Compliance, Reporting, Documentation, and HIPAA

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ACMSS CONTINUING SCRIBE EDUCATION

Definitiions

• Physician Quality Reporting Systems (PQRS): a reporting program that uses incentive and penalties to promote reporting of quality information by healthcare professionals

• Value-Based Purchasing (VBP): a program in which participating hospitals are paid for services based on the quality of care.

• Accountable Care Organizations (ACO): groups of health care providers who come together voluntarily to coordinate high quality patient care, reimbursements, quality metrics, and cost reduction.

• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS): a survey used to measure patients’ perspectives of hospital care, that creates a national system of information that enables consumers to compare hospitals.

Definitions

• Evaluation and Management (E&M): Coding practice that allows health care providers to bill insurers for reimbursement for services provided to patients.

• The Centers for Medicare & Medicaid Services (CMS): an agency within the US Department of Health & Human Services (DHHS) which administrates Medicare, Medicaid, the Children’s Health Insurance Program and a number of other services.

• The Joint Commission (TJC): An independent organization that accredits and certifies over 20,000 health care organizations in the United States.

Definitions

• Current Procedural Terminology (CPT): codes published by the American Medical Association to provide a uniform language to describe medical, surgical, and diagnostic series used by healthcare professionals for reimbursement from insurers.

• International Classification of Diseases, 9th or 10th Revisions (ICD-9 and ICD-10): A coding system that is used to identify signs, symptoms, injuries, diseases, and conditions and must correlate with CPT and E&M codes for reimbursement and documentation purposes.

HIPAA

• The Health Insurance Portability and Accountability Act which was passed in 1996
• The primary purpose:

– Make it easier for patients to keep health insurance
– Protect patient confidentiality
– Control administrative costs within the healthcare and health insurance industry.

• PHI: Protected Health Information:

– Electronic chart
– Paper chart
– Word of mouth
–Financial, personal information, and medical data.

HIPAA

• HIPAA has three components that are vitally important:

– Protecting PHI
– Applying the Minimum Necessary Rule to the use of PHI
– To guarantee certain patient rights involving the PHI

• Definitions associated with HIPAA:

– DHHS: The United States Department of Health and Human Services
– OCR: Office of Divil Rights
– PHI: Protected Health Information

The HIPAA Privacy Rule

• The HIPAA Privacy Rule:

– Creates national standards to protect PHI
– Applies to everyone in the healthcare industry that comes into contact with sensitive patient information
– Requires placement of appropriate systems to protect the privacy of PHI
– Sets restrictions on the use of such information with and without patient authorization (The Security Rule).
– The Privacy Rule also gives patients the rights regarding their medical records.

HIPAA: Patient Rights

• Under HIPAA, patients have the following rights regarding the PHI.

– Get a copy of their medical record
– Correct any information in their medical record
– Request confidential communication with a healthcare provider
– Ask their healthcare providers to limit the information they share about the patient
– Get a list of covered entities with whom information is shared
– Get a copy of a privacy notice from the healthcare provider
– Choose someone to act on their behalf (e.g., a power of attorney, next of kin, etc.)
– File a complaint if their privacy rights have been violated

HIPAA defines PHI as:

• Names
• All geographical identifiers smaller than a state
• Dates directly related to an individual
• Phone numbers
• Fax numbers
• Email addresses
• Social Security numbers
• Medical record numbers
• Health insurance beneficiary numbers

• Account numbers
• Certificate and license numbers
• Vehicle identifiers
• Device identifiers
• Web Uniform Resource Locators
• Internet Protocol (IP) addresses
• Biometric identifiers
• Full face photographic images and other patient images

Section 160.103 of HIPAA: defines “health information”

• “Health information means any information, whether oral or recorded in any form or medium, that

– Is created or received by a healthcare provider, health plan, public health authority, employer, life insurer, school or university, or healthcare clearinghouse; and
– Relates to the past, present, or future physical or mental health or condition of an individual; the provision of healthcare to an individual; or the past, present, or future payment for the provision of healthcare to an individual.”

Who has to follow HIPAA? Covered Entities

• All “Covered Entities” must follow HIPAA> These include:

– Health insurance companies
– Health Maintenance Organizations
– Employer health plans
– Government payer programs, such as Medicare and Medicaid.
– Health Care Clearinghouses: entities that process and release health information.

All “Covered Entities” must follow HIPAA

• Health Care Providers
• Doctors
• Clinics
• Hospitals
• Psychologists
• Chiropractors
• Nursing homes
• Pharmacies
• Dentists
• Ancillary personnel used in these settings including, for example, medical scribes.
• Etc.

Who else has to follow HIPAA?

• Any business associates of Dovered Entities that need access to medical records:

– Contractors
– Subcontractors
– Billing companies
– Companies that process your health care claims
– Companies that administer health plans
– Lawyers
– Accountants
– Information technology specialist
– Companies that store medical records

Patient Safety Act and Rule

• Congress passed the Patient Safety and Quality Improvement Act in 2005
• It established:

– A system of patient safety organizations (PSO)
– A national patient safety database
– Privilege and confidentiality protections for Patient Safety Work Product.
– This work product is defined as any data, reports records, analyses, or written or oral statements, which could improve patient safety, health care quality, or health care outcomes, which are assembled or developed by a provider for reporting to a Patient Safety Organization (PSO).
– Patient safety work product does not include a patient’s medical record, billing and discharge information, any original patient or provider information, or information that is collected, maintained, or developed separately, or exists separately, from a patient safety evaluation system (for example research or clinical care).

Minimum Necessary Requirement Rule

• The minimum necessary standard, a part of the Privacy Rule, states the PHI should not be used when it is not necessary.
• It requires covered entities to limit unnecessary or inappropriate access to and usage of PHI.
• The minimum necessary standard does not apply to the following:

– Information needed by a health care provider for diagnosis and treatment.
– Disclosures to the patient themselves.
– Information usage requested by an individual’s authorization.
– Disclosures to the DHHS when disclosure of information is required under the Privacy Rule for enforcement purposes.
– Uses or disclosures that are required b other law.

The Breach Notification Rule (Under the Privacy Rule)

• A breach is use of disclosure of PHI without appropriate permissions that results in a significant risk of harm to the patient.

– Covered entities must notify patients and the DHHS of all elements of the breach.
– This is especially paramount if the PHI breach affects over 500 patients.
– Reports of breaches must occur within a specified amount of time.
– Breaches that affect 500 or more patients are publicly reported.
– In order to prevent unwanted breaches of PHI, scribes should only look at PHI when your licensed provider asks you to OR is a required part of your documentation.
– Important safeguards

– Not discussing the patent or anything regarding their care outside of the patient visit
– Avoid using someone else’s passwords
– Avoid any other compromise in confidentiality of a patient’s PHI.

• Violations of this type can result in institutional, state0level, and federal disciplinary actions as well as criminal convictions.

HITECH Act

• The Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act of 2009, was enacted to help healthcare providers and hospitals use health information technology in a responsible and patient-protective way.

• Part of the bill addresses privacy and security concerns involved with the usage of dispersal of electronic health information by strengthening the enforcement ability of the IPAA rules.

Outcomes Reporting Requirements

• Physician Quality Reporting System

• Value Based Purchasing

• Hospital Consumer Assessment of Healthcare Providers and Systems

Physician Quality Reporting System

• CMS created the Physician Quality Reporting System (PQRS)

– Under the Tax Relief and Health Care of 2006
– Bonus payment for successful participation by health care providers.
– Participating providers send quality data regarding Medicare patients to CMS.
– CMS is required to post on a website the names of healthcare professionals who have satisfactorily reported under the PQRS.

Physician Quality Reporting System:
Penalties

• Several PQRS program changes were included in the 2010 The Affordable Care Act (ACA)

– Required the establishment of an informal appeals process by 2011
– Calls for PQRS payment penalties starting in 2015 for measure that are based on 2013 performance.
– Those physicians who are not in compliance during the 2013 program years, will receive a 1.5 percent payment penalty, and 2 percent thereafter
– In every cycle thereafter, CMS has made the application of penalties of a specific year based on measures from performance 2 years prior.

Physician Quality Reporting System:

• The PQRS measures address various aspects of patient care

– Preventative care
– Chronic- and acute-care management
– Surgical and office based procedures
– Resource utilization
– Coordination of care
– Healthcare practices have flexibility in choosing which core measures they wish to report.

Value Based Purchasing: Pay for Performance

• Value based purchasing (VBP):

– Created by CMS
– Incentives based on a combination of clinical outcomes and certain core process outcomes
– Many physicians and healthcare providers believe that VBP or P4P systems have brought mixed results because sometimes incentives do not change the way healthcare providers practice medicine.

Value Based Purchasing

• Correlation wit improvement in clinical outcomes is still under investigation by the research community, with mixed results in terms of outcome improvement and cost-savings.
• The governments VBP payment model rewards physicians, hospitals, and other healthcare providers for meeting certain performance measures for quality and efficiency and imposes negative incentives to caregivers for poor outcomes or increased costs.

Value Based Purchasing

• CMS has several projects offering incentives for improvements.

– In 2005, CMS started a value-based purchasing pilot program with ten large, multi-specialty physician practices caring for more than 200,000 Medicare patients.
– These practices reported on quality metrics for preventive care and chronic illness management, and those meeting or exceeding standards are rewarded.

• More than 3,000 hospitals across the country are eligible to participate in Hospital VBP.

Value Based Purchasing: Hospital volume is important

• To be eligible, hospitals must report on at least four VBP measures during the performance period with a minimum of 10 cases per measure.
• Data from the performance period is compared to the hospital’s baseline data.
• The VBP program consists of two domains:

– Clinical patient care processes
– Patient’s experience of their care.

– This is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) reporting information.
– This is an example of where different measure reporting requirements dovetail towards common programs.

Examples of core measures that are reported by hospitals

• Acute Myocardial Infarction (AMI)

– AMI-7a Fibrinolytic Therapy Received Within 30 Minutes
– AMI-8a Percutaneous Coronary Intervention (PCI) Received Within 90 Minutes

• Hear Faiure (HF)

– HF-1 Discharge Instructions

• Pneumonia (PN)

– PN-3b Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital
– PN-6 Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patient

Examples of core measures that are reported by hospitals

• SCIP = Surgical Care Improvement Project

– SCIP-Inf-1 Prophylactic Antibiotic Received One Hour Prior to Incision
– SCIP-Inf-2 Prophylactic Antibiotic Selectio for Surgical Patients
– SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
– SCIP-Inf-4 Cardiac Surgery Patients with Controlled 6:00am postoperative Blood Sugar
– SCIP-Card-2 Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker
– SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism (VTE)
– SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 hours Prior to Surgery to 24 Hours After Surgery

Update on SCIP measures by CMS

• Effective January 1, 2015
• The Joint Commission will retire the following measures:

– SCIP-Inf-2
– SCIP-Inf-3
– SCIP-Inf-6
– SCIP-Card-2
– SCIP-VTE-2

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

• A national, standardized, publicly reported survey of patients’ experiences of hospital care.

– Hospital “customer services” survey

• A 27-item survey
• Allows valid comparisons to be made across hospitals nationally
• HCAHPS was designed and implemented under the following assumptions:

– There was need for meaningful comparisons of hospitals on topics that were important to patient
– Public reporting of the data creates incentives for hospitals to improve quality of care
– Public reporting enhances accountability through transparency.

Hospital Consumer Assessment of Healthcare Providers and Systems

• In 2002, CMS and the Agency for Healthcare Research and quality (AHRQ) developed and tested the HCAHPS Survey through a rigorous scientific process.

– Public input
– Literature review
– Interviews
– Focus groups
– Pilot tests
– Field tests

• The first public reporting was in March 2008.
• Since July 2007, hospital HCAHPS reporting has been tied to their payment updates.
• The Affordable Care Act included HCAHPS performance in the calculation of value-based.

Hospital Consumer Assessment of Healthcare Providers and Systems

• Asks recently hospitalized patients about aspects of their hospital experience

– Between 48 hours and six weeks after discharge
– Medical, surgical or maternity care.
– HCAHPS can be implemented through mail, telephone, mail with telephone follow-up, or active interactive voice recognition (IVR).
– Hospitals must survey patients every month

– Must have least 300 surveys a year

Hospital Consumer Assessment of Healthcare Providers and Systems

• Ten HCAPHS measures are publicly reported for each participating hospital.

– Healthcare provider communication with patients
– Staff responsiveness to patient needs
– Pain management
– Explanation of medicines
– Information at discharge
– Cleanliness
– Quietness
– Recommendation of the hospital to family and friends.

Coding and Billing

• Current Procedural Terminology (CPT) Codes Including Evaluation & Management (E/M)
• Physicians, outpatient facilities, and hospital outpatient departments use CPT codes to identify procedures and surgeries performed during a patient encounter.

Coding and Billing

• CPT codes are used to bill for E/M services provided inpatient and outpatient.
• CPT and E/M Coding is a medical billing procedure that providers use for reimbursement by federal and private insurers.
• The codes specify what kind o encounter occurred and leads to a specified payment.
• E/M standards and guidelines were established by Congress in 1995.
• E/M codes are a subset off the Current Procedural Terminology (CPT) codes established by the American Medical Association (AMA).
• Almost every annual iteration refines and adds more necessary codes to the list.
• E/M services are categorized into different settings: outpatient, hospitals, Emergency departments, and Nursing facilities.

Coding and Billing

• The codes used E/M services are categorized so that a more complex the visit equals higher level of code equals higher reimbursement.
• The codes must reflect the services provided to the patient.
• There are thereby components to the code for billing: history, examination, and medical decision making.
• For counseling or coordination of care, time indicates the level of E/M coding.
• The documentation within the patient chart must support the coding.
• The level of coding that is used depends on the amount of depth and detail provided within the history, physical examination, and medical decision making.

Medical Documentation and Coding: History

• The table on the next slide illustrates the requirements for documenting a history
• To qualify for a given type of history, all four elements indicated in a row must be met. As the type of history becomes more complex, documentation also increases in intensity.
• The table below indicates the level to which each element of the history must be documented in order to qualify for that categorization of history.

Documentation and Coding: History

TYPE OF HISTORY	CHIEF COMPLAINT	HISTORY OF PRESENT ILLNESS	REVIEW OF SYSTEMS	PAST, FAMILY, SOCIAL HISTORY
Problem Focused	Yes	Brief	Name	None
Expanded Problem Focused	Yes	Brief	Problem Focused	None
Detailed	Yes	Extended	Extended	Problem Focused
Comprehensive	Yes	Extended	Complete	Complete

Elements of patient history documentation

• Chief Complaint (CC)

– A CC is a brief, summary statement that describes the reason for the patient encounter. It can be the patient’s own words or a brief phrase by the healthcare provider, and must be clear in the medical record.

• History of Present Illness (HPI)

– HPI is a detailed description of the development of the patient’s present disease or condition presented as chronological story. The elements of the condition or symptom (e.g., pain) within the HPI that should be discussed include:

– Location on body
– Quality or type
– Severity
– Duration and timing
– Modifying factors

– Associated signs and symptomss

• HPIs can be brief or extended. A brief HPI includes documentation of one to three of the above HI elements, whereas an extended HPI should discuss at least four elements.

Review of Systems (ROS)

• A ROS is an inventory of symptoms and conditions, organized by body or physiologic systems.

– Identify symptoms that the patient may be experiencing or has experienced related or unrelated to the HPI.

• The following systems are recognized within a ROS:

– Constitutional and General Symptoms
– Eyes
– Ears, Nose, Mouth, Throat
– Cardiovascular
– Respiratory
– Gastrointestinal
– Genitourinary
– Musculoskeletal
– Skin and/or Breast
– Neurological
– Psychiatric
– Endocrine
– Hematologic/Lymphatic
– Allergic/Immunologic

Review of Systems (ROS)

• There are three types of ROS: problem focused, extended, and complete
• A problem focused ROS inquires about the systems directly related to the problem in the HPI
• An extended ROS inquires about the systems directly related to the problems(s) in the HPI and a limited number of additional systems.
• A complete ROS inquires about the systems(s) directly related to he problem(s) in the HPI plus all organ systems
• Those systems with positive or pertinent negative responses must be individually documented
• For the remaining systems, a notation indicating all other systems are negative is permissible
• In the absence of such a notation, at least ten systems must be individually documented

Past, Family, and Social History (PFSH)

• PFSH consists of three areas:

– Past history including past illnesses, operations, injuries, and treatments
– Family history
– Social history: Etoh, Smoking, Drugs, Living arrangements, etc

• There are two types of PFSH:

– Pertinent
– Complete

• Pertinent PFSH: focused review as it directly relates to HPI

– Document at least one item from any of the three history areas

• Complete PFSH: Two or all three areas

– A review of all three history areas: comprehensive assessment of the patient

Important Aspects of History Documentation

• The CC, ROS, and PFSH may be listed separately or included lump sum
• The physician can review and updated previous information
• The review and update should be documented by describing any new ROS or PFSH information or noting there has been no change
• The ROS an/or PFSH may be from a patient- or ancillary staff- recorded form
• If the physician is unable to obtain a history from the patient or other source, the record should describe this situation

Examination: Four types of examinations

• Problem Focused is limited examination of a specific body area or organ system
• Expanded Problem focused includes any other symptomatic or related organ systems(s)
• Detailed includes an extended examination of the affected area and any related areas
• Comprehensive is ageneral multi-system examination or complete examination of a single organ system

– A general multi-system examination or a single-organ system evaluation can have 4 different levels of intensity depending upon the number of elements and organ systems of the physical examination are included: 1) Problem-Focused, 2) Expanded problem-focused, 3) Detailed, and 4) Comprehensive

Medical Decision Making

• Medical decision making describes the amount of effort the physician must exert to decide how to treat the patient
• It includes documentation of

– Radiologic or laboratory tests reviewed or ordered.
– The different management options and the level of risks and benefits or each management strategy
– Diagnostics ordered or tratment options available
– Complexity of medical records that must be obtained, reviewed, and analyzed

Medical Decision Making

• The levels of medical decision-making include:

– Straightforward
– Low complexity
– Moderate complexity
&ndas; High complexity

• In genderal, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem
• Problems that are resolving are less complex than those that are worsening or failing to respond to treatment
• Higher complexity problems sometimes involve the need to seek advice from other health care professionals

Medical Decision Making

• For a presenting problem with an established diagnosis, one should document if the problem is:

– Improving
– Well-controlled
– Resolved
– Inadequately controlled
– Worsening
– Failing treatment

Medical Decision Making

• For a problem without a diagnosis, one may document

– Differential diagnoses (a list of potential diagnoses)
– “Possible,” “Probable,” or “Rule out” diagnosis
– Treatment initiation or modifications must be documented, and these treatment may include giving patient instructions, giving nursing instructions, actual therapies, and medications
– The medical record should also indicate whether referrals or consultations are requested, or expert advice sought, because these clearly point towards a higher complexity of medical decision-making

Medical Decision Making

• The amount or complexity of data to be reviewed is directly related to the type of test performed
• Increasingly complexity of medical decision-making can involve a

– Decision to obtain and review history from old medical records or other complex sources
– Discussion of realists wit the physician who performed or interpreted the test
– Reviewing the results to supplement additional information fro the physician who prepared the original test report
– If a diagnostic service is ordered or performed at the time of the E/M encounter, the type of service should be documented to indicate complexity

Medical Decision Making

• The review of diagnostic or laboratory tests should be documented no matter how simple or complex the level of review, including, if possible, initialing and dating the results report
• A decision to obtain additional medical records or obtain additional history from other sources should be documented
• One should also include in the patient note and medical record any relevant findings from the review of the additional medical records or additional information form other sources, even if there is no relevant information beyond that already obtained primarily from the patient
• Simply indicating that old records or other informational sources were reviewed will not suffice
• Any discussions with the patients, family, or other physicians regarding diagnostic test results should be documented, as well as ny direct independent interpretation o a diagnostic test for the purposes of that patient visit

Counseling and Coordination of Care

• When the physician-patient encounters becomes a predominantly counseling and/or coordination of care session, time is the most important factor to qualify for a particular level of E/M services
• If the level of service is reported based on documentation of counseling and/or coordination of care,

– The total encounter time should be documented
– Documentation should describe the counseling and activities to coordinate the care
– The average time guidelines for a variety of E/M services are listed in the CPT reference books
– The specific times expressed in the definitions of the codes are averages and the actual times may be higher or lower depending on actual clinical circumstances

Medical Record Documentation

• Medical record documentation is the art and science of chronologically recording facts, findings, and observations of the medical history, medical decision making, treatments, and treatment outcomes
• The medical record is an important element contributing to high quality care, is central to the reporting of outcome and process measures, and is necessary to justify coding and billing
• The medical record helps a physician and other healthcare professionals to plan a patient’s treatment and monitor the patient’s healthcare over time
• It is essential in communication and continuity of care among physicians, is needed for accurate and timely claims review and payment, is necessary for utilization review and quality of care evaluations, and is a vital source of data for research development
• A well written medical record can result in smoother claims processing and provide a strong medicolwegal resource to verify the care provided

Medical Record Documentation

• The principles of documentation listed below are applicable to all types of medical documentation
• The medical record should be complete and legible
• Tdocumentation of a patient visit should include:

– Chief complaint, medical history, examination, and diagnostic test results
– Assessment, clinical impressio, or diagnosis
– Plan for care
– Identity of the observer

• The rationale for ordering diagnostic and other ancillary services should be documented and/or easy to infer from the documentation
• All of the history documentation and rationale for treatment accessible to the treating or consulting physician
• Document all lifestyle and health risk factors
• The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented
• The billing CPT and ICD-9-CM codes must supported by the documentation in the medical record