CY2011 Billing Compliance New Resident Orientation

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CY2011 Billing Compliance New Resident
Orientation

• Provided by
• Mathew Spencer Director of Billing Compliance
• 743-1634 or mathew.spencer_at_ttuhsc.edu

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OBJECTIVES

1. Gain a basic awareness of TTUHSC Billing
   Compliance Program
2. Gain a General understanding of Fraud, Waste
   Abuse
3. Gain a General understanding of EMR risks
4. Gain a General Understanding of Basic Coding
   Concepts
5. Gain a Basic understanding of Teaching Physician
   Rules

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Your Billing Compliance Team

• Mathew Spencer, Director 806-743-1634
• 7 years in academic billing compliance
• Certified Professional Coder (CPC)
• Graciela Cowan, Senior Analyst 806-743-1632
• 18 years healthcare experience
• Certified Professional Coder (CPC)
• Millie Johnson, JD., Institutional Compliance
  Office 806-743-3949
• 13 years experience in healthcare law and
  academic healthcare compliance
• Certified Professional Coder (CPC)

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BILLING COMPLIANCE?

• What is Compliance
• It is a process to conduct activities within the
  rules, regulations and policies.
• Government Payers University Policies
• The purpose is to minimize risk of Fraud, Waste
  Abuse.
• Training Programs
• Open Lines of Communication
• Institutional Policies
• Internal Auditing and Monitoring Activity

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TTUHSC BILLING COMPLIANCEFraud, Waste Abuse
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Objectives

• Identify Explain the general federal health
  care fraud standards, laws and policies and
  TTUHSC fraud, waste abuse policies.
• Identify various types of fraud and consequences
  for non-compliance.
• Describe how to report fraud, waste abuse and
  employee protections.

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Fraud, Waste Abuse (FWA) - Defined

• FRAUD Intentional act of deception,
  misrepre-sentation, or concealment to gain
  something of value.
• WASTE Over-utilization of services and misuse
  of resources (non-criminal activity)
• ABUSE Excessive or improper use of services or
  actions inconsistent with acceptable business or
  medical practice.

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Relevant FWA Laws

• FALSE CLAIMS ACT (FCA)
• Imposes civil penalties on anyone who knowingly
  presents or causes to be presented to the federal
  government (or its subcontractors) a false or
  fraudulent claim for payment or approval such as
  intentional upcoding.
• ANTI-INDUCEMENT STATUTE
• Prohibits payments to Medicare beneficiaries that
  might induce them to seek health care
  items/services from a provider. Example Waivers
  of co-pays, deductibles without determining
  financial need.

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Relevant FWA Laws

• ANTI-KICKBACK STATUTE
• Criminal offense to knowingly and willfully
  offer, pay, solicit or receive any remuneration
  to induce or reward referrals of items or
  services paid by a federal health care program
  (i.e., Medicare).
• STARK LAW
• Physicians are prohibited from referring Medicare
  patients to an entity for provision of designated
  health services where the physician or his/her
  family member has a financial relationship.

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Relevant FWA Laws

• Excluded Entities Individuals
• TTUHSC cannot employ or contract with any
  individual or entity listed on federal or state
  exclusion lists.
• See HSC OP 52.11
• HIPAA Privacy Security Laws

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Examples of FWA

• Providers
• Billing for services not provided or at a higher
  level than what was provided (i.e., upcoding).
• Billing separately for services bundled into a
  single code.
• Prescribing medications based on illegal
  inducements.
• Writing prescriptions for drugs not medically
  necessary.
• Falsifying information to justify coverage.
• Medicare Beneficiaries
• Doctor shopping (narcotics, stockpiling or black
  market)

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Possible Consequences of FWA

• Criminal Penalties
• Prison if fraud causes injury to patient.
• Civil Monetary Penalties
• Up to 11,000/claim plus treble damages under
  FCA
• Up to 25,000 for each Medicare beneficiary
  adversely affected (prescription fraud, injury)
• Up to 25,000 for violations of Anti-Kickback
• Litigation Settlements
• Costs of Litigation and Corporate Integrity
  Agreement
• Educational plan, auditing, reporting, etc.

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Possible Consequences of FWA

• Administrative Actions
• License Suspension.
• Exclusion from participation in federal health
  care programs.
• Denial or Revocation of Medicare Enrollment.
• Suspension of Provider payments.

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Reporting FWA at TTUHSC

• We have a duty to report identified FWA.
• Regents Rules, Chapter 7
• HSC OP 52.04, Reporting Violations
  Non-Retaliation
• Non-Retaliation Policy HSC OP 52.04
• Reporting Resources
• Immediate Supervisor
• Billing Compliance/Institutional Compliance
  Offices
• Confidential Compliance Hotline HSC OP 52.03
• 1-866-294-9352 (toll-free) www.ethicspoint.com
  This is the most anonymous method for making a
  report.

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Electronic Health Record
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Billing Compliance Policies EHR

• BCP 7.2, EHR Cloning (Copy and Paste) Functions
• The policy allows for Cloning (Copy and Paste) of
  Review of Systems verified and confirmed as
  accurate by the billing provider.
• BCP 7.3, Code Selection and Prompt Functions
• BCP 8.1, Coding Discrepancy
• TTUHSC EHR Playbook http//www.ttuhsc.edu/billing
  compliance/documents/EMR_Playbook_12_10.pdf

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Things to be aware of EHR

• Cloning Functions
• Authorship
• Signatures Sign-off on all services in a timely
  fashion by appropriately authenticating the
  service.
• Audit Tracking
• Signatures Proper Authentication
• Code Selection Functionality

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Things to be aware of EHR

• Templates
• Exploding/Pre-Populated Elements
• Default to Negative
• Macros
• Medical Student Documentation
• Can only use medical students ROS and PFSH for
  billing purposes.
• Should be able to clearly delineate the medical
  students work.

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CODING BASICS

• Document the Medically Necessary Care You Provide
• Billing Terminology
• Current Procedural Terminology (CPT)
• Describes the professional service provided
• Internal Classification of Diseases, Vol. 9
  (ICD9)
• Describes the reason for the service e.g.,
  diagnosis and medical necessity.
• Healthcare Common Procedural Coding System
  (HCPCS)
• Describes supplies and drugs provided and other
  services not listed in CPT.

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CPT Codes

• Five Digit Code Service Provided
• Various Sections
• Evaluation Management (E/M) Services
• Anesthesiology
• Specialty Procedures
• Radiology
• Pathology
• Medicine
• Modifiers

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Evaluation Management (E/M)

• CPT Codes 99201-99499
• Office Visits Consultations Facility Visits
  Preventive Visits Critical Care Other Visits
• Most E/M services have various levels from simple
  to complex
• The E/M Code to bill is Based Upon
• Level of Services as Documented
• Location of the Service (Facility v. Office)
• Patients Status (New v. Follow-up)

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Why is Documentation Important?

• Continuity of Care
• Various Providers
• Quality of Care
• Utilization Review
• Billing
• Fraud and Abuse Risks
• Liability
• Malpractice

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SOAP E/M (Components)Documentation Comparison

• SOAP
• Subjective
• Objective
• Assessment/Plan

• E/M Components
• History
• History of Present Illness, Review of Systems,
  and Past Medical, Family Social Hx.
• Examination
• Medical Decision Making
• Diagnosis, Data Risk

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E/M History 4 Elements

1. Chief Complaint
2. History of Present Illness (HPI)
3. Review of System (ROS)
4. Past Medical, Family Social History (PFSH)

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E/M HISTORY ELEMENT - 1

• Chief Complaint (CC) This drives medical
  necessity (Reason the Patient Seeks Treatment)
• A concise statement describing the patients
  problem or reason for the encounter.
• Can be noted as F/U for treatment of a specified
  condition.
• Must be listed for each patient visit (except
  subsequent hospital visit).
• Documented by Patient, ancillary staff, medical
  student, resident or Teaching Physician.

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E/M HISTORY ELEMENT - 2

• History of Present Illness (HPI)
• A chronological description of the development of
  the patients current illness
• Elements
• Documented by Resident AND/OR Teaching Physician
  ONLY

Location Quality Duration
Timing Context Severity
Associated Signs/Symptoms Associated Signs/Symptoms Modifying Factors
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E/M HISTORY ELEMENT - 3

• Review of Systems (ROS)
• An inventory of body systems obtained through a
  series of questions
• Documented by Patient, ancillary Staff or Others.

Constitutional Respiratory Eyes Endocrine GI
Cardiovascular Neurological ENT Musculoskeletal GU
Allergies/Imm. Psychiatric Skin Hematologic/Lymphatic Hematologic/Lymphatic
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E/M HISTORY ELEMENT - 4

• Past Medical, Family Social History (PFSH)
• Past Medical Hx Patients past experiences with
  illness, operations, injuries treatments.
• Family Hx Review of medical events in patients
  family.
• Social Hx Age appropriate review of past
  current activities.
• Documented by Patient, ancillary Staff or Others.

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FOUR HISTORY BILLING LEVELS
LEVEL of HX HPI ROS PFSH
Problem Focused 1-3 N/A N/A
Expanded Problem Focused 1-3 1 N/A
Detailed 4 or more 2-9 1
Comprehensive 4 or more 10 3
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E/M - EXAMINATION

• Two Documentation Standards (Handouts)
• 1995 Number of Organ Systems and/or Body Areas
  examined documented.
• OR
• 1997 Exam elements (i.e. bullets) performed
  documented.
• Documentation Requirements
• By Resident AND/OR Teaching Physician.
• Vital signs can be documented by Ancillary Staff,
  Medical Student

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E/M EXAM Documentation

• Document specific abnormal and relevant negative
  findings for affected or symptomatic body area(s)
  or organ system(s)
• Abnormal without elaboration is insufficient.
• Describe abnormal or unexpected findings of the
  exam of any asymptomatic body area(s) or organ
  system(s) should be described.

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FOUR EXAM LEVELS
LEVEL OF EXAM 1995 (Organ/Body) 1997 (Bullets)
Problem Focused 1 1-5
Expanded Problem Focused 2-7 6-11
Detailed 2-7 12 from 2 organ/body areas)
Comprehensive Multi-System 8 Organ Systems 18 from 9 organ/body areas
Comprehensive Single Organ Not defined All bullets in shaded boxes 1 from unshaded boxes
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E/M-DECISION MAKING (MDM)

• Three Elements
• Diagnosis/Management Options considered by the
  provider based on conditions treated.
• May be Implied from the documentation
• Amount/Complexity of Data Ordered and/or Reviewed
  by the provider.
• Risk of Complications (Table of Risk)
• Documentation Requirements
• Resident and/or TP must document

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FOUR LEVELS OF MDM

• STRAIGHT FORWARD
• Minimal problem, data and risk
• LOW COMPLEXITY
• Limited problem, data with low risk
• MODERATE COMPLEXITY
• Multiple problems, data with moderate risk
• HIGH COMPLEXITY
• Multiple problems, data with high risk

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E/M LEVELS OF SERVICE

• Office New Patient, Hospital Admit, or Consult
• Document all 3 key components
• History, Exam, and Medical Decision Making
• Comprehensive History for highest levels (4 5)
• Document 10 or more ROS
• Document 1 item from each PFHS area
• Comprehensive Exam for highest levels (4 5)
• 8 or more organ systems (1995 Exam Standard)
• 1997 See Guidelines

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E/M LEVELS OF SERVICE

• Office Established Patient or Subsequent
  Inpatient Visit
• Document
• History and/or Exam
• AND
• Medical Decision Making

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E/M - TEACHING PHYSICIAN RULES

• E/M - GENERAL RULE
• Teaching Physician (T.P.) is either present with
  Resident OR personally perform key portions of
  HPI, Exam and Medical Decision Making with or
  without the Resident.
• Teaching Physician MUST personally document
  review of Residents History, his/her
  participation in the exam and management of
  patients care.
• Resident cannot document T.P. presence or
  participation for E/M services

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TEACHING PHYSICIAN RULES

• PRIMARY CARE EXCEPTION - E/M
• Allowable Services
• Low to Mid-level services 99211-99213
  99201-99203
• Medicare IPPE and Texas Medicaid well child
  visits
• Residents must have more than 6 months training.
• Supervising Teaching Physician
• is on site not providing other services.
• supervises no more than 4 residents
• Reviews key portions during or immediately after
  each visit and PERSONALLY documents his/her
  participation.

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