2014
Compliance Training
Billing Compliance Office
Dermatology Staff Meeting
4/10/2014
BWH/BWPO Billing Compliance Office
801 Massachusetts Avenue, 5th Floor
Boston Mass 02118
Phone 617-582-0090 & 617-582-0095 (fax)
Efficiency, Growth, Financial Performance
Efficiency, Growth,
Financial Performance
Physician Billing Compliance
• Audit Process Overview
• Established Patient Definition
• Level 4 – Established
• Level 5 – Established
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Efficiency, Growth, Financial Performance
Audit Process Overview
• New Providers are added into Audit schedule as
soon as they have generated professional services.
• Providers are scheduled for follow-up audits based
on their score.
– Bi-Annual Reviews – score of 0-3
– Annual Reviews – score of 4-12
– Semi-Annual Reviews – score of 13-17
– Quarterly Reviews – score of 18 and over
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Efficiency, Growth, Financial Performance
Selection of Encounters
Encounters are randomly selected from billed services for
each provider based on DOS, Procedure Billed, and Payer
(Medicare/Medicaid is weighted heavier than the other
payers)
• 10 Services are selected for each audit
• DOS can go back 6 months depending on the above
criteria
• Medicare/Medicaid services will be 50% or higher (if
available)
• Professional and Technical services are both audited
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Efficiency, Growth, Financial Performance
Reporting Results
• After each audit is completed, the provider is notified by
an initial e-mail.
• If the provider passes the audit, the e-mail will contain
observations of the audit which can help decrease potential
errors in future audits and attachments of the cover letter
and a high level CPT-4 coding summary.
• A hard copy of these findings and a more detailed
explanation of the review is sent via interoffice mail.
• If a provider does not pass the audit, an e-mail requesting a
meeting is sent. The detailed report will be reviewed and
discussed at this meeting.
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Efficiency, Growth, Financial Performance
Post Audit
• The provider may request a review of any findings within
15 days of receipt of the audit report.
• If warranted, the findings will be revised and a corrected
report sent.
• The Compliance Department will initiate appropriate
refunding and rebilling of any services identified as
documented incorrectly.
• A provider can request a meeting at any time, even if a
meeting is not necessary from a scoring perspective.
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Efficiency, Growth, Financial Performance
Established Patient Definitions
Established patient has seen you, the physician or another
physician of the same specialty and group (within the past
three years)
 Regardless of problem
– New diagnosis/problem does not mean new patient
 Regardless of whether you personally have seen the patient
before
– New patient to you, does not necessarily mean new patient
 Based on billing Tax ID number
– Group Practice tax ID is a determining factor
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Efficiency, Growth, Financial Performance
Visit Level 4 – Established Patient
• Established Patient Visits require that 2 of the 3 key
components meet a given level in order to code at that level
• Level 4 visits require a Detailed History
– 4 or more HPI elements
– 2-9 Systems Reviewed
– 1 element in either Past, Family and Social Hx
• Level 4 requires a Detailed Exam
– Using the Skin Exam– this means 12 exam bullets in 2+
systems
• Level 4 = Moderate Risk MDM
Efficiency, Growth, Financial Performance
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Visit Level 5 – Established Patient
• Established Patient Visits require that 2 of the 3 key
components meet a given level in order to code at that level
• Level 5 visits require a Comprehensive History
– 4 or more HPI elements
– 10+ Systems Reviewed
– Past, Family and Social Hx (all 3)
• Level 5 requires a Comprehensive Exam
– Using the Skin Exam– this means perform all elements
identified by a bullet; document every element in each box
with a shaded border and at least one element in each box
with an unshaded border.
• Level 5 = High Risk MDM
Efficiency, Growth, Financial Performance
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Established Patient Visits (2 of 3)
Code &
Extent of
Work
History
Single Exam
Skin
MDM
99213
99214
99215
Expanded
Problem Focused
Detailed
Comprehensive
HPI = 1-3
ROS = 1
HPI = 4+
ROS = 2-9
PFSH = 1
HPI = 4+
ROS = 10+
PFSH = 2 of 3
Bullets =6
At least 6 Bullets
Bullets = 12
At least 12 bullets
Bullets = 25
2 in 9 systems
Dx/mgmt = 2
Data = 2
Risk = Low
Low
Dx/mgmt = 3
Data = 3
Risk = Mod
Moderate
Dx/mgmt = >4
Data = >4
Risk = High
High
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Efficiency, Growth, Financial Performance
Questions?
Thank You !
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Efficiency, Growth, Financial Performance