CY2011 Billing Compliance
New Resident Orientation
Provided by:
Mathew Spencer – Director of Billing Compliance
743-1634 or mathew.spencer@ttuhsc.edu
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
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: 806-7433949
• 13 years experience in healthcare law and academic
healthcare compliance
• Certified Professional Coder (CPC)
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
TTUHSC BILLING COMPLIANCE
Fraud, Waste & Abuse
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.
Fraud, Waste & Abuse (FW&A) - Defined
• FRAUD: Intentional act of deception, misrepresentation, 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.
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.
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.
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
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)
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.
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.
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); www.ethicspoint.com This is the
most anonymous method for making a report.
Electronic Health Record
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/document
s/EMR_Playbook_12_10.pdf
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
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.
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.
CPT Codes
• Five Digit Code = Service Provided
• Various Sections
– Evaluation & Management (E/M) Services
– Anesthesiology
– Specialty Procedures
– Radiology
– Pathology
– Medicine
– Modifiers
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)
Why is Documentation Important?
• Continuity of Care
– Various Providers
• Quality of Care
– Utilization Review
• Billing
– Fraud and Abuse Risks
• Liability
– Malpractice
SOAP = E/M (Components)
Documentation Comparison
SOAP
1. Subjective
E/M Components
1. History
•
History of Present Illness,
Review of Systems, and Past
Medical, Family & Social Hx.
2. Objective
2. Examination
3. Assessment/Plan
3. Medical Decision Making
•
Diagnosis, Data & Risk
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)
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.
E/M: HISTORY ELEMENT - 2
• History of Present Illness (HPI)
– A chronological description of the development of the
patient’s current illness
– Elements:
• Location
• Quality
• Duration
• Timing
• Context
• Severity
• Associated Signs/Symptoms
• Modifying Factors
– Documented by: Resident AND/OR Teaching Physician
ONLY
E/M: HISTORY ELEMENT - 3
• Review of Systems (ROS)
– An inventory of body systems obtained through a
series of questions
• Constitutional
• Respiratory
• Eyes
• Endocrine
• GI
• Cardiovascular • Neurological
• ENT
• Musculoskeletal • GU
• Allergies/Imm. • Psychiatric
• Skin
• Hematologic/Lymphatic
– Documented by: Patient, ancillary Staff or Others.
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.
FOUR HISTORY BILLING LEVELS
LEVEL of HX
HPI
ROS
PFSH
Problem Focused
1-3
N/A
N/A
Expanded Problem
Focused
Detailed
1-3
1
N/A
4 or more
2-9
1
Comprehensive
4 or more
10
3
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
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.
FOUR EXAM LEVELS
1995 (Organ/Body)
1997 (Bullets)
1
1-5
Expanded Problem
Focused
2-7
6-11
Detailed
2-7
12 from 2+ organ/body
areas)
8 + Organ Systems
18 from 9 organ/body
areas
Not defined
All bullets in shaded
boxes & 1 from
unshaded boxes
LEVEL OF EXAM
Problem Focused
Comprehensive MultiSystem
Comprehensive – Single
Organ
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
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
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
E/M: LEVELS OF SERVICE
• Office Established Patient or Subsequent
Inpatient Visit:
– Document
• History and/or Exam
AND
• Medical Decision Making
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
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.