FBLA Healthcare Administration (ALL INFO)

health record

A health record can be defined as written or graphic information documenting facts and events during the rendering of patient care. Either paper or electronic format.

American Recovery and Reinvestment Act of 2009 (ARRA)

encourages implementation by offering five annual financial incentives for qualifying offices that convert to an electronic format beginning in 2011 and ending in 2015 or 2016.

1. Patient registration (demographic information)

2. Medication record

3. history and physical exam, notes or report

4. Progress or chart notes

5. Consultation reports

6. imaging and x-ray reports

7. Laboratory reports

8. Immunization record

9. Consent and authorization forms

10. Operative report

11. Pathology report. In hospital setting would also include

• attending physician's orders

• date of admission

• hospital stay dates

• discharge date

• discharge summary

Health record content (common)

1. problem-oriented record (POR system)

2. source-oriented record (SOR system or integrated system)

What types of systems are used in electronic health record system (EHR)

Problem-Oriented Record System (POR)

consists of: flow sheets, charts, or graphs, that allow aphysician to quickly locate information and compare eaulation

Source-Oriented Record system (SOR)

documents are arranged according to sections (e.g., H&P section, progress notes, lab tests, radiology reports, or surgical operations) SOR system filed in reverse chronological order. More difficult to locate data due to scattering throughout

Electronic Health Record System

collection of medical information about the past, present and future of a patient that resides in a centralized electronic system.

: An EMR is individual physician's EMR for the patient, including medical history, allergies, and appointment information. An EHR is all patient medical information from many information systems, including all components of the EMR.

Difference between an EHR and an EMR

1. no physical space required

2. abstracting data is eliminated except when free-form documentation such as narrative notes, dictations, and natural language processing is used.

3. free-text approach, encourages use of abbreviations or fewer spelled out words may result in scant or undecipherable documents.

4. Electronic systems have built in security safeguards to protect against improper disclosure, unauthorized access, or unintended alteration of information for both the data and the system.

5. ARRA requires covered entities to notify individuals if their protected health information is accessed or disclosed in an unauthorized manner.

Advantages of EHR

SNOMED-CT

Systemized Nomenclature of Medicine for Clinical Terminology. Medical terminology cassification system that codes text data in an EHR system will assist in standardizing clinical medical terminology

Medicare Modernization Act

created the Commission on Systemic Interoperability to develop a strategy to make health care information abailable at all times to patients and physicians. Goal by 2014.

Electronic medical report

part of health record that is used to complete the insurance claim form. permanent legal document that formally states outcomes of the patients' examination or treatment in letter or report form.

Insurance claim

• DOS, date of service

• POS, place of service

• Dx, diagnosis

• Procedures

• codes are used for interpretation by the insurance company when processing a claim

documenters

all individuals providing health care services that chronlogically record pertinent facts and observations about patient's health.

documentation

charting, may be electronically handwritten, dictated and transcribed or downloaded from a (PDA) personal digital assistant or smartphone

speech recognition system

computerized voice recognition system which makes it possible for computer to respond to spoken words

medical editor

correctionist, proofreads and edits the computer-generated documents

attending physician

refers to the hospital staff member who is legally responsible for the care and treatment given to a patient

consulting physician

provider whose opinion or advice regarding evaluatio or management of a specific problem is requested by another physician

non-physician practitioner (NPP)

nurse practitioner, clinical nurse specialist, licensed social worker, nurse midwife, physical therapist, speech therapist, audiologist, or physician assistnat who furnishes a consultation or treats a patient for a specific medical problem, pursuant to state law, and who use the results of a diagnostic test in the management of the patient's specific medical problem

ordering physician

individiual in the hospital directing the selection, preparation, or administration of tests, medication, or treatment

primary care physician (PCP)

oversees the care of the patients in a managed health care plan and refers patients to see specialists for services as needed

referring physician

provider who sends the patient for tests or treatment

resident physician

physician who has finished medical school and is performing one or more years of training in a specialty area on the job at a hospital (medical center). Residents perform the elements required for an evaluation and management (E/M service in the presence of or, jointly with, the teaching physican, and residents document the service.

teaching physician

doctor who has responsibilities for training and supervising medical students, interns, or residents and who takes them to the bedsides of patients in a teaching hospital to review course and treatment. Teaching physicians must document that they supervised and were physically present at the time during key portions of the service provided to the patient when performed by a resident.

Treating or performing physician

provider who renders a service to a patient. In the Medicare program, the definition of a treating physician is a physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of a diagnostic test in the management of the beneficiary's specific medical problem.

Five reasons for legible documention:

If handwritten, entries in patient record must be legible. a. avoids denied or delayed payments by insurance carriers b. enforcement of medical record-keeping rules by insurance carriers requiring accurate document that supports procedure and diagnostic codes. c. Subpoena of health records by state investigators or the court for review. d. Defense of a professional liabilty claim. e. Execution of the physician's written instructions by a patient care-giver.

E/M

Evaluation and management, occurs in office visit, inpatient hospital facilities, and nursing homes

CPT

Current Procedural Terminology

CMS

Centers for Medicare and Medicaid Services.

American Medical Association and Centers for Medicare and Medicaid Services.

Developed documentation guidelines for CPT E/M services.

Medicare administrator contractors

also called fiscal intermediaries, fiscal agents, and fiscal carriers, conduct reviews for irregular reporting patterns. HAVE WALK IN RIGHTS, access to a medical practicde w/o apptment or search warrant.

Third-party payers and federal programs have responsiblity to ensure that professional services provided to patients were medically mecessary

Documentation must support the level of service and each procedure rendered.

medical necessity

criterion used by insurance companies, as well as federal programs, when making decisions to limit or deny payment. Payment may be delayed, downcoded or denied if the medical necessity of a treatment is questioned.

Good medical practice standards

Insurers differ on definition and may not cover services depending on the benefits of the plan.

ABN

Advance beneficiary Notice of Noncoverage, also know as waiver of liability agreement or responsibility statement

Audit

If provider has submitted insurance claims for payments deemed fraudulent or inappropriate by government.

External Audit Point System

A point system used while reviewing each patient's health record during the performance of an audit. Points award only if documentation is present for elements required in health record. Point system is used to show where deficiencies occur in health record documentation, evaluation and substantiate proper use of diagnostic and procedural codes.l

consequences of accidental (or intentional) miscoding.

HMO, PPO, private carriers can claim refunds Medicare has power to levy fines and penalties and exclude providers from Medicare program

Insurance carrier and documentation

If it is not documented, then it was not performed. (have right to deny reinbursement)

Medicare carriers frequent audits

prepayment and postpayment audits to monitor accuracy physicians' use of medical services and procedure codes.

Billing Patterns causing possible audits

a. billing intentionally for unnecessary services b. billing incorrectly for services of physican extenders (NPP) C. billing for diagnostic tests w/o separate report in health record d. changing DOS on insurance claims to cmply with policy coverage dates e. waiving copayments or deductibles, or allowing other illegal discounts f. ordering excessive diagnostic tests g. using 2 different provider numbers to bill the same services for same patient h. failing to return overpayments made by the Medicare program i. misusing prover ID number j. using improper modifiers for financial gain

Common Medical Office Documents/ Documentation guidelines for Medical Services

1. The health record should be accurate, complete (detailed), and legible.

2. Documentation of each patient encounter includes or provide reference to following: a. chief complaint or reason for encounter b. relevant history c. physical examination d. findings e. prior diagnostic test results f. assessment, clinical impression, or diagnosis g. plan for care h. date and eligible identity of the health care professional

3. The reason for encounter stated

4. Past and present diagnoses

5. Appropriate health risk factors should be identified

6. The patient's progress, response to and changes to treatment, planned follow-up care and instructions and diagnosis should be documented.

7. Patient refusal to follow medical advise

8. Procedure and diagnostic codes reported on the insurance claim form or billing statement supported by documentation.

9. Confidentiality of health record maintained

10. Each chart entry dated and signed

11. Standardized charting procedures for progress notes. Use either SOAP or CHEDDAR styles or narriative or detailed descriptive style. Must be detailed enough to support current documentation requirements.

12. Treatment plans written and consistent with working dx.

13. medications prescribed and taken, listed

14. request for or need for consultation must be documented. Include: consultant's opinion, services ordered documented, and communicated to requesting physician.- see pg 96 for additional Four R's: requesting, render, report, reason, (and possibly return"

15. Record patient's fialture to return for needed treatment, in Heath record, appointment book, financial reocrd or ledger, follow telephone call or letter to patient indicated

16. How to correct documentation "errors". see pg 96. Never delete or or key over incorrect data. or flag it as amended or obsolete and create an addendum typed

Contents of a Medical Report

Degree of documentation depends on the complexity of the service and the specialty of the physican. history, examination, medical decision making

Documentation of History

includes: chief complaint (CC), History of Present Illness (HPI), review of systems (ROS), past history, family, or social history (PFSID) extent of each depends on present problems

Chief complaint (CC)

concise statement usually in patient's own words describing symptom, problem, condition, diagnosis, physician-recommended return, or other factor. REQUIRED FOR ALL LEVELS OF HISTORY:

History of present illness (HPI)

chronological description of development of the patients present illness from first sign or symptom or from previous encounter to present (may include one or more of the following): 1. location, 2, Quality/Character of the symptom/pain, 3. severity or degree (1-10), 4. Duration, 5. Timing, when, 6. Context - situation associated with symptom 7. Modifying factors that make it better or worse, 8. Associated signs and symptoms

Review of Symptoms (ROS)

Inventory of body systems obtained through a series of questions that is used to identify signs or symptoms patient might be experiencing or has experienced. In ROS, trhe body systems are counted and totaled. The health record should describe one system of the ROS for a pertinent to problem level. For a complete level, at least 10 organ systems must be reviewed and documented.

Past History (PH)

Patients past experiences with illnesses, operations, injuries, and treatments

Family History (FH)

A review of medical events in the patient's family including diseases that may be heriditary or place the patient at risk.

Social History (SH)

An age-appropriate review of past and current activities (smoking, alcohol, etc.)

Documentation review/audit worksheet

there are specific requirements of documentation.

1. Problem focused (PF) chief complaint; brief history of present illness or problems

2. Expanded problem focused (EPF) chief complain; brief HPI problem-pertinent system review

3. Detailed (D) - Chief complaint; extended history of present illness; problem-pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family, or social history direcdtly related to the patient's problems

4. Comprehensive (C) - chief complaint; extended HPI: ROS that is directly related to the problem identified in the history of the present illness, plus a review of all additional body systems; complete PFSH.

Levels of History

Physical Examination (PE or PX)

objective in nature consists of physcian's findings by examination or test results

Physical exam Types

1. Problem focused (PF)

2. Expanded problem focused (EPF)

3. Detailed (D)

4. Comprehensive (C)

Problem focused (PF) physical exam

A limited exam of affected body area or organ

Expanded Problem focused (EPF) physical exam

A limited exam of affected body area or organ system and other symptomatic or related organ systems.

Detailed (D) physical exam

An extended examination of the affected body areas and other symptomatic or related organ systems.

Comprehensive (C ) physical exam

A general multisystem examination or complete examination of a single organ system.

Comorbidity

means underlying disease or other conditions present at the time of the visit.

Medical decision making (four types)

1. straighforward (SF)

2. low complexity (LC)

3. moderate complexity (MC

4. high complexity (HC)

new patient (NP)

one who has not recieved any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years

established patient

patient who has received professional services from the physican or another physician of the same specialty who belongs to the same group practice with the past 3 years

consultation

includes services rendered by a physician whose opinion or advise is requested by another physican or agency in the evaluation or treatment of a patient's illness or a suspected problem.

referral

transfer of the total or specific care of a patient from physician to another for known problems. Not a consultation, ex. patient with fracture sent to orthopedist

concurrent care

providing of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. (ex. cardiologist and endocrinologist)

continuity of care

(e.g., a patient who has received treatment for a condition and is then referred by the physician to a second physician for treatment for the same condition),

Critical care

intensive care provided in a variety of acute life-threatening conditions requiring constant "full attention" by a physician. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition.

Emergency care

it may be given by the physician in a hospital ED or in a physician's office setting. Emergency care is that is provided to acutely ill patients and may or may not involve organ system failure, but does require immediate medical attention.

Emergency medical condition as defined by Medicare

medical condition that manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediately medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to body functions, or serious dysfunction of any body organ or part.

Lay person definition of an emergency

Any medical condition of a recent onset and severity , including but not limited to severe pain, that would lead a produent lay person, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injry is of such a nature that failure to obtain immediate medical care could result in placing the patient's health in serious jeopardy, seirous impairment to bodily functions, or serious dysfunction of bodily organ or part

Counseling

discussion with a patient, family, or both concerning one or more of the following: diagnostic results, impressions, or recommended diagnostic studies; prognosis; risks and benefits of treatment options; instructions for treatment or follow-up; importance of complication with chose treatment options; risk factor reduction, and patient and family eduction.

imp

impression

dx

diagnosis

AMA policy on abbreviations

should be eliminated from vital sections of health record, such as final diagnosis, operative notes, discharge summaries, and descriptions of special procedures

eponym.

term including the name of a person (e.lg. Graves' disease)) s hould not be used when a comparable anatomic term can be used in its place ex. "Buerger's disease compared to thromboangitis obliterans

acute

a condition that runs a short but relative severe course

chronic

a condition persisting over a long period of time

diagnostic terminology and abbreviations

problems can occur with documentation because of missing or misused essential words (ex. diastolic dysfunction instead of heart failure due to diastolic dysfunction

within normal limits (WNL), noncontributroy, negative/normal, other than the above, all systems were normal

may not support billing of services, instead, documentation must indicate exatly which limb was examined and abbreviated wording would not pass an audit. "CANNED" notes mean no assessment was actually performed, this is fraud.

Detailed documentation justifies billed services by providing verification

ex. chest x-ray report reviewed, or read instead of "chest x-ray negative"

surgical terminology

a) preoperative vs postoperative, (b) simple/intermediate/complex (c) undermining (d) take down (e) lysis of adhesion (f) surgical position (g) surgical approach (ex. vaginal vs. abdominal

preoperative

(preop) period before a surgical procedure, begins with the first preparation to a patient fore surgery and ends with anestheia in operating room

postoperative

(PO) period of time after surgery, beginning with patient emerging from anesthesia and continues through time required for acute effects of anestheia and surgical procedures to decrease

surgical procedures for integumentary system

(example, repair of lacerations) listed as simple, intermediate or complex repairs. Documentation should liste the length (in centimeters) of all incisions and layers of involved tissues sothat correct procedure codes for excision of lesions and type of repair can be determined.

simple laceration (superficial)

one layer closure

intermediate laceration

requires layered closure of one or more of the deeper layers of the skin and tissues

complex lacerations

require more than layered closure and may require reconstructive surgery

If time is factor in coding for reimbursement.

Document length of time spent on procedure, especially if of unusual duration such as prolonged services, counseling, or team conferences. Stated somewhere in the report.

State of art equipment

document

Surgical procedures one of two categories

therapeutic or cosmetic procedures

undermining

cut in a horizontal fashion

take down

to take apart

lysis of adhesions

destruction of scar tissue

key words that may affect coding

• bilateral ( pertaining to both sides)

• blood loss of more than 600 ml (severe bleeding)

• complete or total (entire or whole)

• complicated by (involved with other situations at the same time)

• hemorrhage (escape of blood from vessels; bleeding)

• initial: (first procedure or service)

• multiple (affecting many parts of the body at the same time)

• partial: (only a part, not complete)

• prolonged procedure due to (series of steps extended in time to get desired result)

• simple (single and not compound or complex)

• subsequent (second or more procedures or services)

• surgical (pertaining to surgery)

• uncomplicated or straightforward (not intricately involved)

• unilateral (pertaining to one side)

• unusual findings or circumstances (rare or not usual conclusion)

• very difficult (hard to do, requiring extra effort and skill)

internal reviews

prospectus review, prebilling audit or review done periodically (daily, weekly, monthly)

Prospectus review, stage 1

review to verify that completed encounter forms match patients seen according to appointment book and have been posted on daysheet, then see if all charges are posted

Prospectus review, stage 2

review verifies all procedures or services and diagoses listed on encounter form match data on the insuranc eclaim form.

retrospective review

review done after billing insurance carrier, usually done by biller/coder to determine if sufficient documentation exists

When diagnosis not completed correctly in health record:

an active dx has not been entered i nto the computer system and the computer defaults to the last dx given for established patient. OR dx is not linked to proceudre. PROBLEMS MUST BE FOUND BEFORE BILLING AND CORRECTED BEFORE CLAIMS ARE PRINTED