Chapter 3
Freestanding Ambulatory Care
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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.
(continues)
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2
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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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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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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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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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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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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Regulatory Issues:
Accreditation
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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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certain product or service or otherwise on a password-protected website for classroom use.
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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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Special Requirements
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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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certain product or service or otherwise on a password-protected website for classroom use.
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Patient Identifier/
Filing Methods
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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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certain product or service or otherwise on a password-protected website for classroom use.
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Reimbursement Resources
•
•
•
•
Program manuals
Program transmittals
Local coverage determinations (LCDs)
National coverage determinations (NCDs)
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certain product or service or otherwise on a password-protected website for classroom use.
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Coding and Classification
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Data and Information Flow
• Visit is basis of workflow
• Appointment methods
– Standard scheduling
– Block appointment method
– Modification of standard and block
(continues)
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Data and Information
Flow (continued)
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Data and Information
Flow (continued)
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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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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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certain product or service or otherwise on a password-protected website for classroom use.
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Computer Systems
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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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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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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 records
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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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certain product or service or otherwise on a password-protected website for classroom use.
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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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certain product or service or otherwise on a password-protected website for classroom use.
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