Coding and Compliance
Review for Provider Reappointments
Course Objectives
The purpose of this course and its follow-up
test is to provide physicians and other
clinicians, who are being re-appointed by
UNC Hospitals, with important information on
three issues…
Course Objectives
1.
Why coding and compliance is important to you
and your practice
2.
Keys to correctly coding hospital and office visits
- Evaluation and Management (E&M) Services
3.
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
1. Why coding and compliance
is important to you and your
practice
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 Faculty Physician practices as well as the
quality of the medical record documentation.
Why Compliance
 Good documentation and billing practices make for
good patient care
 Office of Inspector General (OIG), Health & Human
Services
 Routine and probe audits by CMS contractors and
third parties
UNC SOM Compliance
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 (TP) 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 may not bill.
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 in the note did not
support the level of service billed
2. Keys to correctly coding hospital
and office visits - Evaluation and
Management (E&M) Services
Choose the Outpatient Category
 Outpatient E&M Categories
 Consultation
 New
 Established
Use of Consultation Codes
 Outpatient consult codes: 99241-99245, inpatient consult
codes 99251-99255
 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
Use of Consultation Codes
 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. The shared medical record is
sufficient communication for providers in the UNC system
 Medicare has not recognized consultation codes since 2010, but Epic
translates the consultation codes to the appropriate E&M category and
level for Medicare.
 Providers retain Relative Value Units (RVUs) associated with the consult for productivity
measures.
 Please continue to bill consultation codes for all payers when provided and documented.
Documenting Consultations
Documentation of a consultation request must be
clearly stated in the note:
WRONG: Mr. Patient was 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 include the referring provider in the in the
referring provider field. This will help in communicating a
letter to the provider that requested a consult. A letter can be
sent to the requesting provider through the communications
tab in Epic.
New Patient
 New Patient CPT codes: 99201-99205
 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
Established Patient
 Established Patient CPT codes: 99212-99215
 Has received an E&M service from the division
within the past three years including inpatient,
emergency room or inpatient or outpatient
consultations
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
 Review of systems
 Past family and social history
Click these links for more information
 Physical examination
Documenting History
History example
1995 Physical Exam
1997 Single Organ Exams
 Medical decision Making
 Diagnosis and management options
 Amount and complexity of data reviewed
 Overall risk
Documenting MDM
Risk Table
Visit Levels
 Billing at a higher level than actually provided and/or
documented is one of the two chief issues contributing to
CMS fraud allegation settlements
 There is a laminated, pocket-sized physician’s coding card
that may be a valuable guide to correct coding. To request
a copy of this card please call 919-843-8638
 Questions on correct coding and compliance issues should
be directed to the Compliance Auditors at 919-843-8638
 Click on this link for documentation requirements at various
E&M levels of service
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 to 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
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
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 as 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
Modifier 25
 For an established patient, if the E&M service
results 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
 The modifier 25 should be appended in the
modifier field on the level of service in Epic.
Modifier 59
 Modifier 59 (distinct procedural service) is being split into 4 new
modifiers accepted by Medicare effective 1/1/2015. The new
modifiers are:
 -XE: Separate encounter (services that are separate because
they take place during separate encounters)
 -XS: Separate structure (Performed on different anatomic
organs, structures or sites)
 -XP: Separate practitioner (services are distinct because
different practitioners perform them)
 -XU: Unusual non-overlapping services (services that are distinct
because they do not overlap the usual components of the main
service)
 Beginning with date of service 1/1/2015, if you assign a
-59 modifier, also assign the corresponding “X” modifier.
The system will make sure that the correct modifier gets to the
correct insurance carrier.
3. Teaching physician (TP)
rules—supervision of residents
and billing Medicare and
Medicaid
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, or a
computer statement initiated by the TP
Medical Student Involvement in E&M Services and
Documentation Requirements
 The documentation of an E/M service by a student that may be
referred to by the teaching physician is limited to documentation
related to the review of systems and/or past family/social history.
 Any contribution and participation of a medical student to the
performance of a billable service (other than the review of systems
and/or past family/social history which are not separately billable)
must be performed in the physical presence of a teaching physician
or a resident.
 The teaching physician or resident must verify and redocument the
history of present illness, perform and redocument the physical
exam and medical decision making.
 These regulations are found: http://www.cms.gov/Regulations-
and-Guidance/Guidance/Transmittals/downloads/R2303CP.pdf
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/Internal Medicine
 General Pediatrics
 Women’s Primary Health
 Med Geriatrics
 For Add’l Information: Primary Care Exception
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
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
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: a
co-signature only is 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
psychotherapy code is used
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
echocardiogram
Medicare Supervision Guidelines for Critical Care
Only the teaching physician time may be counted toward critical care time. A
combination of the TPs documentation and the residents documenting may
support the critical care service.
The teaching physician medical record documentation must provide the following
information:
 time the teaching physician spent providing critical care,
 that the patient was critically ill during the time the teaching physician saw
the patient,
 what made the patient critically ill; and
 the nature of the treatment and management provided by the teaching
physician. The medical review criteria are the same for the teaching
physician as well as for all physicians.
This attestation will meet the TP requirements for billing to Medicare.
“Patient is critical with ______. I spent ___ minutes while the patient was in this
condition providing ______. I reviewed the residents documentation and I
agree with the residents assessment and plan of care.”
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.
Where To Get Help
 www.med.unc.edu/compliance/
 UNC FP Professional Coders—code inpatient services
and some outpatient procedures. (See your division
manager for your coder’s name.)
 School of Medicine Compliance Office 919-843-8638
 Heather Scott, CPC, Compliance Officer
 Dana Sheffield, CPC, Compliance Review Analyst
 Tracy Rentner, FNP, CPC, Compliance Consultant
 Confidential Help Line 800-362-2921
 AMA CPT Manual