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Presented by

Why Templates Can

Make You Cry!!!

Angela Jordan, CPC

Senior Managing Consultant

AAPC National Advisory Board, Southwest

DisclaimerThe speaker has no financial relationship to any products or services referenced in this program. The program is intended to be informational only. The speaker is not an authoritative source by law. Attendees are advised to reference payer specific provider manuals, on-line or otherwise, for verification prior to making changes to their coding, documentation and/or billing practices.

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EHR’s, EMR’s and PHR’s

Where Problems Start

Documentation and Link to Coding

New Role of the Coder

Objective

Electronic Health Records (EHRs) focus on the total health of the patient—going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient’s care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the information

EHR

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Electronic Medical Records (EMRs) An electronic medical record (EMR) is a digital version of a paper chart that contains all of a patient’s medical history from one practice. An EMR is mostly used by providers for diagnosis and treatment.

EMR

Patient Health Records (PHRs) contain the same types of information as EHRs—diagnoses, medications, immunizations, family medical histories, and provider contact information—but are designed to be set up, accessed, and managed by patients. Patients can use PHRs to maintain and manage their health information in a private, secure, and confidential environment. PHRs can include information from a variety of sources including clinicians, home monitoring devices, and patients themselves.

PHR

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HealthIT.gov https://www.healthit.gov/

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Patient portal

Active Problem List

Orders tracking and results

Flowsheets and treatment logs

Documentation completed timely

Outside records and correspondence

Patient and staff communication

Complete EMR

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Where Problems Start

Step 5: Achieve Meaningful Use Stage 2

Clinical Importance: Providers are encouraged to electronically record progress notes to provide access to the most well rounded patient information available to support continuity of care across patient care settings. Narrative entries in the progress note are an important component of patient records and complement data captured in defined structured fields; together these components create a more complete picture of the patient’s status and can be used to track patient progress and sharing of information across care settings.https://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures-2/electronic-notes

Electronic Notes

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E/M leveling

Procedure code master

Diagnosis code master

Typos perpetuated through templates

Cloning

Problem Areas

Template creation

Auto populate

Cut and paste

Shared templates

E/M Leveling

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History of Present Illness:

1. follow up

Very pleasant 81-year-old white female who started using her Norco and states it has

helped significantly with her pain. She denies any side effects with the medications that

she is constipation or increased sedation. However she just saw her rheumatologist Dr.

who felt that her left knee looks terrible and her arthritis has progressed. Her pain

otherwise isn't 10 in intensity. She cannot walk any distance whatsoever although is

able to do her activities of daily living. She cannot stand for long periods of time and is

usually in a wheelchair. However she still lives independently and drives and does her

activities of daily living independently. She would like referral to orthopedic surgery so

she could possibly get a total knee replacement and become ambulatory again. She is

diabetic she doesn't check her blood sugars however she does check her blood

pressures and they've been controlled. She just saw her cardiologist recently who

stated everything cardiac-wise was stable. The patient denies any issues with chest

pains or shortness of breath. Icemaker was also recently interrogated and was

functioning fine. She has had no lightheaded spells.

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History of Present Illness:

1. Swelling

The patient has swelling in the bilateral ankle.

This is a very pleasant 57-year-old white female patient who is undergoing a lot of family issues. There is multiple issues with incest and sexual assaults. Her brother she was sexually assaulted her daughter when she was 12 passed away. Her issues with her mother who doesn't recognize it and it totally ignores it. Although there is been several reported incidences by the dietitian was sexually falsify her grandfather as well as another in law in the family. The patient denies being suicidal or homicidal. She actually feels better now that the weather has pounds. She has attempted to call or contact her psychiatrist on multiple occasions. According to her they've been unable to talk. Pimpling phone tag. Therefore she has not been into see them. The patient is complaining of intermittent anterior chest wall pain which she feels like it a bicycle around her chest. It sometimes radiates into her neck. She states it lasts for 10 minutes and can occur at rest as well as with activity. Complains of feeling tired all the time and has noticed some swelling in her legs. She has been compliant with taking her thyroid but has not started her vitamin D yet. She still continues to smoke.

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HPI: Patient is here for an acute visit for hypertension. She has the following cardiac diagnoses: 1. Hypertension 2. Shortness of breath chronically 3. Bradycardia secondary to calcium channel blocker therapy now resolved. 4. Diastolic Dysfunction Grade II 5. Intolerance to norvasc which was back pain.

She has had good blood pressures at Rockwell. She has it checked by one of the nurses there and it has been within normal limits with Systolic blood pressures in the 120's to 130's. She states she has been under a lot of stress today. One of her coworkers was found dead and she just heard about it earlier today. She said she has been upset over it. She has a sleep study scheduled through Dr. office on May 15.

Physical Exam (No changes noted in this exam, and no notation that no changes from previous exam date is documented)PHYSICAL EXAMINATION: NECK: Supple. Trachea midline. No jugular venous distention noted. Good carotid upstroke. No bruits. No thyromegaly or lymphadenopathy is noted. LUNGS: Clear without any rales, rhonchi or wheezes. Good chest expansion bilaterally. HEART: Tones are regular without any murmurs, rubs, gallops, lifts or heaves. PMI is unremarkable. No subclavian or abdominal bruits are noted. There are good distal pulses. EXTREMITIES: Free of any cyanosis, clubbing or edema. NEUROLOGIC: Grossly nonfocal. Alert, oriented, cooperative. Stable affect and mood and attentiveness during the examination. Moves all four extremities without limitations.

Problem List Items Addressed This Visit None

PLANS: 1. Hypertension is uncontrolled today. She is under a lot of stress today. She will continue to get her blood pressure checked at work once or twice a week. She states that the blood pressure has been under excellent control at work with SBP of 120's to 130's. She is currently on coreg, hydralazine, hctz, and lisinopril. Her renal artery ultrasound was negative for stenosis. She has a sleep study that has been ordered by Dr. Cearras' office for May 15. She had a normal nuclear stress test 11/2014. 2. Shortness of breath chronically. This is chronic and controlled. Slightly improved on Advair. 3. Bradycardia secondary to calcium channel blocker therapy now resolved. 4. Grade II diastolic dysfunction. No signs of fluid overload.

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A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

Describing any new ROS and/or PFSH information or noting there has ben no change in the information; and

Noting the date and location of the earlier ROS and/or PFSH.

ROS and PFSH

“It is always important for providers to remember that a note needs to stand on its own. Using a statement indicating the exam is unchanged from the last/prior is a great summary, they must document EXACTLY what they did on that specific visit and bringing forward the previous exam does not do that.” So therefore, we would not consider any portion of an exam statement that simply referred back to previous exam.

Exam – Policy Staff at WPS

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Claim – 13131 Complex Repair

Medical Procedures

We conducted a wound check and/or repair. Applicable diagnosis: 882.0-OPEN WOUND OF HAND. Prepared for the procedure

by cleaning with hibicleanse. was 0 - 2.5 cm Instructions were provided to the patient as documented elsewhere. Patient's wound

was cleansed post-operatively with saline. Patient tolerated the procedure well. A Gauze was used to cover the wound

Claim – 99203-25, 12001

Treatment / Orders / Work Restrictions

Ordered Tetanus/diphtheria/pertussis, acel (Tdap), 5 units-2 units-15.5 mcg/0.5 mL.1 injection I.M. Administer: 1 injection.

Prescribed Keflex 500 mg oral capsule, 500mg.1 capsule orally twice a day, for 5 days. Finish all medication. #10 capsules. No refills

Medical Procedures

We conducted a simple (0 - 2.5) laceration repair procedure on the finger. Applicable diagnosis: 883.0-OPEN WOUND OF FINGER. The laceration involved the

following elements: epidermis. Prepared for the procedure by cleaning with betadine and saline irrigation. Wound was 1 cm. Wound was closed with dermabond.

Instructions were provided to the patient as documented elsewhere. Patient tolerated the procedure well.

Patient Instructions

The laceration on your finger was closed with skin glue. The glue will stay on for approximately 3-5 days and then start to wear off. Apply a bandaid over the wound

anytime you are around a dirty environment, avoid excessive water on your hands, and do not apply any ointments or creams to the wound. Clean with soap and

leave dry most of the time. Take the antibiotics to avoid an infection. If you have concerns or feel it is infected then return and be seen again, otherwise no follow up

is necessary.

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Defaulted findings

History and ROS contradictory

Shared template

Copy and paste

Lack of description

Over documentation

Unable to identify who contributed to the note

The Bad Note

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Presenting problem clearly stated

PFSH appropriate

ROS and Exam patient specific

Provider thought process obvious

Care plan generates appropriate follow-up

Note identifies the contributors

The Good Note

There appears to be a heightened interest among medical providers to include non-patient specific information in medical record documentation. An example is, "if the patient was a smoker, they were advised to stop," or "education was given, if new medications were prescribed." Providers need to be cognizant that the medical record must demonstrate the existence of a relationship between the patient and the provider and that it is difficult and potentially dangerous to design a medical treatment plan in which "one size fits all." Documentation must support that only medically necessary services were actually provided in order for Medicare to consider reimbursement for otherwise covered services.

Non-Patient Specific Information in Documentation - WPS GHA

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WPS Medicare has recently been informed of a new trend in medical record documentation - that of using some type of disclaimer. Examples include the following: "Due to possible errors in transcription, there may be errors in documentation"; "Due to voice recognition software, sound alike and misspelled words may be contained in the documentation"; and "I am not responsible for errors due to transcription." Providers are responsible for the medical record documentation. Disclaimers such as those above do not remove that responsibility. The provider should verify the information is complete and accurate prior to attaching his/her signature.

More Guidance for Provider Signature Requirements can be found on our website.

Disclaimers Used as Part of Physician's

Signature

Physician typing

Dragon speak

Dictation

Templates with only check boxes

Flexibility Pros and Cons

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Front line support

Linking diagnosis for all services

Selecting appropriate service codes

Add on codes

Modifier usage

NCCI and other payer specific edits

Coders as Educators

Rescue and Recovery

James M. Taylor, MD, CPC, is medical director of revenue cycle, Kaiser Permanente, Denver

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James M. Taylor, MD, CPC, is medical director of revenue cycle, Kaiser Permanente, Denver

Educator and Auditor

EMR/EHRCMS Rules

Some Things Never Change

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95 and 97 E/M Documentation Guidelines

NCD’s and LCD’s

ABN’s

Time based billing

Special Payer policies

CMS and Payer Guidelines

Records legible

Track corrections

Documentation complete

Orders tracking

Audit logs

Benefits

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Password required at save and sign

Physician signature

Responsibility to show all work entries

Authorship vs. countersigning

Validation

QUESTIONS

www.medicalrevenuesolutions.com

Embrace technology, never turn down an opportunity to learn, and you will continue to

grow.

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Presented by