Review for Provider Reappointments. Coding and Compliance. Course Objectives. The purpose of this course and its follow-on test is to provide physicians and other clinicians, who are being re-credentialed by UNC Hospitals, with important information on three issues…. Course Objectives.
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The purpose of this course and its follow-on test is to provide physicians and other clinicians, who are being re-credentialed by UNC Hospitals, with important information on three issues…
Providing good care while billing accurately and confidently requires:
Understanding and applying coding and compliance conventions can improve the level of reimbursement for UNC P&A practices as well as the quality of the medical record documentation.
Good documentation and billing practices make for good patient care
Recovery Audit Contractors (RACS)—Medicare and Medicaid
Office of Inspector General (OIG), Health & Human Services
Routine error rate testing and auditing programs
Two problems have caused a majority of refunds and penalties:
Documentation of a consultation request must be clearly stated in the note:
WRONG: Mr. Patient 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 document that a copy of the note (cc: Dr. Jones) is to be sent to the requesting physician.
Consults and new patient visits must include all three of the following components – established patient visits must include any two of the three:
1997 Single Organ Exams
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The preceding six and similar statements don’t make it possible to determine whether the TP was present, evaluated the patient, and/or had any involvement with the plan of care.
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.
Only physicians can make a decision to admit as an inpatient, place in observation status or extended recovery.
Only physicians can change the patient status. Clinical Care Management (CCM) staff assist in determining the appropriate status.
Short stays have been a recent focus of government auditors and large refunds have been required due to documentation of medical necessity for an inpatient admission
EXR will always be red, as it is an unbillable status.
OBS Appears green until 12 hrs
Appears yellow from 13-20 hrs
Appears red from 21 hours onward
Think: when the field is red, we’re in the red
Problems with the “Admit” word
Avoid an order contradiction in notes
Delay in H&P or admit note with intent
Delay in Billing Status Order