University Specialty Clinics Annual Compliance Training 2014

Billing Compliance

In Practice

Billing Compliance PlanReviewed in orientation also on the websiteFormalizes expectation that employees will

report concernsAddresses protection against retaliation

Code of ConductSigned at orientationAn agreement to comply with the Billing

Compliance Plan

Why have a compliance plan?

State Investigative Agencies Dept. of Health & Human Services Medicaid Fraud Control Unit

Federal Investigative Agencies Federal Bureau of Investigation Office of Inspector General Internal Revenue Service Palmetto Government Benefits

Administrators

Who’s looking?

Please Contact Us With Compliance Concerns

New information from specialty society that will change how something is billed

Uneasiness with the way services are being billed

Advice regarding particular situations prior to billing

Hearing information that is contrary to your current understanding

Things to Remember About New Faculty

Services provided by a new faculty member cannot be billed until credentialing is completed

The co-signature of a current faculty member on a service provided by a new faculty member does NOT create a billable service

History of the False Claims Act

Originally enacted 1863 under President Lincoln Targeted unscrupulous defense contractors billing

for defective goods Recognized that citizens might have information

that government did not Allows citizens to sue on behalf of the government

and share in the rewards (Qui tam) Protects these whistleblowers from retaliation Amended 1986. Expanded use in healthcare

fraud

How does the False Claims Act work in healthcare?

Must have specific knowledge that the defendant has knowingly submitted (or caused to be submitted) false claims to the United States

Must file an official complaint and turn over all evidence

Must be first to file Department of Justice will decide whether to

become involved based on scope, strength of evidence, $$

New on the Horizon for 2014

New Government Guidelines for Clinical Trials

Effective January 1, 2014, Medicare policy updates and Affordable Care Act brought major changes to billing compliance for clinical trials

Under these laws, health plans cannot: Deny a person the right to take part in a clinical trial Limit or deny routine patient costs for items or services

connected with the clinical trial Discriminate against a person on the basis of their participation

in a study

Clinical Trials According to the new laws, insurance companies do not

need to pay for: Treatments, devices, or services that are usually covered by the sponsor Items and services only needed for data collection and analysis Any services that are clearly not in line with the established standards of

care for a certain diagnosis

To ensure compliance with regulations, communication regarding regulatory statues and study participants needs to flow through: Principle investigator and faculty participants Research administration and study staff Nursing staff and nurse auditors Billing and coding personnel Patient registration personnel

What is the impact? Transmittal 540 (effective 9/8/14)

Authorizes the MAC’s (Palmetto GBA) and ZPIC (fraud investigators) the discretion to deny claims that are “related” before or after the claim in question has been processed.

When Part A claim is in question, Part B claim may be denied or recouped.

CMS example: • The MAC performs post-payment review of the admitting physician’s

Part B services. For services related to inpatient admissions that are denied because they are not appropriate for Part A payment (i.e., services could have been provide as outpatient or observation), the MAC will review the hospital record. For services where the patient’s history and physical, physician progress notes or other hospital documentation does not support the medical necessity for performing the procedure/service, post-payment recoupment will occur for the performing physician’s Part B service.

New Proposals by CMS

Established a policy to allow payment for complex chronic care management to primary care practitioners

Is proposing to transform all 10- and 90-day global codes to 0-day global codes in CY 2017

To expand telehealth services to include annual wellness visits, psychoanalysis, psychotherapy, and prolonged E/M services

Consultations

What Is Expected for Consultation Documentation?

Request: Inpatient - Request and response in common record Office - Records must clearly indicate the request for

consultation vs new patient service Strongly recommend getting hardcopy request

Render: Levels of service- same requirements as new patient

office visits regardless of location Respond:

Must have a process to ensure that a written response is sent

What Documentation is required for a Level Five Consultation?

Comprehensive History Four descriptors of the History of Present Illness Remember to include an element of Past, Family

and Social history or a reason why it cannot be obtained

A ten system review of systems

Examination of Eight Organ Systems / Comprehensive specialty specific / 18 bullets from 9 organ systems

Medical Decision Making that includes two of the three : Diagnosis, Data, Risk at the highest level

I spent 45 minutes explaining ……to the patient….

What Happens When I Spend Most of the Visit in Counseling?

Medically Appropriate Counseling is a discussion of : Prognosis Test results Educating patient and family about treatment or

disease Risks and benefits of management and/or follow up

When more than 50% of a face to face visit is spent in medically appropriate counseling, the level of service can be chosen based on the total face to face time

In the hospital setting, total time includes bedside time and time on the patient’s unit or floor

What Codes Do I Use?

The same CPT codes are used. A 99214 could be chosen if the visit was

documented as: An extended exam of two to seven organ systems for

a new problem assessed as a moderate risk to the patient

OR A 25 minute face to face visit by the attending with 15

minutes spent in medically appropriate counseling with a description of the content of the discussion

What Has to be Documented?

If medically appropriate counseling dominated the visit, document :

1. Total time face to face with the patient

2. Counseling Time > 50%

3. Content of the discussion

Remember : Only the billing provider’s face to face time can be

considered. Staff and Resident time cannot. (In the hospital setting, total time includes bedside time and time on the patient’s unit or floor)

Total Times for Billing Based on Counseling Time

99205 (Office visit) 60 minutes99245 (Office consult) 80 minutes99255 (Inpatient consult) 110 minutes

Established patient visits99215 40 minutes99214 25 minutes

Reminders

Things to take note of:

Things to Remember About an Electronic Medical Record

A secure log in, password and electronic signature identifies the provider

Everyone, including students, must log in with their own password before documenting

Templates can be helpful prompts but be mindful of the quality of the clinical record

Copy/paste and cloned note increase the risk of error and leads to questions of authenticity in the medical record

Goal: Payment on the first submission Diagnosis codes explain why this particular service

was provided that day Listing diagnosis codes that were not specifically

addressed on a visit misrepresents the service Documentation must support choice Insurers have CPT/diagnosis combinations that will

not be paid

Things to Remember About Reporting Diagnosis Codes

What Do I Document for Tests?

We cannot defend the medical necessity for a test that is never shown to be used in treating the patient

The reason for all tests/procedures/x-rays must be documented in the clinical record

You must then address all findings/results in the clinical record

A process must be in place for insuring that test results are acknowledged

Teaching Documentation

Medicare services provided with a resident must be filed with a GC or GE modifier

GC modifier tells Medicare That a resident was involved in the serviceThat the attending examined the patient as wellThat there may be two notes to document the

service GE modifier tells Medicare that we are using

the Primary Care Exception

Medicare Teaching Modifiers

Outpatient Teaching Requirements

Teaching Physician Requirements

Medicare The Teaching Physician be

present in the office suite and personally evaluate the patient during the visit

The Teaching Physician must:• Be physically present with

the resident for the key portions of the E/M service

OR• Repeat the key portions of

the service independently

Documentation Requirements Medicare

The Teaching Physician must:• Link their note to the

resident’s signed note• Document that they have

examined the patient• Document their teaching

interaction with the resident• Document their agreement

and/or changes to the residents assessment and plan of care

Both the resident and the Teaching Physician must sign their note in the medical recordGC Modifier is required to indicate the residents involvement

Office and Outpatient Medicare Using the Primary Care Exception

You do not have to see the patient You must be present in the office suite You must personally document your presence and participation

You must link your note to the resident’s note in order to use the resident’s documentation to support the level of service

These Medicare claims will need a GE modifier

Outpatient Teaching Requirements

Teaching Physician Requirements

All Payers Except Medicare The Teaching Physician

must be present in the office suite and immediately available to direct or provide patient services

Documentation Requirements

All Payers Except Medicare The medical record must

include a statement referencing the Teaching Physician’s presence and involvement in the service

Both the resident and the Teaching Physician must sign the note in the medical record

No Modifier is required for resident involvement

Inpatient Teaching Documentation

Inpatient Teaching DocumentationOne Standard- All Payers

Note the Date of service in the documentation Reference specific resident’s note if used to

choose the level of service May link to Resident’s Admission H&P if patient is

seen within 24 hours May link to resident notes from the same

calendar date for follow-up visits and consultations

Medicare claims will need a GC modifier

Examples of subsequent hospital visits

99231 1. One or two established problems that are stable. Chest x-ray ordered.

99231 2. One established problem that is worsening. Pulmonary function test ordered.

99233 3. Two established problems worsening and the decision not to resuscitate.

99232 4. Three established problems that are stable or one new problem. IV antibiotics

99233 5. A new problem requiring additional work-up and posing a threat to life or a bodily function

99232 6. Two established problems, one stable and one worsening. Change in antibiotic.

These examples assume that the history an exam meets the appropriate level of service

Teaching Documentationfor Procedures

Were you present and is that documented?

Documenting Procedures When Residents Are Involved

Procedures are separately billable only if documented in a separately identifiable note

This includes minor office procedures Attending presence during the procedure

must be documented in that separately identifiable note

See procedure presence guidelines on the Compliance website

What Does that Documentation Look Like?

Attending presence and participation can be documented by the resident or the attending

Just listing the attending’s name does not meet the billing requirement for any payerAttending: Dr. X Not BillableAttending: Dr. X was present for the central

line placement. Billable If your presence has been clearly documented

by the resident, only a co-signature is required

Things to Rememberabout Teaching Notes in Electronic Medical Records

Medicare A canned statement (“macro”) can be used as a

base - if additional clinical detail is presentRefer to Medicare Teaching brochure on the

Compliance websiteSignatures are automatically timed and dated

If the attending note is completed before the resident’s note is signed - cannot link to incomplete note

All Other Payers

Be sure that the statement of presence clearly notes “present at the time of the visit”

Things to Remember about Students and Billing

The resident teaching supervision and documentation rules do not apply to any other kind of student.

Students are not licensed providers of service. They are not recognized by insurance plans

Procedures done by students are not billable

What a Medical Student Can Do

A student can act as a scribe:Records information at the direction of the

attending Must Note “Acting as scribe for Dr. ____”Both signatures are required

A student can independently record a PFSH and ROS. The attending references the student’s note,

documents review and confirmation of that information, writes own HPI, exam and plan.

Billing Compliance15 Medical Park, Suite 300256-0977 (Fax)

Tara Farmer, MA, LPC/I, CPC545-5022 – Office tara.farmer@uscmed.sc.edu

Billing Compliance Website http://billingcompliance.med.sc.edu

If you have question, please contact the Compliance Department.