Can I get paid to sign the home health certification form?

CMS pays a small fee for the planning, certification, supervision and re-certification of home health services.  Don’t do the work and forget to get paid. Click the link below to watch this brief video about getting paid to sign the home health certification form.

Can I get paid to sign the home health certification form

For more coding resources visit www.codingintel.com

 

Clues that your SCRIBE is in DISGUISE

Scribes in medical practices are in the news as a way for physicians to more effectively care for patients and use their EHRs. The scribe enters the exam room with the physician and does all of the data entry or typing while the physician takes the history, does and describes out loud the exam and develops the treatment plan with the patient. The scribe doesn’t interact directly with the patient at all, and probably isn’t the medical assistant who roomed the patient. The scribe writes, “Scribed by Betsy Nicoletti.” The physician reviews the scribed note, edits it and signs it.

 But, sometimes, medical practices don’t understand the concept of a scribe. Here are tell tale clues that the person who is “scribing” isn’t really a scribe.

  • Instead of saying, “Scribed by Betsy Nicoletti” the note says, “Dictated for Dr. Palmisano.” Huge warning sign!
  • Your scribe is disguised as a student: Medical student services are never billable services, and a medical practice can’t use the student documentation as a basis for submitting a claim to an insurance company. It usually isn’t the model for students. The student doesn’t sit and type while the clinician asks questions and examines the patient, as a scribe does. In case you need more information on this, page down to my most recent post. This relates to PA and NP students, as well.
  • Your scribe is disguised as an NP or PA or physician with an advanced degree: But, the practice has neglected to enroll the PA or NP with insurances because the medical professional is “only filling in for this week” or “really never works on his/her own.” This is an enrollment issue. Medicare and Medicaid enroll physicians, NPs and PAs, so get them enrolled and report the services appropriately. Contracts with commercial insurers vary. In some models, the PA/NP sees the patient first, does the bulk of the documentation and then the physician arrives and does a briefer visit. Report that service under the PA/NP provider number. “Dictating for Dr. Orthopedist” is not scribing as defined above and does not allow you to report the service under Dr. Orthopedist’s NPI.
  • Your scribe is disguised as an NP or PA and is doing a procedure that typically only a physician or NP or PA would do. Re-read the above example. Your PA/NP may perform procedures independently or incident to. If independently, report under the NP/PA provider number. If incident to, be sure the Medicare incident to rules are met.
  • Your scribe is disguised as you, in the room without you, asking questions or doing an exam, disguised as an independent practitioner: Scribes are typically medical assistants trained to work with a clinician as a scribe in the room. They don’t ask questions, do a physical exam or formulate a tentative plan. They don’t interact with the patient. A scribe is like a fly on the wall, recording what happens in the exam room.

If you are using scribes, that is a terrific way to unchain a physician from data entry. But, look at the list above and make sure your scribe is really a scribe. Don’t use the concept of scribing as a way to not enroll eligible professionals.

No Chart Left Behind

Years ago, I worked with a physician who was chronically behind in dictating his notes.  The charts were crammed into boxes by date, lining the walls of his office.  Sometimes, they flowed over into the hallway or into the break room.  This caused major inconveniences when a patient called for a lab result or returned for a visit.  I know you can picture this: the staff hurrying around the office with a list of charts for which they were searching, thumbing through the labels.  Inevitably, dictations were forgotten.  Could the doctor remember a week or two or three later what happened at the office visit?  He took handwritten notes and used them to jog his memory.  He said that worked.

 The boxes of charts were a visible reminder to him, to the staff and to administration of the problem.

 Today, unfinished charts can be all but invisible unless someone in the practice is running regular reports.  The clinician can see on her desktop or task bar the number of open notes, messages, reports to review and prescription renewals needed.  (Take your eyes off the task bar to see a few patients and the number of tasks in the queue explodes).  Medical practices need two things to prevent the modern day equivalent of boxes of charts lining the walls: regular and consistent monitoring and a policy on chart completion. 

 The practice leader should review the number of incomplete charts by clinician each week and monitor the age of those claims.  This will avoid unwelcome surprises like, “Do you know that we are holding hundreds of unbilled claims waiting for the charts to be finished?”

 As for policy:

 Medicare has no stated time policy about how soon after a service is performed on a Part B fee-for-service patient that it needs to be documented.  The Medicare Claims Processing Manual says only “The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”

  • We can probably all agree that “weeks later” is not “as soon as practicable after it is provided.”
  • Many groups suggest that visits are documented the same or next day, and mandate that all are documented within three days.
  • Consider a policy that for visits documented and closed after a certain time period (7 days? 14 days?) the physician won’t be given RVU credit.
  • There is no regulation in the Claims Processing Manual that states the visit must be documented before the claim is submitted.  Some groups have this policy in place.  In my opinion, I don’t think a group needs to hold claims unless there is a problem.  Most clinicians finish their notes in a reasonable period of time.   If the charge is submitted the day before the note is signed off, this isn’t a problem.  But, if there is a clinician who is regularly behind or who neglects to document for some visits, don’t submit claims until the documentation is complete.
  • Increased training on the EHR will often help a clinician to complete notes more quickly.  There are shortcuts in all systems, and some clinicians haven’t found them and haven’t been trained.  In groups of clinicians I often hear “Oh, don’t you know how to look that up from the visit page? You don’t have to open a new window….”
  • Consider allowing physicians to dictate into the HPI and comments into the assessment/plan section.  It adds value to the note.
  • Look at the schedule: is it optimal?

 Incomplete notes are a quality of care issue as well a compliance and billing issue.  Medical practices that find themselves in this situation need to address and solve the problems quickly.

Teaching physician rules for psychiatry

Psychiatrists use two distinct sets of codes, and so must know two sets of teaching physician rules: the rules for Evaluation and Management (E/M) services (admissions, rounds, established patient office/outpatient visit) and the rules for Psychiatry codes, such as psychiatric diagnostic evaluation and psychotherapy.  The previous blog on this site describes the teaching physician rules for E/M services.  This post will describe the teaching physician rules for using the Psychiatry codes.

 

The Medicare Claims Processing Manual states that the general rules described in the previous section applies to psychiatry.  That is, in order to bill for a service the attending must be present for or personally perform at a separate visit the key components of the service.  The attending must see the patient, participate in the treatment plan and personally document his/her participation in the care.  Supervision and case conference alone is insufficient for an attending physician to report Psychiatry services performed by a Psychiatric resident. 

 

However, for some psychiatry codes, concurrent observation may be substituted.  The rules say, “The general teaching physician policy set forth in §100.1 applies to psychiatric services. For certain psychiatric services, the requirement for the presence of the teaching physician during the service may be met by concurrent observation of the service by use of a one-way mirror or video equipment. Audio-only equipment does not satisfy to the physical presence requirement.”

Only a physician, not a psychologist, may supervise and report the services of a resident under the teaching physician rules.

For codes selected on the basis of time, such as psychotherapy, only the teaching physician’s time may be counted toward reporting the code.  Do not add together the resident’s time and attending’s time.