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MHCM 6320 Corporate Compliance and Legal Issues in Healthcare

Chapter 6 Compliance Documentation

Chapter 7 Compliance Reporting

Week 5 Lecture Notes

It is important that the compliance program highlight this requirement for adequate

documentation of all aspects of patient care delivery. The documentation serves a

number of valuable purposes, besides the requirements of compliance. Specifically, it

provides support for medical decision making, provides for continuity of patient care,

supports patient and public safety, assists in the allocation of resources, supports

research and education, and finally provides evidence of compliance. Good

documentation also contributes to quality improvement programs and supplies

necessary information to proper payment/reimbursement.

In order for documentation to serve all of these aspects of patient care well, it must be

complete, accurate, timely and accessible. It should always be signed or otherwise

confirmed.

A growing practice that presents considerable danger in any documentation is the

practice of excessive abbreviations or use of mnemonics, acronyms, symbols or other

shortcuts in word usage. This is a dangerous practice throughout our culture,

aggravated by the use of texting and email as well as the generally sloppy use of

language. No abbreviation should be used in a document without first using the full

word or phrase to be represented by the shortened version. Unfortunately, many

abbreviations have “twins” with totally different meanings, and this can lead to

misunderstanding at the least and disaster at the greatest. This problem has reached

the point that some organizations have published “Do Not Use” lists of such

abbreviations.

The False Claims Act sets out specific elements for documentation compliance.

According to the Act, patient records must be complete and specific with regard to

medical necessity, certification of medical necessity, refunding of overpayments,

contractual agreements with billing service companies, release of information regarding

reimbursement, diagnostic X-Ray interpretation, certification of compliance, dates of

service, and claims support.

The Federal Stark Law, which is reinforced or expanded by many state laws, forbids a

referring physician from financial gain when referring a patient to another physician –

usually a specialist, when the patient is a Medicare or Medicaid beneficiary. This rule is

applied across a broad spectrum of referral situations and is not restricted to only

physician to physician referrals, but includes referrals to organizations or companies in

which the referring physician may hold an interest and therefore benefit from the

revenue or any other benefit generated from the referral.

There is also federal legislation known as the Federal Anti-Kickback Statute that makes

it a crime to exchange any type of benefit for a referral. This is broader than the Stark

Law in that no involvement of Medicare or Medicaid is required to be in violation.

There are certain required elements of documentation for physicians in every patient

encounter. These elements must always be present: the date; the patient identity; a

unique identifier for the patient; the identity of the provider; the reason for the encounter;

details of all communications; details of any examination/s; objective findings; complete

description of all services performed; follow-up orders; provider’s signature.

Hospitals have an additional set of documentation requirements, and these were

expanded in 2007 when the CMS mandated that hospitals report those conditions

identified for each patient that were present at the time of admission. There are also

specific requirements for documentation of physician’s notes in the patient’s record.

Electronic Health Records (EHR) are finally becoming a reality. Your instructor was

President of one of the three first companies in the United States to develop total

hospital information systems (THIS), in the late 1960s- specifically beginning in 1967. It

was an element of these early systems to produce an electronic patient record as a by-

product of the use of these computer driven communication and data collection systems

by capturing the medical information at the source and processing it and recording it to

the finish. Unfortunately, the road has been very long and frustrating and fraught with

not only technological difficulties but with patient care deliverers resistance to change.

In 2004, President George W. Bush set a goal for implementation of the electronic

health record by 2014. While that goal too has failed to be met, progress has now been

great and the end result is definitely in sight.

As the dream becomes a reality, it is vital that the compliance officer work with the

technology department to ensure that such a record be kept secure. It is necessary to

assure the identity of everyone working with and having access to this record, and that

their integrity and honesty be thoroughly researched and clear. Next, assure that

access to the records is also protected through the use of a strong password that is

unique and used only for accessing these records. The make certain that access to the

data is restricted to only those having a legitimate need.

Also be certain that the technology provides for authentication by only the proper

authorities, and that an audit trail of access to the records is created and maintained.

Clinical laboratory records are the subject of special regulations under the Clinical

Laboratory Improvement Amendments (CLIA) wherever the tests are performed

Even such things as notices to patients of their rights to speak on their own behalf have

become the subject of regulations of information. Medicare has such a requirement in

its form “An important Message from Medicare About Your Rights”. This form notifies

patients of their right to question the timing of their release from hospital care if it is felt

that they are being released too early to reduce billing.

Health care facilities are required by the U. S. Government to retain patient records for

ten years, in most cases. Other governmental agencies and payer or accreditation

organizations may have added requirements.

Upon expiration of the required retention period/s, there are additional requirements

regarding the disposal/destruction of these records.

Coding of medical information preceded the introduction of automation/computerization

in healthcare information processing, but the rather thorough permeation of the

processing of healthcare information through computer technology has increased the

speed and comprehensiveness of this activity. Coding simply is the conversion of

words and phrases into unique sets of numbers so that the processing of the

information may be more efficient and effective.

The first two major coding systems to become familiar with is the International

Classification of Diseases (ICD) – Clinical Modification, currently in its 9th edition,

therefore ICD – 9 – CM, and Current Procedural Terminology (CPT). It is vital that only

valid, accurate data is passed to the agencies and third-party payers who rely on this

information. To this end, the American Health Information Management Association

(AHIMA) publishes Standards for Ethical Coding.

The most common areas of concern in accurate reporting include the place of service

codes, duplicate billing, unbundling, phantom patients, “incident to” services, services

not performed, and balance billing. Each of these areas are more fully discussed in the

Textbook and should be studied in detail.

A new code, created on January 23, 2004, by the action of the Secretary of the

Department of Health and Human Services, known as the National Provider Identifier

(NPI) replaces all previous provider identifiers, including the UPIN. This code is free for

the asking and is to be used for all claims forms used in billing for physician and

outpatient services as well as for inpatient hospital claims.

Coders and billers are responsible under the law, not only the Federal False Claims Act

but state and other counterparts to it, for filing claims that contain false information if

they “know or should have known” that the information filed was false. Ignorance of the

law is NO EXCUSE. Numerous examples of this are given in the textbook in Chapter 7.

A number of other coding systems are in use and must be recognized in carrying out

required compliance reporting. The Physician Quality Reporting Initiative (PQRI) is a

voluntary reporting system that uses Category II codes. These Category II codes are

separate from: Category I codes – or Regular CPT codes and Category III Codes –

Emerging technology codes or HCPCS, Level II codes – for ancillary services such as

durable medical equipment and medical supplies.

States vary as to the mandatory reporting requirements with respect to domestic

violence, abuse and neglect, but most require physicians, osteopaths, chiropractors,

nurses, health personnel engaged in the admission, examination and care or treatment

of children, health professionals, and mental health professionals, among others.

Likewise, in the case of communicable diseases, there is broad legal and ethical

requirements placed on health care providers to report contagious or communicable

symptoms that may lead to epidemics or pandemics.