Clinical Issue Listing

The Clinical Issue Listing is a tool that displays a list of issues that may impact your revenue or compliance. These issues need to be fixed in order to stay compliant and receive full payment for services provided. Most of these issues can be corrected by the clinical staff, though some may require the involvement of the clinical administrator or therapist. You can double-click on the issue to drill down on that issue and go directly to the window that you need to make the change to fix the issue. The list also gives you a visual cue of which issues have been looked at, by highlighting the row yellow if you have already double clicked on the issue. The yellow highlight is removed once you log out of Insight, even if the issue still displays on the list.

Filter information using a drop down arrow on any column or select the column header and drag to the gray area.

How Do I Access The Clinical Issue Listing?

The Clinical Issue List can be accessed by opening the Run menu in INSIGHT EMR or INSIGHT Billing and selecting Clinical Issue Listing.

How Often Should I Use It?

Front desk and billing staff should run the clinical issue listing daily to correct errors that can delay payment or result in noncompliance.

Clinical Issue Settings

The Clinical Issues Settings dialog box allows you to control which alerts you want to track, who those alerts are visible to and when to trigger the alert. You can display information in this window by issue or by permission. Once an alert is triggered, it will appear on the clinical issues list until it is resolved, except for the issues below.

Note: The following issues drop off of the Clinical Issues list after 30 days if they are not resolved: No Activity, No First Appt, Plan of Care Due, Progress Report Due, and Under/Overbilled Visits.

The table below provides detail for each column in the Clinical Issue Settings

Column Description
Issue Type of issue that is captured by the Clinical Issue List.
Active Check box to select whether to include the issue in the report.
Offset Allows you to determine how far in advance you want to be warned.
Units Identifies how the issue type is measured (in dollars, days, minutes, etc).
Issue Permissions Check box to select which security groups are alerted of the issue.

The table below shows reports that can be run to find issues that have dropped off of the Clinical Issue Listing after not being resolved within the 30 day time period. All reports can be found under the Reports F8 tab.

Issue Corresponding Report
Fax Failed Less Than X Days Ago Fax Status By Date of Transmission
Manual Medicare Review Manual Medical Review Upcoming Appointments
Medicare Therapy Threshold Limitation Warning Medicare Used
No Activity / No First Appointment

Active Patients with No Apppointments

Active Patients By Clinic By Therapist (including patients without appointments)

Overbilled / Underbilled Visits Trimmed Procedures
Plan of Care Approval Outstanding POC Approvals

What issues appear on the Clinical Issues Listing?

The table below briefly describes the types of alerts that are flagged in the Clinical Issues List.

Note: The following issues drop off of the Clinical Issues list after 30 days if they are not resolved: No Activity, No First Appt, Plan of Care Due, Progress Report Due, and Under/Overbilled Visits.

Issue Type Issue Description
Failed Fax Transmission Fax for visit date <mm/dd/yyyy> sent on
<mm/dd/yyyy> failed.
Insurance Authorization Insurance authorization has expired for <case description>.

Medicare Therapy Threshold

Discipline <XX> has <amount> remaining before KX is required.

or

Discipline <XX> is over KX cap by <amount>.

Medicare MMR No Activity * No activity since <mm/dd/yyyy>.
No First Appointment * No initial appointment. Registered on <mm/dd/yyyy>.
Plan of Care Approval A Plan of Care Approval missing for Evaluation on <mm/dd/yyyy> for <case>.
Plan of Care Due * Plan of Care for Medicare Secondary expires on <mm/dd/yyyy>.
Progress Report Due * Progress Report for <case description> has expired. Due on <date>.
Referral Expiration Referral has expired for <case description>.
Referral Expiration

Visit on <mm/dd/yyyy> is overbilled by <NNN> minutes.

or

Visit on <mm/dd/yyyy> is underbilled by <NNN> minutes.

Failed Fax Transmission

The following addresses faxes sent with a failed status display on this list.

To correct this, double click on the issue to open the Resend Fax? window and click Resend. The issue drops off of the Clinical Issue Listing once you resend the fax or the number of days reaches the offset according to the Clinical Issues Settings.

Insurance Authorization

Warns you when the patient's insurance is about to expire or has expired, based on the Clinical Issues Settings. Insurance authorization notifications can be set by visit, end date, or dollar amount. When using dollar amount, Insight uses the insurance Allowed amount as entered in the Allowed schedule for the payer until the visit is paid by the insurance company at which time it is updated to the actual paid amount.

Correct this by double clicking the issue to open the Client Editor and edit the Insurance Authorization information on the Case Information.

Medicare Therapy Threshold

For Medicare patients, the Medicare Therapy Threshold alert warns you as you approach or exceed the Medicare Therapy Threshold, based on the Clinical Issues Settings. Once the patient exceeds this cap, the warning stays on the Clinical Issue List until the next calendar year.

Warn the client that they are about to reach the Medicare Therapy Threshold. The patient can then talk to the therapist to determine if services are medically necessary. If the therapist determines that the services are no longer medically necessary, use an ABN to transfer financial liability for treatment to the patient. Refer to Advanced Beneficiary Notices (ABNs). If the therapist determines that the services are medically necessary, they should check mark the box to add a KX modifier at time of sign-off. Refer to Medicare Warnings for Therapists for more information.

Medicare MMR

For Medicare patients, the alert warns you as you approach or exceed the Medicare Manual Medical Review cap, based on the Clinical Issues Settings. Once the patient hits exceed this cap, the warning stays on the Clinical Issue List until next calendar year.

Warn the therapist they are about to reach the cap. Additional treatment requires additional authorization from Medicare.

No Activity

Tracks patients who have not made an appointment in the number of days specified in the Clinical Issues Settings window. If offset is 14 days, all active patients who have not made an appointment in the last 14 days will display on the Clinical Issues Listing.

Correct this by double clicking the issue to open to the Client Editor. To clear a patient from this list you can either make an appointment, or inactivate the patient by deselecting the Active Client check box. You may wish to send a letter to the patient or physician using the Letters tab in the Client Editor. Decreasing the number of patients that appear under the No Activity issue can help manage your clinic's no show percentage, which is one of the 7 critical metrics of a healthy practice.

No First Appointment

Identifies patients who have registered but no appointment has been established. It is useful for tracking down lost referrals. Your clinic should have a process in place to determine how to manage these patients, whether it is to follow up with the patient to schedule an appointment or discharging the patient if you cannot schedule an appointment within a certain period of time.

Correct this by double clicking the issue, which opens the Client Editor so you can have patient information in front of you to schedule the appointment.

Plan of Care Approval

Identifies patients who have had a Plan of Care added to the system, but the Approved On field has not been completed. The system starts counting once the Plan of Care is added until the Plan of Care approval date is entered. For example, if the Plan of Care was entered 6/14/19 and the Clinical Issues Settings for Plan of Care Approval is set to five days, on 6/14/19 if an approval has not been entered, the patient will appear on the Clinical Issue Listing report.

Correct this by double clicking the issue to open the Client Editor and add Plan of Care approval information on the Case Information tab.

Plan of Care Due

Identifies patients who have a Plan of Care that is approaching the expiration date or has already expired. Visits that have been signed that do not have a Plan of Care display in the With Issues on the Claims tab if the claim has been created and the payer is set to require a Plan of Care.

If the front desk administrator is running the clinical issue list, when this issue appears, talk to the therapist to determine if the patient needs to be scheduled with a supervising therapist. The therapist also sees the warning once they are viewing the patient's case in the Chart tab. To clear the warning, the therapist can click on the case description to open the Client Editor and add a new Plan of Care using the Add P.O.C. button. Update the documentation to reflect the new Plan of Care and, if necessary, change the appointment type to a Progress Evaluation appointment.

Progress Report Due

Triggers when you approach the threshold set to warn when the patient's Progress Report is due. Use the Edit Payer window (General Billing Data tab, Required Data Entry Fields section) to set this threshold.

Therapist will be warned as they approach the time when a Progress Report is due. The case information bar will turn red and the therapist can click the Add Prog Rpt button to add a Progress Report.

Referral Expiration

Warns you when a referral is expiring or has expired. Referral information is entered in the Case tab using the Client Editor. You can specify an expiration date or a number of visits. As a patient is marked arrived, the number of remaining visits is reduced—similar to an insurance authorization. You can update the visits or add a new referral to address an expiring referral.

Contact the referring MD to obtain a new referral. Once you have a new referral, double click on the issue to open the Client Editor and enter the new referral information.

Under/Overbilled Visits

Identifies patients with a charge ticket that does not match the length of the appointment. The therapist can adjust the minutes for each procedure, each CPT code or the patient time in and time out in order to ensure that the documented time is not more or less than the visit time.

Note: Alerts are based on the minutes documented not the minutes billed. It is possible that time will be documented but not billed due to billing rules in place for the payer. Any code that is not billed will appear on the Trimmed Procedures Report which is found on the Reports tab in the Management reports category.

Double-click on the alert to open the chart for that visit. Review the chart note and open the associated charge ticket to see if the billing differences are justified. If it is not justified, the therapist needs to correct the documentation by un-signing the visit. Any changes to the charge ticket that impacts billing automatically creates a system task notifying the biller that the documentation has changed for a billed visit. This ensures that you maintain compliance between the clinical and billing record at all times. Refer to Sign Off Clinical Documentation for more information.

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