Building a Medical Records Compliance Program

for Your Office:

Charles B. Brownlow, OD, FAAO cbrownlow@revolutionehr.com

December 17, 2012

• 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”

Plan of Action for this Webinar

Series

• 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!

Compliance Programs…

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

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!

Medical Records Compliance Program

Instituted January 1, 2013

Purpose and CommitmentThe 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.

1. Conducting internal monitoring and auditing through the performance of periodic audits;

2. Implementing practice standards through the development of written standards and procedures;

3. Designating a compliance officer or contact to monitor compliance efforts and enforce practice standards;

4. Conducting appropriate training and education on practice standards and procedures;

Our office is committed to medical records compliance

by…

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; and7. Enforcing disciplinary standards through well-publicized guidelines.

Our commitment to compliance…

– 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)

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

And, our doctors and staff are trained to…

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

– 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

1. Internal audits of care, charts, and claims…

• 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

2. Implementing practice standards through the

development of written standards and procedures

• 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

3. Designating Our Compliance Officers

• 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

4. Staff and Doctor Training

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; and7. Enforce medical records standards by open communication, coaching, and ongoing cooperative education of doctors and staff

Our compliance officers fulfill goals 5, 6, and 7 as they…

The following slides are a review of basic standards for appropriate patient care

and excellent medical record keeping

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

• 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

The basics for providing care form the basics for medical

records

• 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

Good medical records reflect good quality

care

Review CPT definitions for common services annuallyList 20-30 most common CPT codes reported

in previous yearRefer to 2012 CPT for definitions of those

servicesReview Medicare and all other provider

agreements at least once each yearIf not found…Contact payer for copy!Check payers’ websites for other informationReview each payer’s requirements for

medical records and codingReview each payer’s reimbursement schedule

Know and comply with national rules and payers’

contracts

• 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

Procrastination is passé

Questions?Best wishes for a happy, healthy

and audit-free 2013!

cbrownlow@revolutionehr.com

Part III in this series: “Medical Records and Coding”

January 10, 2013