University Specialty
Clinics
Annual Compliance
Training 2014
Billing Compliance
In Practice

Billing Compliance Plan
Reviewed in orientation also on the website
 Formalizes expectation that employees will
report concerns
 Addresses protection against retaliation
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Code of Conduct
Signed at orientation
 An agreement to comply with the Billing
Compliance Plan
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Why have a compliance plan?
State Investigative Agencies
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Who’s
looking?
Dept. of Health & Human Services
Medicaid Fraud Control Unit
Federal Investigative Agencies
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Federal Bureau of Investigation
Office of Inspector General
Internal Revenue Service
Palmetto Government Benefits Administrators
Please Contact Us With
Compliance Concerns
New information from specialty society that
will change how something is billed
 Uneasiness with the way services are being
billed
 Advice regarding particular situations prior to
billing
 Hearing information that is contrary to your
current understanding

Things to Remember About
New Faculty


Services provided by a new faculty member
cannot be billed until credentialing is
completed
The co-signature of a current faculty member
on a service provided by a new faculty
member does NOT create a billable service
History of the False Claims
Act
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Originally enacted 1863 under President Lincoln
Targeted unscrupulous defense contractors billing
for defective goods
Recognized that citizens might have information
that government did not
Allows citizens to sue on behalf of the government
and share in the rewards (Qui tam)
Protects these whistleblowers from retaliation
Amended 1986. Expanded use in healthcare
fraud
How does the False Claims
Act work in healthcare?
Must have specific knowledge that the
defendant has knowingly submitted (or
caused to be submitted) false claims to the
United States
 Must file an official complaint and turn over all
evidence
 Must be first to file
 Department of Justice will decide whether to
become involved based on scope, strength of
evidence, $$

New on the Horizon for
2014
New Government Guidelines
for Clinical Trials
Effective January 1, 2014, Medicare policy
updates and Affordable Care Act brought
major changes to billing compliance for
clinical trials
 Under these laws, health plans cannot:

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Deny a person the right to take part in a clinical trial
Limit or deny routine patient costs for items or services
connected with the clinical trial
Discriminate against a person on the basis of their participation
in a study
Clinical Trials

According to the new laws, insurance companies do not
need to pay for:
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Treatments, devices, or services that are usually covered by the sponsor
Items and services only needed for data collection and analysis
Any services that are clearly not in line with the established standards of
care for a certain diagnosis
To ensure compliance with regulations, communication
regarding regulatory statues and study participants needs
to flow through:
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Principle investigator and faculty participants
Research administration and study staff
Nursing staff and nurse auditors
Billing and coding personnel
Patient registration personnel
What is the impact?

Transmittal 540 (effective 9/8/14)

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Authorizes the MAC’s (Palmetto GBA) and ZPIC (fraud
investigators) the discretion to deny claims that are “related”
before or after the claim in question has been processed.
When Part A claim is in question, Part B claim may be denied
or recouped.
CMS example:
• The MAC performs post-payment review of the admitting physician’s
Part B services. For services related to inpatient admissions that are
denied because they are not appropriate for Part A payment (i.e.,
services could have been provide as outpatient or observation), the
MAC will review the hospital record. For services where the patient’s
history and physical, physician progress notes or other hospital
documentation does not support the medical necessity for performing
the procedure/service, post-payment recoupment will occur for the
performing physician’s Part B service.
New Proposals by CMS
Established a policy to allow payment for
complex chronic care management to
primary care practitioners
 Is proposing to transform all 10- and 90-day
global codes to 0-day global codes in CY
2017
 To expand telehealth services to include
annual wellness visits, psychoanalysis,
psychotherapy, and prolonged E/M services

Consultations
What Is Expected for
Consultation Documentation?
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Request:
 Inpatient - Request and response in common record
 Office - Records must clearly indicate the request for
consultation vs new patient service
 Strongly recommend getting hardcopy request
Render:
 Levels of service- same requirements as new patient
office visits regardless of location
Respond:
 Must have a process to ensure that a written response
is sent
What Documentation is required
for a Level Five Consultation?
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Comprehensive History
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Four descriptors of the History of Present Illness
Remember to include an element of Past, Family
and Social history or a reason why it cannot be
obtained
A ten system review of systems

Examination of Eight Organ Systems /
Comprehensive specialty specific / 18 bullets from
9 organ systems
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Medical Decision Making that includes two of the
three : Diagnosis, Data, Risk at the highest level
I spent 45 minutes
explaining ……to the
patient….
What Happens When I Spend
Most of the Visit in Counseling?
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Medically Appropriate Counseling is a discussion of :
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Prognosis
Test results
Educating patient and family about treatment or
disease
Risks and benefits of management and/or follow up
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When more than 50% of a face to face visit is spent
in medically appropriate counseling, the level of
service can be chosen based on the total face to
face time
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In the hospital setting, total time includes bedside
time and time on the patient’s unit or floor
What Codes Do I Use?
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The same CPT codes are used.
A 99214 could be chosen if the visit was
documented as:
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An extended exam of two to seven organ systems for
a new problem assessed as a moderate risk to the
patient
OR
A 25 minute face to face visit by the attending with 15
minutes spent in medically appropriate counseling with
a description of the content of the discussion
What Has to be Documented?
If medically appropriate counseling dominated the
visit, document :
1. Total time face to face with the patient
2. Counseling Time > 50%
3. Content of the discussion
Remember :
Only the billing provider’s face to face time can be
considered. Staff and Resident time cannot. (In the hospital
setting, total time includes bedside time and time on the patient’s unit or floor)
Total Times for Billing Based
on Counseling Time
99205 (Office visit)
99245 (Office consult)
99255 (Inpatient consult)
60 minutes
80 minutes
110 minutes
Established patient visits
99215
99214
40 minutes
25 minutes
Reminders
Things to Remember About an
Electronic Medical Record

A secure log in, password and electronic
signature identifies the provider
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Everyone, including students, must log in with
their own password before documenting
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Templates can be helpful prompts but be
mindful of the quality of the clinical record

Copy/paste and cloned note increase the risk
of error and leads to questions of authenticity in
the medical record
Things to Remember About
Reporting Diagnosis Codes
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Goal: Payment on the first submission
Diagnosis codes explain why this particular service
was provided that day
Listing diagnosis codes that were not specifically
addressed on a visit misrepresents the service
Documentation must support choice
Insurers have CPT/diagnosis combinations that will
not be paid
What Do I Document for
Tests?
We cannot defend the medical necessity for
a test that is never shown to be used in
treating the patient
 The reason for all tests/procedures/x-rays
must be documented in the clinical record
 You must then address all findings/results in
the clinical record
 A process must be in place for insuring that
test results are acknowledged
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Teaching Documentation
Medicare Teaching
Modifiers
Medicare services provided with a resident
must be filed with a GC or GE modifier
 GC modifier tells Medicare
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That a resident was involved in the service
 That the attending examined the patient as well
 That there may be two notes to document the
service

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GE modifier tells Medicare that we are using
the Primary Care Exception
Outpatient Teaching
Requirements
Teaching Physician Requirements
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Medicare
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The Teaching Physician be
present in the office suite and
personally evaluate the patient
during the visit
The Teaching Physician must:
• Be physically present with
the resident for the key
portions of the E/M service
OR
• Repeat the key portions of
the service independently
Documentation Requirements

Medicare

The Teaching Physician must:
• Link their note to the
resident’s signed note
• Document that they have
examined the patient
• Document their teaching
interaction with the resident
• Document their agreement
and/or changes to the
residents assessment and
plan of care
Both the resident and the
Teaching Physician must sign
their note in the medical
record
GC Modifier is required to indicate the residents
involvement

Office and Outpatient
Medicare Using the Primary Care
Exception
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You do not have to see the patient
You must be present in the office suite
You must personally document your presence
and participation
You must link your note to the resident’s note in
order to use the resident’s documentation to
support the level of service
 These
Medicare claims will need a GE modifier
Outpatient Teaching
Requirements
Teaching Physician Requirements

All Payers Except
Medicare

The Teaching Physician
must be present in the
office suite and
immediately available to
direct or provide patient
services
Documentation Requirements

All Payers Except
Medicare
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The medical record must
include a statement
referencing the Teaching
Physician’s presence and
involvement in the service
Both the resident and the
Teaching Physician must
sign the note in the medical
record
No Modifier is required for resident involvement
Inpatient Teaching
Documentation
Inpatient Teaching Documentation
One Standard- All Payers
 Note
the Date of service in the documentation
 Reference specific resident’s note if used to
choose the level of service
 May link to Resident’s Admission H&P if patient is
seen within 24 hours
 May link to resident notes from the same
calendar date for follow-up visits and
consultations
 Medicare
claims will need a GC modifier
Examples of subsequent
hospital visits

99231
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99231
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99233
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99232
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99233
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99232
1. One or two established problems that are
stable. Chest x-ray ordered.
2. One established problem that is worsening.
Pulmonary function test ordered.
3. Two established problems worsening and the
decision not to resuscitate.
4. Three established problems that are stable or
one new problem. IV antibiotics
5. A new problem requiring additional work-up
and posing a threat to life or a bodily function
6. Two established problems, one stable and one
worsening. Change in antibiotic.
These examples assume that the history an exam meets the appropriate level of service
Teaching Documentation
for Procedures
Were you present and is that
documented?
Documenting Procedures
When Residents Are Involved
Procedures are separately billable only if
documented in a separately identifiable note
 This includes minor office procedures
 Attending presence during the procedure
must be documented in that separately
identifiable note
 See procedure presence guidelines on the
Compliance website
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What Does that Documentation
Look Like?

Attending presence and participation can be
documented by the resident or the attending

Just listing the attending’s name does not meet
the billing requirement for any payer
Attending: Dr. X
Not Billable
 Attending: Dr. X was present for the central
line placement.
Billable
If your presence has been clearly documented
by the resident, only a co-signature is required
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Things to Remember
about Teaching Notes in
Electronic Medical Records
Medicare
 A canned statement (“macro”) can be used as a
base - if additional clinical detail is present
 Refer to Medicare Teaching brochure on the
Compliance website
Signatures are automatically timed and dated
 If the attending note is completed before the
resident’s note is signed - cannot link to
incomplete note
All Other Payers
 Be sure that the statement of presence clearly
notes “present at the time of the visit”
Things to Remember about
Students and Billing
 The
resident teaching supervision and
documentation rules do not apply to any other
kind of student.
 Students
are not licensed providers of service.
They are not recognized by insurance plans
 Procedures
done by students are not billable
What a Medical Student
Can Do

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A student can act as a scribe:
 Records information at the direction of the
attending
 Must Note “Acting as scribe for Dr. ____”
 Both signatures are required
A student can independently record a PFSH and
ROS.
 The attending references the student’s note,
documents review and confirmation of that
information, writes own HPI, exam and plan.
Billing Compliance
15 Medical Park, Suite 300
256-0977 (Fax)
If you have question, please contact the Compliance Department.
Tara Farmer, MA, LPC/I, CPC
545-5022 – Office
tara.farmer@uscmed.sc.edu
Billing Compliance Website
http://billingcompliance.med.sc.edu