The “Ups and Downs” of

Implementing a Medical Compliance

Plan in a Dental World

Teresa Bivens, CPC, CHC

University of Louisville

HSC Office of Compliance

Louisville, KY

Medical vs. Dental

• The “ups and downs” of implementing the

University of Louisville HSC center compliance

plan for the medical school to the dental

school

• Dental school added to plan 2004

• My personal insights on the dental

compliance “rollercoaster ride”

“Medical” vs. “Dental”

• Dentist’s aren't like “physicians”

• “We don’t use CPT codes”

• “Our student’s can do more on their own than medical residents”

• “Our resident’s/fellows supervise Students – how does that fall into the Teaching Physician Guidelines?”

• “Our billing guidelines are different from medicine’s, so the compliance plan does not apply to us”

“Medical” vs. “Dental”

• Dental provider compliance “push back”

• Who is signing off on patient services

• Credentialing issues

• Teaching provider hospital services dilemmas

• Annual training – medical vs. dental

• Training auditors

• Who are services being billed under and how to set up auditing plan

• Implementation of EHR/billing system

The “Ups”

• Better understanding of compliance

• Better documentation of patient services

• Decrease of risk

• Clarification of teaching provider compliance responsibilities and supervision

• Promotes “we are all in this together”atmosphere

• Networking with other dental school facilities

• Better patient care

Documentation Requirements for

Teaching Dentists

Kim Johnson, RHIA, CPC, CHC

University of Kentucky Office of Compliance

42 CFR Section 415, Subpart D

Definitions

• Approved Graduate Medical Education (GME)

Program

• A residency program approved by the Accreditation

Council for Graduate Medical Education of the American

Medical Association, by the Committee on Hospitals of the

Bureau of Professional Education of the American

Osteopathic Association, by the Council on Dental

Education of the American Dental Association………….

42 CFR Section 415, Subpart D

Definitions

• Teaching Hospital

• A hospital engaged in an approved GME residency

program in medicine, osteopathy, dentistry, or podiatry.

42 CFR Section 415, Subpart D

Definitions

• Intern, Resident or Fellow

• An individual who participates in an approved GME

program, including programs in osteopathy, dentistry, and

podiatry.

• A “physician” who is not in an approved GME program, but

who is authorized to practice only in a hospital, for

example, individuals with temporary or restricted licenses,

or unlicensed graduates of foreign medical schools. For

purposes of this subpart, the term resident is synonymous

with the terms intern and fellow.

42 CFR Section 415, Subpart D

Definitions

• Students

• An individual who participates in an accredited

educational program that is not an approved GME

program.

• In Dentistry, this could mean predoctoral or postdoctoral

students.

General Rule

• Services of a Teaching Dentist (TD) are payable by

Medicare only when:

• Personally furnished by the TD or

• TD is personally present during the critical or key portions of the service rendered by a resident and,

• Documented in the patient record.

Participation by Students

• Contribution by a “student” to a billable encounter are limited

to elements of history, specifically:

– Review of Systems

– Past/Family/Social History

• The TD or resident must “refer” to the student’s note for

billing purposes.

Evaluation & Management Services

• To bill an E/M service, the TD must document:

• That they performed the service or were physically

present during the critical or key portions of the service

furnished by the resident and,

• His or her participation in the management of the patient.

• The combined entries by the TD and resident support the

service rendered and should support medical necessity.

Documentation by TD

• I saw and evaluated the patient, discussed with the Resident

and agree with Resident’s findings and plan as documented.

• I saw and evaluated the patient. I agree with the resident’s

note with the addition of a bilateral nasal fracture.

GC Modifier

• GC modifier must be used to bill for all services that

involve a Resident, regardless of the Teaching Dentist’s

presence during the entire service or for just the key

portion of the service.

Electronic Records & Macros

• When using an electronic medical record, it is acceptable to use a macro as the required personal documentation if the Teaching Physician adds it personally in a secured (password protected) system.

Minor Procedures

• Minor procedures take only a few minutes (5 minutes or less) to complete, involve relatively little decision making, and have a global period of 0-10 days.

• The TD must be present for the entire procedure in order to bill for the procedure. “Entire” procedure means opening to closing.

• Documentation should reflect the TD’s presence for the entire procedure.

Major Procedures

• A major procedure is a procedure with a one-day preoperative period and typically a 90-day global period. The global fee includes all pre- and postoperative care as well as intraoperative services.

• The TD must be present in the operating room with the Resident during all critical or key portions of the procedure and remain immediately available to return to the operating room during the entire procedure. Opening and closing may or may not be considered critical or key portions.

Major Procedures

• Appropriate documentation

� I was present during (or personally performed) the key

portions of the procedure, which included [list key

portions].

� I was present for the entire case.

Major Procedures

• Overlapping Cases

• 3 overlapping concurrent cases are not billable

• 2 overlapping concurrent cases are billable if the TD

completes the key portions of case #1 before starting case

#2

For More Information

• Medicare Claims Processing Manual, Pub. 100-04,

Chapter, Chapter 12, Section 100 – Teaching

Physician Services

• CMS Guidelines for Teaching Physician Services

located at:

http://www.cms.hhs.gov/MLNProducts/downloads/

gdelinesteachgresfctsht.pdf

Dental Billing & Coding

Is there a “fudge factor”?

Glena Jarboe

Compliance Analyst

University of Kentucky

College of Dentistry

Exams

• Consultation

– Used when second opinion is requested

• Evaluation

– Comprehensive

• New or established patients

• Absent for 3 or more years

– Periodic

• Established patient

– Problem focused

• Limited to specific problems or complaints

Radiographs and Diagnostic Tests

• Limit to Necessary Films/Tests

• Ensure Diagnostic Quality

• Document Film/Test Interpretation(s)

• Label all Films

– Date of Exposure

– Patient Name

– Medical Record Number

• Original Films are Owned by the Dentist/Practice

Restorative

• Core Buildup

– Buildup anatomical crown before cast crown is placed

– Used with or without pins

• Post and Core

– Prefabricated

• Core built around prefabricated post

– Cast Post & Core

• Fabricated in the laboratory

Treatment Plans

• Why?

– Document recommendations for care

– Aid in coordination of care

– Help patients understand course of treatment as

well as financial obligation

• How?

– Sequence your treatment plan

– Review multiple options (if applicable)

– Obtain patient signature

Crowns and Fixed Partial Dentures

• Metal Content

– High Noble

– Titanium and Titanium alloys

– Noble

– Predominantly base

– Porcelain/Ceramic

– CERAC

– Resin

• Identification system

Dental Implants

• Prefabricated Abutment

– Manufactured component generally made of

titanium

• Straumann Solid Abutment

• Custom Abutment

– Laboratory fabricated typically using a casting

process

• UCLA Abutment

Oral Surgery

• “Medical” vs. “Dental”

– Medically necessary

• Trauma

• Significant illness and/or life altering condition

– Surgical Extractions

• Document with detailed report

• Include radiographs

– Sedation

• Administration

• Drugs and dosage

Miscellaneous

• Unspecified Procedure, by Report

– 999 codes are procedures without a representative code

– Time, material and expertise should determine fee charged

• Other Drugs and/or Medicaments, by Report

– Dispensed from office for home use

• Remake

– Establish standard criteria