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Medicare’s Medical Records Requirements: What Else Do You Need to Know About Record Keeping?
Recorded Webinar
This webinar covers the following objectives regarding medical records requirements and Medicare’s unique record keeping requirements:
Individual health care practitioners in private practice and medical records directors at health care facilities may be confused on how long to retain medical records in a complex health services environment with many different health care practitioners. If or when a length of time is established, the practitioners and directors need to know whether and
how to dispose of medical records. For example, does having digital records require records to be kept indefinitely, or does it simply allow it? Even if you can keep a medical record indefinitely in an electronic format, is it wise to do so?
There are differing and conflicting sources of requirements for the retention and disposition of medical records, which may vary based upon the specific health care practitioner. Attendees will review special rules existing regarding the confidentiality, security, retention, and disposition of electronic medical records.
Attendees to this webinar will learn to identify and apply these differing and conflicting rules with respect to the specific health care practitioner, the specific health care facility practice, and the emerging rules and regulations for electronic medical records confidentiality, security, and disposition.
This advanced webinar also educates Medicare health care providers, including physicians, non-physician practitioners, hospitals, other health care providers, and suppliers on the updated federal regulations for medical record keeping. This webinar gives information on updated documentation maintenance and access requirements for billing services to Medicare patients. This webinar also answers how long to keep the documentation and who is responsible for providing access.
Venue: Recorded Webinar
Many providers have seen a significant increase in claims delays and outright denials. The reasons may be many, but focused attention to three major elements can improve your results. Documentation, Coding & Billing work together to support adequate reimbursement. Weaknesses in any of these areas will affect the ability to capture optimal revenue. Documentation is the Foundation of Every Patient Encounter. Record pertinent facts, findings, observations about past & present illnesses, examinations, tests, treatments and outcomes Documents the care of the patient Facilitates planning immediate treatment Monitor patient’s healthcare over time Tells the patient’s story Strong Documentation drives the coder’s ability to capture all conditions that are relevant to the current encounter. The primary reason for the encounter must be clear. Secondary conditions that require management or affect the current encounter should be addressed by the provider. Problem lists can be misleading. Is the condition current or a historical occurrence no longer requiring treatment? Documentation and coding will support accurate claims billing serving to decrease the liklihood of payer delay or denial. These 3 functions are strongly intertwined. It is imperative that providers and staff collaborate to protect revenue, reduce reworking of the claim, and maintain a strong cash flow. Patient satisfaction is heavily influenced by the provider’s proficiency in obtaining correct and timely payment. Target Audience Chargemaster Maintenance Staff Physicians Practice managers Medical assistants Nurses Compliance staff Billers Coders Revenue Cycle Risk Management Charge entry staff
A hospital chargemaster is a comprehensive list of a hospital's products, procedures, and services. Everything from prescription drugs to supplies for diagnostic tests has a unique price listing in the chargemaster. Major components include revenue codes that reflect the site of service and applicable CPT/HCPCS codes that indicate the service provided/charged. Poor matches between these code sets may lead to distorted cost centers, lost revenue, charges bundled that should be separately reported and incomplete departmental charging. Webinar’s Goals Understand chargemaster code functions Understand revenue leakage resulting from poor chargemaster structure Understand why correct departmental charging is vital to revenue integrity Appropriate training for charge entry staff Billing attention to posted charges Who Should Attend Chargemaster Maintenance Staff Compliance staff Billers Coders Revenue Cycle Managers & Staff Risk Management Charge entry staff
Areas Covered A major component of successful revenue management is accurate charging for services provided. Charges must be identified, posted timely and completely. Hospital charge capture is typically handled by the department that provided the service. Professional charges may be posted by the provider. In either case, the function may be a low administrative priority with little to limited training for charging activities. Coordination between departments may not be established. Accountability for correct charging may be minimal. There may be no formal policies or baseline controls for correct charge capture. Different systems may be used for charging and reconciliation An effective charge audit can identify lost revenue opportunities Webinar’s Goals Understand the importance of accurate charge capture Tips for charge review Departmental charge capture errors & omissions Revenue leakage resulting from charging errors Reduce non-compliance exposure Improvement of operational efficiency Enhance patient satisfaction Key Points Why Errors Occur Multiple departments entering charges Charge master may be incorrect or incomplete Error in number of units selected Error in item selection Inactive charge New service not added Incorrect revenue code/cost center System conversions Overreliance on claims scrubber Target Audience Physicians Practice managers Medical assistants Nurses Compliance staff Billers Coders Revenue Cycle Risk Management
Clinical documentation is the cornerstone for all patient medical records. This information should be of the highest quality to allow for optimal patient outcomes as well as supporting research, medical coding and other uses of the medical record. Its purpose is to adequately relate the patient’s current and historical conditions and treatments with primary focus placed on situations that affect the current medical encounter. It also supports the provider’s defense should the case become a legal issue. Webinar’s Goals Review of 7 criteria that all entries in the medical record should include Impact of documentation on coding & claims Establishing a CDI team Significance of abnormal lab results: querying the provider. Measurement of lesions, when taken and inclusion of margins. Why it matters & how reimbursement may be affected. Start & stop times & methodology for infusions & discrepancies in billing. Complete reporting for administration and substance. Diagnostic testing and medications should be supported in a diagnosis. Unsupported documentation may cost you money. Depth of wounds and cause should be clear. Clarity needed for both depth and origin of wound. Severity of illness. Hospitals and payers are increasingly scrutinizing patient severity. Lack of detail costs money. Diagnosis present on admission? Certain conditions do not generate additional revenue if occurrence after admission. Areas Covered The ICD-10 code set requires explicit documentation of conditions & treatments in order to support the severity of patients under treatment as well as allow for the significant specificity required by this code set. Ambiguous documentation and generic coding will no longer guarantee reimbursement and may generate a claims denial for lack of medical necessity. In this session, we will review the theory of high-quality clinical documentation which has the support of healthcare regulatory guidelines and peer-review research. Additional consideration involves medical outcomes that may result in legal action. When clinical documentation is vague, missing key elements and conflicting statements, the provider may find that he/she is handicapped in supporting medical decisions and patient results, particularly when the result is a negative outcome for the patient. In today’s healthcare environment, many patients have become educated consumers of medical services. They are more inclined to request their own medical record, carefully review explanation of benefits from payers, and request a review of any information they deem to be incomplete or questionable. Target Audience Coding Billing Revenue Cycle Physicians Mid-level providers Nurses Claims follow-up Compliance Auditors