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Department of Anesthesiology
Billing Compliance Plan
December 2003
I. Billing Compliance Administrative Policies and Procedures
II. Billing Compliance Rules Policy and Procedures1.0 INTRODUCTION
The Department of Anesthesiology has a strong and abiding commitment to ensuring that its billing activities are conducted in accordance with applicable law. The Department recognizes the need to ensure that our physicians and staff are well informed about state and federal regulations applicable to billing, that we comply with these rules, and that performance is regularly audited so as to strengthen detected weaknesses. This plan is designed to assist in meeting these goals and to provide guidance to the staff of the Department of Anesthesiology.
2.0 REPORTING OF COMPLIANCE CONCERNS
The College of Medicine of the University of Florida is committed to providing an environment of honesty, integrity and trust. If you have concerns about legal or ethical issues speak with your departmental compliance officer or you may call the Office of Compliance Gator Hotline at 1-866-574-2867.
The Gator Compliance Hotline is a resource for all employees who may be confronted with ethical issues in areas such as Billing Issues, Proper Accounting and Record Keeping, and Relations with Government Officials and Regulatory Agencies.
Anonymous reports are accepted. You may use this number to follow up or learn the results of the investigation process.
3.0 DEPARTMENTAL COMPLIANCE OFFICER
The Chairman of the Department shall appoint a Departmental Compliance Officer for the Department of Anesthesiology. The Departmental Compliance Officer is responsible for actively participating in the COM Compliance Committee, working with the Office of Compliance personnel during the centralized audit process and working as a liaison between the Chair, Committee, Administrators, and the Office of Compliance to accomplish all the requirements of the Institutional Compliance Agreement. Such requirements include the screening for ineligible persons, regular centralized audits, and general and specific education of College of Medicine employees.
4.0 DEPARTMENTAL EDUCATION ACTIVITIES AND EDUCATION OF NEW EMPLOYEES
The educational activities and the education of new employees will be conducted in coordination with the Office of Compliance, so that such activities may be centrally documented and will meet the requirements of the Institutional Compliance Agreement. Additionally, compliance issues may be discussed on an ad hoc basis at department or divisional meetings.
5.0 REVIEW OF BILLING PRACTICES
6.0 REVIEW AND UPDATE OF COMPLIANCE PLAN5.1 Chart Monitoring
5.1.1 The Office of Compliance shall audit 12 encounters per Provider per audit cycle, in accordance with the Institutional Compliance Agreement.
5.1.2 The Departmental Compliance Officer will act as a contact person and facilitator within the Department. If requested, the Department will provide space for auditors to work and review documents during the audit process. The Departmental Compliance Officer or his or her designee will review audit outcomes prior to the circulation of audit findings.
5.2 Reporting
Once completed, the Office of Compliance will provide audit results to the Departmental Compliance Officer and the Department Chair. The Office of Compliance also shall maintain a database of audit outcomes.
5.3 Post-Audit Education
The Department is responsible for ensuring that any individual determined to require corrective educational action (as a result of the audit findings) attend educational sessions coordinated with the Office of Compliance.
5.4 Discipline
5.4.1 The Department Chair, pursuant to University rules and in consultation with the Office of Compliance, will be responsible for imposing the appropriate remedies and sanctions when compliance problems occur with Providers. The University’s existing remedial and disciplinary mechanisms for violations of billing compliance policies and procedures include but are not limited to letters of counseling, letters of reprimand, suspension without pay and termination.
5.4.2 A more detailed review of potential compliance violations and probable consequences can be found in a memorandum entitled Billing Compliance Assurance Information. This memorandum is available for review from the Office of Compliance web site at http://www.med.ufl.edu/complian/index.htm.
5.5 Expanded Audits and Refunds
5.5.1 There may be instances when the results of the audit process require that expanded auditing be conducted. The Department will be financially responsible for the costs of expanded auditing, which will be conducted by the Office of Compliance.
5.5.2 The Office of Compliance will identify overpayments, if any, arising from compliance audit activity (including regular and expanded audits), and track the timeliness of the refund processing by FGP Billing & Accounts Receivable Group in accordance with the provisions of the Institutional Compliance Agreement. The College of Medicine Director of Compliance, in consultation with General Counsel, will determine if any further action needs to be taken or if any disclosure needs to be made.
This document, as well as other written policies and procedures for billing activities, will be maintained by the Office of Compliance in coordination with the Department. The Department of Anesthesiology Compliance Plan will be reviewed on an annual basis by the Departmental Compliance Officer and the Chairman of the Department in order to identify any needed modifications as well as specific compliance objectives during the succeeding year.
7.0 BILLING FOR SURGICAL ANESTHESIA SERVICES
In general, Teaching Physicians may bill for the supervision of a fellow, resident, intern, certified registered nurse anesthetist (“CRNA”), anesthesiologist assistant (“AA”), or student nurse anesthetist in one of three ways, depending on the level of supervision and the number of concurrent anesthesia services being provided. Specifically, Teaching Physician participation in surgical anesthesia services can be performed on the three following levels:
Personal Performance; Medical Direction; or Medical Supervision. Each of these levels of billing (and the corresponding level of Teaching Physician participation) is outlined in greater detail below.
8.0 PERSONAL PERFORMANCE OF SURGICAL ANESTHESIA SERVICES
8.1 Definition
A Teaching Physician is considered to have “personally performed” a service, and therefore to be entitled to full payment of the Medicare fee schedule amount (an unreduced fee) for the service, if either:
8.1.1 The Teaching Physician personally performed the entire anesthesia procedure alone, or
8.1.2 The Teaching Physician was personally and continuously involved in a single anesthesia procedure performed by a resident, intern, fellow, AA, or student nurse anesthetist. (See Item 9.4 below for instances when a Teaching Physician and a CRNA are involved in a single case.)
NOTE: The Teaching Physician’s physical presence during only the pre-operative or post-operative visits with the patient is not sufficient to bill for the services.
8.2 Billing Code Modifier
When billing for services that are personally performed, the Teaching Physician should use the -AA modifier.
8.3 Immediately Available
When billing for services that are personally performed, the Teaching Physician must be present during all critical (key) portions of the anesthesia procedure (such as induction and emergence) and be immediately available during the entire service or procedure.
NOTE: The Teaching Physician is not immediately available if he or she is performing services involving other patients (e.g., pain blocks, epidural administration, or pre- or post-operative visits), except as noted in section 9.2.
8.4 CRNA Direct Billing
If the anesthesiologist leaves the O.R. for an extended period of time and he or she had been supervising a CRNA, the CRNA may bill directly for the service. The claim form for this service should note clearly that the service was provided by the CRNA and not the anesthesiologist.
8.5 Payment for Directing CRNA in Single Case
An anesthesiologist personally performing a single case with a CRNA will not be able to receive an unreduced fee. Instead, the anesthesiologist and CRNA will split the fee 50-50.
8.6 No Billing by Resident
If the anesthesiologist leaves the O.R. for an extended period of time and he or she had been supervising a resident or intern, the resident or intern may not bill Medicare directly for the service.
8.7 Post-Anesthesia Visits
The Teaching Physician is not required to perform the pre- or post-anesthesia visit. Rather, a resident or fellow may provide the pre- or post-anesthesia visit. However, when providing supervision to a CRNA or AA, the anesthesiologist still must perform these peri-operative visits.
9.0 MEDICAL DIRECTION / CONCURRENT CARE OF SURGICAL ANESTHESIA SERVICES
9.1 Conditions for Medicare Payment
Medicare pays for the anesthesiologist’s medical direction of anesthesia services for one, two, three or four concurrent anesthesia services furnished to patients only if the physician for each patient:
- Performs a pre-anesthesia examination and evaluation;
- Prescribes the anesthesia plan;
- Personally participates in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence1;
- Ensures that any procedures in the anesthesia plan that the physician does not perform are performed by a qualified individual;
- Monitors the course of anesthesia administration at frequent intervals;
- Remains physically present and available for immediate diagnosis and treatment of emergencies; and
- Provides indicated post-anesthesia care.
The anesthesiologist alone must document in the patient’s medical record that the conditions set forth above have been satisfied, specifically documenting that he or she performed the pre-anesthetic exam and evaluation, provided the indicated post-anesthesia care, and was present during the most demanding procedures, including induction and emergence where applicable.
9.2 Limited Exception to Concurrency Limits for Short Term Emergencies in Immediate Area
A physician who is concurrently directing the administration of anesthesia to not more than four surgical patients ordinarily cannot be involved in furnishing additional services to other patients. However, the anesthesiologist may address an emergency of short duration in the immediate area while medically directing concurrent surgical cases.
Specific examples of such short-term emergencies include: (1) administering an epidural or caudal anesthetic to ease labor pain; (2) periodic rather than continuous monitoring of an obstetrical patient; (3) receiving patients entering the operating suite for the next surgery; (4) checking or discharging patients in the recovery room; (5) handling scheduling matters; or (6) providing brief guidance to pre-op clinic personnel via telephone from the operating room.
9.3 Billing Code Modifier
When billing for medical direction of concurrent care, the anesthesiologist should use the -QK modifier.
9.4 Reduced Number of Concurrent Cases for Student Anesthetist
If the anesthesiologist is medically directing a student nurse anesthetist, then the anesthesiologist may only receive reimbursement for directing one additional concurrent operation. In such a case, the anesthesiologist may bill in full, but may only receive 50% of Medicare allowed amount for each procedure.
9.5 Rules Applicable If Even One Concurrent Case Is Medicare
Concurrency does not require each of the cases to involve a Medicare patient. For example, if an anesthesiologist directs three concurrent procedures, two of which involve non-Medicare patients and the remaining involves a Medicare patient, this represents three concurrent cases.
9.6 Reimbursement Effect of Failing to Meet Concurrency Requirements
If the anesthesiologist leaves the immediate area of the operating suite for other than a short duration or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the anesthesiologist’s services to all of the surgical patients become supervisory in nature and do not meet the criteria for medical direction. Medicare payments would be reduced from the concurrency rates for medical direction for the surgical cases to the supervisory rates described below.
10.0 MEDICAL SUPERVISION OF SURGICAL ANESTHESIA SERVICES
10.1 Definition
If the anesthesiologist is involved in more than four concurrent procedures or is performing other services while directing the concurrent procedures, the anesthesiologist should bill only for medical supervision of the surgical cases.
10.2 Billing Code Modifier
When billing for medical supervision, the anesthesiologist should use the -AD modifier.
10.3 Reimbursement of Anesthesiologist
Payment for medical supervision consists of three base units per procedure. An additional time unit can be recognized by a carrier if the anesthesiologist can document that he or she was present at induction.
11.0 MINOR PROCEDURES
If a resident (or fellow in an approved training program) performs a minor procedure (a procedure taking less than five (5) minutes to complete), the Teaching Physician may bill for the procedure only if the Teaching Physician was physically present, elbow-to-elbow with the resident, during the entire procedure. The medical record should document explicitly that the Teaching Physician performed or was physically present during the entire minor procedure.
12.0 INPATIENT VISITS
Inpatients are followed by members of the Department of Anesthesiology. While most inpatients are in the Intensive Care and Intermediate Care Units, other patients may receive care on other inpatient units. Teaching Physicians should follow the General Rules for E/M Services outlined in the Teaching Physician Billing Policy. The –GC modifier should be used to designate instances when the Teaching Physician provides the procedure with the assistance of a resident or fellow.
13.0 OFFICE OR OUTPATIENT VISITS
Outpatient medical care of patients is frequently provided in the Pain Clinic and in the Preoperative Clinic. Teaching Physicians should follow the General Rules for E/M Services outlined in the Teaching Physician Billing Policy. All criteria of the clinic visit must be fulfilled to justify the charge submitted. The –GC modifier should be used to designate instances when the Teaching Physician provides the procedure with the assistance of a resident or fellow.
13.1 Surgical Procedures for Pain Clinic Patients
Surgical procedures for Pain Clinic patients may be performed at the clinic or at surgical centers. Professional fees for the service rendered should be billed in accordance with the current requirements of the surgical procedure.
13.2 Preanesthetic Clinic
Patients may be seen in the Preanesthetic clinic for routine preoperative visits or as consultations.
13.2.1 Shands Hospital employs individuals (hereinafter “Pre-op Clinic Providers”) who perform directed preanesthetic interviews and examinations for the purpose of optimizing preanesthetic evaluation. No professional fees shall be charged for these evaluations. These evaluations will be reviewed by faculty of the Department of Anesthesiology for the purpose of supervision, to improve patient care, and to further the education and performance of the Pre-op Clinic Providers.14.0 CONSULTATIONS (INPATIENT & OUTPATIENT)
Patients seen on a consulting basis may be seen by appropriate members of the Department of Anesthesiology. As with any other E/M service, the Teaching Physician should follow the General Rules for E/M Services outlined in the Teaching Physician Billing Policy.
15.0 TIME BASED BILLING
Outpatient visits (99201-5, 99211-5), inpatient services (99221-3, 99231-3) and consultations (99241-5, 99251-5) may be billed based on time so long as the Teaching Physician spends more than 50% of his or her time with the patient providing counseling or coordination of care. If a Teaching Physician chooses to bill based on time, the following items must be documented in the chart:
- the total Teaching Physician time spent with the patient;
- the time spent counseling the patient or coordinating patient care; and
- the subject matter of the counseling and/or coordination of care.
Acceptable documentation of the Teaching Physician’s participation would read: I spent 30 minutes with [patient name], 25 minutes of which was spent counseling [patient] on [list subject of counseling (e.g. surgical and non-surgical options for treatment of patient’s condition)]. Do not add the time spent by the resident with the patient in the absence of the Teaching Physician to time spent by the resident and the Teaching Physician with the patient, or time spent by the Teaching Physician alone with the patient. For example, a code that specifically describes a service of 20-30 minutes applies only if the Teaching Physician is present for 20-30 minutes.
NOTE: If the resident provides the service without the Teaching Physician’s direct participation, the resident must dictate the clinic note, but the service cannot be billed.
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1 If applicable, the medically directing physician participates in emergence if he or she is present and observes the patient’s condition any time between the administration of the last medication used to produce or maintain anesthesia until 30 minutes after the patient is left in the care of another healthcare provider in a Post Anesthesia Care Unit or Intensive Care Unit.
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