Coding and Compliance

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Coding and Compliance

• Review for Re-credentialing Providers
• To view the presentation, right click now and
  choose the Full Screen option. Change slides
  using the Page up and Page Down keys on the
  keyboard.

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Course Objectives

• The purpose of this course and its follow-on test
  is to provide physicians and other clinicians,
  who are being re-credentialed by UNC Hospitals,
  with important information on three issues

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Course Objectives

• Why coding and compliance is important to you and
  your practice
• Keys to correctly coding hospital and office
  visits - Evaluation and Management (EM) Services
  
• Teaching physician (TP) rules. In order to bill
  for services when working with residents and
  fellows, the teaching physician must abide by
  federal and state laws and regulations

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Why coding and complianceis important to you and
your practice
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Reimbursement
Providing good care while billing accurately and
confidently requires

• Doing only what is medically necessary
• Documenting what you do
• Billing what you document

• Understanding and applying coding and compliance
  conventions can improve the level of
  reimbursement for UNC PA practices as well as
  the quality of the medical record documentation.

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Why Compliance

• Good documentation and billing practices make for
  good patient care
• Recovery Audit Contractors (RACS)Medicare and
  Medicaid
• Office of Inspector General (OIG), Health Human
  Services
• Routine error rate testing and auditing programs

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Why Compliance

• Residents are paid through the hospital by Part A
  Medicare. Medicare pays a portion of the
  residents salaries based on the proportionate
  share of Medicare at the teaching hospital.
• Teaching physicians are paid by Part B Medicare
  on a fee-for-service basis.
• The government, through Medicare, will pay for
  both resident and TP services if both
  participate. If the TP does not participate in a
  given patient service, the TP cannot bill.

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Why Compliance

• Two problems have caused a majority of refunds
  and penalties
• The TP billed and he/she may have been present
  and participated in the care, but TP presence was
  not documented.
• The documentation did not support the level of
  evaluation and management (EM) service billed.
  The billed level of service may have been
  provided, but it was not documented.

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Keys to correctly coding hospital and office
visits - Evaluation and Management (EM) Services

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Choose the Outpatient Category

• Outpatient EM Categories
• Consultation
• New
• Established

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Use of Consultation Codes

• Use when expert opinion or advice is requested by
  an appropriate source involved in that patients
  care
• Does not include patients referred for
  management of a condition or self-referred
• Use outpatient consultation codes only one time
  per request, subsequent visits are established
  patient visits
• A consulting physician may initiate diagnostic
  and/or therapeutic services at the same visit and
  the initial visit remains a consultation
• Written or verbal request must be documented in
  the rendering physicians note and the
  consultants opinion communicated by written
  report to the requesting physician

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Documenting Consultations
Documentation of a consultation request must be
clearly stated in the note WRONG Mr. Patient
referred by Dr. Jones for management of GERD
symptoms. RIGHT Mr. Patient is seen in
consultation at the request of Dr. Jones for
evaluation of abdominal pain. Please be sure
to document that a copy of the note (cc Dr.
Jones) is to be sent to the requesting physician.
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New Patient

• Has not received any professional evaluation and
  management (EM) services from the physician or
  another physician of the same specialty who
  belongs to the same group practice within the
  past three years, including inpatient, outpatient
  or emergency room.
• A patient would still be considered new if a
  diagnostic procedure was billed without an EM
  visit charge.

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Established Patient

• Has received an EM service from the division
  within the past three years including inpatient,
  emergency room or inpatient or outpatient
  consultations

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Visit Components

• Consults and new patient visits must
  include all three of the following components
  established patient visits must include any two
  of the three
• History
• History of present illness
  Documenting History
• Review of systems
  History example
• Past family and social history
• Physical examination 1995
  Physical Exam
• 
  1997 Single Organ Exams
• Medical decision Making
• Diagnosis and management options
  Documenting MDM
• Amount and complexity of data reviewed
• Overall risk
  Risk Table

Click these links for more information
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Visit Levels

• Billing at a higher level than actually provided
  and documented is one of the two chief issues
  contributing to CMS fraud allegation settlements
• The laminated, pocket-sized physicians coding
  card is a valuable guide to correct coding. To
  request a copy of this card please call 843-8638.
• Questions on correct coding and compliance issues
  should be directed to either of the Compliance
  Auditors at 843-8638.
• Click on this link for documentation requirements
  at various EM levels of service.

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Visit levels based on time

• Document the total time of the visit.
• Over 50 of an outpatient visit must be spent in
  face-to-face counseling and treatment planning
  and so documented. For Medicare patients, count
  only face time between the Teaching Physician and
  the patient.
• For inpatient count total for the day of
  counseling, coordination of care and time on
  floor in care of the patient.

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Visit levels based on time (cont)

• The note must include a description of the
  counseling and treatment planning.
• The physicians coding card contains minimum time
  requirements for each visit level.
• Note that the minimum times are different for
  each of the three categories of visits consults,
  new patient and established patient.
• Click on this link for additional time-based
  billing information.

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Modifier 25

• Append a modifier 25 to an EM code if a
  significant, separately identifiable EM service
  is performed by the same physician on the same
  day of a procedure or other service.
• The patients condition must require EM services
  above and beyond what would normally be performed
  in the provision of the procedure.
• The necessity for the EM service may be prompted
  by the same diagnosis as the procedure.
• A new patient EM service is considered separate
  from the same day surgery or procedureno 25
  modifier needed.

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Modifier 25

• For an established patient, if the EM service
  resulted in the initial decision to perform a
  minor procedure (0-10 days global period) on the
  same day and medical necessity indicates an EM
  service beyond what is considered normal protocol
  for the procedure, the 25 modifier is
  appropriate.
• To determine the correct level of EM service to
  submit, identify services unrelated to the
  procedure and use as EM elements.
• Clearly mark the encounter form to indicate that
  a 25 modifier should be attached to the EM.

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3. Teaching physician (TP) rulessupervision of
residents and billing Medicare and Medicaid
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Medicare TP Attestation Requirement

• The 11/22/02 revisions to the regulations provide
  that, for EM services, the TP does not have to
  duplicate any resident documentation.
• The TP must be present during the key portions of
  the service and personally document his or her
  presence.
• The resident note alone, the TP note alone or a
  combination of the two may be used to support the
  level of service billed.
• Documentation by a resident of the presence and
  participation of the TP is not sufficient.
• Documentation may be dictated and typed,
  hand-written or a computer statement initiated by
  the TP.

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Medicares Examples of Unacceptable TP notes

• "Agree with above." followed by legible
  countersignature or identity
• "Rounded, Reviewed, Agree." followed by legible
  countersignature or identity
• "Discussed with resident. Agree." followed by
  legible countersignature or identity
• "Seen and agree." followed by legible
  countersignature or identity
• "Patient seen and evaluated." followed by legible
  countersignature or identity and
• A legible countersignature or identity alone.

The preceding six and similar statements dont
make it possible to determine whether the TP was
present, evaluated the patient, and/or had any
involvement with the plan of care.
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Medicare Exception for Primary Care

• CMS does not require direct patient contact for
  primary care, lower-level visits provided by
  residents with more than six months training
  working in approved primary care programs.
• Approved primary care centers at UNC
• Family Medicine
• General Medicine
• General Pediatrics
• Womens Primary Health

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Medicare Primary Care Exception

• TP may supervise up to 4 residents on immediately
  available basis
• Residents must have completed 6 months training
• TP must review each patient case w/resident
  during or right after visit
• TP must document his/her contemporaneous
  discussion of the patients condition with the
  resident.
• Only EM codes 99201-03, 99211-13 may be billed
• TP may see and evaluate a patient in a primary
  care exception clinic and bill a higher level of
  service

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Medicare Supervision Guidelines for Procedures
Performed with Residents

• TP must be present during critical and key
  portions immediately available throughout
  surgical procedures and endoscopic operations
• TP decides what portions are key
• If present entire time, the residents note can
  attest to that
• If present for key portions only, TP must
  document extent of involvement
• Two overlapping surgeries
• Key portions must happen at different times
• Must be available to return to either

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Medicare Supervision Guidelines for Procedures
Performed with Residents

• Minor procedures of lt5 minutes
• Must be present the entire time
• Endoscopies (other than surgical operations)
• TP must be present for entire viewing including
  insertion and removal

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Medicare Supervision Guidelines for Supervision
of Specific Procedures

• Radiology/Diagnostic Tests
• Image and resident interpretation must be
  reviewed by TP to be billable
• TP may sign acknowledging agreement or edit,
  co-signature insufficient
• Psychiatry
• TP presence requirement met by concurrent
  observation of the service by video or one-way
  mirror
• Must be present for entire period of time billed
  if time-based psychotherapy code is used

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Medicare Supervision Guidelines for Specific
Procedures

• Time-based procedures billed on TP time only
• Critical care
• Hospital discharge day management
• Prolonged services
• Care plan oversight
• EM counseling/coordination of care
• Specific complex or high-risk procedures require
  continual personal TP supervision
• Interventional radiologic/cardiologic codes
• Cardiac cath, stress tests, transesophageal ekg

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Medicaid Requirements

• Medicaid requires that the TP be
  "immediately available" to the resident and
  patient and use "direct supervision" for
  procedures. Direct supervision does not
  necessarily mean that the TP must be present in
  the room when the service is performed. The
  degree of supervision is the responsibility of
  the TP and is based on the skill, level of
  training and experience of the resident as well
  as the complexity and severity of the patient's
  condition. Written documentation in the medical
  record for Medicaid patients must clearly
  designate the supervising physician and be signed
  by that physician.

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The Hospitals financial health is important to
you
Short stays have been a recent focus of
government auditors and large refunds have been
required due to documentation of medical
necessity for an inpatient admission
Leaving patients in observation who should be
admitted results in lost revenue to UNC
Hospitals.

• Only physicians can make a decision to admit as
  an inpatient, place in observation status or
  extended recovery.
• Only physicians can change the patient status.
  Clinical Care Management (CCM) staff assist in
  determining the appropriate status.

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Summing Up Billing Status
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You can identify the outpatients on your census
Billing Status
OBS (16)

OBS (28)
EXR (6)
EXR will always be red, as it is an unbillable
status. OBS Appears green until 12 hrs Appears
yellow from 13-20 hrs Appears red from 21 hours
onward Think when the field is red, were in
the red
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Eliminating Confusion (and Revenue Loss)

• Problems with the Admit word
• Interpreted as inpatient intent to CMS
• Means Place Patient in Bed at UNCH
• Does not define a billing status
• Generally causes confusion
• Can cause CMS retractions
• Avoid an order contradiction in notes
• Will admit to Obs
• Will place on Inpatient Observation

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The Importance of the HP

• Admitting team documentation required for billing
  status determination
• Inpatient medical necessity is established by a
  review of criteria and documented intent/risk by
  the admitting team
• Billing status begins when the order is placed

Delay in HP or admit note with intent
Delay in Billing Status Order
Un-billable days


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Where To Get Help

• www.med.unc.edu/compliance/
• UNC PA Professional Charges (code inpatient
  services and some outpatient procedures) 962-8391
• School of Medicine Compliance Office 843-8638
• Charles Foskey, Compliance Officer
• Chris Carreiro, Compliance Review Analyst
• Nirmal Gulati, CPC, Compliance Auditor
• Heather Scott, CPC, Associate Compliance Officer
• Lateefah Ruff, Office Assistant
• Confidential Help Line 800-362-2921
• AMA CPT Manual