Building a Medical Records Compliance Program for Your Office:

1. Building a Medical Records Compliance Program for Your Office: Charles B. Brownlow, OD, FAAO cbrownlow@revolutionehr.com December 17, 2012

2. Plan of Action for this Webinar Series • Part I: November 29, “The Reality of Audits” • Part II: December 17, “Building Your Medical Records Compliance Program” • Part III: January 10, “Medical Records Coding”

3. Compliance Programs… • Federal Office of the Inspector General instituted a mandatory compliance program for large offices and hospitals nearly twenty years ago • Compliance program for small offices is still voluntary, but a very, very good idea!

4. Building a Voluntary Compliance Program for Your office Creating and implementing a compliance program for your office will be beneficial in: Building protocols for quality care in your office Building protocols for better records in your office Surviving audits by Medicare and others

5. Feel free to use the following slides as ‘templates’ for creating a Medical Records Compliance Program for your office. You will be glad you did!

6. Medical Records Compliance ProgramInstituted January 1, 2013

7. Purpose and Commitment The medical records compliance program for our office is built on the seven elements included in the Office of Inspector General’s program (listed on the next pages). Each doctor and staff member in our office is aware of the program and is as committed to complying with its components as we are to providing excellent care to each of our patients.

8. Our office is committed to medical records compliance by… • Conducting internal monitoring and auditing through the performance of periodic audits; • Implementing practice standards through the development of written standards and procedures; • Designating a compliance officer or contact to monitor compliance efforts and enforce practice standards; • Conducting appropriate training and education on practice standards and procedures;

9. Our commitment to compliance… 5. Responding appropriately to detected violations through the investigation of allegations and developing a corrective action program; 6. Developing open lines of communication with the practice’s employees; and 7. Enforcing disciplinary standards through well-publicized guidelines.

10. Our doctors and staff are trained to… • Focus all the care we provide upon the needs of each patient • Keep complete, thorough, legible, and compliant medical records • Choose codes correctly based on the content of each record, and to • Know and respect the rules of each patient’s insurer(s)

11. And, our doctors and staff are trained to… • Communicate the rules and limitations of each patient’s coverage to the patient and the patient’s caregivers • Respect the requirements of the Health Information Portability and Accountability Act (HIPAA), especially as they pertain to keeping and protecting patient privacy

12. Our compliance program focuses on each of the seven goals through the following processes…

13. 1. Internal audits of care, charts, and claims… • Quarterly internal reviews of (five) charts/doctor, checking for: • Appropriateness of care provided as related to the reason for each visit • Accuracy of code choices for visits and procedures based on the reason and the content of the record • Thoroughness and legibility of records, including history, examination and medical decision making • Necessary orders, assessments, interpretations and reports, supporting documentation, test results, initials, signatures • First audits completed (January), 2013

14. 2. Implementing practice standards through the development of written standards and procedures • We have adopted the handouts and other materials from educational seminars, (11/29/12, 12/18/12, 1/10/13), as our practice standards and procedures relative to medical records • Our practice standards and procedures will be revisited and revised from time to time as needed • Compliance officers will determine when and how the standards and procedures will be revised

15. 3. Designating Our Compliance Officers • Our office will have two compliance officers • One doctor • One staff person • Our current compliance officers are • ______________________________, OD • ______________________________ • Compliance officers are charged with monitoring compliance efforts and enforcing practice standards • Compliance officers will serve until replaced by our practice’s leadership

16. 4. Staff and Doctor Training • Our training is accomplished through… • Quarterly education sessions for all doctors and staff • First training session completed October 25, 2012 • Additional training quarterly, beginning January, 2013 • Subjects will be chosen by our compliance officers, based on quarterly audits of patient records, review of claims history, review of provider agreements, and any problem areas or policy changes identified on a day to day basis • Education may be provided individually or in group sessions, as appropriate

17. Our compliance officers fulfill goals 5, 6, and 7 as they… 5. Respond appropriately by identifying any departures from accepted medical records standards and develop a corrective action program as needed; 6. Maintain open lines of communication with the practice’s employees, encouraging comments regarding medical records; and 7. Enforce medical records standards by open communication, coaching, and ongoing cooperative education of doctors and staff

18. The following slides are a review of basic standards for appropriate patient care and excellent medical record keeping

19. An excellent formula for appropriate patient care, good records (paper or EHR) & accurate coding is… “Do what is needed to diagnose and manage the patient’s issues today; no more, no less; and grade the chart based only on the content of the record, guided by CPT and the Documentation Guidelines.” -CBB

20. The basics for providing care form the basics for medical records • The reason for visit (eg chief complaint, presenting problem, signs or symptoms) must be clearly stated on the record, and • All care provided and all contents of the record must be driven by the reason for visit

21. Good medical records reflect good quality care • The record for the visit must be thorough and legible: • Details of all care provided must be carefully recorded • Include orders for all ancillary testing (fields, photos, return to office, etc.) • Interpretation and report for each such test • Note: Ignorance is no excuse… Doctors and staff must know and abide by national rules and the rules included in each provider agreement

22. Know and comply with national rules and payers’ contracts • Review CPT definitions for common services annually • List 20-30 most common CPT codes reported in previous year • Refer to 2012 CPT for definitions of those services • Review Medicare and all other provider agreements at least once each year • If not found…Contact payer for copy! • Check payers’ websites for other information • Review each payer’s requirements for medical records and coding • Review each payer’s reimbursement schedule

23. Procrastination is passé • Most providers have ignored this stuff too long • Commit all doctors and staff in your practice to focusing on patient care and compliance with national rules and payers rules • Conduct internal audits of each doctor’s charts each 3-6 months (e.g. 5-10 charts/audit) • Develop in-office protocols to ensure consistent record keeping and compliance with payers’ rules

24. Part III in this series: “Medical Records and Coding” January 10, 2013 Questions? Best wishes for a happy, healthy and audit-free 2013! cbrownlow@revolutionehr.com