CDI, Compliance & Auditing Covering All Basis

CDI, Compliance & AuditingCovering All Basis Presented by Lee Williams, RHIT, CCS, CPC, CPCO ljulien@post.com (404)397-7851

CDI, Compliance & Auditing Objectives: • What is CDI? • Role of a CDI Specialist • Benefits of a CDI Program • Evolution of Coder to Auditor • Compliance & You • Comprehensive Compliance Program

CDI, Compliance & Auditing • Clinical Documentation Improvement (CDI) is designed to “improve the accuracy, specificity and completeness of clinical documentation through education, assessment, review, communication, clarification, querying and analysis of clinical documentation patterns” Excerpt from Catholic Healthcare West CDI Program

CDI, Compliance & Auditing • CDI mainly focuses on acute inpatient stays. The CDI specialist reviews cases concurrently during the inpatient stay and work collaboratively with physicians to ensure accurate and specific documentation within the medical record. • While CDI continues to gain momentum, many outpatient organizations are beginning to also recognize the importance of CDI and implement some practices of CDI within their facilities/practices.

CDI, Compliance & Auditing So why CDI and why now? • CDI is not new, as a matter of fact the program has been around for a number of years. • For decades, coders have worked arduously to promote & improve proper documentation. However, the relationship between coders & providers can be a little strained and tense at times resulting in good communication falling on deaf ears.

CDI, Compliance & Auditing • Team Effort

CDI, Compliance & Auditing • There is some overlap between CDI and coding professionals… • A good CDI program should have a healthy mix of nurses and coders. • Coders and nursing staff have shared competencies in the ability to read and analyze information in the health record, excellent critical thinking skills, clinical knowledge in terms of medical terminology, A&P, pathophysiology, and pharmacology.

CDI, Compliance & Auditing • The coder will have more skilled training in coding concepts & guidelines, healthcare regulation & compliance issues, as well as documentation requirements (think E/M Documentation Guidelines, Risk Adjustment Coding, etc)… • The nurse will have more skilled training in disease process, more in depth knowledge relating A&P, pathophysiology, pharmacology, and identifying clinical indicators…

CDI, Compliance & Auditing • Physicians went to medical school and received education in pathology & physiology while also learning about signs/symptoms causation and disease etiology/manifestations. • For most, clinical documentation was not a part of their coursework. Case A: GU – Foley in place (PE System Review) Case B: HF Systolic Heart Failure ( DRG) Acute Systolic HF ( DRG)

CDI, Compliance & Auditing Benefits of CDI: • Identify areas for documentation improvement. • Capture data to reflect patient SI and ROM. • Improve clinical documentation to better reflect care provided. • Receive accurate reimbursement for services provided. HIMSS “The CDIP: Key Success Factors for a Winning Strategy”

CDI, Compliance & Auditing Live from actual cases: • DC status: Alive but w/o my permission. • Patient has 2 teenage children, but no other abnormalities. • Healthy appearing decrepit 83-year-old female, mentally alert, but forgetful. • She stated that she had been constipated for most of her life until she got a divorce. • Pt refused autopsy. From Reader’s Digest

CDI, Compliance & Auditing • The primary goal of CDI and any other documentation improvement process is to improve the quality of the provider’s documentation. • The goal should never be to increase revenue or insurance reimbursement. • The good news is improvement in documentation should result in increased reimbursement!

CDI, Compliance & Auditing RAC CERT OIG ZPIC MAC Compliance and You!!! JCCLIA HIPAA RAT-STATS CIA

CDI, Compliance & Auditing Breaking News: • A Michigan doctor is accused of committing health care fraud after he allegedly mistreated cancer patients and bilked the government of millions in false Medicare claims, a federal complaint said. • Dr. Farid Fata, 48, of Oakland Township, Mich., reportedly gave "unnecessary chemotherapy to patients in remission" and deliberately misdiagnosed patients in order to defraud the federally-funded health care program of approximately $35 million over a two-year period, according to the complaint. • Fata "systematically defrauded Medicare by submitting false claims for services that were medically unnecessary" for patients, which included a variety of cancer and hematology treatments given to people who did not need them, the complaint said. • Fata, who owns and operates Michigan Hematology Oncology Centers (MHO), was arrested and booked into Wayne County Jail in Detroit, Mich. on Tuesday, U.S. Attorney's Office for the Eastern District of Michigan said. Federal agents raided his multiple offices in the Detroit area and seized his medical records as they continue to build a case against him. Excerpt from ABC News.

CDI, Compliance & Auditing • Each year hundreds of healthcare fraud and abuse cases are reported. For the most part (unlike the example on the previous slide), most providers are not out to intentionally defraud their patients, CMS, or any other payer. • For many, it goes back to not knowing, understanding or adhering to appropriate documentation guidelines. This results in lack of support in the medical record, which is then interpreted as “lack of medical necessity.” • Remember this line: If it’s not documented, it wasn’t done.

CDI, Compliance & Auditing • With the increase volume in EMR implementation, the OIG now states: It’s documented, was it really done? • Some disadvantages of the EMR is the ability to copy/paste or copy forward data from one visit to the next. The EMR also enables the provider to ‘drop in’ certain elements (ROS/PE) into a note with a simple point & click. • EMR management has been and will continue to be on the OIG’s Work Plan.

CDI, Compliance & Auditing • In addition to the numerous fraud/abuse audits and legislation, there is also added financial pressures on the providers in terms of ratings and performance (Physician Profiling): Health Grades Joint Commission WebMD.com State Health Depts.CMS.gov Employers/PRO UHC/Humana/Aetna Patients

CDI, Compliance & Auditing Poor rating? But, my patient is sicker!… Show me! —Principal Dx: CVA • Specify the type: Ischemic or hemorrhagic? If ischemic, which artery(ies) are affected? If hemorrhagic, what’s the site? —Assessment: HIV with PNA. Pt c/o SOB w/ABGs: PH: 7.54, pCO2 O2 sat. 48%. Pt placed on 02. • The above ABG points to acute respiratory failure which adds an MCC to the final DRG.

CDI, Compliance & Auditing • Coders and Auditors are on the frontline to not only ensure proper documentation, but to also reduce fraud and abuse. • Coding & CDI should work hand in hand to educate and provide feedback to the provider. • All of this should be done while adhering to all established compliance laws and regulations (national, local/state, and facility).

CDI, Compliance & Auditing • What are auditors looking for? COMPLIANCE • Compliance in documentation requirements/guidelines. • Compliance in proper code assignment. • Compliance in appropriate use of modifiers and NCCI edits. • Compliance in proper administration of drugs and services… • Compliance in support of 2-Midnight Rule*

CDI, Compliance & Auditing • Assign codes/DRG based on the information documented. • If clinical indicators suggest a more detailed assessment, the appropriate query protocol should take place. • Do not assume or lead! • Do review all documents in the medical record for supporting documentation!

CDI, Compliance & Auditing • Every organization should have an effective compliance program. At a minimum, comprehensive compliance programs should include the following seven elements (OIG): (1) The development and distribution of written standards of conduct, as well as written policies and procedures that promote the hospital’s commitment to compliance… (2) The designation of a chief compliance officer and committee… (3) The development and implementation of regular, effective education and training programs for all affected employees… (4) The maintenance of a process, such as a hotline, to receive complaints… protect anonymity… and to protect whistleblowers… (5) The development of a system to respond to allegations of improper/ illegal activities… (6) The use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem area… (7) The investigation and remediation of identified systemic problems…

CDI, Compliance & Auditing • ICD-10 brings about increase scrutiny in documentation & compliance. • Providing appropriate documentation training/feedback to your providers now will ensure a smoother transition as the industry gears up for the new nomenclature. • New effective date – October 1, 2015. • CMS is seeking input on those clinical situations that would warrant an inpatient stay. Email your professional opinion to IPPSAdmissions@cms.hhs.gov (subject line “Suggested Exception”). * 2-Midnight Rule

CDI, Compliance & Auditing • Prescription drug fraud involving non-controlled substances is becoming more common. The billing but not dispensing of non-controlled medications presents a massive financial loss to the Medicare program. Schemes typically involve brand-name, high-cost medications, including respiratory, HIV/AIDS, and anti-psychotic medications, along with co-conspirator beneficiaries who assist in obtaining the prescriptions in exchange for a kickback. • In one south Florida case, a pharmacy was found to be billing but not actually dispensing expensive non-controlled medications. The pharmacy received fake invoices from a wholesaler to cover this shortage. OIG special agents infiltrated the wholesale company and arrested the owner. During the investigation it was discovered that the wholesaler had supplied fake invoices to 17 other local pharmacies. Testimony of: Gary Cantrell Deputy Inspector General for Investigations Office of Inspector General U.S. Department of Health and Human Services – 06/2014

CDI, Compliance & Auditing • In closing, we must all stay aware and alert to potential fraud/abuse practices. We must ensure compliance with all aspects of healthcare. • Do not fall victim to the ‘Head in the Sand’ mentality. Be responsible and ethical at all times! • Questions…

CDI, Compliance & Auditing Covering All Basis