University of Florida College of Medicine

Department of Radiology
Billing Compliance Plan
Reviewed December 2008


I. Billing Compliance Administrative Policies and Procedures

1.0 COMPLIANCE ASSURANCE

The Department of Radiology 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 Radiology.

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 Radiology. 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.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. The College of Medicine Director of Compliance, in consultation with General Counsel, will determine if any further action needs to be taken.

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 Radiology 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: Policy 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 INTERPRETATION OF DIAGNOSTIC RADIOLOGY TESTS

All radiologic tests and interpretations from the Department of Radiology and its peripheral sites will be promptly reviewed by a Teaching Physician-radiologist, including examination of any film or image itself by the Teaching Physician-radiologist. A Teaching Physician will be present during the key portions(s) of all interventional procedures and this presence will be documented in the chart note, including the specification of the key portion. No professional charge will be generated if the Teaching Physician is not present during the key portion of the interventional procedure or if the film or image is not reviewed by the Teaching Physician. Review of the film or image will be documented in the record.

9.1 Standard radiographic procedures do not require the presence of the Teaching Physician during the acquisition of the diagnostic image. This includes plain films of the body; appropriate CPT codes are identified on the basis of the requesting physician's order.

9.2 Non-interventional special imaging studies, such as computed tomography, ultrasound, nuclear medicine, magnetic resonance and fluoroscopy, are also assigned an appropriate CPT code, based upon the requesting physician's order.

9.3 Documentation Requirements. Medicare Carriers have been instructed to assume that if the Teaching Physician's signature is the only signature on the interpretation that is an indication that the Teaching Physician personally performed the interpretation. If the 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 that he or she either agrees with it or edits the findings.

NOTE: A countersignature by the Teaching Physician to the resident's interpretation is not sufficient documentation.

9.4 Documentation Examples

9.4.1 Teaching Physician prepares interpretation. Use the standard language for interpretation and sign the report.

9.4.2 Resident prepares interpretation. Documentation of the review is included in the printed verified report that is part of the official medical record. Include a notation in the medical record that states: "I have personally reviewed the film and the resident's findings and [agree or disagree and make the appropriate changes]. No report is final unless verified and electronically signed by the Teaching Physician. A resident physician may approve his or her dictation but verification may only be indicated after review of the report by the Teaching Physician. Approval of the dictated report and verification of the final report may be done with an electronic signature through the Radiology Information System, which has a security system to prevent unauthorized approval and verification.

10.0 INTERVENTIONAL AND SURGICAL RADIOLOGY PROCEDURES (INCLUDING ENDOSCOPIC 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.

10.1 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.

10.1.1 Sample Documentation. "I was present for (or performed) the entire procedure" along with the signature of Teaching Physician.

10.1.2 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.

10.2 Endoscopic Procedures. In order to bill Medicare for endoscopic procedures, 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.

NOTE: Viewing of the entire procedure through a monitor in another room does not meet the teaching physician presence requirement.

10.3 Other Complex or High Risk Procedures. In order to bill Medicare, personal supervision by the Teaching Physician is required for those complex or high-risk procedures for which national Medicare policy, local policy, or the CPT description indicates. These procedures include interventional radiologic supervision and interpretation codes.

10.4 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.

10.5 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. The following requirements apply:

  • The cases must be scheduled so that the key portions do not take place simultaneously.

  • The billing surgeon must complete the key portion of case #1 before moving to case #2.

  • There must be a surgeon who is immediately available to provide assistance in case #1. If the billing surgeon cannot return to case #1 because he or she has become involved in the key portion of case #2, then arrangements must be made for another surgeon to cover case #1.

  • The billing surgeon must document his or her participation in the key portion of each case, including in that documentation a description of the key portion.

  • In those instances when it is necessary for another surgeon to provide coverage for case #1 on an immediately available basis, the identity of the covering surgeon should be noted in the operative record.

10.6 Documentation for Surgical Procedures: The Teaching Physician must document his or her participation in surgical cases by completing the designated section at the bottom of the Operative Record. The key portion(s) of the procedure must be designated, as well as any immediately available Teaching Physician who covered non-key portion(s) of the case, and what portion specifically they covered (e.g. opening or skin closure). The signature of the Teaching Physician is required on the Operative Record.

10.7 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.

10.8 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.

10.8.1 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.

10.9 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.


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