Section D.18 - Memorandum 136-005 Provider Responsibility for Workload and Billing Documentation.pdf

Department of Veterans Affairs Memorandum 136-005 Central Texas Health Care System (CTVHCS) November 15, 2017 Austin-Temple-Waco Community-Based Outpatient Clinics (CBOCs)

PROVIDER RESPONSIBILITY FOR WORKLOAD AND BILLING DOCUMENTATION

1. CHANGES: Minor changes highlighted in gray.

2. RESCISSION: Memorandum 136-005 dated August 11, 2014.

3. NEXT REVIEW DATE: November 2020.

4. AFFECTED SERVICES: All clinical services.

5. POLICY: This policy clarifies the responsibilities of patient care providers for medical record and encounter form documentation of patient encounters. VHA facilities are required to be compliant with Medicare regulations. The Bylaws and Rules of the Medical Staff of CTVHCS state: (1) "Medical Staff members are responsible for complying with CTVHCS policies and oversight bodies for ensuring compliance with medical records policies regarding third party billings and collections." (2) "Supervision of residents by attending physicians will be guided by the regulations of the Center for Medicare and Medicaid Services (CMS), the Accreditation Council for Graduate Medical Education (ACGME), and the VHA."

a. Definitions:

(1) Encounter Form. An electronic abstract or electronic module in the Computerized Patient Record System (CPRS) designed to collect essential billing and workload data on patient encounters.

(2) Provider Categories. Staff physicians, dentists, surgeons, nurse practitioners, licensed physician's assistants, and other VHA-allowed allied healthcare providers whose services can potentially be reimbursed by presenting a bill to third-party insurance companies in the private sector. These providers will be considered billable providers. Residents in training are billable providers under strict documentation rules.

Staff nurses, in most cases, are not considered billable providers but their work and documentation are essential to the healthcare team.

6. RESPONSIBILITY:

a. All providers are responsible for appropriately documenting patient visit progress notes or other required forms in the electronic medical record, unless handwritten documentation is specifically approved by the Chief of Staff. Limitations of the medical record system are required because of unexpected failure of the electronic medical record system (see facility contingency plan for documentation specifics).

b. All provider entries into the medical record will be completed and signed in a timely fashion. Electronic entries into the record using the CPRS or similar mechanism

CTVHCS Memorandum 136-005 should be signed within 24 hours after they are uploaded, entered or reviewed.

Documents that are dictated and transcribed into the record will be signed within the prescribed time as stated in the Medical Staff Rules, Regulations, and Bylaws. Each VistA/CPRS user is charged with checking for unsigned/uncosigned notes before leaving their tour of duty.

c. Providers are responsible for the completion of an encounter form for all patient encounters.

d. Staff physicians are responsible for the completion of documents created by students, residents and/or house staff assigned to their supervision. When a resident in training is involved in an outpatient encounter, the attending physician or surgeon supervising the resident is responsible and accountable for the quality of the data provided in the resident's progress note, procedure note (if any), and encounter form documenting the encounter. Proper documentation rules are outlined in the Physicians at Teaching Hospitals, or the VHA Supervision of Residents Handbook will be followed.

e. Professional billing for patient care is based on medical record documentation.

Billable providers are responsible for providing written documentation of their involvement in patient care.

f. Each service chief is responsible for having ADPACs/administrative officers/supervisors check for unsigned/uncosigned notes on a weekly basis, and sharing this information with the employees’ respective supervisors.

7. PROCEDURE:

a. Billable providers are responsible for documenting patient care in the medical record and are expected to do the following:

(1) Providers seeing patients without residents are responsible for all aspects of medical record documentation, as stipulated in the Bylaws and Rules of the Medical Staff.

(2) Attending physicians supervising an acute inpatient medical unit are expected to write an admission note within 24 hours of admission, as well as daily progress notes.

(3) Attending physicians serving on a consultation service are expected to write a consultation note within 24 hours of the visit.

(4) Attending physicians supervising residents in a clinic are responsible for seeing the patient and documenting the encounter in the medical record. Residents may participate in the process, but the attending physician must document their involvement with an appropriate addendum to the resident's note or a separate attending physician's note.

(5) Attending surgeons supervising operative procedures are expected to document the extent of their involvement with the procedure in the medical record. Involvements refer to the supervising surgeon making either an entry independent of the supervised resident and/or in collaboration with the resident that reflects active surgical participation of both parties (i.e., evaluate note, and progress note). They are also expected to assure the appropriateness and adequacy of documentation for preoperative and postoperative care of their patients.

b. Billable providers are responsible for the encounter forms if it is a required element of documentation for the venue of care in question. The provider is specifically expected to do the following:

(1) Correctly identify on the encounter form whether or not the encounter is for a service-connected condition.

(2) Choose a single primary diagnosis for the encounter form that best characterizes the reason for the patient encounter, expressed as an ICD-9 code, plus ICD-9 codes for any secondary diagnoses.

(3) Choose for the encounter form a CPT code or code(s) that accurately reflect(s) the level of service documented in the progress note.

(4) Sign the progress note, either with an electronic or handwritten signature. If the note does not have an electronically printed name for the provider, the provider's name must be clearly spelled out or provide a legible personal identification number (PIN) to assure accountability for the process.

c. A "view alert" to the author and expected signers/cosigners of progress notes will be automatically generated by the software system any time a document is closed without a signature. Each VistA/CPRS user is charged with checking for unsigned/uncosigned notes before leaving their tour of duty. Each service chief is responsible for having ADPACs/administrative officers/supervisors check for unsigned/uncosigned notes on a weekly basis and sharing this information with the employees’ respective supervisors. Failure to complete electronic documentation will result in appropriate administrative action up to, and potentially including, VA disciplinary action.

8. REFERENCES: Current Medical Staff Bylaws and Rules of CTVHCS; VHA Handbook 1907.01, Health Information Management and Health Records, March 19, 2015; VHA Handbook 1400.01, Resident Supervision, December 19, 2012; Current CBI Fact Sheet and Documentation Fact Sheet, dated May, 2008; VHA Directive 1030.01, Compliance and Business Integrity (CBI) Program Administration, July 31, 2006; VHA Handbook 1030.02 Compliance and Business Integrity (CBI) Program Standards, November 8, 2010.

/s/ Christopher R. Sandles, MBA, FACHE Director