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Slide 1 - Coding, Documentation, and Data Management Kyle C. Dennis, Ph.D., Deputy Director, Audiology & Speech Pathology Service Department of Veterans Affairs
Slide 2 - Session Objectives Understand basic code systems and development of codes Understand basic organization and principles of procedure and disease coding Understand basic principles of coding and billing Understand basic principles of documentation
Slide 3 - Topics for Discussion Coding systems Procedure codes Disease codes Coding, billing, and compliance Documentation Referral guidelines and service agreements
Slide 4 - How are codes used? Revenue generation (reimbursement) Documentation of services Workload and utilization Productivity Cost analysis Provider profiles (privileging) Analysis, health research, and trending
Slide 5 - Why is coding compliance so important in data management? Critical to workload and data capture Critical to resource allocation Critical for health care planning Critical to third-party (insurance) reimbursement Must conform to uniform national standards (CMS compliance)
Slide 6 - …and more importantly Demonstrates adherence to community standards of care Demonstrates accountability to patients and stakeholders Demonstrates to stakeholders that critical services and special programs are maintained
Slide 7 - Basic Management Questions How much work did my clinic do? What did it cost? Can I bill for it? If I can’t bill for it, does it affect my costs and productivity? How much revenue did I generate? Is my clinic a “value-added” service? Is my clinic efficient?
Slide 8 - Basic Data Elements Patient demographics (name, SSN) Diagnoses, conditions, symptoms, or problems Procedures or services Provider Successful capture of encounter data requires these basic elements.
Slide 9 - Basic Data Flow AppointmentVisitEncounter Encounter datadatabase=management reports, analyses, and trends Encounter databilling system=reasonable charges=revenue Important…accurate coding is essential because data management systems are linked. It all starts with the basic data elements.
Slide 10 - The Manager’s Task Use various data systems to optimize workload, efficiency, utilization, costs, and revenue generation Benefits to the organization data-driven decision making maximized value quality improvement accountability justification of resources tracking of utilization, costs, and health care trends predictable, consistent health care delivery
Slide 11 - Coding Systems
Slide 12 - Topics for Discussion Coding Systems Procedure Codes Disease Codes Coding and Billing Documentation
Slide 13 - Procedure Coding Systems Healthcare Common Procedure Coding System (HCPCS) Current Procedural Terminology (CPT) HCPCS Level II (National or HCPCS) ICD-9 PCS Future: ICD-10 and ICD-10 PCS
Slide 14 - Disease Coding International Classification of Diseases, Ninth Edition, with Clinical Modifications (ICD-9-CM) Future: International Classification of Diseases, Tenth Edition (ICD-10-CM)
Slide 15 - Future Code Systems ICD-10-CM Developed by World Health Organization Clinical modification for U.S. developed by National Center for Health Statistics ICD-10 PCS developed by 3M under contract from CMS HIPAA mandates universal code system.
Slide 16 - ICD-10-CM Ear and hearing problems found in Chapter 8 More descriptive than ICD-9-CM Examples: H90.3--bilateral SNHL H90.4--unilateral SNHL with unrestricted hearing on contralateral side
Slide 17 - ICD-10 PCS Greatly expands procedures codes Not proprietary Example: Pure tone audiometry-9C03Z1C 9=Rehabilitation and Diagnostic Audiology C=assessment 03=test method (pure audiometry) Z=body system (none) 1=equipment (audiometer) C=qualifier (individual)
Slide 18 - HCPCS Codes Level I--Current Procedural Terminology (CPT-4) Level II--National codes Level III-local codes used by Medicare intermediaries, no longer used Modifiers for Level I and Level II
Slide 19 - CPT Codes Copyrighted and published by AMA Five digit codes (e.g. 99211) Revised annually by AMA Describes physician and non-physician services by specialty Complexity- or time-based Includes modifiers
Slide 20 - Organization of CPT Codes Evaluation & Management (99201-99499) Anesthesiology (00100-01999, 99100-99140) Surgery (10040-69990) Radiology (70010-79999) Pathology and Laboratory (80049-89399) Medicine (90281-99199) Miscellaneous Services (99000-99090) CPT Modifiers (Appendix A)
Slide 21 - Categories of CPT Codes Category I--procedures and services (5 digits) Category II--performance measurement (4 digits followed by a letter) Category III--temporary codes (4 digits followed by a letter)
Slide 22 - HCPCS Level II (National) Codes Supplemental codes Updated annually by CMS Designated by letter and four digits (e.g. V5020) Ambulance services, dental services, durable medical devices, drugs and injections, home services, non-covered services, temporary and experimental codes
Slide 23 - What is New for 2003? New Evaluation and Therapeutic Section in the Otolaryngology Section (92500-series) Cochlear implant codes Major changes for Speech Pathology New unlisted ENT service code (92700)
Slide 24 - How are CPT Codes Developed? Developed and copyrighted by AMA CPT Editorial Panel--16-member panel meets quarterly to revise, update or modify CPT codes Health Care Professionals Advisory Committee (HCPAC)--14-member non-physician advisory panel. ASHA represents Audiology and Speech Pathology with AAA as an observer
Slide 25 - How are CPT Codes Developed? Resource-based Relative Value System Update Committee (RUC)--29-member panel assigns reimbursement value RUC HCPAC Review Board--recommends reimbursement for non-physician codes Practice Expense Advisory Committee (PEAC)--being phased out
Slide 26 - How are CPT Codes Developed? Application to Editorial Panel--must be FDA approved, proven benefit in peer-reviewed literature, widely used, standard of care (category I codes) Application sent to RUC or RUC HCPAC for review and value determination CMS generally follows AMA recommendations
Slide 27 - Calculating RVU Physician work (55%) Practice expense (42%) Medical liability insurance (3%) RUC determines only the physician work and practice expenses Global RVU x Medicare conversion factor=dollar reimbursement value
Slide 28 - Practice Expenses Most Audiology procedures do not involve physician work. Resource-based relative values (RBRVU) include practice expenses (e.g. clinic labor, equipment, supplies). Sources of data: Socioeconomic Monitoring Survey (SMS) and Clinical Practice Expert Panel (CPEP)
Slide 29 - Practice Expenses SMS data is used to calculate physician practice expense per hour (PE/HR) SMS includes clinical staff time but does not include independent audiologists. CMS created “zero work pool”, now called the Non-physician Work Pool (NPWP)
Slide 30 - Practice Expense Data Where do Audiology practice expenses come from? All physician PE/HR average (SMS) and clinical staff time (CPEP) for procedure CMS calculates an expense pool (e.g. clinical labor) using “all-physician” PE/HR and the CPEP average clinical staff time Data may not be accurate for audiologists.
Slide 31 - How Does this Affect Audiologists? 70% of Audiology codes are in the NPWP 90.6% of Audiology revenue comes from NPWP, highest of any clinical specialty NPWP does not accurately reflect true practice expenses Options: obtain survey data or continue to use physician data
Slide 32 - Pros and Cons Are audiologist practice expenses more than physician expenses? All-physician average: $69.00 per hour ENT: $105.70 per hour Many physician specialties are included in NPWP (e.g. oncology, radiology, internal medicine, cardiology) If some physician groups leave the NPWP, the remaining groups will be paid less.
Slide 33 - Professional & Technical Codes may not have physician work value Some codes have technical (TC) and professional (26) components. Professional component=physician work (May be billed by audiologists.) Technical component=practice expense Most Audiology codes do not have physician work.
Slide 34 - RVU Example 1--92585-TC Technical procedure without interpretation Physician work--0.0 Practice expense--1.18 Malpractice--.10 Non-facility RVU--1.26 Medicare fee (unadjusted)--$44.28
Slide 35 - RVU Example 2--92585-26 Professional component Physician work--0.50 Practice expense--.22 Malpractice--.02 Non-facility RVU--.74 Medicare fee (unadjusted)--$25.60 Notice how small the professional fee is compared the technical fee.
Slide 36 - RVU Example 3--92585 Global Physician work--.50 Practice expense--2.06 Malpractice--.14 Non-facility RVU--2.70 Medicare fee (unadjusted)--$93.40 Global can be billed by audiologists.
Slide 37 - Complexity-based Codes Unless otherwise specified, procedures are based on complexity Enter one code per procedure regardless of time spent Most CPT codes are complexity-based.
Slide 38 - Time-based Codes Time period is specified (e.g. 15 minutes) Enter one code for each time period Total volume=total time Example: 2 units=30 minutes for a 15-minute procedure Few Audiology codes are time-based. Time must be documented.
Slide 39 - Audiology Services CPT codes in the 92500-series Technical and professional services Do not require supervision by a physician Performed by qualified audiologists Must be ordered by a physician to be billed.
Slide 40 - General Purpose Codes 92506--evaluation of auditory processing and/or aural rehabilitation status 92507--treatment of auditory processing disorder (includes aural rehabilitation) 92508--group treatment Often used (and abused) for hearing evaluation and treatment, not elsewhere classified
Slide 41 - Audiology Treatment Codes Audiologists cannot be reimbursed for treatment services under Medicare 69200--foreign body removal 69210--cerumen management 97112--vestibular rehabilitation
Slide 42 - Implant Services Cochlear implant evaluation: Use audiological assessment codes Post-op analysis and fitting: 92601--Diagnostic analysis of CI, <7 yoa 92602--Subsequent programming, < 7 yoa 92603--Diagnostic analysis of CI, >7 yoa 92604--Subsequent programming, > 7 yoa Billable as diagnostic services CI Rehab (treatment)--92510 or 92507?
Slide 43 - Implant Services No specific codes for brainstem implants Use codes for cochlear implant With diagnosis of vestibular schwannoma (225.1) or NF-2 (237.72)
Slide 44 - Vestibular Function Tests With electrical recording 92541--spontaneous nystagmus test 92542--positional nystagmus test 92543--caloric vestibular test, each irrigation 92544--optokinetic nystagmus test 92545--oscillating tracking test (pursuit) 92546--sinusoidal vertical axis rotation test
Slide 45 - Vestibular Function Tests 92547--use of vertical channel recording Add-on code--usually limited to 92541 and 92542 No specific code for saccades (use 92700)
Slide 46 - Vestibular Function Tests Observation without electrical recording No reimbursement value 92531--spontaneous nystagmus 92532--positional nystagmus 92533--caloric vestibular test 92534--optokinetic nystagmus
Slide 47 - Audiological Assessment Codes 92551--screening test, air only 92552--pure tone audiometry, air only 92553--pure tone audiometry, air/bone 92555--SRT 92556--SRT and speech recognition No code for PI/PB (use modifier 22)
Slide 48 - Audiological Assessment Codes 92557--comprehensive audiometry Bundled code (includes 92553 and 92556) Do not code separately if all component tests are performed 92559--group audiometric test
Slide 49 - Middle-ear Function Tests 92567--acoustic immittance (tympanometry) 92568--acoustic reflexes 92569--acoustic reflex decay
Slide 50 - Site of Lesion Tests 92571--filtered speech test 92572--SSW 92576--SSI (ICM or CCM) 92563--tone decay test 92564--SISI 92565--pure tone Stenger test 92577--speech Stenger test 92589--central auditory function test
Slide 51 - Less Commonly Used Procedures 92573--Lombard test 92575--SAL 92562--loudness balance test (ABLB) 92560--Bekesy screening test 92561--Bekesy diagnostic test
Slide 52 - Electrophysiological Tests 92584--electrocochleography 92586--auditory evoked potentials, screening 92585--auditory evoked potentials (ABR, MLR, late potentials), diagnostic 92587--otoacoustic emissions, screening 92588--otoacoustic emissions, diagnostic 95920--intraoperative monitoring (added on to primary procedure, e.g. 92585)
Slide 53 - Hearing Aid Services 92590--HAE, monaural 92591--HAE, binaural 92592--hearing aid check, monaural 92593--hearing aid check, binaural V5014--hearing aid repair 92594--electroacoustic test, monaural 92595--electroacoustic test, binaural
Slide 54 - Hearing Aid Services Programming--Use 92594 or 92595 Ear impression--V5275 Real-ear measurement--V5020 Otoscopy is part of examination and is not coded separately. Video-otoscopy is diagnostic and is coded as 92700.
Slide 55 - Hearing Aid Services 97703 (each 15 min)--hearing aid orientation 92506--outcome measures 92507-aural rehabilitation (except implant) Considered to be part of fitting*: device ordering/handling (99002) special supplies (99070) patient education materials (99071) group patient education (99078) *not billable by audiologists
Slide 56 - Evaluation & Management Level of care determined by complexity Time determines level only for counseling and coordination of care Office visits, inpatient services, consults, case management, prevention, disability assessment
Slide 57 - Evaluation & Management Cannot be billed Medicare, Medi-gap, and many third-party payers but may be billed to some HMOs Controversy: use E&M? 99499? 99211? 99211 is allowed but does not describe level of service. 99499 is unspecified service and may not pass through billing system. Not appropriate when more specific codes are applicable.
Slide 58 - Balance Treatment Audiologists treat vestibular disorders including BPPV. Peripheral vestibular rehab (canalith repositioning) is within the audiologist’s scope of practice. Code 97112. PT/OT treats global balance problems (sensory integration, proprioception). Dynamic posturography (92548) is within the PM&R scope of practice. Global vestibular rehabilitation (97112).
Slide 59 - Audiology: HCPCS Codes V5008-hearing screening V5010-V5298--hearing aid services V5299--miscellaneous hearing service L8614--cochlear implant device/system L8619--speech processor replacement L7510--repair of prosthetic device (not hearing aid)
Slide 60 - CPT Modifiers
Slide 61 - CPT Modifiers 31 CPT modifiers 6 Anesthesia modifiers 13 Ambulatory Surgery modifiers
Slide 62 - Why Use Modifiers? To indicate that a service was more or less complex than typical To indicate that a service was repeated or discontinued To add more information regarding the purpose or anatomic site of the procedure To help to eliminate the appearance of duplicate billing To help to eliminate the appearance of unbundling (fragmentation).
Slide 63 - CPT Modifiers Not all modifiers are appropriate for use by audiologists Modifiers should be used when appropriate to describe or clarify the service provided. Not all modifiers may be applicable to all codes.
Slide 64 - CPT Modifiers 22--unusual procedural service 26--professional component (interpretation) 51--multiple procedures during same encounter 52--reduced service. Example: unilateral procedure when bilateral is assumed.
Slide 65 - CPT Modifiers 53--discontinued procedure 59--distinct procedural service on same day 76--repeat procedure by same provider 77--repeat procedure by other provider 99--multiple modifiers
Slide 66 - CPT Modifiers The following modifiers are restricted: 50--bilateral procedure 76 and 77--not used for quality control or verification Other modifiers clearly identified as medical or surgical (21, 23, 24, 25, 27, 32, 47, 54, 55, 56, 57, 58, 62, 66, 73, 74, 78, 79, 80, 81, 82, 90, 91) Physical status modifiers (P1, P2, P3, P4, P5, P6)
Slide 67 - HCPCS Modifiers TC--technical component CC--procedure code change RP--repair/replace prosthetic device RR--rental or lease of DME or prosthetic device
Slide 68 - ICD-9 PCS Used mainly for inpatient procedures CPT used exclusively in U.S. for outpatient procedure coding Surgical procedures (00.01-86.99) Diagnostic and therapeutic procedures (87.01-99.9) Hearing tests (95.41-95.49)
Slide 69 - ICD-10-CM Replaces ICD-9-CM Disease and procedure sections ICD-10 PCS proposed as replacement for CPT AMA opposes ICD-10 PCS and is developing a new system, CPT-5
Slide 70 - Disease Coding
Slide 71 - Structure of ICD-9-CM 3-, 4-, and 5-digit codes indicating levels of specificity Updated annually by working group Diseases and injuries (001-999) Factors influencing health status and contact with health services (V-codes) External causes of injury or poisoning (E-codes)
Slide 72 - Principles of Disease Coding General rule: code to the highest degree of medical certainty. Use the most specific code possible. Avoid NOS and NEC codes. Non-physicians may code symptoms. Choice of disease code has a great affect on reimbursement.
Slide 73 - NEC and NOS Codes NEC--not elsewhere classified (xxx.x8) NOS--not otherwise specified (xxx.x9) NEC means that no appropriate code was found in the tabular list based on the information provided. NOS means that the condition was not adequately described by the provider. NOS codes are usually not accepted
Slide 74 - Inpatient Disease Coding Principal diagnosis (DXLS)--condition established after study that occasioned the admission V-codes are rarely used as principal diagnoses and rarely stand alone. Exception: rehab services
Slide 75 - Inpatient Disease Coding “possible”, “probable”, “suspected”, or “rule out” diagnoses are coded as confirmed. “rule out”--diagnosis is possible “ruled out”--diagnosis is not possible If condition is ruled out, it is not coded. Abnormal findings are not coded unless the clinic significance is indicated.
Slide 76 - Inpatient Disease Coding Conditions that have no bearing on current stay are not coded. All conditions observed during evaluation are coded. Only conditions treated or that have direct bearing on the condition being treated are coded during treatment. Conditions that are integral to a disease process are not coded separately.
Slide 77 - Outpatient Disease Coding Condition that is chiefly responsible for the patient’s visit is the primary diagnosis. Primary diagnosis may be a disease, condition, problem, symptom, injury, or reason for encounter. Secondary diagnoses may describe co-existing conditions, symptoms, or reasons Do not code conditions previously treated and no longer exist.
Slide 78 - Outpatient Disease Coding Do not code “probable”, “suspected”, “questionable”, or “rule out” diagnoses. Code to the highest degree medical certainty. If unsure, code symptoms or reasons. Symptoms may be coded as primary if a confirmed diagnosed has not been assigned. As a general rule, follow outpatient rules
Slide 79 - Primary and Secondary Primary Diagnosis: disease, symptom, condition or reason that is chiefly responsible for the visit. Secondary Diagnosis: other diagnoses (e.g. relevant chronic conditions), conditions that have impact on care, or other conditions found after study.
Slide 80 - Primary and Secondary For treatment services: Primary Diagnosis: reason that is chiefly responsible for the visit. Secondary Diagnosis: Condition treated and other diagnoses (e.g. relevant chronic conditions) or other conditions found after study.
Slide 81 - Routine or Administrative Exams Primary Diagnosis: appropriate V-code to indicate the reason for the exam Secondary Diagnosis: any diagnoses, conditions, or symptoms found after study
Slide 82 - Organization of V-codes Health hazards related to communicable diseases (V01-V06) Health hazards related to personal or family history (V10-V19) Reproduction and development (V20-V29) Classification of live births (V30-V39) Conditions influencing health status (V40-V49) Specific procedures and after-care (V50-V59) Other circumstances (V60-V68) Persons without diagnosis (V70-82)
Slide 83 - V-codes Do not confuse ICD-9-CM V-codes with HCPCS Level II V-codes. ICD-9-CM codes are diseases, conditions, symptoms, or reasons. HCPCS Level II codes are procedures.
Slide 84 - V-codes Some V-codes must be coded as primary; others are coded as secondary Consult your ICD-9-CM guide or your local registered health information specialist
Slide 85 - Audiology: ICD-9-CM V-codes V19.2 (family history of hearing loss) V41.2 (problems with hearing) V53.2 (fitting/adjustment of hearing aid) V65.2 (non-organic condition) V71.8 (observation for suspected condition) V70.5 (disability exam)
Slide 86 - Normal Function There is no ICD-9-CM code for normal function. Normal function is not coded as a disease. V65.5 when there are no risk factors. V71.89 when there is clinical reason to suspect a problem.
Slide 87 - Coding and Billing
Slide 88 - Caveats Every insurance carrier has its own rules. Coding is not the same as billing. Coding errors may lead to billing errors Even accurate coding may lead to errors. Not all billed codes are reimbursable. Not all encounter codes are appropriate or billable. Billing errors, however innocent, may be viewed insurance fraud.
Slide 89 - Coding Rules Coding must conform to uniform coding standards. CMS has the right to audit medical records, levy fines, and file claims for false and fraudulent billing. Insurance carriers may also audit medical records and file civil claims for fraud and abuse. May lead to civil and/or criminal penalties
Slide 90 - What is Required to Assure Accuracy (compliance)? Billing codes must match documentation. Documentation must support the scope and level of service (complexity or time). CPT codes must match diagnosis. Services must be appropriate by provider type. Services must be ordered by a physician (in writing)
Slide 91 - What will Medicare audit? Eligibility processes, identification and verification of insurance Medical record documentation, legibility, and accuracy of medical terms Medical record completeness Consistency of descriptive and decision-making terms in the medical record Accuracy of encounter forms Matching of medical terms in the record with encounter codes Accuracy of codes on claim form and bill sent
Slide 92 - Reasons for Fraudulent Billing Inadequate documentation Improper coding Services not provided Fragmentation (unbundling) Lack of medical necessity
Slide 93 - Role of the Provider Fully document clinical care Provider is responsible documentation Use accurate encounter forms Encounter form is a tool. Documentation is what is important. Follow applicable coding and documentation guidelines Assist in verifying claims
Slide 94 - Coding Dilemma: Data Capture vs. Billing Data capture: enter codes that appropriately describe the service provided. Purpose: workload reports, costing, staffing, efficiency, health care trends, research
Slide 95 - Coding Dilemma: Data Capture vs. Billing Billing: enter codes that is appropriately describe the service provided Purpose: revenue generation
Slide 96 - Coding Dilemma: Data Capture vs. Billing Problems: Not all codes entered for data capture purposes are appropriate for billing. Exceptions: codes entered into non-billable clinics, codes without charges High probability of errors if data capture and billing systems are linked. Concerns: Codes may be eliminated if they are not appropriate by provider type. Problematic codes may be restricted or removed from encounter forms or software.
Slide 97 - Lesson Provider must know the reason for coding: Data capture (workload, costing, etc.) Reimbursement (revenue generation) Define the purpose of coding up front. Coding rules are different for each purpose.
Slide 98 - What Can Be Done to Improve Coding? Coding handbooks and guidelines Standard encounter forms (super bills) Education Good dialogue with coding and billing officials Electronic aids (templates, code filters, prompts, taxonomies, e.g. CHCS-2)
Slide 99 - Provider Billing Providers may bill for services (e.g. physician services). Non-providers: Other types of practitioners may provide services but procedures are billed as ancillary or facility charges. Facility decides who is a provider.
Slide 100 - Billing by Non-providers Audiologists may bill for global (TC + 26 components). Audiologists may not bill Medicare for physician (E&M) services. Technical services may be billed as facility charges if the procedure has technical (TC) and professional (26) components. Technical services are facility charges regardless of who provides the service.
Slide 101 - Professional and Technical Services Some CPT codes have both technical and professional components. Technical component includes the time of the ancillary staff. Professional component includes the physician’s work and expertise. Technical services are billed as facility charges. Professional services are billed as physician services.
Slide 102 - Medicare Charges Hearing aid services are not covered services. Routine services are not be covered. Treatment services by audiologists are not covered. All services must be ordered by a physician.
Slide 103 - Medicare Charges Most procedures are billed as facility charges. ENG, ABR, and OAE have TC and 26 components. Cerumen management is a physician charge. Intraoperative monitoring has TC and 26 components. Miscellaneous services (99000-99090) are physician charges.
Slide 104 - Case Management Services Case management services such as team management (99361-99362) are physician charges. These codes are considered as evaluation & management codes which are not appropriate for use by audiologists.
Slide 105 - Advanced Billing Issues Physician charges are billed on HCFA 1500. Facility charges are billed on UB-92. It is not appropriate to put a physician charge on a UB-92 and then attach a TC modifier to indicate it is a “technical” (non-physician) service.
Slide 106 - Medical Necessity Physicians determine medical necessity. All orders, consultations, and referrals must be signed and dated by physician. All orders, consultations, and referrals must indicate why the care is medically necessary. Referrals for evaluation must be medically necessary and pose a diagnostic question.
Slide 107 - Reasonable and Necessary “reasonable and necessary for the diagnosis or treatment of an illness, injury, or to improve the function of a malformed body member.” To be reimbursable, all services must be reasonable and necessary.
Slide 108 - Covered Audiology Services ordered by a physician reasonable and necessary used by the physician for evaluating appropriate medical or surgical treatment not covered when the diagnosis is known to the physician therapeutic services by audiologists are not covered
Slide 109 - Documentation
Slide 110 - Principles of Documentation Documentation must be: Accurate--describes the care provided Codable--supports CPT, ICD, DRG codes Understandable--clear to reader Timely--written at time patient was seen Error free--stands alone as a legal document
Slide 111 - Principles of Documentation If ain’t documented, it weren’t done! All care must be documented. Anecdotal or historical events (patient not present) should be documented. All documentation must be dated and signed.
Slide 112 - Principles of Documentation Assessments must address: chief complaint or reason for the visit pertinent medical, social, and family history examinations, diagnostic tests diagnosis or diagnostic impressions plan of care
Slide 113 - Principles of Documentation Treatment plans are derived from assessments. Treatment plans must address: diagnoses, conditions, or problems objectives or goals of treatment expected outcomes treatment modalities duration of treatment
Slide 114 - Principles of Documentation To be reimbursable, all treatment services must be ordered by a physician. Ongoing treatments (e.g. AR) must be re-certified by the referring physician at least every 30 days during and at the termination of treatment. All documentation must include: patient’s name, SSN referring physician
Slide 115 - Principles of Documentation Progress notes must address: goals or objectives of treatment progress toward stated treatment goals documented, measurable outcomes alterations to treatment plan patient and/or family education
Slide 116 - Service Agreements and Referral Guidelines
Slide 117 - Service Agreements Bilateral agreement (contract) Usually between Audiology and Primary Care but can be with ENT or any other referring source.
Slide 118 - Service Agreements Defines scope of services available Referral criteria (specific, pre-work) Timeliness agreements Roles defined for both parties Criteria for co-management or return Communication methods Measuring effectiveness
Slide 119 - Referral Guidelines Operational version of service agreement Electronic template Examples: cerumen, sudden hearing loss, routine repair/adjustment for hearing aid, disability or fitness exam, non-visit consult Ensures appropriate, efficient, and timely referrals
Slide 120 - Example: Sudden Hearing Loss Patient reports sudden hearing loss in one or both ears. Time of onset and precipitating factors are important in diagnosis. Treatment must be started early to be effective. Send STAT consult to Audiology and ENT followed by phone call to Audiology for appointment
Slide 121 - Consult Template Are ear canals clear of cerumen? Y/N Does patient have associated dizziness? Y/N Is there evidence of middle-ear effusuon or otitis with exudate? Y/N Hearing loss in RE, LE, Both ears
Slide 122 - Patient Education
Slide 123 - What is Patient Education? Preventive care & wellness programs? What about... advance directives informed consent objectives, benefits, risks, alternatives to treatment community resources test results, health status, medical findings treatment and discharge plans patient and/or family responsibilities
Slide 124 - JCAHO Requirements Required patient education: rehabilitative & compensatory techniques safe and effective use of medical devices safe and effective use of medications food/drug interactions nutrition, modified diets, food consistency test results, health status, medical findings treatment options and alternatives
Slide 125 - JCAHO Requirements risks and benefits of treatment awareness of community resources obtaining additional care, entitlements, access to care issues informed consent and advanced directives patient and family responsibilities self care skills and personal hygiene
Slide 126 - Documentation of Patient Education assess patients ability & readiness to learn assess motivation assess barriers and special need assess preferred mode of learning document educational content, medium document educational outcomes and level of understanding