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It is mandatory to have signature on medical records


13th September 2016

Payers and the Centers for Medicare & Medicaid Services (CMS) require that the medical chart documentation sent to support a claim contain a legible and timely signature. For medical review purposes, Medicare requires the author, using a handwritten or a valid electronic signature, to authenticate the services provided/ordered. Even if the coding is accurate but the document lacks a legible signature the entire note will be disregarded.

For the Medicare medical review purposes, if the signature is missing in a document then an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the patient.

Auditors will not raise concern if a signature log is included which includes the typed or printed name of the author associated with initials or an illegible signature. The signature log might be included on the actual page where the initials or illegible signature are used, or might be a separate document. Auditors will not accept a single attestation to cover several chart notes or a length of time. A generic statement will not suffice.

New code and payment changes updated to Outpatient Prospective Payment System (OPPS)

The October 2016 update to the Outpatient Prospective Payment System (OPPS) includes one new HCPCS Level II code, two deleted HCPCS Level II codes; ambulatory payment classification (APC) and status indicator (SI) changes to several drug codes; and other changes to various payment policies.

  • New ultrasound code- HCPCS Level II code C9744 Ultrasound, abdominal, with contrast is effective Oct. 1, 2016. This new code has been assigned an OPPS SI of S and an OPPS APC of 5571.
  • Deleted G codes- HCPCS Level II codes G0436 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes and G0437 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes will be deleted with effective from 30 Sep 2016 and on or after 1st Oct 2016, CPT codes 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes and 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes will be applied for claims submitted after that.
  • Non-therapy Outpatient Department Services- Providers may report non-therapy outpatient department services that are adjunctive to a Comprehensive APC procedure (SI=J1) or the specific combination of services assigned to the C-APC 8011 (SI=J2) in one of two ways for claims received on or after 1st Oct 2016, with dates of service on or after Jan. 1, 2015:
    • With revenue code 0940 Other therapeutic services; or
    • With the appropriate occurrence codes, CPT codes, modifiers, revenue codes, and functional reporting requirements.
  • Updates to Drugs, Biologicals, and Radiopharmaceuticals- Four drugs/biologicals granted OPPS pass-through status (SI=G) with effective from 1st Oct 2016, are:
    • C9139 Injection, Factor IX, albumin fusion protein (recombinant), Idelvion, 1 i.u.
    • C9481 Injection, reslizumab, 1 mg
    • C9482 Injection, sotalol hydrochloride, 1 mg
    • C9483 Injection, atezolizumab, 10 mg
  • Changes to OPPS Pricer Logic- OPPS drug pricing will now apply the average sales price (ASP) fee schedule amounts from the Fiscal Intermediary Shared System (FISS) and not the OPPS Pricer.

Changes to 2017 Inpatient Prospective Payment System (IPPS) final rule to have bigger impact than ICD-10 itself

The 2017 Inpatient Prospective Payment System (IPPS) final rule brings with it a number of changes that are likely to have an even bigger impact on documentation, coding, and revenue than ICD-10 itself. Changes will be effective from 1st Oct 2016.

Hypertensive crisis” and “emergency” are back as new codes, and both will qualify as a complication and comorbidity (CC). When ICD-10 was introduced, there was only generic hypertension, with no way of reporting the clinical scenario when a patient exhibited an emergent presentation. The exact ICD-10 codes are I16.0, I16.1, and I16.9. Hypertensive urgency is also in the mix, but will not qualify for a CC designation.

Hypertension with heart failure is specifically addressed in the new guidelines. On 1st October, if a patient has hypertension and heart failure, the cause-and-effect relationship will be assumed regardless of the documentation (again, unless the heart failure is documented as being caused by a different condition). This will have a significant impact on patients who are in the DRG [diagnosis-related group (DRG)] triplet of 291, 292, and 293.

CMS has doubled down on insisting that it is appropriate to report the Glascow coma scale on patients other than those suffering traumatic brain injuries. In short, the agency wants a Glascow coma scale for any patient with a catastrophic condition or severely depressed neurological state. Previously in the first year of ICD-10, most coders and documentation specialists ignored this advice stating that same was done inadvertently but according to the final rule this reasoning would not be entertained. Multiple codes to be assigned for pressure injuries when the stage progresses during a hospital admission. This would have significant impact on each hospital’s value based payment scoring and reimbursement.

The new guidelines include an instructional note that coders are not allowed to selectively dismiss a diagnosis that has been documented by a physician. New codes for bilateral strokes, codes to be assigned for both left and right sides. Non-physician personnel (such as nurses) will be allowed to document the wound description of a non-pressure ulcer.

The Centers for Medicare and Medicaid Services (CMS)put physician practices on alert after hacking report

The Centers for Medicare and Medicaid Services (CMS) issued a reminder in July to physicians to guard patient personal health information closely prompted by a report by the Cyber Health Working Group under InfraGard, a partnership between the FBI and the private sector.

Apparently, someone called “thedarkoverlord” claims online to have hacked into more than 650,000 health care records and is offering them for sale for hundreds of thousands of dollars. The records contain Social Security and insurance policy numbers of patients from a few states, with most coming from Georgia (close to 400,000), and the Mid and Central United States. CMS indicates that the records are part of six databases, three of which seem to have come from orthopaedic practices.

All of the hacking incidents reported since mid-June in the states affected total approximately 300,000 records. The largest breach noted in the database was from an orthopaedic practice in Georgia, which reported in July that about 200,000 records had been accessed via a cyber attack.

The agency’s reminder to physicians state that covered entities must report its detection of breaches affecting more than 500 individuals to the secretary of the Department of Health and Human Services within 60 days of the discovery of the breach. For breaches less than 500 individuals, entities must fill out a separate form for each breach but can submit all the forms on the same date.

Health and Human Services Office (HHS) for Civil Rights recorded close to $15 million in compliance related settlement payments through July of this year

According to an article posted in the National Law Review, the Health and Human Services Office for Civil Rights recorded close to $15 million in compliance related settlement payments through July of this year. These settlements demonstrate OCR’s (Optical Character Recognition) more aggressive posture in enforcing HIPAA regulations.

The basis for the settlements addressed in the involved consent agreements varied from stolen laptops that were unencrypted despite the findings of multiple risk assessments by the entity. This posed a critical risk to incomplete risk analysis and failure to take timely action on findings.

A failure to obtain business associate agreements with business associates who had the need to access PHI (Protected Health Information) was also the basis for one consent agreement. Through the above scenarios, OCR is making it very clear that it is serious about its enforcement role.


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