I HAVE SEVERAL QUESTIONS from readers this month, including one on all-too-common documentation practices that can land clinicians in hot water with auditors. Here’s what readers want to know.
Problematic documentation
Our center handles a lot of head trauma and brain injury patients, so patients can be here for many days. Some of our hospital docs appear to “copy and paste” documentation from day to day, changing only the service date and vital signs. While I have told them this is not acceptable, the practice continues. Can you provide me any references that I could use?
You are not alone in facing this challenge—and it’s one that can place providers at risk should their services ever be audited.
Read our article “Your patient is going to a SNF. Should you follow her there?”
Here’s why: When documentation in the medical record appears to be the same or very similar to that of previous service dates, that can call into question the medical necessity of a visit. It also does not indicate that a face-to-face visit actually took place.
Auditors look very closely at cloning documentation.
In recent years, the CMS, along with organizations like the American Health Information Management Association, have taken strong positions on cloning documentation or using “copy and paste.” Regulatory references that offer guidance include an OIG report entitled “CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs” (January 2014) and a CMS fact sheet titled “Electronic Health Records Provider” (December 2015). As the above-referenced OIG report notes, auditors look very closely at the use of such features.
Why? Because some types of documentation practices—and cloning is one that’s singled out—could be used to commit fraud. When clinicians copy and paste information that isn’t updated, “inaccurate information may enter the patient’s medical record and inappropriate charges may be billed.” Moreover, using copy and paste “could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”
Another practice that’s called out in the report is overdocumentation, which is defined as “the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services.” Copying and pasting can contribute to overdocumentation because not all the information lifted from one service date may be necessary for another and could result in a higher service level being inappropriately assigned.
To avoid unwanted audit scrutiny, make sure documentation reflects patient changes between hospital visits. Documentation should also clearly indicate that a face-to-face visit took place.
And if you review documentation that appears to be the same or similar to that in the record for the same patient on different days, bring this to the provider’s attention or enlist the support of your medical director. You shouldn’t be submitting claims for services that are not medically necessary—but that’s a decision only the provider or medical director can make.
Billing a SNF admission
Is there a guideline for having an inpatient claim conclude on the same date a claim for a skilled nursing facility (SNF) starts for Medicare patients? Would the SNF facility not be able to bill the admission date?
There are a number of rules around billing for an initial admission to a SNF.
If a physician discharges a patient from inpatient status directly to a SNF, the physician may bill both a hospital discharge (CPT codes 99238 or 99239) and a nursing facility admission code (99304-99306) if the two services are performed on the same date. He or she would bill the nursing facility admission under Medicare Part B, and the doctor wouldn’t need to be employed by either the hospital or the SNF.
If a surgeon admits a patient to a SNF for a condition unrelated to the surgery, that doctor may bill an initial nursing facility admission by appending the modifier -24. Modifier -24 indicates that the admission is unrelated to the surgical condition.
But if a surgeon is admitting a patient to a SNF for a condition related to the surgery and the surgery has a global period, the doctor cannot bill the initial SNF admission. Payment for that admission and subsequent services are included in the global fee and cannot be paid separately.
A doctor employed by the SNF can also perform the initial nursing facility admission as well as the other E/M visits; that physician may bill Medicare Part B independently. An advanced practice provider employed by the SNF or nursing facility may perform (and bill Medicare Part B directly for) those services as well. Further, a physician, NP or CNS (but not a physician assistant) can bill Medicare directly or reassign payment for his/her professional service to the facility. This information is from the Medicare Internet-Only Manual 100-4, chapter 12, section 30.6.9.2.
What do you mean by “present”?
Please clarify something from your column, “A look at teaching physician rules” (April). Here’s what you wrote: “if a resident performs discharge services, reports CPT code 99239 (discharge, 30 minutes or more) and spends 50 minutes doing the service, a teaching physician must be present the entire 50 minutes. Any time spent by the resident without the teaching physician present cannot be reported.”
Do you mean the attending physician needs to be physically present with the resident in the room doing the discharge, or can he or she be in an office reviewing the discharge orders? What exactly is meant by “present”?
The CMS teaching physician rules offer clear direction when it comes to what is required for a teaching physician to bill for services provided by a resident. The Medicare Internet-Only Claims Processing Manual, 100-4, chapter 12, section 100, defines physically present as follows: “The teaching physician is located in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service.”
In addition, section 100.1.4 addresses time-based codes, which include hospital discharges (as well as critical care and prolonged services, among others). According to that section, “the teaching physician must be present for the period of time for which the claim is made. For example, a code that specifically describes a service of from 20 to 30 minutes may be paid only if the teaching physician is physically present for 20 to 30 minutes.” That section prohibits adding in the time a resident may spend when the teaching physician isn’t present—or time the teaching physician spends alone with the patient.
Sue A. Lewis, RN, CPC, PCS, has more than 40 years of health care experience.
