8/28/2018 Putting the Pieces Together: Financial Stability Quar Quarterly rly Ph Physician ysician Clinical Documentation Im Clinical Documentation Impr provement ement A portion of these materials were produced in partnership with the Iowa Department of Public Health for the Iowa Small Hospital Improvement Program (SHIP) Grant FY 18Contract #5888SH01 and the Georgia State Office of Rural Health for the Georgia Small Hospital Improvement Grant FY 18. AGENDA Welcome & Introductions Jennie Price, Pre-Assessment Survey HomeTown Health, LLC E/M Note Construction Dr. James Dunnick, The Dunnick Group Upcoming Events & Jennie Price, Resources HomeTown Health, LLC Ph Physician Clinical Docum ysician Clinical Documentation Im entation Impr provement Series ement Series 1
8/28/2018 Program Goals Clinical Documentation Improvement programs are critical to rural hospitals in providing complete and accurate patient documentation. The purpose of the Physician Clinical Documentation Improvement Series is to provide physician- to-physician training in common areas of clinical documentation improvement (CDI) in order to support physicians in improving their documentation, identifying the value of their role in CDI programs, and identifying opportunities for improvement. Physician C ian Clinica ical D Documenta mentation I ion Impr provement ement Series es Financial Stability Pre-Assessment Survey Responses 2
8/28/2018 On a scale of 1‐10, with 1 being extremely poor and 10 being outstanding... please rate the focus level of your providers in improving coding and billing speed and accuracy. 16 14 12 10 Count 8 14 6 12 11 4 8 5 5 2 2 1 1 0 1 2 3 4 5 6 7 8 10 Value We have a physician champion on board to help us in our Clinical Documentation Improvement (CDI). Yes Unsure 12% 15% Yes, but it is a relatively new area of focus 12% No 61% 3
8/28/2018 We have experienced an audit in the last year that identified areas for improvement related to physician documentation. Unsure 17% Yes 37% No 46% Do you have a compliance program in place that audits each providers chart on a monthly basis? Yes ‐ at least on a monthly basis 14% Unsure 10% No Yes, but less often than 32% monthly 36% No, but we have plans in place to begin soon 8% 4
8/28/2018 If you answered yes to “have a compliance program in place for physicians,” do you provide the feedback of why the chart failed the internal audit? Yes ‐ in great detail, and there is always conversation follow up 19% Unsure 22% No 19% Yes ‐ but we could improve in this area 41% We have had training specific to physicians in Clinical Documentation Improvement... On an ongoing basis, including the last year 15% Unsure 20% Never, that I know of 29% In the past three years 36% 5
8/28/2018 Disclosure of Proprietary Interest The Dunnick Group does not have any proprietary interest in any product, instrument, device, service, or material discussed during this learning event. The education offered by The Dunnick Group in this program is compensated by the HRSA Small Hospital Improvement Program (SHIP) grant from multiple participating states, including Iowa, Georgia and Florida. Speaker Biography James Dunnick, MD, F MD, FACC, CHCQ CHCQM, M, CPC CPC, , CMD CMDP Physician – Boarded in Cardiologist Certified medical coder Certified in Electronic Medical Records Certified in Quality and Utilization Published author Email: jdmd62@gmail.com Website: www.dunnickgroup.com Physician Clinical Docum Ph ysician Clinical Documentation Im entation Impr provement Series ement Series 6
8/28/2018 Qua Quarterly P rly Physicia ysician C n CDI S I Series: ries: E/M – Creating a Not E/M – reating a Note Present Presented b ed by Dr Dr. James Dunnick . James Dunnick A portion of these materials were produced in partnership with the Iowa Department of Public Health for the Iowa Small Hospital Improvement Program (SHIP) Grant FY 18Contract #5888SH01 and the Georgia State Office of Rural Health for the Georgia Small Hospital Improvement Grant FY 18. Disclaimer 1. Do NOT assume I am correct, I make mistakes. 2. Read and self educate. 3. Government manuals, online resources. 4. Obtain professional teaching, from more than one source. 5. Consultant opinions vary. 6. Auditor opinions will vary. 7. States vary. 8. Payers vary. 9. Rules change. This is meant as general and initial information only. 7
8/28/2018 Lear arning O ning Outcomes comes When you have completed this training, you should be able to: Re Recall ll Describe Descr be Explain Explain Explain Explain the key parts the differences how to match why we must of the provider between the an evaluation do this. note – history, various levels and physical exam, of code management and medical selection. level to an ICD- decision 10-CM code. making. The Other Point of View Pa Payers • They have their problems. • They have their goals. • Are they the same as yours? 8
8/28/2018 The Other Point of View Pa Payers as as the C e CFO • They are trying to cover lives • They must be profitable • Their opinion of fair is fair from their view point The Other Point of View Payers They do not want to overpay E/M E/M They do not want to be the victim of fraud Medical Necess Medical Necessity ity They want to receive value ICD 1 ICD 10 None of this seems unreasonable 9
8/28/2018 CMS-Fraud Prevention System • The Fraud Prevention System was created in 2010 by the Small Business Jobs Act, and CMS has extensively used its tools made possible by the Affordable Care Act. CMS news letter July 2015 CMS Fraud Prevention System FPS FPS • Predictive analytics • Outliers • Billing patterns 10
8/28/2018 Fraud Prevention System 2010 – 2012 prevented $820 M of payments 2014 prevented $420 Million Million in payments 2011-2015 returned returned $25 Billion Billion of payments CMS news letter July 2015 ECONOMIC PENALTIES • Civi Civil f fals lse claim claims act: act: 1. $5,500 – 11,000 per claim 2. Three times the value of each claim • Cri Criminal al f fals lse claim claim act: act: 1. Felony 2. Up to 5 years imprisonment 3. $25,000 fine • MC/MC civil mone MC/MC civil monetary penalties la penalties law: w: 1. $10,000 per claim 2. Three times the value of each claim Corporate Integrity Agreement (CIA) Exclusion List 11
8/28/2018 Penalties CMS t CMS terminat rminates Idaho es Idaho hospit hospital's Me al's Medicar care co contract* ract* Flori Florida Hospi a Hospital al f fine ned 85 million 85 million Detr Detroit Area Hospital oit Area Hospital Syst System t em to Pa Pay $8 y $84.5 4.5 Million** Million** * Written by Ayla Ellison (Twitter | Google+) | July 27, 2018 **Department of Justice Office of Public Affairs August 2, 2018 Penalties Louisiana psychiatrist con Louisiana psy hiatrist convict icted d of Medicare fraud ($258 of Medicare fraud ($258 millio million) * • 7 years in prison Car Cardiologist con iologist convict icted of d of 350 f 350 false claims ($238,230)** lse claims ($238,230)** • Pay back $721,960 • 1.7 years in prison Car Cardiologist indict iologist indicted f ed for unnec r unnecessar essary pr procedures and ocedures and testing sting ** *** • Hospital f Hospital faces 1 ces 15 la law w suits suits *On August 25, 2014, Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division announced **Written by Ayla Ellison (Twitter | Google+) | August 02, 2018 | Print | Emai ***lSecurities and Exchange Commission filing Written by Ayla Ellison (Twitter | Google+) | February 13, 2015 12
8/28/2018 Penalties 2017 an EHR company was fined 155 million dollars and CIA • Falsified certification standards 2018 fined 132K dollars • Failed to report patient safety issues with in 48 hours Written by Julie Spitzer | July 31, 2018 Becker’s Hospital Report Penalties Inadvertent Raleigh Hospital • Audited 263 claims (MC billing requirements); 187 were accurate; 71% passed. • 76 charts failed; $250,000 over payment • Extrapolation; $697,000 13
8/28/2018 Penalties Inadvertent Dentist $84,000 Family Practice Physician 162,676 ENT 750,000 Pediatrician 336,298 Coders Fined Exclusion list Examples; August Medical Practice Medical Practice • Pediatrician; LPN on Exclusion list • $45,735.42 • Allergy and Asthma MD; RN on Exclusion list • $61,142. Posted by CJ Wolf Aug 13, 2018 11:00:00 AM 14
8/28/2018 Tr Trying t to Adapt 26 states that have seen at least one rural hospital close since 2010 https://www.beckershospitalreview.com/finance/state-by-state-breakdown-of-83-rural-hospital-closures.html 7 rural Georgia hospitals have closed since 2010 8 hospitals have closed between June 1 and July 26 2018 Written by Ayla Ellison (Twitter | Google+) | August 02, 2018 | Print | Email Objectives • 1. Recall the key parts of the provider note – history, physical exam, and medical decision making • 2. Describe the differences between the various levels of code selection • 3. Explain how to match an E/M level to an ICD-10-CM code. • Explain why we must do this 15
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