Documentation Standards

1
DocumentationStandards

• 2008

2
Agenda

• Goals of documentation training
• Iowa Administrative Code
• SURS Medical Services Reviews
• CDAC Service Record
• Questions answers

3
Documentation Standards Training

• Goals
• - To discuss IAC as it pertains to documentation
• - To emphasize compliance with doc standards in
  relation to SURS review
• - To facilitate awareness that SURS reviews
  according to code in affect at the time of
  service
• - To educate about requirements, but not to
  provide specific documentation wording
• - To stress that Medical Services review is not
  equal to SURS review

4
Discussion of Iowa Administrative
Codewww.dhs.state.ia.us/PolicyManualPages/ Manua
l_Documents/Rules/441-79.pdf
5
Financial Records

• 79.3(1) Financial (fiscal) records
• a. A provider of service shall maintain records
  as necessary to
• (1) Support the determination of the providers
  reimbursement rate
• (2) Support each item of service.
• b. A financial record does not constitute a
  medical record.

6
Medical (clinical) records

• 79.3(2) Medical (clinical) records
• - Provider shall maintain complete and legible
  medical records for each service
• - Required records will include records
  required to maintain license in good standing

7
Definition of Medical Records

• 79.3(2)a Definition.
• - Medical record means a tangible history that
  provides evidence of
• (1) The provision of each service and each
  activity billed to the program
• (2) First and last name of the member receiving
  service

8
Purpose of Medical Record

• 79.3(2)b Purpose
• The Medical record shall provide evidence that
  the service provided is
• (1) Medically necessary
• (2) Consistent with the diagnosis
• (3) Consistent with professionally recognized
  standards of care

9
Components of Medical Records

• 79.3(2)c(1-4) Components
• (1) Identification
• (2) Basis for coverage
• (3) Service documentation
• (4) Outcome of service
• Each will be discussed in greater detail in
  following slides.

10
Medical Records Component- Identification

• 79.3(2)c(1) Identification
• Each page or separate electronic document
• - Members first and last name
• Associated within document
• - Medical assistance id number
• - date of birth

11
Medical Records Component Basis for Service

• 79.3(2)c(2) Basis for Service
• Medical record shall reflect
• - the reason for performing the service
• - substantiate medical necessity
• - demonstrate level of care
• 1. Complaint, symptoms, and diagnosis
• 2. Medical or social history

12
Medical Records Component Basis for Service

• 3. Examination finding
• 4. Diagnostic, lab, X-ray reports
• 5. Goals or needs identified in Plan of care
• 6. Physician orders and required PAs
• 7. Medication pharmacy records, providers
  orders
• 8. Professional consultation reports

13
Medical Records Component Basis for Service

• 9. Progress or status notes
• 10. Forms required by the department as
  condition of payment
• 11. Treatment plans, care plans, service plans,
  etc.
• 12. Providers assessment, clinical impression,
  etc
• 13. Any additional documentation to demonstrate
  medical necessity

14
Medical Records Component Service Documentation

• 79.3(2)c(3) Service documentation
• Record shall include information necessary to
  substantiate the provided service.
• 1. Specific procedures or treatments
• 2. Complete date of service with begin and end
  dates

15
Medical Records Component Service Documentation

• 3. Complete time of service with begin and end
  time
• 4. Location
• 5. Name, dosage, and route of medication
  administration

16
Medical Records Component Service Documentation

• 6. Supplies dispensed
• 7. First name, last name credential of
  provider
• 8. Signature of provider or initials if signature
  log used
• 9. 24-hour care needs documentation, members
  response, providers name for each shift

17
Medical Records Component Outcome of Service

• 79.3(2)c(4) Outcome of Service
• Medical record shall indicate
• - members progress in response to services
• - including
• - changes in treatment
• - alteration of plan of care
• - revision of diagnosis

18
Basis for Service Requirements

• 79.3(2)d Basis for service requirements for
  specific services
• New as of 4/1/08
• 5 pages of specific requirements for more than
  35 provider types
• Outlines documents needed by provider type for
  SURS review

19
Corrections to Documentation

• 79.3(2)e Corrections
• Provider may correct the medical record before
  submitting a claim.
• (1) Made or authorized by provider of service
• (2) No write over line through and correct
• (3) Indicate person making change, and person
  authorizing change
• (4) If change affects paid claim, then amended
  claim is required

20
Maintenance of Documentation

• 79.3(3) Maintenance requirement
• a. During time member is receiving services
• b. Minimum of 5 years from claim submission date
• c. As required by licensing authority or
  accrediting body

21
Reviews and Audits of Documentation

• 79.4 Reviews and Audits
• Revisions as of 4/1/08.
• Definitions
• SURS can review at any time
• Documentation check list used by SURS
• Review procedures
• Report of findings
• Deadlines and extensions

22
Self Assessments

• - Quality assurance is in best interest of
  providers.
• - Value to providers of their own QA assessments
• Quickly ID narratives that are not adequate
• Corrections can be made before claim submission
• Quickly identify staff who need additional
  training

23
Summary of IAC Discussion

• Providers can develop a process or system of
  their own design
• Chosen system must demonstrate that Medicaid
  rules are met
• IAC does not require 2 sets of documents
• Providers should proactively review their current
  system to ensure IAC requirements are met

24
SURS and Medical Services Reviews
25
New Provider Option

• Under old IAC
• If received a Findings letter, no opportunity to
  submit additional information
• Under new IAC
• May receive Preliminary Finding of a Tentative
  Overpayment letter
• May request re-evaluation
• May submit clarifying or supplemental
  documentation not previously provided

26
Errors in Responding to SURS Review

• - Failure to submit docs timely per IAC 79.4
• - Documentation submitted for wrong dates
• - Submitted documentation not detailed
• - Do not submit
• Individual Service Plans
• Individual comprehensive plans
• CDAC agreements

27
Documentation Errors

• Illegible writing
• No in/ out times
• Wrong code vs. service
• Documentation does not match services
• Invalid correction
• No signature or signature sheet

28
More Documentation Errors

• No dates of service
• Failure to use Remittance Advice
• Missing member response to interventions
• Physician orders not followed
• Chiro must indicate area of treatment
• Vision must state replacement reason
• DME use of UE modifier

29
Medical Services Documentation Requirements I

• Services where required medical documentation
  frequently missing.
• Not a complete list situations where medical
  documentation is required.
• Endoscopy op rpt w/ 43450 other upper GI endo
  code
• Sterilization sterilization consent form
• Hysterectomy consent form or doc of prior
  sterility

30
Medical Services Documentation Requirements II

• Abortions op rpt, hx p, fetal ultrasounds.
  Labs, abortion certificate, progress notes,
  consult notes
• B9998 description of service/item
• Delivery of multiples operative report
• Septoplasty op rpt, hx p, nasal endoscopy,
  other imaging or photos, hx of symptoms prior
  treatments
• Breast reduction mammoplasty op rpt, hx p,
  pre-op photos, 6 months hx of symtpoms prior
  treatments
• Blepharoptosis op rpt, hx p, visual field
  test, pre-op photos

31
Medical Services Documentation Requirements III

• Skin tags keloids op prt, hx p, pre-op
  photos, clinical notes w/ medical necessity
• Botox for diagnosis of Primary Focal
  Hyperhidrosis, docs to explain condition
  interference with ADLs
• Natalizumab hx of failed trials of preferred
  meds
• All dump codes description of billed service,
  invoice or op report

32
CDAC Service Record
33
CDAC Service Record

• Required of all CDAC providers
• Must be legible
• Must support the number of units billed
• Must be signed by member
• To be kept for 5 years
• Used as response to SURS for review purposes

34
Medicaid 101
35
MediPASS MHC

• MediPASS plus HMOs contracted with DHS
• One of the five provider types that provide
  primary care services
• Managed Care is mandatory in many counties
• Providers of care must obtain a referral from the
  Patient Manager

36
Contact Information

• Provider Services
• 800-338-7909
• 515-725-1004 (Des Moines area)
• 515-725-1155 fax
• ELVS
• 800-338-7752
• 515-323-9639 local to Des Moines

37
Medical Assistance Card

• No specific eligibility month or program will be
  indicated on the card
• Provider must verify eligibility through ELVS or
  Web Portal
• No change for IowaCare card
• Info Release 632 included additional detail

38
ELVS

• Eligibility 24/7
• Verify
• Monthly eligibility
• Spend Down
• TPL insurance
• Managed Health Care information

39
Web Portal

• Available 24/7
• Check eligibility
• Check claim status
• Contact EDISS for login ID and password

40
Retro Eligibility

• If before 12 months from DOS, submit thru regular
  channels
• Write words Retro Eligibility on form
• Attach copy of retro letter
• If after 12 months from DOS, them submit to
  address in training packet
• Must submit claim within 1 year from date of
  award letter
• Copy of letter must be attached to the claim

41
Iowa Administrative Code 441

• 79.9(4) Recipients must be informed before the
  service is provided that the recipient will be
  responsible for the bill if a non-covered service
  is provided.
• The member must be informed of the date and
  procedure that will not be covered by Medicaid.
  This information should be noted in the patients
  file.

42
Timely Filing Guidelines

• Initial Filing
• Must be filed within 12 months of the first date
  of service
• Medicare crossovers must be filed within 24
  months of first date of service
• Exceptions
• Retroactive eligibility
• Third-party related delays

43
Timely Filing Guidelines continued

• Resubmissions
• If a claim is filed timely but denied, an
  additional 365 days from the denial date is
  allowed
• Claims must be submitted on paper with the a copy
  of the denial RA
• Claim Adjustments
• Requests for claim adjustments must be made
  within 12 months of the payment date
• Claim credits are not subject to a time limit

44
Claim Submission Issues

• Data outside of box
• Provider , Member or DOS missing
• Dollars cents not noted on form
• Dash used to indicate negative or cents
• Total charge box not completed
• J code drug not in correct location
• Not billing with correct NPI

45
Top Denial Reasons

• Exact duplicate claim
• Member not eligible
• Missing or invalid MediPASS referral number
• Third-party insurance should have been billed
  primary
• Medicare should have been billed primary
• Missing or invalid member ID number
• Procedure/treating provider conflict
• Incorrect NPI/Taxonomy combination

46
Credit/Adjustment Request

• When to request a credit
• When to request an adjustment
• If crediting, do not send a refund check
• New form has been created to address NPI concerns