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CY2011 Billing Compliance New Resident Orientation Provided by: Mathew Spencer – Director of Billing Compliance 743-1634 or

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Presentation on theme: "CY2011 Billing Compliance New Resident Orientation Provided by: Mathew Spencer – Director of Billing Compliance 743-1634 or"— Presentation transcript:

1 CY2011 Billing Compliance New Resident Orientation Provided by: Mathew Spencer – Director of Billing Compliance 743-1634 or

2 OBJECTIVES I.Gain a basic awareness of TTUHSC Billing Compliance Program II.Gain a General understanding of Fraud, Waste & Abuse III.Gain a General understanding of EMR risks IV.Gain a General Understanding of Basic Coding Concepts V.Gain a Basic understanding of Teaching Physician Rules

3 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)

4 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


6 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.

7 Fraud, Waste & Abuse (FW&A) - 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.

8 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.

9 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.

10 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

11 Examples of FW&A 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)

12 Possible Consequences of FW&A 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.

13 Possible Consequences of FW&A Administrative Actions – License Suspension. – Exclusion from participation in federal health care programs. – Denial or Revocation of Medicare Enrollment. – Suspension of Provider payments.

14 Reporting FW&A at TTUHSC We have a duty to report identified FW&A. ◦ 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); This is the most anonymous method for making a

15 Electronic Health Record

16 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: s/EMR_Playbook_12_10.pdf s/EMR_Playbook_12_10.pdf

17 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

18 Things to be aware of – EHR Templates Exploding/Pre-Populated Elements Default to Negative Macros Medical Student Documentation – Can only use medical student’s ROS and PFSH for billing purposes. – Should be able to clearly delineate the medical students work.

19 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 (ICD–9) 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.

20 CPT Codes Five Digit Code = Service Provided Various Sections – Evaluation & Management (E/M) Services – Anesthesiology – Specialty Procedures – Radiology – Pathology – Medicine – Modifiers

21 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) – Patient’s Status (New v. Follow-up)

22 Why is Documentation Important? Continuity of Care – Various Providers Quality of Care – Utilization Review Billing – Fraud and Abuse Risks Liability – Malpractice

23 SOAP = E/M (Components) Documentation Comparison SOAP 1.Subjective 2.Objective 3.Assessment/Plan E/M Components 1.History History of Present Illness, Review of Systems, and Past Medical, Family & Social Hx. 2.Examination 3.Medical Decision Making Diagnosis, Data & Risk

24 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)

25 E/M: HISTORY ELEMENT - 1 Chief Complaint (CC) – This drives medical necessity (Reason the Patient Seeks Treatment) – A concise statement describing the patient’s 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.

26 E/M: HISTORY ELEMENT - 2 History of Present Illness (HPI) – A chronological description of the development of the patient’s current illness – Elements: – Documented by: Resident AND/OR Teaching Physician ONLY Location Quality Duration Timing Context Severity Associated Signs/Symptoms Modifying Factors

27 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

28 E/M: HISTORY ELEMENT - 4 Past Medical, Family & Social History (PFSH) Past Medical Hx: Patient’s past experiences with illness, operations, injuries & treatments. Family Hx: Review of medical events in patient’s family. Social Hx: Age appropriate review of past & current activities. – Documented by: Patient, ancillary Staff or Others.

29 FOUR HISTORY BILLING LEVELS LEVEL of HXHPIROSPFSH Problem Focused 1-3N/A Expanded Problem Focused 1-31N/A Detailed 4 or more2-91 Comprehensive 4 or more103

30 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

31 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.

32 FOUR EXAM LEVELS LEVEL OF EXAM 1995 (Organ/Body)1997 (Bullets) Problem Focused11-5 Expanded Problem Focused 2-76-11 Detailed2-712 from 2+ organ/body areas) Comprehensive Multi- System 8 + Organ Systems18 from 9 organ/body areas Comprehensive – Single Organ Not definedAll bullets in shaded boxes & 1 from unshaded boxes

33 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

34 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

35 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

36 E/M: LEVELS OF SERVICE Office Established Patient or Subsequent Inpatient Visit: – Document History and/or Exam AND Medical Decision Making

37 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 Resident’s History, his/her participation in the exam and management of patient’s care. – Resident cannot document T.P. presence or participation for E/M services

38 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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