersegmental or Roller

tables meet criteria, BUT check with 3rd party payer guidelines• Flexion Distraction

technique is a CMT & should be coded as an adjustment

Mechanical Traction•Manual or mechanical pull

on extremities or spine to relieve spasm and pain •Considered medically

necessary for chronic back or neck pain• Typically used in conjunction

with therapeutic procedures, not as an isolated treatment• For cervical radiculopathy,

treatment beyond 1 month is often self-administered mechanical traction in the home.


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97014 Electrical Stimulation (EMS)

•Application of Electric stimulation to a specific area for nerve or muscle disorders

•Billed only once per visit• Sometimes you must use

G0283 instead of 97014 for unattended EMS

Presently United Health Care & Medicare are the only carriers that requireG0283

Interferential Therapy (IFT) / Premodulated

•Proposed to relieve musculoskeletal pain and increase healing in soft tissue injuries and bone fractures• IFT delivers a crisscross

current resulting in deeper muscle penetration• Theorized that IFT prompts

the body to secrete endorphins and other natural painkillers and stimulates parasympathetic nerve fibers to increase blood flow and reduce edema UHC MN 2016

Other Waveforms

Transcutaneous electrical nerve stimulation (TENS) Russian•Muscle strength and torque

generation

High Voltage Pulsed•Pain and edema reduction

•Microcurrent•Speeds healing process• Increases circulation•Used in dermatological practices to

tighten skin on face

Constant Attendance Modalities

•97032-97039 require direct one-on-one patient contact by provider.

•These are timed based codes for billing

•Documentation should include total time spent

One on One means “One on One”

•One-on-one attendance means one provider is attending to one patient individually for the minimum unit of time for that CPT code for that particular therapy service

97035 Ultrasound

•Ultrasound, each 15 mins. One or more areas

•Great for adhesive scars, spasm, soft tissue


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Laser Therapy

• Low-level laser therapy is a non-invasive light-source treatment that has no heat, sound or vibration• Provides pain relief,

reduce damage due to the injury and improve function

Coding is either 97039 or S8948Each billed in 15 min. increments

• Indications for laser therapy • Pain• Edema• Muscle strains• Ligament sprains• Nerve injuries/irritations

CA-101: The 4 Things Every CA Must Know

Part 2 Presented by:

Becky Walter, MCS-P, CMQP, CCCA

Topics Covered

Part 2:

• Boundaries and Ethics

• Patient Safety

• Documentation

Patient Safety

• Noticing potential risks in patient interaction and treatment and responding to the unique needs

• All offices have risks

• Having well documented policy and procedures of how your office will handle possible safety issues is key

OSHA

• Occupational Safety and Health Administration (OSHA) governs workplace safety

• Many states have their own version that may have stricter rules and/or resources

• They will do a free onsite audit to help you get to legal

Blood Born Pathogens• Even if your doctor does not do

acupuncture or venipuncture this area must be addressed

• OSHA has direct minimum guidelines

• Your policy should address:• Handling blood or other body fluid

spills or open wounds

• State-required vaccinations and/or declination for employees if applicable (even if your doctor is anti-vaccine)

• Policy and Procedure for coming in contact with body fluids

• “If it is wet and not yours, DON’T TOUCH IT”


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Radiology Considerations

• X-rays do contain risks and contraindications

• Potential risks• Pregnancy or possible

pregnancy

• Active or recent radiation treatment

• Metal in the body (MRI)

• Possible or confirmed fracture (positioning)

• To staff as well

Therapies Some therapies have counterindications which could harm the patient:

• Pacemaker for EMS or ultrasound

• Open wounds

• Active Cancer

• Heart conditions with rigorous exercises

• Balance issues

• Pregnancy

• Current flu/cold

• Medications (blood thinners and others)

If the patient has these or others, it does not mean they cannot have the treatment.

Alert your doctor and they will assess the risks of the therapy vs. the rewards of treatment

Responding to Health EmergenciesHow will your office respond to :• Heart Attack/stroke• Patient/team member

fall or injury• Loss of conscience• Active labor • Others

Have policies in place and train annually on how they are to be handled

Easy Phone Access List

• Look up the numbers

• Post this by every phone

• Everyone trained when to use these numbers

Ethics/Boundaries/ Managing Risk

• Most Common Causes of Malpractice

• Licensing Board Complaints

• Cultural Sensitivity and Diversity

• Inappropriate Patient contact

Harassment and the Work Place

No matter the office size, possible harassment must be addressed

• Comments or actions effect the tenor of the workplace

• Does not have to be sexual to cause harm

• Staying or leaving is a problem

• Lawsuits or audits steal your attention

• Guilty until proven innocent situation – policy can protect!


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When Harassing Conduct Violates Law

Unwelcome conduct based on:

• Race

• Color

• Religion

• Sex (including pregnancy)

• Nationality

• Age

• Disability or genetics

Hostile Work Environment

• Quid Pro Quo – “this for that”

• Hostile Environment –Frequent and Severe

Cultural Sensitivity and Diversity• Patients represent religion,

race, sexual orientation, and/or gender

• Refusing a patient is a business decision that should not be taken lightly

• Avoid casual comments that injure

• Be aware of what you say

• Write it on paper and read it before you say it or post it

Inappropriate Patient Contact

Consider:• Proper draping/gown

usage of exposed skin• Comments about

wardrobe or other physical attributes

• Men or women• How will the office

handle inappropriate patients

• Ethics of patient/team member dating

Documentation

Why Is Documentation So Important?• Ensures quality patient

care• Meets licensure

requirements to protect the public

• Guards against malpractice action

• Secures appropriate reimbursement

• Because…if it wasn’t written down, it didn’t happen!

Know your Audience

• Another health care provider

• Your board

• A malpractice attorney

• Third party payer's medical necessity auditor


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Good Documentation Tells a Story CA’s Play a Huge Part in Documentation• Patients will tell you

things they don’t tell the doctor

• You likely spend more time with the patient than the doctor

• They give you LOTS of subjective data that effects their care

• Write it down!

Help Your Doctor to Be a Good Documentarian

• Elaborate on subtleties

• Dig deeper

• Evaluate all the systems that apply to chiropractic care

• Elaborate on those that may not apply

• Document the “good doctoring”

Most Important Communication Tool

• 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”

Documentation in History

• Patients should be asked about a specific incident for every new episode when billed to third party

• What ADL is reduced now and how much

• Why are they here now as opposed to last week

Minimum Documentation Standards

• Each state has written or implied documentation rules

• Sometimes one is not aware until it’s too late

• Find out whether your state has specific rules

• Don’t find out the hard way


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State Specific RulesGood Documentation Includes

• Timeline of treatment

• Consistency of patient care

• Quality of the care given

• Actual happenings in the visit

• The value of the treatment (improvement)

• Phone calls, labs, radiology and other “orders”

Bad Documentation Examples

• Altered records

• Missing dates, patient names, provider signatures

• Obliterated entries

• Illegible and many blanks

• Failure to document patient non-compliance

• Lack of documenting phone calls

• 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

Your Best Defense is a Good Offense

• Protection from accusations

• Support for billing

• Trail of treatment for other providers

• State and federal laws require it

Signature and Patient Name Issues

Why Authenticate?

• To verify provider who treated

• Prove services were provided

• Indicate and verify who provided them

• Validates the entry and legally binds the physician for the included info


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Can we Identify Provider? Review Signature RequirementsFamiliarize providers and office staff with signature requirements to ensure

more complete compliance with

signature authentication policies

How do we authenticate signatures?

Signature Log

Update Signature Log

• Every year have each provider sign again, even if it hasn’t been a year since the last signature

• Add new providers to the log as they join the group

• Replace previous logs with most recent signatures, however save old copies

• Make sure every log has a start and end date

Patient Identifiers

• Patient name must appear on every item, page or piece of paper

• Name and Address of the Provider must be clear

• Patient number and DOB helps identify

What is Timely Documentation?

Definition:

Describing the events of a patient encounter, supporting the care with subjective and objective clinical rational, assessing the effectiveness of the encounter, and certifying that the services were rendered within the legally mandated medical guidelines


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What is Timely Documentation?

In plain English:

• Record details of the service and encounter

• Support why you did it

• Signing says “I declare that it happened”

• Do all of the above right away or by the end of the day!

Why Timely Documentation Matters

• Affects patient care• You could forget clinically important and relevant data if

you wait to write it down

• Affects quality of documentation• Cloning becomes more likely

• Not documenting timely directly effects your bottom line• Slower reimbursement

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.

Not Just Medicare

• Remember all 3rd party payers base their policies on the CMS standard

• Most states have adapted CMS’s guidelines on this as well. So your license may depend on your timely documentation!

Documenting More than a Daily Note

There are situations that need a bit more clarification:

• Day 1.5 Considerations

• Corrections and omissions to already complete records


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Day 1.5 Considerations

• Doctor “Think-time” for diagnosing, reading X-rays, weighing the findings of the exams, and writing a plan of care takes time

• If you need the whole 48 hours, take it

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

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.

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

Why did they make these rules?

• Your documentation quality is in question?• Did what happened in the visit really happen?

• Did you make any of the note up after the fact to make it payable when it should not be?

• Are you providing appropriate care if your notes can’t be trusted?

• They don’t want to pay you for incomplete or late work!

So what happens I don’t want to follow the rules?


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What Medicare Says

• A provider can't submit a claim for payment until documentation is completed. • No claim until the note

is fully documented and signed

• It must be “contemporaneous”

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!!!

Cold Pizza Analogy

• When was it made?

• Why isn’t it correct?

• Do I have to pay?

Non-timely documentation is delivering a two day old, cold pizza to the payer, expecting full payment for it

Take Away

• Document note at the time of service (or at max 48 hours afterwards)

• Even E/M have a time clock for completion

• Amending the record with new or corrected information is possible but original must be preserved

• Scribes may be able to help get documentation done more quickly

Need help? [email protected]

Documents

Getting Started with OIG Compliance - KMC University · •Pathway for electrochemical nerve impulses •Made of mostly Fats (Omega 3’s) Physiology Physiology is the study of movement