Neurology 2008 Departmental Compliance Plan

Department of Neurology
Billing Compliance Plan
Reviewed December 2008

I. Billing Compliance Administrative Policies and Procedures

1.0 COMPLIANCE ASSURANCE

The Department of Neurology 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 provide guidance to the staff of the Department of Neurology.

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 Neurology. 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 enhance and maintain the College of Medicine's billing compliance program (the "Program"). The Program includes procedures such as 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 Program. Additionally, compliance issues may be discussed on an ad hoc basis at department or divisional meetings.

5.0 REVIEW OF BILLING PRACTICES

5.1 Chart Monitoring

5.1.1 The Office of Compliance shall audit 12 encounters per Provider per audit cycle, in accordance with the Program.

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.html.

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. 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.

6.0 REVIEW AND UPDATE OF COMPLIANCE PLAN

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 Neurology 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.

II. Billing Compliance Documentation Rules: Policies and Procedures

7.0 GENERAL RULE FOR E/M SERVICES

On November 22, 2002, the Centers for Medicare and Medicaid Services (CMS) revised the documentation requirements for Evaluation & Management Services (E/M) billed to Medicare by Teaching Physicians. These revisions still require that Teaching Physicians personally document their participation in the service, however, for E/M services, Teaching Physicians need not repeat documentation already provided by a resident.

7.1 Participation and Presence. In general, Teaching Physicians may bill and be reimbursed for services involving residents when:

the Teaching Physician personally furnishes the services; or

the Teaching Physician was physically present during the critical or key portion(s) of the services that a resident performs.

7.2 Documentation. For purposes of payment, E/M services billed by the Teaching Physician require that they personally document at least the following:

they performed the service or were physically present during the critical or key portion(s) of the service when performed by the resident; and

the participation of the Teaching Physician in the management of the patient.

This rule change now makes it permissible to append the Teaching Physician documentation when reviewing the resident's note, upon condition that the time lapse between the date of service, and appending the note is reasonable.

As a result, what the resident did and documented may be combined with what the Teaching Physician did and documented to support a service. The Teaching Physician must only perform the key elements of the exam. However, the resident's note must be available to review. For example, if the resident's note supports a 99203 and the Teaching Physician is billing a 99205, then the Teaching Physician's note must include additional documentation required to support the service.

NOTE: 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.

7.2.1 Acceptable Documentation. The following are examples of minimally acceptable documentation of three scenarios for E/M encounters in teaching settings.

Scenario 1

The Teaching Physician personally performs all the required elements of an E/M service without a resident. In this scenario the resident may or may not have performed the E/M service independently.

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 #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident's note."

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."

NOTE: In this scenario if there are no resident notes, the Teaching Physician must document as he or she would document an E/M service in a non-teaching setting.

Scenario 2

The 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. In this case, the 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. The Teaching Physician's note should reference the resident's note. For payment, the composite of the Teaching Physician's entry and the resident's entry together must support the medical necessity and the level of the service billed by the Teaching Physician.

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

The resident performs some or all of the required elements of the service in the absence of the Teaching Physician and documents his or her service. The 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. In this instance, the 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. The Teaching Physician's note should reference the resident's note. For payment, the composite of the Teaching Physician's entry and the resident's entry together must support the medical necessity of the billed service and the level of the service billed by the Teaching Physician.

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."

7.2.2 Unacceptable Documentation. The 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.

7.2.3 Medical Student Documentation. Students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by a Teaching Physician is limited to documentation related to the review of systems and/or past family/social history. These items are not separately billable, but are taken as part of an E/M service, and must be performed in the physical presence of a Teaching Physician or physical presence of a resident in a service meeting the requirements set forth in the teaching physician rules.

Additionally, 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.

A student is never considered to be an intern or a resident. Medicare does not pay for any service furnished by a student.

NOTE: The only Medical Student documentation that supports a portion of the bill is the Review of Systems and the Past, Family/Social History portion of the history. The Teaching Physician must both perform and document the rest of the service. The Teaching Physician must repeat the exam, even if the medical student performed the exam in the Teaching Physician's presence, except for those elements that the Teaching Physician can assess by observing the medical student's performance of the element (for example: gait).

8.0 CONSULTATIONS (INPATIENT OR OUTPATIENT)

8.1 Requirements. Consultations require a request from another physician for evaluation of a patient's condition AND that a written report on the consultation be sent back or otherwise be communicated (such as by inclusion in a hospital chart for an inpatient) to the physician who requested the consultation. The identity of the physician requesting the consultation, as well as the actual request for the consultation must be documented in the record.

A consultation is meant to provide advice to another physician who has primary care of the patient and should not be billed as a consultation if the expectation is that the "consulting" physician is simply accepting a transfer of primary responsibility for treating the patient. Nonetheless, a consulting physician may prescribe and begin treatment of the patient. If the consulting physician will then continue to follow the patient's course of treatment, all subsequent services are office or inpatient visits, not follow-up consultations.

8.2 Consultation vs. Inpatient Visit. The rules governing when services are consultations as opposed to being a transfer of care are complicated and auditors are known to particularly focus on this issue. Therefore, although the rules permit a consulting physician to begin treatment of a patient at the initial consultation, it is the Department's recommendation that, if treatment is undertaken for inpatient consultations, the Teaching Physician may wish to bill using "initial inpatient visit" and "subsequent inpatient visit" procedure codes instead of consultation codes.

8.3 Participation and Documentation. Guidelines for Consultations and teaching physician participation and documentation are as outlined in Section 7.0.

9.0 EMERGENCY ROOM (ER) VISITS

Guidelines for ER Visits and teaching physician participation and documentation are as outlined in Section 7.0.

10.0 TIME BASED CODES

10.1 For procedures determined on the basis of time, the Teaching Physician must be present for the period of time for which the claim is made. 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. Examples of codes falling into this category include:

critical care services (CPT codes 99291-99292);

hospital discharge day management (CPT codes 99238-99239);

E/M codes in which counseling and/or coordination of care dominates (more than 50%) the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service;

prolonged services (CPT codes 99358-99359); and

care plan oversight (HCPCS codes G0181-G0182)

10.2 Documentation. If a Teaching Physician chooses to bill based on time, the following items must be documented in the medical record:

the total Teaching Physician time spent with the patient;

the time spent counseling the patient and/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)].

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.

11.0 PHYSICIAN ASSISTANT (PA) OR ADVANCED NURSE PRACTITIONER (ARNP) SERVICES

On October 25, 2002, CMS provided revisions to address payment for E/M services provided by a physician and non-physician practitioner (NPP). This revision clarifies the billing criteria for combined E/M services between a physician and an NPP in the same practice group.

11.1 Hospital-Based Inpatient / Hospital-Based Outpatient / Emergency Department Setting. When a hospital inpatient / hospital outpatient / emergency department E/M encounter is shared or split between a physician and a PA/ARNP from the same group practice the E/M encounter may be billed under the physician's name and provider number if and only if:

The physician provides any face-to-face portion of the E/M encounter (even if it is later in the same day as the PA/ARNP's portion); and

The physician personally and contemporaneously documents in the patient's record the physician's face-to-face portion of the E/M encounter with the patient.

NOTE: If the physician does not personally perform and personally and contemporaneously document a face-to-face portion of the E/M encounter with the patient, then the E/M encounter cannot be billed under the physician's name and provider number and may be billed only under the PA/ARNP's name and provider number.

11.2 Non-Hospital-Based Outpatient Clinic / Office Setting. When a non-hospital outpatient clinic / office E/M encounter is shared or split between a physician and a PA/ARNP the E/M encounter may be billed under the physician's name and provider number if and only if:

The patient is an established patient; and

The "incident to" rules are met. (Medicare has clarified that "incident to" billing is not allowed for new patients/first visits).

NOTE: If the patient is not an established patient and the "incident to" rules are not met, then the E/M encounter cannot be billed under the physician's provider number and may be billed only under the PA/ARNP's provider number.

This means that a physician cannot combine the E/M services of a PA/ARNP and a physician for a NEW patient on a FIRST visit E/M encounter and bill under the physician's name and provider number. Additional guidelines on incident-to billing are provided in the Teaching Physician Billing Policy.

12.0 SURGICAL PROCEDURES

The Teaching Physician is responsible for the pre-operative, operative, and post- operative care of the patient. The Teaching Physician's presence is not required during the opening and closing of the surgical field unless these activities are considered critical or key portion(s) of the procedure.

NOTE: When a Teaching Physician is not present during the critical or key portion(s) of the procedure and is participating in another surgical procedure, he or she must arrange for another qualified physician to immediately assist the resident in the other case should the need arise. Additional guidelines for documentation are provided in the Teaching Physician Billing Policy.

12.1 Minor Procedures. For procedures that take only a few minutes (5 minutes or less) to complete, for example, simple suture, and involve relatively little decision-making once the need for the procedure is determined, the Teaching Physician must be present for the entire procedure in order to bill for the procedure.

12.1.1 Sample Documentation. "I was present for (or performed) the entire procedure" along with the signature of Teaching Physician.12.1.2 Minor procedures during which the Teaching Physician is not present for the entire procedure will not be billed. Additionally, emergency and/or elective major procedures (i.e. burr holes, craniotomy for trauma, etc.) performed on patients without the attendance of the Teaching Physician for the key portion (regardless of telephone consultation or availability within the medical center) will not be billed.

12.2 Single Surgery. When the Teaching Physician is present for the entire period between opening and closing of the surgical field, his or her presence may be demonstrated by notes in the medical record made by the physician, resident or O.R. nurse. However, the Teaching Physician must document his or her participation in surgical cases by completing the designated section at the bottom of the Operative Record.

12.3 Two Overlapping Surgeries. Teaching Physicians may bill Medicare for two, but no more than two, overlapping procedures, provided that the Teaching Physician is physically present for the key portion(s) of both operations and all the key portions of the initial procedure have been completed before the Teaching Physician begins to become involved in a second procedure. It is critical that the Teaching Physician personally document the key portion(s) of each procedure in their respective Operative Record, as well as document his or her "immediate availability" or the identity of the "covering" Teaching Physician. Additional guidelines for surgical procedures are provided in the Teaching Physician Billing Policy.

12.4 Three or More Overlapping Surgeries. In the case of three or more concurrent surgical procedures, the Teaching Physician's role in each of the cases would be classified as supervisory and not payable under Medicare Part B.

12.5 Specific Surgical Procedures.

12.5.1 Lumbar Puncture. The Teaching Physician must be present for needle insertion, pressure measurement, fluid withdrawal, and needle removal.

12.5.2 Needle EMG. The Teaching Physician must be present for the entire procedure.
12.5.3 Tensilon Test. The Teaching Physician must be present for the control injection and the Tensilon injection, plus the time for observation.

12.5.4 Sphenoidal electrode placement. The Teaching Physician must be present for the insertion of the electrode.

12.7 Pre-Operative Evaluation. Routine pre-operative visits are included in the "global" surgical fee. The Teaching Physician will personally see patients upon whom they will be doing surgery within a reasonable period of time prior to surgery. The pre-operative visit in such cases can safely and effectively be performed by a resident to merely confirm that no significant change has occurred in the patient's condition since the prior visit which might change the considerations in going forward with the surgery. The Teaching Physician is responsible for determining whether the pre-operative visit is a key portion. If the pre-operative visit is a key portion, but the Teaching Physician does not participate in it, then a reduced fee for the surgical procedure must be billed.

12.7.1 Documentation of Pre-Operative Evaluation: "I was present for the pre-operative evaluation. Signature Dr. Teaching Physician." This documentation should be a part of the pre-operative evaluation in written or dictated form. This may be entered in the chart by either a written or typewritten note.

12.8 Post-Operative Visits. The Teaching Physician determines which post-operative visits are considered critical or key and require his or her presence. If the post-operative period extends beyond the patient's discharge and the Teaching Physician is not providing the patient's follow up care, then instructions on billing for less than the global surgical fee apply.

13.0 ASSISTANTS AT SURGERY

Generally, no payment is allowed for services of assistants at surgery when furnished in a teaching hospital that has a training program related to the medical specialty required for the surgical procedure and a qualified resident is available. For limited exceptions to this rule, see the Teaching Physician Billing Policy.

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