CY2011 Billing Compliance New Resident Orientation Provided by: Mathew Spencer – Director of...
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![Page 1: CY2011 Billing Compliance New Resident Orientation Provided by: Mathew Spencer – Director of Billing Compliance 743-1634 or mathew.spencer@ttuhsc.edumathew.spencer@ttuhsc.edu.](https://reader030.fdocuments.net/reader030/viewer/2022032517/56649ca65503460f94967e9f/html5/thumbnails/1.jpg)
CY2011 Billing Compliance New Resident Orientation
Provided by:Mathew Spencer – Director of Billing Compliance
743-1634 or [email protected]
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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 risksIV. Gain a General Understanding of Basic Coding
ConceptsV. 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 COMPLIANCE
Fraud, 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 (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.
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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 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)
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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.
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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.
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Reporting FW&A at TTUHSCWe 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 52.04Reporting 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/billingcompliance/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 student’s ROS and PFSH for
billing purposes.– Should be able to clearly delineate the medical
students work.
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CODING BASICSDocument 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.
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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)– Patient’s 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
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
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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 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.
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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
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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
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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.
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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 LEVELSLEVEL 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 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
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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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