Clinical Documentation Improvement Boot Camp

RCPA ConferenceOctober 8, 2014

Agenda

Behavioral Health Services Cultural Overview

Current Regulatory Environment – New Compliance Challenges

Function of the Progress Note

Defensive Maneuvers – Audit Proof Documentation– Technical Basics– Medical Necessity– Standard of Care

Offensive Maneuvers – Moving Forward– EMR Issues– DSM-5/ICD-10-CM Transition

Field Training Exercise - Mock Audits

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Boot Camp Begins

CULTURAL OVERVIEW

Behavioral Health Services

Cultural Overview

Historically, behavioral health services have been isolated and managed separately from other medical disciplines; Behavioral health services are “carved out” from medical health

insurance plans and most often managed by a separate company with different rules.

Long-standing differences in coverage between behavioral health and medical benefits.

Behavioral health services are less understood than other medical specialties and often viewed as a “little different” and medicine’s “stepchild.”

Neglect by parent organizations of their behavioral health programs; Audit and Compliance programs have traditionally not looked

“under the hood” until a governmental audit occurs.

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Cultural Overview

Historical lack of evidence based treatment interventions with measurable outcomes; traditional treatment focused on the patient-provider relationship.

Translates into poorly worded, overgeneralized and un-measurable treatment goals for patients.

Difficulty measuring progress and defending medical necessity.

High emphasis on confidentiality results in suboptimal documentation to support services rendered:

How much to document? Where to document? What can be shared under HIPAA?

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Cultural Overview

Practitioner independence to practice in their own way:

Lack of consistency among practitioners translated into variable documentation styles and language.

Difficulty for third party entities to interpret/understand treatment rendered and assess if medical necessity met.

Behavioral health providers have largely not been targeted by major governmental entities resulting in complacency in documentation.

Providers not being held accountable for documentation.

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Cultural Overview

Practitioner resistance to financial implications, “but we’re here to help people.”

Not understanding documentation’s link to reimbursement.

Liability issues may not be as heightened as in a medical model.

Decreased lack of attention to documentation and continuity of the overall patient medical record.

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Cultural Overview

Separation between mental health and substance abuse services;

Differences in licensing and accreditation standards. Differing approaches to treatment. Differing standards for staff qualifications.

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Cultural Overview

Impact on Medical Necessity

While medical necessity is not new for inpatient/Partial Hospitalization Programs (“PHP”), it is a relatively new concept for outpatient services.

In the 80’s, services were available to whomever could access and wanted them; patient/client/consumer motivation was key criteria.

Challenge of providing services for those who may not understand need for services, i.e., documenting medical necessity for involuntary treatment.

Mental health services have served a protective function for patients who may have not met traditional criteria for medical necessity; challenge of defending through documentation , role of social issues as safety issues.

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Current Regulatory Environment:

A Changing Landscape

New Compliance Challenges

Overhaul of CPT psychiatric codes; Effective January 1, 2013

Roll-out of DSM-5; Introduced May 2013

Transition to ICD-10; October 1, 2015

Transition to the Electronic Health Record

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Overhaul of CPT Psychiatry Codes

Most significant change is physician shift to Evaluation & Management (“E&M”) codes;

Elimination of the long standing pharmacologic management CPT code 90862 which contained general documentation requirements.

E&M codes requires specific documentation requirements, for which psychiatrists in outpatient settings in particular are not accustomed to utilizing.

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Office of Inspector General - 2014 Work Plan

“We will determine the extent to which selected payments for evaluation and management (E/M) services were inappropriate. We will also review multiple E/M services associated with the same providers and beneficiaries to determine the extent to which electronic or paper medical records had documentation vulnerabilities. Context—Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the billing code for the service on the basis of the content of the service and to have documentation to support the level of service reported. “

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Getting Down to Basics:

The Progress Note

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Function of the Progress Note

Invoice for Services Rendered

Is the only “proof” of what occurred in treatment and what services were delivered; to whom, by whom, why, for how long, whether it was effective and whether it should be reimbursed.

Justifies the purpose of the service; supports medical necessity.

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Function of the Progress Note

Communication Tool

  Documentation needs to be sufficiently clear and detailed to

enable another practitioner to take over the case for any number of reasons.

Documentation needs to be readily understood by a third party entity who may/may not have knowledge of behavioral health.

 

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Function of the Progress Note

Standard of Care

  In the event of negligence, Standards of Care (“SOC”) will be the

measuring tool for determining whether a practitioner was negligent.

A SOC holds a person of exceptional skill or knowledge to a duty of acting as would a reasonable and prudent person possessing the same or similar skills or knowledge under the same or similar circumstances.

  SOC include Practice Acts, state and federal laws, accreditation

agencies, professional associations, scientific literature and/or specific organizational standards.

 

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Defensive Maneuvers for Compliant Documentation:

Making Your Progress Notes Audit-Proof

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Defensive Maneuvers

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Defensive Maneuvers

Strategic Tactics

1. Technical Basics

2. Support medical necessity

3. Standard of Care

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Strategic Tactic #1

Technical Basics

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Technical Basics

Compliance is not an option

Know regulatory and organizational policies for documentation and billing:

Timed codes; includes “rounding” rules Unit limits Non-reimbursable services

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Technical Basics

Write legibly and ensure legible, written signature with credentials. Alternatively, ensure timely, electronic signature authentication of

documentation.

Do not attempt to alter the record. Ensure that the original and the correction/addition are clearly and correctly marked.

  Small errors – single line drawn through the error with initial and

date. Correction of previous entry – begin a new entry with corrected

content with current date and time. Appropriate process to correct entries in the EMR

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Technical Basics

Be concise and “smart” in documenting; more is not necessarily better.

Use lay language and ensure acronyms are spelled out; records may be reviewed by others with little/no behavioral health background and will need to readily understand the content.

Using templates for progress notes may increase efficiency but inherently contribute to compliance risks to include lack of patient specificity, boxes/lines left blank and /or inadequate documentation.

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Technical Basics

Remain mindful of content that becomes standard/pre-populated on each progress note; always read your note and edit appropriately.

Consider the potential reader audiences of your notes; other clinicians, supervisory staff, utilization reviewers, insurance companies, the client and/or client family, significant other(s), plaintiff attorneys and/or exhibit in a court proceeding.

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Strategic Tactic #2

Support Medical Necessity

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Medical Necessity

Initial Evaluation

Support for medical necessity begins with the initial evaluation resulting in a diagnoses as the primary focus of treatment and the individual’s capacity to participate in treatment, development of an individualized treatment plan, progress notes that address the patient/client progress relative to the treatment goals and establishing a discharge plan from day one.

  There must be continuity between these components; disjointed record

conveys lack of direction in treatment and invites questions about medical necessity.

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Medical Necessity

Treatment Plan

Diagnostic formulation from the initial evaluation drives treatment direction articulated in the individualized treatment plan.

Practitioners often view negatively and underestimate the significance of the treatment plan.

Behavioral health providers will be held increasingly accountable for measurable outcomes; incorporating evidence based practices when possible and articulating them in the treatment plan will support medical necessity.

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Medical Necessity

Treatment Plan

• Establish long and short term goals that are easily understood, concrete, measurable and obtainable so that progress can be demonstrated. Unrealistic goals set patient/client up to appear as having failed and medical necessity of intervention(s) more likely questioned.

• Avoid use of stock, repetitive goals from client to client; i.e. “stabilization of mood,” “improved social functioning,” “absence of risk,” “normalization of functioning.”

• Update goals regularly or when interventions appear ineffective.

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Medical Necessity

Progress Notes

Clinical notes for therapy sessions serve to document not only the patient’s clinical status and progress, but also serve to ensure that quality of care is adequate and payment is made for services provided. Progress notes should include:

Date and length of the therapy sessions; start/stop times. Patient's current clinical status as it relates to diagnosis;

current symptoms and functional status.

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Medical Necessity

Progress Notes

Content of the therapy session, i.e., note of the major themes discussed.

Summary of the therapeutic intervention of the session; be specific.

Summary assessment of the patient's progress or lack of progress toward the treatment goals. KNOW THE TREATMENT PLAN.

Plan for the immediate future; connect back to the treatment plan.

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Medical Necessity

HIPAA and Psychotherapy Notes

Psychotherapy notes are notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual’s medical record.

Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

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Strategic Tactic #3

Standard of Care

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Standard of Care

Documentation needs to reflect that your actions were similar to what reasonable clinicians would do under the same or similar circumstances; what would a comparable peer social worker, psychologist, licensed counselor, nurse have done.

More important to document details of decisions that increase risk rather than those that decrease risk; i.e. documenting a decision to hospitalize may not require as lengthy an assessment versus allowing the patient to return to an unsupervised, unmonitored setting which required more comprehensive evaluation.

Health care providers have a duty to be familiar with SOCs – ignorance is not a defense.

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Standard of Care

Medical record will be the only defense regarding whether professional specialty specific standards of care were followed.

Mistake in judgment does not necessarily violate SOCs. Important to document a reasonable and complete thought process and clinical considerations, in addition to the final decision.

Include both positive and negative, verbatim responses from the client.

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Offensive Maneuvers

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Moving Forward – EMR Design

Ensure EMR documentation templates will capture required regulatory information.

All entries into the medical record must be unambiguously identified and authenticated by their author.

Be aware of default information in templates and/or cut and paste functions.

• Failure to appropriately edit records, challenges documentation integrity and credibility of the information.

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Moving Forward – DSM-5/ICD-10

DSM-5 maps to ICD-9 & ICD-10.

Full use of DSM-5 projected by October 1, 2015 when ICD-10-CM is adopted as our standard coding system.

Dates when DSM-IV may no longer be used will be determined by the American Psychiatric Association.

• Handout “DSM-5/ICD-10 Overview for Behavioral Health Providers”

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Field Training Exercises - FTX

Break – Out Groups for

Mock Documentation Audits

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Resources

American Psychiatric Association

http://www.psych.org/

American Academy of Child and Adolescent Psychiatry

http://www.aacap.org/

American Psychological Association

http://www.apa.org/

National Association of Social Workers

http://www.naswdc.org/

American Association for Marriage and Family Therapists

http://www.aamft.org/iMIS15/AAMFT/

American Counseling Association

http://www.counseling.org/

Judge David L. Bazelon Center for Mental Health Law

http://csmh.umaryland.edu/

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Boot Camp Instructors

– Georgia Rackley, MSN, RN, CPC, CLNC, Senior Clinical Specialist

• georgiarackley@sunstoneconsulting.com• 717-574 -1947

– Laura Ehrlich, RN, BSN, CCM, Senior Consultant• lauraehrlich@sunstoneconsulting.com• 717-968 – 5035

www.sunstoneconsulting.com

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