© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Chapter 3

Freestanding Ambulatory Care

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Learning Objectives

• List the types of freestanding ambulatory centers and differentiate among them regarding the kinds of programs and services they offer.

• Define basic terms related to freestanding ambulatory care facilities.

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(continues)

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Learning Objectives (continued)

• List the major agencies or organizations that set standards for the facility and interpret their standards.

• Discuss pertinent record completion, filing, quality assessment, coding and indexing, and computer systems for freestanding ambulatory care facilities.

• Discuss payment systems for ambulatory care.

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Care Settings

• Public health departments

• Community health centers

• Rural health clinic• Industrial or

occupational health centers

• Ambulatory surgery centers (ASCs)

• Urgent care centers• Physician private

practices• University health

centers• Birth centers

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Types of Patients

• Not critically ill

• Wellness care

• Minor acute problems

• Chronic conditions

• Sometimes specific types of patients cared for in certain settings (e.g., pediatric clinic)

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Types of Caregivers

• Physician

• Nurse practitioner (NP)

• Certified nurse midwife (CNM)

• Physician’s assistant (PA)

• Dentist

• Nutritionist

• Counselor/therapist

• Psychologist

• Social worker

• Chiropractor

• Podiatrist

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Regulatory Issues: Licensure

• Laws vary from state to state

• Licensure does not usually apply to physician offices

• Licensure does usually apply to ambulatory surgery centers and birth centers

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Regulatory Issues: Medicare Certification

• Conditions of Participation or Conditions of Coverage exist for some settings

• Ambulatory surgical services, rural health clinics, and federally qualified health centers must meet Conditions to qualify for Medicare and/or Medicaid reimbursement

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Regulatory Issues: Accreditation

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Other Regulations: Compliance

• Office of the Inspector General (OIG) issued compliance guidance for development of compliance programs

• Areas to monitor: coding and billing; reasonable and necessary services; documentation; improper inducements, kickbacks, and self-referrals

• Medicaid Integrity Program (MIP): Medicaid Integrity Contractors (MICs) audit providers

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Documentation

• Registration/demographic information

• History and physical, reason for visit

• Laboratory and X-ray reports

• Progress notes

• Encounter form (superbill)

• Copies of hospital records

• Problem list

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Special Requirements

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Record Format

• Source oriented: Arranged according to source (e.g., laboratory, nursing, etc.)

• Integrated: Chronological order

• Problem oriented (POMR): Problem list with other documentation keyed to problem number.

• Electronic health record (EHR)

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Patient Identifier/Filing Methods

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Reimbursement

• Fee for Service• Medicare Physician Fee Schedule (PFS)

based on resource-based relative value scale (RBRVS)– Payments for “incident to” services by MLP– Payments under locum tenens arrangements

• Ambulatory Surgery Centers• Capitation• Medicaid and EPSDT

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Reimbursement Resources

• Program manuals

• Program transmittals

• Local coverage determinations (LCDs)

• National coverage determinations (NCDs)

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Coding and Classification

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Data and Information Flow

• Visit is basis of workflow

• Appointment methods– Standard scheduling– Block appointment method– Modification of standard and block

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(continues)

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Data and Information Flow (continued)

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Data and Information Flow (continued)

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Filing

• Identifier impact on filing method (e.g., alphabetical identifier=alphabetical filing)

• Numerical filing– Straight numerical order– Terminal digit order

• Color coded file folders available for both alphabetical and numerical filing systems

• Equipment: cabinets, open-shelves• Late reports

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Record Linkage to Other Sites

• Electronic health records allow multiple user access from various sites simultaneously

• Paper-based systems designate home base for record– patient-selected site– last site seen

• Transporting records: courier, fax, security considerations

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Computer Systems

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Incentives for Electronic Systems

• Electronic Health Records

• E-prescribing

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Uniform Ambulatory Minimum Data Set

• Patient data

• Provider data

• Encounter Data

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Quality Assessment and Performance Improvement

• Select problem or process, collect data, assess data, develop improvement

• Patient compliance affects quality

• Patient satisfaction

• Quality of data within patient record

• Physician quality reporting system (PQRI)

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Utilization Management (UM)

• Appropriateness of services and treatment

• Examine high cost or high volume services

• Two approaches to UM– Prospective review/precertification– Retrospective review

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Risk Management & Legal Issues

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Role of the Health Information Manager

• Information management

• Supervision of personnel

• Knowledge of regulations

• Knowledge of electronic information systems

• Training and education

• Non-traditional roles

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Trends

• Shifting of care from inpatient to ambulatory settings

• Integration of freestanding facilities into networks of providers

• Increased scrutiny of documentation for support of reimbursement requested

• Medical home

• Increased use of electronic health records30

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Summary

• Types of facilities and caregivers

• Accreditation and licensing standards

• Reimbursement

• Information Management

• Performance Improvement and Utilization Management

• Risk Management and Legal Issues

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© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Web Activity

• Review LCDs and NCDs in the Medicare Coverage Database at the CMS Web site.

• http://www.cms.gov• Follow instructions to locate and review the

LCD or NCD of your choice. • What type of information does the LCD or

NCD document contain? How might this information be useful to a freestanding ambulatory care provider?

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