¶ Intro / Opening
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¶ Essential Medical Record Keeping
Hello and welcome to another episode of The Good GP. I'm your host today, Maria Lee, and I'd like to start by acknowledging that I'm recording from Gadigaland, and my guest is recording from Nunavorland. We pay our respects to elders past, present, and emerging. Now this is part two in our podcast series on Medicare compliance. If you missed part one, it was a really interesting episode and I would encourage you to check out the episode from last week.
Now, I have back to talk through this topic, Associate Professor Antonio De Dio, who is a GP, and the Director of the Professional Services Review, which is the Medicare Compliance Regulator. So Antonio, welcome back.
Good eye, Maria. Thank you so much for having me back on.
Oh, it's my pleasure. Now last time we had you on the pod, you were telling us about the purpose and the function of the PSR and how the PSR process or what the PSR process looks like. So Antonio, you are a GP and you also regulate Medicare compliance. So if you could share your top tips on Medicare billing and how not to end up in hot water with a PSR in the first place, what would they be?
Thanks Maria. So yeah, there's it's not that long a list actually, and it's mostly pretty common sense. But before I start, can I add to your wonderful acknowledgement by also acknowledging the Gumbangia people of Maxville and Nampaka where I grew up? Of course. Who were so kind to me all through those years. So in terms of PSR and how not to get in trouble in the first place, for the vast majority of
The absolute vast majority. They will never come anywhere near PSR anyway. But if even if that does not assuage any anxiety and you're still feeling, well, you know, I'm still worried, then the most important thing. what a medical defense organization would tell you about every regulator and every person that walks in your door. And that is medical right, good quality, contemporaneous medical records that justify what it is that you build. So if you build an item thirty six
write down what you did that would explain that it's a long consultation with a detailed history and a detailed examination. Write those things down so that the person reviewing it can say Oh yeah, that took twenty minutes. That'd take me twenty minutes, for sure. If you build a three one three six three, it's an excision item and it might be for a melanoma. It's more than fourteen millimeters. I can't remember off the top of my head.
But if that's what the item number is, then make sure that the history pathology says it's a melanoma and that it's more than fourteen millimeters.
or whatever.
have medical records that support what it is that was claimed. And the best way, of course, to do that is to know what was claimed. Some of our colleagues have no idea what was claimed under their provider number. So know what was claimed. Every day or every third day, check what was billed under your provider number and make sure that it is accurate and that it accords with what you did. When you write your medical records, make sure that they are contemporaneous.
When a medical record is written that records a blood pressure of one hundred and thirty four over sixty six and it was created three days later, it's hard to see how a person can remember that for fifty different patients three days later. Similarly, if every single person has the same blood pressure of 134 over 66, or a patient has the same blood pressure every time they're seen fifteen years in a row, again, it's hard to see how that's real. So it's important to do the work.
and to record that the work was done. When I say that to doctors when I travel around, they look at me and think, but that's what I do. And I say, yeah. And that's why you've got nothing to worry about, because it's writing the notes. contemporaneously, honestly, and in a way that explains what it is that took up the time that you claimed. The other things that that are important is to look at
¶ Navigating Telehealth and the 3020 Rule
how we do things and organize ourselves in a particular way. There's a different rule called the 3020 rule, which is Medicare automatically refers practitioners to us at PSR. Should a practitioner have done thirty or more science services on twenty or more different days in a twelve month period, make sure that you look at that and make sure you don't trip that.
I have a question about the thirty twenty rule. What if a practitioner does primarily telly her? Let's say they see four patients an hour. 30 divided by four is about seven and a half. It's conceivable that a practitioner could work more than seven and a half hours a day for twenty days of the year if they primarily did telehealth. So does that mean they actually, by virtue of just doing their normal job, would flag with a PSR?
Yes, if they're doing it over the phone. If they're doing it by video, no.
Okay. Can you clarify that please?
Yeah, so it's the telephone attendances that add up to the thirty. It's not the video calls.
Right. Okay.
But it is absolutely true that you could trip that thirty twenty rule if you did what you were saying. Yep. So you've got to be careful.
Okay, gotcha. And I guess if it did trip in addition to being careful, if it did trip we would then explain to you or the person would have to then explain to you or your associate directors. the way that they work and why it is that they trip that rule and have the medical documentation to back it up, like you said.
That's right.
¶ Templates for Individualized Patient Records
Yeah. I have oh sorry, I know you weren't finished with your points, but I do have a couple of questions about your previous points I wanted to clarify. What is your view on the use of template? to make documentation more efficient.
That's a really important question because we see that all the time. So uh the template is uh a fantastic starting point for a good quality medical record. I use them. I think everybody should use them. For things like care plans, a template is brilliant to remind you of what you should be doing. But if the only thing you see in the record is the template and nothing's been added to it.
So that your care plan, for example, looks exactly the same word for word, year after year. Yeah, it looks like there's been no input whatsoever. Or if your template is a series of history and examination points, you know, blood pressure is this. pulse rate is eighty-two, respiratory rate is twelve, and it's the same for every single patient, then that template's not helping create a unique, contemporaneous, useful medical record that helps your patient.
Or your skin excision template is the same thing every time.
That's right. So when I do skin excisions, I use a template and it's got lots of blanks and I put in this number of millimeters, that part of the body. Yeah, templates are a fantastic starting point to remind you to write good records. But the problem with templates is if they don't have anything added to them to make them unique or contemporaneous to the patient you're seeing on this particular day on this particular occasion.
So the key is use the template as the foundation, but build on top of that to make it individualize for the consultation. You just conduct it.
Absolutely.
This you can't have it's impossible to have every patient exactly the same, or indeed to have the same patient present identically every time.
Well, that that's exactly right.
Yes, okay. Sorry I interrupted you, but thank you for clarifying those. Yes, please do continue.
¶ Implementing Robust Billing Systems
Look, there's not much else that I would add other than to make sure that you have a system where what gets built under your name gets built correctly. So some practitioners will tell us that they have a fantastic system where, you know They might use best practice, click on the number, click on the item number. And so when the patient goes to the front desk, the staff at the front desk know exactly what item number you build and whether it's private or TVA or Medicare only or whatever.
Other practitioners say, Look, I I don't really know. The receptionist at the front desk or the practice manager decides what gets spelled depending on their clock or some other strange variable. So have a a robust system where you know what you built and you look at the medical record and you read it to yourself and you can think, yep, that justifies exactly what I built.
I actually have a story to tell about this from my own experience. So I've always worked in practices where I had to tell the reception staff what I built, so that was never But at one point when I was a registrar and it was it was almost towards the end of my term, I checked my billing for the first time.
And I'd realized that the front desk had built one specific item number, which I cannot actually even remember. It was a very small, it was like a$8 rebate or something. So it was nothing crazy. But they'd repeatedly billed it for many of my patients. And I'd never heard of this item number before. So when I raised it, it turns out that they thought it was a bulk billing incentive number. So they had billed it by default for every Medicare patient.
And when I advised the practice owner, they were in the dark as well. And they said, Oh gosh, no, no, no, we've got to have a chat with the staff. So sometimes it's not out of malice. or malintent, it's just a misunderstanding by front desk staff of what the item number is and which situation it should be billed.
I can assure you that's happened to me too. And uh you just think, oh my god. Yeah. The software sometimes has gremlins in it. Yeah. You know. And that's just a a fantastic reason as you've illustrated why we should just double check these things every now and again to make sure that they're correct.
So check billing, make sure you have a system for making sure that what is billed under your name is actually what you did with the patient. Make sure your documentation is thorough enough that it supports the item numbers that you have built.
¶ Reviewing AI Scribe Documentation
That's right. And in terms of that documentation, I, like many practitioners, have moved the last couple of years to an AI scribe. And you know, that it's just fantastic. But it is so important. The research tells us that a number of people within two weeks of starting using the scribe stopped checking and reading it and editing it. So for heaven's sake, read every word, because it's your work. If it's incomprehensible or if it's nonsense, it's your nonsense.
And I'm talking to myself as much as I'm talking to all of our colleagues listening. My patients will confirm I'm I'm not making it up. I tell a lot of stupid, boring stories. And it's very important to make sure that you remove unnecessary guff from your notes. And one of the things that I found that uh it actually very cleverly and very efficiently removes a lot of my boring anecdotes.
But what it doesn't do is sometimes if I say, Oh yeah, look, that happened to me, it will record that as the patient's history. So please make sure that what is written by the scribe under your name is exactly what you wanted it to write.
Yeah. It can hear it can misattribute quotes to the wrong person, or sometimes I've heard of it frankly hallucinating and just writing things that didn't
Yeah, it does. That's right. Yeah.
And also there are things that you perhaps don't want to say out loud that you're thinking to yourself, like clinical judgment, you know, differential diagnoses that you perhaps don't want to announce to the patient at that point in time that you may want to populate the medical records with as well.
Yeah. That's right. A very good point.
Yes, yes. Okay. Any more tips?
¶ MBS Descriptors and Peer Advice
Just a couple more, Maria. Firstly, we used to get the book, the physical book front with the MBS descriptors, and now it's online. But I would encourage everybody to read the descriptor for what it is that you've just built, particularly if you're not familiar with it. You know, it might only take you ninety seconds to read a descriptor, but it could really help.
support you make a great decision about whether you should be billing an item or not. Maybe you're billing the wrong item and you should be billing one that actually pays more. But education yourself. And the next tip I guess in terms of that education is that we work communicate with all of the colleges. But particularly with the RSCGP who we meet with least every couple of months. And the RSCGP's got some really good modules about Medicare appropriate billing and
communication BSR and I would encourage you to have a look at those as well. They're excellent.
Excellent. Well that actually really neatly segues into my next question is if GPs want to learn more about Medicare compliance or the PSR, apart from what you just mentioned, what resources can we go to?
So R S E G P but also I would have a look at our reports on our website that we publish every month to see what it is that we're getting through the door and why we make So we do make a list of that. Have a look at other education and c talk to your peers as well. The definition of inappropriate practice in relation to billing is what would be unacceptable to the general body of peers?
So it's not the highest bar. It's not the gold standard. It's not passing a fellowship exam. It's what would the general body of peers say? No, do not accept. And so the most useful thing to do to find out what the general body of peers would think is to talk to some peers, particularly if you're building something you haven't built before.
Yep, absolutely.
¶ Beyond Algorithmic Billing Checks
And further to that, and I think it's important that we clarify Sometimes people talk about underbilling and I've seen it myself. It's not an imaginary phenomenon. If you spend twenty five minutes with a patient because They've come in with a UTI, but while they're there, they want you to follow up their depression and they want to talk about their kids' ADHD.
And they sort of haven't spoken to you for three years about their chronically sore knee. And you do four or five things and each of them has a history and each of them has an examination and it took you twenty five and anybody reading the medical record says, Yeah, wow, that took twenty five minutes, then for God's sake, fill it. You know, PSR does not exist.
to tell people not to build things that they have genuinely done and genuinely and appropriately recorded in a medical record. Nor do we say find some strange loophole that says that, well, don't bill that work that you did. in order to not get into trouble with the regulator.
Or do you I'm assuming you don't have ratios like eighty percent of your billing must be twenty threes and only ten percent can be thirty sixes and only five percent can be forty fours or else. Nothing like that.
No, no, th that's that's correct. That would be an absolute no The data shows those funny But sometimes we look at the and think, well, this is a female practitioner in a country town who speaks a particular language and of course they're going to get lots of longer consultations. Why should that matter?
But if none of those consultations are supported by a single word written in the medical record, they're problematic. So yeah, I mean we all practice differently. General practice has so many different tribes and craft groups who do different things in different ways.
Some of us are at a particular end of the cold face seeing lots of people with acute primary care. Some people at a different end of the cold face where they might only see twelve patients a day, but it takes them ten hours because those patients are tough. and have a particular burden in relation to psychological interventions or or something else. So there's no sort of assumption about people based upon the ratio of 23s to 36s to 44s.
That's reassuring. And just reflecting on my own practice, I inherited almost the entire patient base of elderly GB who retired, and there were no reliable notes. They were all handwritten on cards wick and completely illegible. So I suddenly became the local geriatrician. And I think for that first year I would have built a lot of thirty sixes and forty. because I was trying to figure out what to do with all these complex, multi-morbid elderly patients.
Yeah, I think I'd be pretty disappointed if you didn't because that's what those patients needed for
But I think it to reflect on this compliance issue, I build the appropriate number for the number of hours that I worked, if you know what I mean. I guess that's what you're trying to allude to. I think you mentioned something about more hours in the day than there is in there's more hours in the billing than there is in the day. That's impossible.
Well, that's right. So if we see a practitioner, for example, who's built a sixty item thirty sixes in a day and a couple of forty fours and even if they didn't sleep or didn't go to the bathroom it adds up to twenty nine hours in that day. We need to have a look at that and see, wonder what's happening here. That's absolutely right. But There is no doubt that looking at the at the data across Australia that there is a a huge burden placed upon particular practice.
to review things which just don't fall into anybody else's tasks. And sometimes in general practice you might think to yourself, wow, am I a geriatrician today or a psychologist? And as a wonderful medical writer who I I shared a practice with for years called Louise Stone, who writes beautifully about the burdens that female general practitioners are under and how they have to pick up a lot of the heavy lifting in providing primary care in Australia.
So, you know, there's very good reasons why organizations like us should under no circumstances judge people according to how many long consultations they do to short ones. We all practice differently. What we're interested in. appropriate and that we review it diligently.
¶ PSR Support for GPs
It's actually really reassuring to hear that it is an individualised process and it's not algorithmic. You don't hit a s certain threshold and then all of a sudden you you're definitely are in trouble. It's nice to hear that you take into account the context. Of what actually happens on the ground.
But just I I I would remind you, have a look. Make sure that that 3020 rule, if you're doing a lot of phone calls, just look what it is that you're doing.
Yeah, and the IT twin.
Yes, absolutely. Okay.
Excellent. Um, is there a web page somewhere that talks about the eighty twenty rule and the thirty twenty rule? Like a Medicare web page or a PSI webpage.
Yeah, no Medicare's got a uh about six months ago they put out a fantastic paper. It's like it's a book on guide to Medicare compliance, which is very good.
Lovely, I will put that in the show notes.
Excellent. That'd be wonderful if people read.
All right. Antonio, really good tips. If you had to sum it up, what is your take-home message for our colleagues in terms of Medicare billing? And is there anything you want to add that we haven't already covered?
Nothing further to add other than my sincere thanks to you for allowing me to reach out to your And also my sincere thanks to whatever combination of stars led me into general practice, which is just so wonderful. I mean, it's hard. I got pretty badly burnt out, as so many of us do. But it's
It's such a privilege to be a GP. But I would just reiterate, check what is billed under your provider number. Check that whatever you bill, you can justify in your medical records. If You do get a referral, whether it's to us or to DBA or to APRA or to anybody else, call your NPO, share with your family and friends, seek out the support.
Very often I think.
saying quite repetitively to the practitioners that I review, this billing may or may not be inappropriate, but what I want to see is whether this process has an outcome that that you like or that you don't like, number one, it'll be respectful. Number two, you'll be listened to. Maybe agreed with or it may not be agreed with, but we listen and we care and we will attend.
And number three, your patients need you and I hope you have a very, very long, happy and successful career in the practice of. We're not here to stop that and many of the not just one or two, but a significant number of people that we get referred to us are doctors who are doing a fantastic service for their community. So yeah, make sure that as much as is possible in the challenging environments that we've been enjoy and thrive and privilege that it is to be a GP.
Thank you so much, Antonio. I love the knowledge that you bring, but I also love the humanity that you bring. And the fact that you're one of us just makes it so much better because you get you get what we're about. So thank you so much for your time coming on not one but two podcast episodes to let us know about the PSR and also ways to avoid interacting with the PSR. I've learned a lot, I'm sure our listeners have too. So thank you so much for your.
Oh, Maria, it's an absolute privilege. Thanks so much, Maria.
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