NEW RESIDENT ORIENTATION 2005

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NEW RESIDENT ORIENTATION2005

• PRESENTED
• BY
• James D. Snell, Jr., M.D.
• Linda Martin, M.B.A.

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What is Compliance and Corporate Integrity?

• Doing our work for VUMC well and within the laws,
  regulations, policies, and procedures which
  govern us. Requires actively learning the rules
  and the changes as they occur.
• Integrity Do the right thing

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Compliance Plan

• Board and Vice Chancellor Commitment
• Compliance Plan, Manual and Code of Conduct
• Compliance Officer
• Compliance Corporate Integrity Committee
• Reports to Board of Trust

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Compliance Tasks

• Assessment of risks
• Policy and procedure modification or development
• Education of all parties
• Monitoring and reporting
• Discipline and re-education
• Review of policies and procedures

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Health Care Fraud

• New laws define and punish health care fraud
• Penalties are 5,000 per line incorrect, plus
• damages
• Tennessee 1993 and 2001, private insurance fraud
  and TennCare Fraud
• Congress 1996, health care fraud in government
  plans plus all bills sent by mail for health care

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Our Practice Environment is Changing Rapidly

• Medicare and commercial insurance rejections are
  high for lab, radiology, EKG, ECHO, and pulmonary
  function because of improper ICD-9 diagnosis
  information submitted by physicians.

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ICD-9 Diagnosis Codes

• International codes express why patients seek
  medical help using diagnoses, symptoms, signs,
  and ill-defined conditions.
• Insurance companies and Medicare assess medical
  necessity for tests we order or services we
  provide by computer checking of each test or
  service compared to the diagnosis or symptom.

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ICD-9 Diagnosis Codes

• All inpatient and outpatient radiology
  procedures, EKGs ECHO, stress tests, and PFT
  must have the specific reason for each test
  ordered, because the physician interpretation
  services are not in the DRG.
• No rule out diagnoses are allowed. Use
  symptoms, signs, or established diagnoses on the
  requisition or in WIZ order.

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EXAMPLES

• Chest x-ray for fever and cough not R/O
  pneumonia or pneumonia
• Same patient order EKG for chest pain not fever
  and cough or R/O coronary or pneumonia
• Same patient had x-ray proven pneumonia on first
  x-ray, now order follow-up chest x-ray on
  treatment day 5 chest x-ray for pneumonia

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Importance of Documentation

• Physicians are paid for work on behalf of
  patients.
• Documentation is a required part of that work.
• No documentation means no payment. Poor
  documentation usually results in poor
  payment.

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VUMC Medical Record Policy

• A complete note shall be hand written (or typed
  into Star Panel) or dictated within 24 hours of
  the clinic visit.
• Admission HPs must be completed within 24 hours
  of admission.
• Operative reports must be dictated immediately
  following surgery.

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Importance of Documentation

• The Vanderbilt Hospital pays your salary.
  Medicare funds support house staff and fellows.
• The hospital can only bill for services which are
  properly documented, and medically necessary.

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Importance of Documentation

• Medicare pays hospitals based on a DRG assigned
  by rigid coding rules using what the doctor
  writes in the chart.
• Coders cannot use any diagnosis you have not
  written in the chart.
• They cannot draw any coding conclusions based on
  lab, x-ray or their medical knowledge.

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EXAMPLES

• Patient has fever, cough, sputum, dyspnea, and
  infiltrate on chest x-ray. You write a diagnosis
  of lung infection and order sputum culture.
• A good coder will be concerned about your
  diagnosis what should It be?

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EXAMPLES

• A patient with COPD is admitted for increasing
  dyspnea. You record COPD in your note. Blood
  gases on room air return with pH 7.34, PCO2
  56, PO248.
• What additional diagnosis do you add in your next
  progress note?
• Why does it matter?

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EXAMPLES

• All organ failures must be written specifically
  as a diagnosis by you, and then you must describe
  your plan to treat it.

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Importance of Documentation

• Procedures done can change reimbursement, but
  only if a procedure note is in the chart.
• Document your request and the reason for all
  consultations.
• Medical students are not licensed to practice, so
  their progress notes cannot replace a resident
  progress note.

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How to Document

• Your new patients HPI (4 or more elements)
• Example this 24-year-old complains of RLQ,
  constant aching pain of moderate severity for the
  last 6 hours. No relationship to food intake or
  body position.

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How to Document

• New Patient ROS ( 10 or more)
• New Pt. Past, Family, Social Hx (3)
• New Patient Exam (8 or more systems)

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How to Document

• Carefully edit macros/templates.
• Electronically sign electronic notes. Do not
  leave for faculty to edit and apply signature.
• Do not use Student or NP/PA notes as though
  yours.

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How to Document

• Progress notes
• Mention failing organs
• Discuss recent treatment and response
• List new problem and complications
• Do not use stable, doing better, no
  complaints, in notes.
• Describe pertinent current exam findings
• DO NOT CLONE NOTES using the information system,
  reuse button or cut/paste!

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Teaching Physician Rules by Medicare

• The attending must evaluate the patient, leave a
  separate but brief note in which your detailed
  findings are confirmed.
• The attending must be present for the key portion
  of any procedures or surgeries.
• You should not fill out any billing documents or
  select a level of service for the attending.

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Summary for Residents and Fellows

• Admission H P should generally be documented at
  comprehensive level ( 4 elements HPI, 10 ROS, PFS
  Hx, 8 organ exam, Dx and Rx
• Coders cannot bill for diagnoses unless recorded
  by a physician and supported by data. (X-ray
  infiltrate is not pneumonia until you write it
  Gram-negative pneumonia requires positive culture
  and your Dx in the chart.)

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Summary for Residents and Fellows

• Give proper established Dx, sign, or symptom for
  each test ordered
• Communicate regularly with the attending and work
  as a team with other health professionals.
• Learn and follow hospital policies

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Summary for Residents and Fellows

• Medical students are not licensed. Therefore,
  residents need notes too, both Adm and Progress.
• Progress notes should emphasize organs failing,
  new problems, precisely what is better, good exam
  plan.

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Questions?