1. Review for Provider Reappointments
Coding and Compliance
Review for Provider Reappointments

2. 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…

3. Course Objectives
Why coding and compliance is important to you and your practice
Keys to correctly coding hospital and office visits - Evaluation and Management (E&M) 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

4. Why coding and compliance is important to you and your practice

5. 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 P&A practices as well as the quality of the medical record documentation.

6. 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
Documentation is an integral part of patient care, aiding in communicating with other providers and in research as well as recording your management and the patient’s progress. Good documentation practices will also protect you from costly recoupments by government or other payers. The Centers for Medicare and Medicaid services have several big programs for ferreting out error, fraud or abuse. Medicare contractors for Part A and Part B are required to conduct error rate testing and auditing. Third parties are contracted to find problems and are paid a percentage of the over or underpayments they find. The OIG for the Department of Health and Human Services has its own audit and recovery agenda. Other inquiries are the result of patient or health care employee complaints. Knowing the standards for billing and documenting services will give you confidence to bill appropriately and fairly. 6

7. 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.

8. 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 (E&M) service billed. The billed level of service may have been provided, but it was not documented.

9. Keys to correctly coding hospital and office visits - Evaluation and Management (E&M) Services

10. Choose the Outpatient Category
Outpatient E&M Categories
Consultation
New
Established

11. Use of Consultation Codes
Use when expert opinion or advice is requested by an appropriate source involved in that patient’s 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 physician’s note and the consultant’s opinion communicated by written report to the requesting physician

12. 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.

13. New Patient
Has not received any professional evaluation and management (E&M) 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 E&M visit charge.

14. Established Patient
Has received an E&M service from the division within the past three years including inpatient, emergency room or inpatient or outpatient consultations

15. 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 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

16. 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 physician’s coding card is a valuable guide to correct coding. To request a copy of this card please call
Questions on correct coding and compliance issues should be directed to either of the Compliance Auditors at
Click on this link for documentation requirements at various E&M levels of service.

17. 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.

18. Visit levels – based on time (con’t)
The note must include a description of the counseling and treatment planning.
The physician’s 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.

19. Modifier 25
Append a modifier 25 to an E&M code if a significant, separately identifiable E&M service is performed by the same physician on the same day of a procedure or other service.
The patient’s condition must require E&M services above and beyond what would normally be performed in the provision of the procedure.
The necessity for the E&M service may be prompted by the same diagnosis as the procedure.
A new patient E&M service is considered separate from the same day surgery or procedure—no 25 modifier needed.

20. Modifier 25
For an established patient, if the E&M 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 E&M service beyond what is considered normal protocol for the procedure, the 25 modifier is appropriate.
To determine the correct level of E&M service to submit, identify services unrelated to the procedure and use as E&M elements.
Clearly mark the encounter form to indicate that a 25 modifier should be attached to the E&M.

21. 3. Teaching physician (TP) rules—supervision of residents and billing Medicare and Medicaid

22. Medicare TP Attestation Requirement
The 11/22/02 revisions to the regulations provide that, for E&M 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.

23. Medicare’s 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 don’t make it possible to determine whether the TP was present, evaluated the patient, and/or had any involvement with the plan of care.

24. 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
Women’s Primary Health

25. 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 patient’s condition with the resident.
Only E&M codes , may be billed
TP may see and evaluate a patient in a primary care exception clinic and bill a higher level of service

26. 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 resident’s 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

27. Medicare Supervision Guidelines for Procedures Performed with Residents
Minor procedures of <5 minutes
Must be present the entire time
Endoscopies (other than surgical operations)
TP must be present for entire viewing including insertion and removal

28. 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

29. 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
E&M 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

30. 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.

31. 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.

32. Summing Up Billing Status
Planned vs unplanned
Medical necessity required?
Billable?
EXR
(Extended Recovery)
Planned No
OBS
(Observation)
Unplanned
Yes
Some
INP
(Inpatient)
Either

33. You can identify the outpatients on your census
Billing Status
OBS (16)
OBS (28)
EXR will always be red, as it is an unbillable status.
OBS Appears green until 12 hrs
Appears yellow from hrs
Appears red from 21 hours onward
Think: when the field is red, we’re in the red
EXR (6)
EXR will always be red, as it is an unbillable status.
OBS Appears green until 12 hrs
Appears yellow from hrs
Appears red from 21 hours onward
Think: when the field is red, we’re in the red

34. 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”

35. The Importance of the H&P
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 H&P or admit note with intent
Delay in Billing Status Order
Un-billable days = =

36. School of Medicine Compliance Office 843-8638
Where To Get Help
UNC P&A Professional Charges (code inpatient services and some outpatient procedures)
School of Medicine Compliance Office
Heather Scott, CPC, Compliance Officer
Keishonna Carter, CPC, Compliance Review Analyst
Nirmal Gulati, CPC, Compliance Auditor
Lateefah Ruff, Office Assistant
Confidential Help Line
AMA CPT Manual