Students may document services in the patient’s record. However, only the medical student’s documentation of the review of systems and past family/social history can be used to support the service billed by a teaching physician.
When two or more physicians of different specialties provide care that is unique to each of their individual medical specialty and managing at least one of the patient’s critical illness(es) or critical injury(ies) at different times then the initial critical care service (CPT 99291) may be billable by each physician. Additional critical care services provided by another physician within the same specialty can be billed using the add-on code for critical care services (CPT 99292).
Yes. Beginning for services performed on or after September 10, 2013 physicians may use the 1997 documentation guidelines for an ‘extended’ history of present illness (HPI) along with other elements from the 1995 guidelines to document an E/M service.
By signing the ABN prior to the performance of the service or procedure, the beneficiary agrees to have the service or procedure done as a non-covered benefit and to assume financial responsibility for the service or procedure in question. The healthcare organization or provider must obtain a properly executed ABN from the beneficiary before rendering the service or procedure. The beneficiary cannot be billed for the non-covered service or procedure in the absence of a properly executed ABN. Alternatively, the beneficiary may elect not to have the service or procedure done and decline the ABN.
CMS manual has defined an advance directive as a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at future time, should he/she lack decisional capacity at that time. Relevant legal forms include, but not limited to, a Health Care Proxy, Durable Power of Attorney for Health Care, a Living Will and/or completion of a Medical Order for Life Sustaining Treatment (MOLST).
Yes, with the exception being Critical Care (CPT 99291-99292) and Neonatal & Pediatric Inpatient Critical Care (99468-99476) and Initial & Continuing Intensive Care Services (99477-99480). The ACP can be billed on the same day as an office/clinic service.
There are no specific documentation requirements for use of these codes. However, as with all documentation, it must support the provision of ACP services. An example of this is: patient has an end stage chronic illness; will be undergoing an emergent or high risk procedure; and has had a condition change that prompts the need for ACP.
The International Statistical Classification of Diseases and Health Related Problems, 10th revision (ICD-10) is a set of codes for reporting diagnoses and inpatient (I/P) procedures developed by the World Health Organization (WHO). The ICD-10-CM code set allows up to 69,000 distinct, alphanumeric codes for diagnosis reporting, as opposed to only 14,000 numeric codes in previous version (ICD-9). Similarly, the ICD-10-PCS code set increases the number of codes for I/P procedure reporting from 3,000 numeric codes to 71,000 alphanumeric codes.
Comprehensive Error Rate Testing (CERT) is a program developed by Center for Medicare and Medicaid Services (CMS) to produce a national Medicare Fee for Service improper payment rate. CERT review professionals analyze the claim and the supporting documentation to determine whether the claim was paid appropriately according to Medicare coverage, coding, and billing rules.
In AMC (Academic Medical Centers), there are times when a surgical procedure is so complex that it requires multiple surgeons. Generally the expectation is that a resident(s) would be used to assist with the surgery. If no resident(s) are available, the resident(s) available are not sufficiently qualified to provide the needed assistance or the attending physician never uses residents then an attending can be used to assist with the surgery. When billing for such assistant surgeon services, one of the following must be documented in the medical record:
A statement that no qualified resident was available to perform the service
A statement indicating that exceptional medical circumstances exist
A statement indicating the primary surgeon has an across the board policy of never involving residents in the preoperative, operative or postoperative care of his/her patients
Non-physicians, including nurse practitioners and physician assistants and auxiliary personnel, such as registered nurses, technicians and other qualified personnel may provider services ‘incident-to a physician service.
No, the visit does not qualify for ‘incident-to’ services. An initial, problem-focused patient visit (CPT codes 99201-99205) cannot be split or shared between the NPP and the physician in order to bill ‘incident-to’ follow-up visits. The physician must independently see the patient and establish a plan of care for the condition.
The first three components (history, examination and medical decision making) are the key components most often used to select the level of E/M services. An exception to this rule is the case of visits which consist predominantly of counseling or coordination of care and time is the key or controlling factor to qualify for a particular level of E/M service.
Current Procedural Terminology (CPT) defines critical care services as physician’s direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life threatening deterioration of the patient's condition.
A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.
A critical care service is time-based. Time counted towards critical care services may be continuous or intermittent and aggregated in time increments on a given day. The total time that critical care services are provided must be documented.
CPT code 99291 is used to report the services of a physician providing full attention to a critically injured patient from 30-74 minutes on a given date.
CPT code 99292 is used to report additional block(s) of time, of up to 30 minutes, each beyond the first 74 minutes of critical care time.
Critical care of less than 30 minutes total duration on a given date should be reported using the appropriate E/M code such as subsequent hospital care.
The code for the Initial Critical Care Services (99291) may only be reported by one physician in the same group practice if he/she has the same specialty as another physician who also performed critical care services for a patient. The physician billing this code must provide critical care services for at least the minimum amount of time associated with this code in either single session or multiple sessions cumulative throughout the day.
Subsequent critical care visits performed on the same calendar date may represent aggregate time met by a single physician or physicians in the same group practice with the same medical specialty in order to meet the duration of minutes required for CPT code 99292.
Only time spent by the resident and teaching physician together with the patient or the teaching physician alone with the patient can be counted when reporting critical care services. Time spent by the resident, in the absence of the TP, cannot be billed by the TP as critical care services.
Medical record documentation must support:
Time the TP spent providing critical care services
That the patient was critically ill during the time the TP saw the patient
According to the Centers for Medicare and Medicaid Services (CMS), a split/shared Evaluation and Management (E/M) visit is an encounter with a patient in which both the physician and a qualified Non Physician Practitioner (NPP), i.e. Nurse Practitioner, personally perform a substantive portion of the E/M visit face-to-face with the same patient, on the same date of service. The NPP must be in the same group practice or be employed by the same employer.
CPT code 99497 – Advanced care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other healthcare professional; first 30 minutes, face-to-face with the patient, family member (s), and/or surrogate.
CPT code 99498 – each additional 30 minutes.
As a time based code, CPT code 99497, is very clear in stating that it is for the “first 30 minutes.” As the provider, the minimum of 16 minutes or more does entitle you to use code 99497. For code 99498, the minimum required total time would be 47 minutes or more.
The Centers for Medicare & Medicaid Services (CMS) did not establish any frequency limits. However, when these services are billed multiple times for a given beneficiary, there should be a documented change in the beneficiary’s health status and/or wishes regarding his/her end-of-life care. CPT does not have limits on the number of times ACP can be reported for a given beneficiary in a given time period.
Effective January 1, 2016, ACP is an optional element of an Annual Wellness Visit (AWV). If an ACP service is provided on the same day as AWV, the deductible and the coinsurance for the ACP are waived. ACP codes must be billed with modifier 33 (Preventive Services) when performed with AWV (HCPCS code G0438, G0439). If Advanced Care Planning services are provided separately or at the time of other E/M services, the deductible and the coinsurance apply.
The UCLA Health System has an ICD-10 Task Force to help prepare for the transition. The task force will work with various components of the Health System to provide for the transition to ICD-10-CM. There will be more to come from the task force regarding this transition process, training and education and other activities.
The Office of Compliance Services participates in the ICD-10 Task Force and its planning processes to help ensure adherence to ICD-10 reporting guidelines and applicable CMS reimbursement requirements.
An NCD is a determination by the Health and Human Services Department (HHS) and CMS regarding national coverage of a particular service, procedure or item by Medicare. NCDs are binding on all Medicare Administrative Contractors (“MACs”), healthcare organizations and providers, and health maintenance organizations.
According to Medicare Administrative Contractors (MAC), the most common errors that impact Part B (services provided by physicians and non-physician practitioners and certain hospital outpatient departments) reimbursement are:
Missing or invalid information such as:
Incomplete or invalid medical record documentation ( progress notes, discharge summaries, etc.)
Dates of service
Mismatch between patient name and ID number
Practice identifying information
Clinical Laboratory Improvement Amendments (CLIA) certification number
Non-compliance with Teaching Physician (TP) requirements
The provider was not eligible or certified to be paid for the service or procedure on a given date of service
Because government and non-government payers depend on diagnoses codes to determine payment for diagnostic services. Medicare also reviews ICD-9 codes to ensure diagnostic services are consistent with National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) that ultimately define reimbursement practices. The diagnostic information should be specific and pertinent to the diagnostic services ordered.
In the context of Medicare Part B fee-for-service billing, the Centers for Medicare and Medicaid Services (CMS) defines “incident-to” as those services/supplies furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness. Medicare Part B “incident-to” billing is applicable when these services are furnished by a Non-Physician Practitioner (NPP) and billed by the supervising physician. Services and supplies furnished incident-to a physician’s professional services are reimbursed at 100% of the Medicare Physician Fee Schedule (MPFS) rate.
The requirements to bill ‘incident-to’ services are:
The NPP is an employee, contracted employee or contractor of the physician/practice/entity billing for the services.
The patient is seen at doctor’s office/clinic setting (POS 11) and the supervising physician is present in suite.
The physician performs the initial patient visit, creates a care plan and is involved in subsequent services at a frequency that demonstrates active involvement in the patient’s care.
The NPP only provides established patient services. The supervising physician cannot bill ‘incident-to’ services provided by a NPP for a new patient or follow-up visits with an existing patient for a new problem(s).
NPP services rendered ‘incident-to’ a physician service are billed under the supervising physician’s National Provider Identification (NPI) number.
The NPP completes and signs the visit/service note. The supervising (billing) physician can sign the note if he/she chooses to.
Residents and fellows cannot supervise ‘incident-to’ services involving NPPs.
All these requirements have to be met in order to bill an NPP service as ‘incident-to’ under a supervising physician’s NPI for 100% reimbursement of the allowable Part B MPFS. Not meeting any one of these requirements will require the NPP to bill directly and receive only 85% of reimbursement of the allowable MPFS.
If the NPP sees an established patient with a new problem, the NPP should ask the supervising physician to see the patient for the new problem and devise the care plan in order to maintain applicability of incident-to billing under the physician’s NPI. Otherwise, the NPP can address the new problem and the visit is billed under the NPP’s own NPI resulting in 85% reimbursement of MPFS.
Yes, NPPs can bill under their own NPI. Direct billings by NPPs are those services rendered and billed by the NPP. This type of service is allowed in any setting within the NPPs scope of practice and reimbursed at 85% of the MPFS.
CMS considers documentation to be cloned when an entry in the medical record for a patient is worded exactly like or similar to previous entries, or documentation is exactly the same from patient to patient.
Per UC policy, all orders and certain medical record entries must be accompanied by the physician’s identification number (UCLA pager number).
One use of this number is to confirm the identity of the signer. The UCLA pager number affixed after the physician signature should only be the number of the person signing the order or medical record entry.
Yes. Medical students can be scribes. However, anything documented in the capacity of a scribe may not be based on the interaction of the medical student with the patient, i.e. Review of Systems (ROS) and Past Medical, Family and Social History (PFSH). Medical students cannot be assigned scribe duty as part of the medical training.
Yes, The UCLA Code of Conduct addresses this issue under several standards. Here are sample statements:
Supporting medical documentation must be prepared for all services rendered. UCLA Health Sciences personnel shall not bill for services if the appropriate and required documentation has not been provided.
The University’s records shall not contain any false, fraudulent, fictitious, deceptive or misleading information.
It is unlawful to knowingly make false entries in a medical record.
UCLA Health Sciences personnel responsible for coding, billing and documentation should ensure that they are knowledgeable about all University policies and procedures, federal and state regulations regarding those activities.
According to Transmittal 2247 (Change Request 7378) dated June 24, 2011 from the Centers for Medicare and Medicaid Services (CMS):
To support the service provided to the patient by the TP, the TP should document he/she personally saw and participated in the management of the patient. The TP may reference the resident’s note to support the service he/she is billing provided that the patient’s condition has not changed substantially since admission and the TP agrees with the resident’s note.
The TP’s note must include any supplemental information necessary to reflect the change in the patient’s condition and clinical course between the time of admission and when the TP personally saw the patient. The date of service for the TP’s professional service(s) must be the date he/she personally saw and participated in the management of the patient.
When the teaching surgeon is involved in overlapping surgeries where the key portions of the surgery do not overlap, the teaching surgeon must be physically present during the key portions of both procedures. All of the key portions of the first procedure must be completed before the teaching surgeon can become involved in the second procedure.
If the teaching surgeon leaves the operating room to become involved in another case, he/she MUST arrange for another qualified surgeon to be immediately available to intervene in the original case, if necessary. The teaching surgeon MUST document his/her participation of the key portions of both procedures.
The risk in reporting the wrong Place of Service (POS) is the physician or physician group will get overpayments or denials and could be accused of submitting a false claim which could result in monetary penalties and other actions by enforcement agencies. It is critical to report accurately the place of physician services to prevent these risks. Different requirements and possibly payments apply to different places of service. For example, physician professional fees are reimbursed at a higher rate when performed in an office setting to cover the overhead expense incurred by the physician/group.
UCLA Health Scribe Policy defines a scribe as an individual who is present during the provider’s performance of a clinical service and documents on behalf of the physician the clinically relevant findings as directed by the provider during the course of the service. The scribe performs no other function at the time acting as a scribe.
In order for a diagnostic test to be submitted to Medicare/MediCal for payment by the TP, the TP must perform the interpretation of the test results and either:
Document the interpretation himself/herself or
Review the interpretation documented by the resident and add the teaching physician attestation indicating either agreement with the resident’s interpretation as documented or addending any corrections or changes.
The Office of Compliance Services has approved TP attestation templates for use in CareConnect for both Evaluation & Management (E/M) services and procedures/surgeries when residents are involved in the care and treatment of patients and the TP wishes to use the resident’s documentation to support the TP’s billed service. The TP attestation choices can be found in the smart phrase section of CareConnect. Use “.att” to pull up the appropriate phrases.