documentation, coding and reimbursement basics presented by the office of reimbursement compliance...
TRANSCRIPT
Documentation, Coding and Reimbursement Basics
Presented by the Office of Reimbursement Compliance
Gretchen L. Segado, MS, CPCDirector of Reimbursement Compliance
NYU School of Medicine316 East 30th StreetNew York, NY 10016
(212) 263-2446(212) 263-6645 fax
NYU School of MedicineCoding and Reimbursement Seminar Series
Agenda for Today
Fraud & Abuse-why do I need to pay attention?
Documentation Guidelines Reimbursement Principles Establishing Medical Necessity CPT & ICD-9 Coding Special Rules for Teaching Physicians
Published On August 31, 2001, Philadelphia Inquirer, The (PA)
Surgeon To Pay Back Medicare Over Billing
A nationally recognized Philadelphia orthopedic surgeon agreed yesterday to reimburse the government almost $2 million to settle claims that he billed Medicare for work done by surgical residents and surgical fellows.
In announcing the $1.89 million settlement with Robert Booth Jr., both the surgeon and the U.S. Attorney's Office said the government investigation had nothing to do with the quality of knee and hip replacements and other surgeries performed.
At issue were billings for surgeries performed between January 1, 1995 and June 30, 1997, at Pennsylvania Hospital. The government claimed that Booth had billed Medicare for treatment handled by junior physicians he was training.
A family practice in West Virginia was audited earlier this month and ordered to pay back almost $6,000 to its carrier for improper billing of school sports physicals back in 2000, a spokesman for the practice said in a statement to a local television reporter. The practice allegedly used the wrong codes and received more reimbursement than it was allowed, a state health department worker confirmed.
Office Audited For Sports Billing Fumble
March 5, 2004 PRESS RELEASEPHYSICIAN PAYS $203,422 TO SETTLE CIVIL FALSE CLAIMS ACT CHARGES ARISING OUT OF MEDICARE AND MEDICAID OVERBILLINGS
… Based on its investigation, the United States alleged that DR. THACKER had overbilled Medicare and Medicaid, during the period January 1, 1997 to December 31, 2002, by charging for "consultation" services that provided higher reimbursement, when she was actually performing regular patient visits. According to the United States, DR. THACKER had done so approximately 1,800 times during this period.
April 2004
In New York, three subjects were sentenced for their roles in a scheme to defraud the Government and private insurers. A podiatrist was sentenced for submitting claims for services that were either upcoded, not rendered, or were medically unnecessary. Also sentenced were two billing clerks who at the direction of the office manager, submitted claims that they knew were fraudulent.
“Let the message be very, very clear. We have made health care fraud a priority and we will pursue it as vigorously as we can.”
Janet RenoAttorney General of the United States
What Is Healthcare Fraud And Abuse?
Fraud-Intentional deception or misrepresentation that the individual knows to be false or does not believe to be true, and makes, knowing that the deception could result in unauthorized benefit to himself or some other person.
Examples: Incorrect reporting of diagnosis or procedures to maximize payments
What Is Healthcare Fraud And Abuse?
Abuse- an incident or action that is inconsistent with accepted sound medical, business or fiscal practice.
• Abuse may directly or indirectly result in unnecessary costs, improper payment, payment for services that fail to meet professionally recognized standards of care, or that are medically unnecessary.
• Examples are billing for services at a higher level than what is supported by documentation, improper billing practices and billing a secondary payer as primary.
Government’s Recent Focus On Fraud
• General failure to achieve health care reform and reduce costs through legislation
• Medicare Trust Fund is going bankrupt as Medicare expenditures continue to rise
• Politically popular• Aging population
Susceptibility
Susceptibility to fraud and abuse varies by the method of reimbursement• Fee for Service (FFS) System - Abuse is from
the provision of excessive services
• Capitated Contract System - Abuse is from the provision of too few services provided per patient
Major Federal Fraud & Abuse Laws
• Medicare Anti-Kickback Statute• United States Criminal Code• Federal False Claims Act• Federal Self-Referral Statute (Stark)• HIPAA• Balanced Budget Act (BBA)• Over 50 statutes used to prosecute
Hypothetical
Dr. I is an attending in the Dept. of Internal Medicine. One of her patients is a 57 year old chronic alcoholic with multiple medical problems. This patient has been non-compliant with medications and has been hospitalized 3 times within the past year. When asked by Dr. I why she was not taking medications, she said she can’t afford them. She then asked Dr. I to write all of her prescriptions in her brother’s name, claiming that he has medical insurance that will pay for them. Hoping to avoid further hospitalizations, Dr. I complies with this request. Does this practice place Dr. I or her patient at any risk?
Federal Civil False Claims Act
Elements of a “False Claim” Offense
• submitting or causing to be submitted a claim for payment to the government or using a false record to get a claim approved
• which claim is false and fraudulent
• wherein defendant acted “knowingly”
Federal Civil False Claims Act (Cont.)
Penalties
• Triple the damage the government sustains plus $5,000-$13,000 penalty for each “false claim”
• Penalties can be so enormous that defendants often choose to settle rather than risk a negative outcome in litigation
Federal Civil False Claims Act (Cont.)
Most Frequent Applications of the False Claims Statute• billing for services not rendered• false cost reports• upcoding• double billing• provision of unnecessary care
(certifying that unneeded services were “medically necessary”)
Federal Civil False Claims Act (Cont.)
Advantages for Government in Prosecuting under this Statute as opposed to Criminal Prosecution• “intent” element easier to prove
• burden of proof less than in criminal prosecution (preponderance of evidence)
• arguably covers broader types of “false” claims
• availability of qui tam prosecutions
Federal Civil False Claims Act (Cont.)
Qui Tam Actions• qui tam cases can be brought
by any citizen on behalf of himself and the government
• qui tam case brought by relator's filing a complaint under seal with the US Attorney
• complaint must be based upon an allegation of a “false claim”
Savvy Seniors on Fraud PatrolAs a result of training senior volunteers to detect and report fraud, the Administration on Aging (AoA) has recouped almost $3.7 million since the inception of the Senior Medicare Patrol Project in 1997. The AoA has trained nearly 35,000 senior volunteers to watch for offers of free groceries, free testing, or free screening in exchange for their Medicare business, numbers, or statements. The volunteers in turn have held over 200,000 educational sessions on fraud, waste, and abuse, and have trained over one million Medicare beneficiaries. Out of a total of 23,142 complaints reported by Medicare beneficiaries in the first five years of the program, the government took action on 2,312 complaints, and recovered $3,679,644 in Medicare funds, and more than $77 million to other payors.
(Medicare Compliance Alert, 4/14/03)
Still don’t think you have to worry?
Check out these web sites:
http://www.quitamonline.com
www.quitam.com
http://www.quackwatch.org/index.html
Hypothetical
Dr. X has a very busy medical practice. When blood tests are medically indicated and documented in the patients’ charts, he refers his patients to Vampire Laboratories for testing. Vampire is owned by Dr. X’s brother.
Is this a problem?
The Federal Self-Referral Statute (the “Stark Law”)
• a physician may not make a referral
• to an entity for the provision of a designated health service for which Medicare payment may be made, and the entity may not present a claim for such referral
• if the physician or an immediate family member has a financial relationship with such entity
• unless the referral or the financial relationship is excepted under the statute.
Designated Health Services Under Stark
clinical laboratory services
physical therapy services occupational therapy
services radiology services radiation therapy
services and supplies durable medical
equipment and supplies
parental and enteral nutrients, equipment and supplies
prosthetics, orthotics, and prosthetic devices and supplies
home health services outpatient prescription
drugs inpatient and outpatient
hospital services
The Stark Law (Cont.)
Penalties• Civil monetary penalties of up to $15,000 for each
service rendered in violation of Stark II if the payment is not refunded on a timely basis
• An assessment of not more than twice the amount claimed for each service that was the basis for the civil monetary penalty
• Exclusion from Medicare and Medicaid
• The total refund of Medicare/Medicaid dollars
Medicare Anti-Kickback Statute
• Key Elements
• “whoever”
• “knowingly and willfully”
• “offers or pays, solicits or receives any remuneration” in return for
• “referring an individual for the furnishing of any claim or service or purchasing, leasing or arranging or recommending the purchase, lease etc., of any item for service paid for in whole or in part under Medicare or Medicaid”
• “shall be guilty of a felony.”
Medicare Anti-Kickback Statute (cont.)
• Penalties• Up to five years imprisonment and/or a fine of
up to $25,000
• Exclusion by DHHS from participation in the Medicare and Medicaid Programs
• New penalty under BBA - civil monetary penalty of $50,000 per violation plus triple damages
Medicare Anti-Kickback Statute (cont.)
Safe Harbors• Types of payments and business
arrangements between providers that the US Attorney and the OIG will not prosecute
• If a transaction satisfies the elements of a safe harbor, it will not be grounds for prosecution regardless of intent.
• There are also safe harbors for managed care arrangements.
Medicare Anti-Kickback Statute (cont.)
Examples of Safe Harbors• investments in public companies
• investments in small businesses
• space rentals
• equipment rentals
• warranties
• certain discount arrangements
• employment
• sale of professional practices
Key Distinctions Between the Stark Law and the Anti-Kickback Statute
• Stark applies only to physicians; Anti-Kickback law applies to all providers
• Stark is a strict liability law -- no intent needed; Anti-Kickback law contains an intent element
• Stark is not a criminal statute; Anti-Kickback law is a criminal statute
Ø Billing Insurance Only! ROUTINE WAIVER OF DEDUCTIBLES,
COINSURANCE/COPAYMENTS IS UNLAWFUL
May subject physicians to False Claims Act or Anti-Kickback liability
Patient’s “cost-share” deters program over-utilization
OIG has issued a special Fraud Alert on this issue
• Example: Provider’s charge is $100 for service. Medicare pays 80% or $80. If actual charge is misstated, Medicare is paying $16 more for the service than is should be. (Medicare should pay 80% of $80, not 80% of $100)
Routine waiver of the deductible/copay can be construed as a misstatement of the actual charge
The Health Insurance Portability and Accountability Act of 1996What’s the fuss over HIPAA?
Privacy rights have become the subject of national debate• Increased internet usage has spawned horror
stories of “Big Brother” watching
• Fear that one click can transmit private info all over the world
HIPAA made Healthcare Fraud & Abuse a crime
The 1996 Health Insurance Portability and Accountability Act (“HIPAA”)
HIPAA’s effect on existing health care fraud and abuse laws:
• increases resources available for combating fraud and abuse
• kickback statute expanded to apply to all federal healthcare payors (e.g.. CHAMPUS)
• extends and increases civil monetary penalties
Overview of the HIPAA Privacy Regulations
The HIPAA Privacy Regulations apply to covered entities’ handling of protected health information (“PHI”)
The Basic Rule: PHI may not be used or disclosed by a covered entity except as specifically required or permitted by the HIPAA Privacy Regulations.
The standard for PHI to be “de-identified” is very high, so the HIPAA Privacy Regulations apply to almost all information regarding a patient.
Balanced Budget Act of 1997
Gave Government additional Health Care Fraud & Abuse Measures• permanent exclusion for those convicted of
three health care related crimes
• authority to refuse to enter into Medicare contracts with individuals or entities convicted of felonies
• imposition of more civil monetary penalties
Did You Ever Read The Back Of A HCFA Form?
Every health insurance claim form (HCFA 1500) includes a certification that all statements made on the form are true and complete, and that any person who knowingly files a statement of claim containing any misrepresentation or any false or misleading information may be guilty of a criminal act punishable by law and may be subject to civil penalties. Additionally, for government payors, each provider certifies that the services rendered were medically necessary, were personally furnished by the provider or furnished by the provider’s employee under the provider’s personal supervision.
With All These Rules, How Can I Be Safe?
Be familiar with the laws governing health care
Document everything you do and the reason for doing it
Learn how to code your services correctly
General Principles Of Medical Record Documentation
Complete medical records for each patient
Make all entries in ink Use drawings, illustrations & pictures
when appropriate Write legibly
General Principles Of Medical Record Documentation
For each encounter:
• reason for the encounter and relevant history, exam and prior diagnostic test results
• assessment, clinical impression or diagnosis
• plan of care
• date and legible identity of the observer
General Documentation(Continued) Make entries promptly Do not leave blank spaces
in the patient records Document relevant
conversations between patient, responsible parties, physicians and staff
Use standard abbreviations
Basics of Medical Reimbursement
Payers are willing to pay for services provided they are:
•covered within the patient’s policy•medically appropriate for the patient's condition•medically necessary•coded correctly
Covered services are those services:•defined as “covered” within the terms of the patient's benefit plan•documented in the medical recordmedically necessary
Variables That Affect Reimbursement Include:
Individual insurance policies and regulations
Patient’s coverage Federal regulations Contractual agreements Accuracy of diagnosis and procedure
coding Physician office systems
Establishing Medical Necessity
The physician’s record should clearly document the medical necessity for all services rendered.
Only clinically proven, effective procedures are reimbursable under the Medicare program
Appropriate procedural and diagnosis coding is the key to establishing medical necessity
What Is CPT-4?
Systematic listing of procedures & services performed by physicians
Five-digit codes for procedures or services Used to describe the physician’s services to a
patient for diagnosis and treatment of the medical condition(s)
Codes and descriptive terminology developed and copyrighted by AMA CPT Editorial Panel
What is ICD-9?
Translates written terminology or descriptions into universal numeric and alphanumeric codes that can be processed electronically
Conveys a patient’s clinical picture to third-party payers
Serve to establish the medical necessity for the resultant procedures, treatment and medical supplies
Linkage Between ICD-9 & CPT (Continued)
CPT-4 represents the “WHAT” was done to the patient
Procedure------------------- 93010 (EKG)
ICD-9 represents the “WHY” it was done
Medical Necessity--------- 786.50 (Chest Pain)
Diagnosis (ICD-9 CM) Coding
While it is important to include differential diagnosis, suspected conditions or “rule-outs” in the medical documentation, an ICD-9 code is never selected based on what is being “ruled-out”. No such rule-out codes exist.• i.e. no code for rule-out MI
Use signs and symptoms or established diagnosis on billing forms
Together, the correct CPT code and and diagnosis code establish the medical necessity
Diagnostic studies ICD-9-CM • X-ray, US, labs, etc. Report signs & • without established symptoms diagnosis (i.e., rule out, probable, suspected)Example:Diagnostic Study: ICD-9 Linkage:Pelvic Ultrasound pelvic painfor R/O Ectopic Pregnancy (625.9)
Medical Necessity (continued)
Diagnostic studies with Report confirmed confirmed or established or established diagnosis diagnosis
Example:Diagnostic Study: ICD-9 LinkagePt. for Pelvic Ultrasound uterine fibroid
(218.9)
Organization Of CPT Manual
• Text organized in 6 major sections• Evaluation and Management ( 99201 - 99499)
• Anesthesiology ( 00100 - 01999,
99100 - 99140)
• Surgery ( 10040 - 69990)
• Radiology ( 70010 - 79999)
• Pathology and Laboratory ( 80049 - 89399)
• Medicine ( 90281 - 99199)
Format Of The CPT-4 Manual Developed as a stand-alone descriptions of the
procedures To conserve space, some are not printed in their
entirety but refer back to a common portion listed in a preceding entry
EXAMPLE:
25100 Arthrotomy, wrist joint; for biopsy
25105 for synovectomy
25105 Arthrotomy, wrist joint; for synovectomy
History ofMedicare’s Teaching Physician Rules
• Federal government payment rules• First billing guidelines established in 1967
• Revisited and the birth of Intermediary Letter 372 (IL 372)
• Continued confusion• Lack of standard application of rules by local
Medicare Carriers• Many institutions paid fines related to Teaching
Physician Rules• University of Pennsylvania- $30 million• University of Pittsburgh- $19 Million• Thomas Jefferson University- $12 million
Johns Hopkins Settles for $800,000
In February 2003 the Office of Inspector General (OIG) released a
bulletin stating that Johns Hopkins University (JHU) had entered into an
$800,000 settlement with the federal government to resolve charges of
fraudulent Medicare billing. Under the Physicians at Teaching Hospitals
(PATH) initiative, the OIG performed audits of teaching physician
services at Johns Hopkins from 1/1/94 through 12/31/94. According to
the OIG audit, Johns Hopkins submitted false claims to Medicare on
behalf of faculty physicians for services that were actually provided by
interns and residents. Documentation did not support that the
teaching physicians were personally involved in the services
provided.
Nephrologist at University of Washington Pleads Guilty
Another teaching physician at the University of Washington (UW) in Seattle has pleaded guilty to submitting false claims to Medicare and Medicaid. Dr. William Couser, ex-Chief of Nephrology, has been accused of billing for renal dialysis services that were actually performed by residents but billed in his name. The accusations stem from a qui tam suit filed in 1999 that brought allegations against three departments at UW: neurosurgery, nephrology, and radiology..…During the federal investigation at UW, which lasted four years, the government examined more than a million documents and issued more than 100 subpoenas. The university spent over $10 million in legal fees, and in addition, has spent $1 million annually on compliance efforts since the suit was filed. The civil investigation is not yet resolved but is expected to conclude quickly. Civil monetary penalties are likely to be in the tens of millions.
What are the Laws that Govern Teaching Physician Rules?
42 CFR §415.172 (a)General rule. If a resident participates in a service furnished in a
teaching setting, physician fee schedule payment is made only if a teaching physician is present during the key portion of any service or procedure for which payment is sought.
42 CFR §415.172 (a)(2)In the case of evaluation and management services, the teaching
physician must be present during the portion of the service that determines the level of service billed.
What are the Laws that Govern Teaching Physician Rules?
42 CFR §415.172 (b)The medical records must document the teaching physician was present at the time the service is furnished. The presence of the teaching physician during procedures may be demonstrated by the notes in the medical records made by a physician, resident, or nurse. In the case of evaluation and management procedures, the teaching physician must personally document his or her participation in the service in the medical records.
42 CFR §415.172 (c)In the case of services such as evaluation and management for which there are several levels of service codes available for reporting purposes, the appropriate payment level must reflect the extent and complexity of the service when fully furnished by the teaching physician.
Presence & Participation
• The two significant principles of teaching physician documentation are presence & participation.
• Presence may not be inferred; it must be stated or “attested” by the teaching physician. Presence is defined in the teaching physician guidelines.
Medicare’s Teaching Physician RulesImportant Definitions:
Resident - an individual in an approved graduate medical education (GME) program or a physician who is authorized to practice only in a hospital setting..
Teaching physician - physician (other than another resident) who involves residents in the care of his or her patients.
Direct medical and surgical services- services to individual patients that are either personally furnished by a physician or furnished by a resident under the supervision of a physician in a teaching hospital
Physically present - located in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service.
Critical or key portion - that part (or parts) of a service that the teaching physician determines is (are) a critical or key portion(s). These terms are interchangeable.
Teaching Physician Rules forEvaluation & Management Services
The teaching physician must personally document at least the following:
That they performed the service or were physically present during the key or critical portions of the service when performed by a resident.
The participation of the teaching physician in the management of the patient.
Reviewers will combine the documentation of both the resident and the physician.
Teaching Physician Rules forEvaluation & Management Services
• Documentation by the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician for an Evaluation & Management service.
• The combined entries into the medical record by the TP and the resident must support the medical necessity of the service.
What Are The Most Recent Changes To The Teaching Physician Requirements?
For E/M services, it is no longer required that the TP document a patient-specific comment related to the history, exam, and medical decision making as required by the code category.
The requirements for TP presence during the critical and key portions of both E/M services and surgical procedures has not changed.
Physicians now have specific examples of minimally acceptable documentation for common E/M scenarios.
To Whom Do these Rules Apply?
These guidelines apply to medical residents only, those individuals with an M.D. or D.O. degree that meet the definition of a resident. These guidelines do not apply to any other health care service provider other than teaching physicians and residents.
• They do not apply to any kind of student: Nursing, PA, Nurse Practitioner Psychology or otherwise.
• They do not apply to Advance Practice Nurses or Physician’s Assistants
• They do not apply to nurses.• They do not apply to anyone else other than those
individuals meeting the definition of a medical resident.
Scenario 1
Teaching physician personally performs all the required elements of an E/M service without a resident.
Where a resident has written notes, the teaching physician's note may reference the resident's note.
Teaching physician must document that s/he performed the critical or key portion(s) of the service and that s/he was directly involved in the management of the patient.
Acceptable Documentation for Scenario 1 Admitting Note: "I performed a history and physical examination
of the patient and discussed his management with the resident.
I reviewed the resident's note and agree with the documented
findings and plan of care."
Follow-up Visit: "Hospital Day #5. I saw and examined the
patient. I agree with the resident's note except the heart
murmur is louder, so I will obtain an echo to evaluate."
If there are no resident notes, the teaching physician must
document as he/she would document an E/M service in a non-
teaching setting.)
Scenario 2 Resident performs the elements required for
an E/M service in the presence of, or jointly with, the teaching physician and the resident documents the service.
Teaching physician must document that he or she was present during the performance of the critical or key portion(s) of the service and that he or she was directly involved in the management of the patient.
Teaching physician's note should reference the resident's note.
Acceptable documentation for Scenario 2
Initial or Follow-up Visit: "I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident's note."
Follow-up Visit: "I saw the patient with the resident and agree with the resident's findings and plan."
Scenario 3 Resident performs some or all of the required elements of
the service in the absence of the teaching physician and documents his/her service.
Teaching physician independently performs the critical or key portion(s) of the service with or without the resident present and, as appropriate, discusses the case with the resident.
Teaching physician must document that he or she personally saw the patient, personally performed critical or key portions of the service, and participated in the management of the patient.
Teaching physician's note should reference the resident's note.
Acceptable Documentation for Scenario 3
Initial Visit: "I saw and evaluated the patient. I reviewed the resident's note and agree, except that picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs."
Initial or Follow-up Visit: "I saw and evaluated the patient. Discussed with resident and agree with resident's findings and plan as documented in the resident's note."
Follow-up Visit: "See resident's note for details. I saw and evaluated the patient and agree with the resident's finding and plans as written."
Follow-up Visit: "I saw and evaluated the patient. Agree with resident's note but lower extremities are weaker, now 3/5; MRI of L/S Spine today."
Following are examples of unacceptable documentation: "Agree with above.", followed by legible countersignature or
identity; "Rounded, Reviewed, Agree.", followed by legible
countersignature or identity; "Discussed with resident. Agree.", followed by legible
countersignature or identity; "Seen and agree.", followed by legible countersignature or
identity; "Patient seen and evaluated.", followed by legible
countersignature or identity; and A legible countersignature or identity alone.
Such documentation is not acceptable, because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care.
E/M Service Documentation Provided By Students The only part of a student’s documentation that may be
used by the teaching physician is the Review of Systems and Past Medical, Family and Social History
The teaching physician may not refer to a student's documentation of physical exam findings or medical decision making in his or her personal note.
If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.
Procedures
In order to bill for surgical, high-risk, or other complex procedures, the teaching physician must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure.
TP Documentation of Minor Procedures
The TP must be present for the entire procedure in order to bill for the service.
• Minor procedures are not defined within CPT, although the Medicare rule characterizes minor procedures as those taking only a few minutes to complete (5 min or less).
The documentation may be provided by either the resident, the nurse or personally by the TP. If the resident provides the documentation, the attestation may be phrased as follows:
• Dr. TP was present during the entire procedure
• Procedure performed with (by) Dr. TP
Surgery (Including Endoscopic Operations
The teaching surgeon is responsible for the preoperative, operative, and post-operative care of the beneficiary.
The teaching physician's presence is not required during the opening and closing of the surgical field unless these activities are considered to be critical or key portions of the procedure.
The teaching surgeon determines which post-operative visits are considered key or critical and require his or her presence.
Surgery (Including Endoscopic Operations
During non-critical or non-key portions of the surgery, if the teaching surgeon is not physically present, he or she must be immediately available to return to the procedure, i.e., he or she cannot be performing another procedure.
If circumstances prevent a teaching physician from being immediately available, then he/she must arrange for another qualified surgeon to be immediately available to assist with the procedure, if needed.
Single Surgery
When the teaching surgeon is present for the entire surgery, his or her presence may be demonstrated by notes in the medical records made by the physician, resident, or operating room nurse.
For purposes of this teaching physician policy, there is no required information that the teaching surgeon must enter into the medical records.
Two Overlapping Surgeries
In order to bill Medicare for two overlapping surgeries, the TP must be present during the critical or key portions of both operations. Therefore, the critical or key portions may not take place at the same time.
When all of the key portions of the initial procedure have been completed, the TP may begin to become involved in a second procedure.
The TP must personally document in the medical record that he/she was physically present during the critical or key portion(s) of both procedures
Two Overlapping Surgeries
When a TP is not present during non-critical or non-key portions of the procedure and is participating in another surgical procedure, he or she must arrange for another qualified surgeon to immediately assist the resident in the other case should the need arise.
In the case of three concurrent surgical procedures, the role of the TP (but not anesthesiologist) in each of the cases is classified as a supervisory service to the hospital rather than a physician service to an individual patient and is not payable under the physician fee schedule.
Published On August 31, 2001, Philadelphia Inquirer, The (PA)
Surgeon To Pay Back Medicare Over Billing
A nationally recognized Philadelphia orthopedic surgeon agreed yesterday to reimburse the government almost $2 million to settle claims that he billed Medicare for work done by surgical residents and surgical fellows.
In announcing the $1.89 million settlement with Robert Booth Jr., both the surgeon and the U.S. Attorney's Office said the government investigation had nothing to do with the quality of knee and hip replacements and other surgeries performed.
At issue were billings for surgeries performed between January 1, 1995 and June 30, 1997, at Pennsylvania Hospital. The government claimed that Booth had billed Medicare for treatment handled by junior physicians he was training.
Endoscopy Procedures
To bill Medicare for endoscopic procedures (excluding endoscopic surgery that follows the surgery policy), the teaching physician must be present during the entire viewing.
The entire viewing starts at the time of insertion of the endoscope and ends at the time of removal of the endoscope.
Viewing of the entire procedure through a monitor in another room does not meet the teaching physician presence requirement.
Anesthesia Pay an unreduced fee schedule payment if a teaching
anesthesiologist is involved in a single procedure with one resident.
The teaching physician must document in the medical records that he or she was present during all critical (or key) portions of the procedure.
The teaching physician's physical presence during only the preoperative or post-operative visits with the beneficiary is not sufficient to receive Medicare payment.
If an anesthesiologist is involved in concurrent procedures with more than one resident or with a resident and a nonphysician anesthetist, pay for the anesthesiologist's services as medical direction.
Interpretation of Diagnostic Radiology and Other Diagnostic Tests Medicare pays for the interpretation of diagnostic
radiology and other diagnostic tests if the interpretation is performed by or reviewed with a teaching physician.
If the teaching physician's signature is the only signature on the interpretation, Medicare assumes that he or she is indicating that he or she personally performed the interpretation.
If a resident prepares and signs the interpretation, the teaching physician must indicate that he or she has personally reviewed the image and the resident's interpretation and either agrees with it or edits the findings.
Medicare does not pay for an interpretation if the teaching physician only countersigns the resident's interpretation.
Psychiatry The general teaching physician policy applies to
psychiatric services. For certain psychiatric services, the requirement for the
presence of the teaching physician during the service may be met by concurrent observation of the service through the use of a one-way mirror or video equipment.
• Audio-only equipment does not satisfy to the physical presence requirement. In the case of time-based services, such as individual medical psychotherapy, see subsection 8 below.
Further, the teaching physician supervising the resident must be a physician, i.e., the Medicare teaching physician policy does not apply to psychologists who supervise psychiatry residents in approved GME programs.
Time-Based Codes For procedure codes determined on the basis of time, the
teaching physician must be present for the period of time for which the claim is made.
• For example, pay for a code that specifically describes a service of from 20 to 30 minutes only if the teaching physician is present for 20 to 30 minutes. Do not add time spent by the resident in the absence of the teaching physician to time spent by the resident and teaching physician with the beneficiary or time spent by the teaching physician alone with the beneficiary.
• Examples: Critical Care, Psychotherapy
Interested in Learning More?Oct 25 Evaluation and Management Coding
This class will cover how to select the proper code levels for office visits, consultations, hospital care and more. 11:30-1 Coles 109
Nov 1 Basics of CPT Coding for Physician PracticesThis is a hands-on beginning level course teaching how to use the CPT manual. Participants will be expected to bring a CPT manual with them to class. Especially recommended for billing personnel, office managers, etc. 11:30-1pm Coles 101
Nov 8 Modifers-Your Key to Proper ReimbursementThis class will cover CPT modifiers and their use. Class appropriate for all specialties, but especially recommended for surgical practices 11:30- 1 Coles 109
Nov 15th Basic ICD-9 Coding for Physician PracticesThis is a hands-on beginning level course teaching how to use the ICD-9 Diagnosis Coding Manual. Participants will be expected to bring an ICD-9 manual with them to class. Especially recommended for billing personnel, office managers, etc. 10:30-12 Coles 109
Nov 22nd Billing for Non-Physician PractitionersIn this seminar you will learn about Medicare's requirements when billing “Incident-to” or “under the doctor’s provider number”; provide the Medicare requirements for billing Medicare directly under a Non-Physician Practitioner's provider number, examine which services can be provided to Medicare patients by nonphysician practitioners; discuss difficulties with Incident-to billing to managed care companies. 10:30-12 Coles 101