2013 Compliance Training Billing Compliance Office

1. 2013 Compliance TrainingBilling Compliance Office Dermatology Staff Meeting 10/10/2013 BWH/BWPO Billing Compliance Office 801 Massachusetts Avenue, 5th Floor Boston Mass 02118 Phone 617-582-0090 & 617-582-0095 (fax)

2. Efficiency, Growth, Financial Performance Physician Billing Compliance • Medicare Teaching Rules – Procedures • PA and MD Documentation • Signature Requirements

3. Teaching Physician Billing and Documentation Medicare (Part A) pays teaching hospitals for the work of Interns and Residents (includes Fellows) Medicare (Part B) pays teaching physicians under the Medicare fee schedule for professional services involving residents/interns only if: • The billed service is personally performed by the Teaching MD ……. OR • The Teaching MD is present with the resident or performs the service together (jointly) with the resident The Medical Record Documentation proves this. Thus, it must include: • Two (2) separate notes: one by the Resident and one by the Teaching Physician • Teaching Physician’s Note Must Document (at a Minimum): • The service furnished • His/Her Participation in providing the service • His/Her Presence (in the room) and Personal Service(s) • Reference to the Resident’s Documentation noting any updates or changes if applicable • Use First Person phrases such as: • “Isaw and examined the patient” or “the patient was seen and evaluated by me” • Billing Modifier GC must be used on all Teaching Claims

4. CMS Examples of MinimallyAcceptable E/M Teaching Documentation • “I performed a history and physical exam 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” • “I saw and evaluated the patient, I agree with the findings and plan of care as documented in the resident’s note” • “I saw and examined the patient. I agree with the resident’s noteexcept that the heart murmur is louder, so I will obtain an echo to evaluate” • “I was present with the 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” • “I saw the patient with the residentand agree with the resident’s findings and plan” • “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s findings and plans as written” • “I saw and evaluated the patient. Agree with the resident’s notebut lower extremities are weaker, not 3/5; MRI of L/S Spine today”

5. Unacceptable Teaching DocumentationResulting in Non-billable Services • Simply “Co-signing” Resident notes or making the following statements followed by Signature do not meet the minimum documentation requirements are not acceptable: • “Agree with above” • “Rounded, reviewed, agree” • “Discussed with resident, agree” • The Resident documenting the presence/participation of the Teaching Physician is unacceptable • No note by the Teaching Physician

6. Teaching Physician Documentation: For Procedures • Minor Procedures • Defined as taking only a few minutes (5 or less) to complete, and involve relatively little decision making once the need for the procedure is determined. • Majority of Dermatological procedures are considered minor for teaching criteria purposes • TP must be present for entire procedure in order to bill professionally for the service and must document his/her presence

7. Teaching Physician Documentation: E&M + Procedure Two (2) separate teaching attestations required • If teaching physician is involved in E/M and a procedure with the resident • One teaching attestation for the E&M service • One teaching attestation for the procedure

8. Teaching Physician’s Documentation for Minor Procedures • “I performed the entire procedure” or • “I was present for the entire procedure.” • “I was present for all the procedures performed in their entirety.”

9. Good Teaching Attestation ExamplesE&M + Procedure Resident Note: Assessment: Rosacea, chronic and now scarred, severe. Plan: - Due to the fact that the patient cannot obtain isotretinoin for insurance reasons, and has GI intolerance to cyclins, will continue bactrim and metrogel which seem to be helping a little.  - IL TAC 10 0.5cc injected today into rosacea cyst on R cheek.- Otherwise, will try low dose prednisone if needed in the future. RTC in 4 months. Signed by M.D. Resident in Dermatology Dermatology Attending Note: I have personally interviewed and examined the patient and reviewed the findings above with Dr. Resident.  I have confirmed the key elements of the history, physical exam, assessment and plan as noted above.  I was present for the entire duration for each of the procedures documented above. Signed MD (Handwritten note) Electronically Signed MD (LMR note)

10. Procedure Note Needs ImprovementE&M + Procedure Scenario 1: E&M Assessment and Plan + Procedure By Resident:   Multiple actinic keratosis, extremities.  I treated many lesions with cryotherapy 10-second freeze time, one freeze cycle. Wound care discussed. She tolerated the procedure well. I gave her efudex to use twice a day to the affected areas, one area at a time for 2 weeks, i.e. R arm, L arm, R leg, L leg, chest, and upper back. Patient agrees. Attending Addendum I saw and evaluated the patient with Dr. Smith, fellow in dermatology. I agree with the findings and plan of care as documented in the fellow's note. “Many” doesn’t identify how many actually treated. Should also more specifically identify which extremities were treated. No documentation by Attending they were present for entirety of procedures.

11. PA Role:acting only as ScribeDocumentation PA Documentation • PA documents only the work done by the MD (ie: history, exam, assessment, plan, review of pathology) • The word “we” should not be documented in the note since the work is being done by the MD. Using the word “we” gives the impression that some of the work was done by the PA. • PA should state “this was written by PA _______ acting as a scribe for Dr. ________.” Specific names of PA and MD are important. • PA signature line should be located below this statement and prior to the MD statement.

12. PA Role:acting only as ScribeDocumentation MD Documentation • Under the PA signature line, MD should state “The documentation above reflects the work and decisions made by me.” • MD signature line should be below this statement. • MD needs to be electronically sign the note – if this is not electronically signed, the note is not authentic for billing purposes

13. PA Role:PA Providing Face to Face Patient CareShared- Visit Documentation PA Documentation • PA documents only the work he/she performs (ie: history, exam, assessment, plan) • Note should be electronically signed by PA MD Documentation • MD should state towards the beginning of the note “this is a shared visit with PA_______.” • The MD note must clearly document history, exam and decision elements performed by the MD. • “Agree with PA note” is not acceptable – there must be documentation of actual workup done by the MD. • This note should be documented separately and electronically signed by the MD: • As an addendum in LMR after the PA has electronically signed his/her note. • As a separate LMR note.

14. PA Role:PA Providing Face to Face Patient CareBilling - Medicare Split-Billed (Hospital Outpatient Practices) New Patient Visits • Can be a Shared Visit • If Shared can be billed under the PA’s name/# or MD’s name/# • If PA performs new patient visit alone, is billed under PA’s name/# Established Patient Visits – New Problem • Can be a shared visit • If Shared can be billed under the PA’s name/# or MD’s name/# • If PA performs visit alone, is billed under PA’s name/# Established Patient Visits – Follow-Up Established Visit • Billed under the PA’s name/# or MD’s name/# Procedures • Procedures can not be shared. Must be billed under the performing provider name/#

15. Billing Compliance Auditing ProtocolsforMissing, Late Signed or Unsigned Notes Standard for Timely Creation and Signature • Physicians will be held to a singular standard for the creation and final signature of any office visit note to 14 days. • The late attestation process had been completely eliminated effective December 1st, 2012. • Undocumented visits or missing clinic notes will be treated strictly • If, on audit, any provider has one or more missing record, those providers will be re-audited within the next quarter . • If he/she has any missing records upon that second audit, the Department will hold all bills for services of those providers until evidence of adherence to timeliness and authentication standards is achieved.

16. Questions