On September 24, 2012, Secretary Katherine Sebelius of the Dept. of Health and Human Services, and Eric Holder, Attorney General, of the Department of Justice, issued a joint letter to several health care associations, including the American Hospital Association and Federation of American Hospitals. You can view a copy of the letter on HCC University, on our Tools page.
Although the letter applauds the widespread adoption of EHRs, it notes that there are indications that some providers are using them to clone records and to game the system. The letter points out that this type of false is not only dangerous to the patient, but also illegal.
The letter notes that CMS is stepping up its medical record review activities to identify these issues, and that the DOJ, FBI and other law enforcement are monitoring these issues and will take action when warranted.
So--how do CMS, the DOJ and others identify cloned medical records? Cloned records are often very obvious. Although they may occur in handwritten records, it is most often found in EMRs with cut and paste and template functionality.
Although templates are not inherently bad, auto-populating them indiscriminately with information can lead to obviously cloned records. While some things may not change significantly from visit to visit (for example, the bulk of the patient's history may remain the same), a patient's condition is rarely, if ever, static. A patient's interim history, vital signs, symptoms and treatment are almost never exactly the same. Copying and pasting these components leads to inaccurate medical records.
Another area where cloning becomes obvious is in the assessment. Often, previously treated or self-limiting diseases remain in the assessment for months or even years. We've seen charts where a diagnosis of "acute sinusitis" continued on for over a year, with no treatment after the initial date of service where it appeared.
It's important to remember that once one part of the medical record is obviously wrong, and auditor is likely to discount the record in its entirety, since it's impossible to tell what is and isn't accurate.
Clinicians using EMR should use templates wisely, and cut and paste functionality very sparingly. All information in the chart should accurately reflect the patient's complaints, conditions, and treatments on the current date of service.
Tuesday, October 9, 2012
Friday, August 24, 2012
Coding Borderline Diagnoses
A recent Coding Clinic (Q 1 2012) answered the following question:
Coders are confused as to the correct coding of “borderline” diagnosis. The advice published in Coding Clinic, First Quarter 2011, pages 9-10, appears to be contradictory. The advice instructs coders to assign code 416.8, Other chronic pulmonary heart diseases, for borderline pulmonary hypertension as if it were confirmed; however, a diagnosis of borderline diabetes without further confirmation of the disease is assigned to code 790.20, Abnormal glucose.
Should code 793.2, Nonspecific (Abnormal) findings on radiological and other examination of body structure, Other intrathoracic organ, be assigned for a diagnosis of “borderline pulmonary hypertension” or should all borderline diagnoses require clarification from the attending physician so that the appropriate code may be reported?
Coding Clinic's Advice:
"Borderline diagnoses" are coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-9-CM, it should be coded as such.
They went on to indicate that borderline conditions are not uncertain diagnoses, and no distinction is made between the care setting (inpatient versus outpatient).
However, when documentation is unclear regarding a borderline condition, coders should query for clarification.
Coders are confused as to the correct coding of “borderline” diagnosis. The advice published in Coding Clinic, First Quarter 2011, pages 9-10, appears to be contradictory. The advice instructs coders to assign code 416.8, Other chronic pulmonary heart diseases, for borderline pulmonary hypertension as if it were confirmed; however, a diagnosis of borderline diabetes without further confirmation of the disease is assigned to code 790.20, Abnormal glucose.
Should code 793.2, Nonspecific (Abnormal) findings on radiological and other examination of body structure, Other intrathoracic organ, be assigned for a diagnosis of “borderline pulmonary hypertension” or should all borderline diagnoses require clarification from the attending physician so that the appropriate code may be reported?
Coding Clinic's Advice:
"Borderline diagnoses" are coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-9-CM, it should be coded as such.
They went on to indicate that borderline conditions are not uncertain diagnoses, and no distinction is made between the care setting (inpatient versus outpatient).
However, when documentation is unclear regarding a borderline condition, coders should query for clarification.
Monday, August 6, 2012
Need Free CMEs?
Check out the newly re-designed SCAN Health Plan® Continuing Medical Education /Performance Improvement Education (CME/PIE) website, at http://www.scancme.com/.
The mission of the SCAN Health Plan® Continuing Medical Education / Performance Improvement Education (CME/PIE) Program is to provide high-quality, evidence-based activities designed to narrow the professional practice gaps of providers caring for geriatric patients.
In addition to earning free CMEs, you'll find practice tools to help make your practice run more smoothly.
Stop by and check out the new SCAN CME/PIE site today!
The mission of the SCAN Health Plan® Continuing Medical Education / Performance Improvement Education (CME/PIE) Program is to provide high-quality, evidence-based activities designed to narrow the professional practice gaps of providers caring for geriatric patients.
In addition to earning free CMEs, you'll find practice tools to help make your practice run more smoothly.
Stop by and check out the new SCAN CME/PIE site today!
Friday, August 3, 2012
OIG Posts Podcast on the Importance of Documentation
The OIG has posted a podcast on the importance of medical record documentation. You can listen to the podcast or view the video by going to the podcast page.
If you can't listen to the podcast, you can review the transcript, here.
If you can't listen to the podcast, you can review the transcript, here.
Friday, July 27, 2012
California Physician Adoption of EHRs
A recent report by the California HealthCare Foundation, showed that 71% of physicians responding have an EHR in their main practice location. That's great news, right? Now for the bad news--only 30% of those physicians can meet 12 Stage 1 Meaningful Use objectives.
The study found that only 37% of the physicians plan to apply for either the Medi-Cal or Medicare incentives.
While the physicians may not meet the requirements (or choose to apply) to receive the $44,000 in incentive money, most physicians are happy with their EHRs --35% of respondents said they were very satisified with their EHR, 38% were somewhat satisfied. The study found a link between the functionality available in the EHR and physician satisfaction.
The study provides recommendations for outreach to physicians by DHCS to help physicians meet the requirements for the Medi-Cal incentives.
The study found that only 37% of the physicians plan to apply for either the Medi-Cal or Medicare incentives.
While the physicians may not meet the requirements (or choose to apply) to receive the $44,000 in incentive money, most physicians are happy with their EHRs --35% of respondents said they were very satisified with their EHR, 38% were somewhat satisfied. The study found a link between the functionality available in the EHR and physician satisfaction.
The study provides recommendations for outreach to physicians by DHCS to help physicians meet the requirements for the Medi-Cal incentives.
Friday, July 6, 2012
What's New on HCC U?
We've updated the Risk Score Calculator on the Tools page, so you can display 2013 risk scores. You can view the calculator here.
In addition, we've updated the presentation explaining the new requirements for the Annual Wellness Visit. There's also a form, and the ICE Health Risk Assessment form, to help you document the patients' Annual Wellness Visit.
That's it for now. If there are new tools you'd like to see on HCC University, you can contact us at coding@scanhealthplan.com.
In addition, we've updated the presentation explaining the new requirements for the Annual Wellness Visit. There's also a form, and the ICE Health Risk Assessment form, to help you document the patients' Annual Wellness Visit.
That's it for now. If there are new tools you'd like to see on HCC University, you can contact us at coding@scanhealthplan.com.
Thursday, July 5, 2012
What's New On HCC University
We've posted an updated list of Payment Year 2013 (2012 DOS) diagnoses in the CMS HCC model on the Tools Page. You can download the Excel file here.
In addition, we've updated our Risk Adjustment 101 presentation. You may want to use it in training new staff. It's on our Training and Presentations page.
In addition, we've updated our Risk Adjustment 101 presentation. You may want to use it in training new staff. It's on our Training and Presentations page.
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