CY2011 Billing Compliance New Resident Orientation

1. CY2011 Billing Compliance New Resident Orientation Provided by: Mathew Spencer – Director of Billing Compliance 743-1634 or mathew.spencer@ttuhsc.edu

2. OBJECTIVES • Gain a basic awareness of TTUHSC Billing Compliance Program • Gain a General understanding of Fraud, Waste & Abuse • Gain a General understanding of EMR risks • Gain a General Understanding of Basic Coding Concepts • Gain a Basic understanding of Teaching Physician Rules

3. 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: 806-743-3949 • 13 years experience in healthcare law and academic healthcare compliance • Certified Professional Coder (CPC)

4. 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

5. TTUHSC BILLING COMPLIANCEFraud, Waste & Abuse

6. 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.

7. Fraud, Waste & Abuse (FW&A) - Defined • FRAUD: Intentional act of deception, misrepre-sentation, 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.

8. 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.

9. 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.

10. 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

11. 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)

12. 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.

13. 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.

14. 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.

15. Electronic Health Record

16. 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/documents/EMR_Playbook_12_10.pdf

17. 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

18. 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.

19. 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.

20. CPT Codes • Five Digit Code = Service Provided • Various Sections • Evaluation & Management (E/M) Services • Anesthesiology • Specialty Procedures • Radiology • Pathology • Medicine • Modifiers

21. 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)

22. Why is Documentation Important? • Continuity of Care • Various Providers • Quality of Care • Utilization Review • Billing • Fraud and Abuse Risks • Liability • Malpractice

23. SOAP = E/M (Components)Documentation Comparison SOAP • Subjective • Objective • Assessment/Plan E/M Components • History • History of Present Illness, Review of Systems, and Past Medical, Family & Social Hx. • Examination • Medical Decision Making • Diagnosis, Data & Risk

24. E/M History: 4 Elements • Chief Complaint • History of Present Illness (HPI) • Review of System (ROS) • Past Medical, Family & Social History (PFSH)

25. 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.

26. E/M: HISTORY ELEMENT - 2 • History of Present Illness (HPI) • A chronological description of the development of the patient’s current illness • Elements: • Documented by: Resident AND/OR Teaching Physician ONLY

27. E/M: HISTORY ELEMENT - 3 • Review of Systems (ROS) • An inventory of body systems obtained through a series of questions • Documented by: Patient, ancillary Staff or Others.

28. 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.

29. FOUR HISTORY BILLING LEVELS

30. 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

31. 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.

32. FOUR EXAM LEVELS

33. 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

34. 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

35. 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

36. E/M: LEVELS OF SERVICE • Office Established Patient or Subsequent Inpatient Visit: • Document • History and/or Exam AND • Medical Decision Making

37. 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

38. 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.