The University of California Health Sciences Campus System Wide Professional Fee Billing Compliance Plan Guidelines were adopted by The Regents of the University of California for implementation at all University of California Schools of Medicine. In adopting our compliance plan, the School of Medicine at UCLA affirms The Regents philosophy of University compliance with applicable laws, regulations, and University policies that impact professional fee billing.
The UCLA Professional Fee Billing Compliance Program is designed to accomplish the following objectives: (1) to familiarize physicians and non-physician employees involved with professional fee billing about applicable laws, regulations, and University policies regarding professional fee billing; (2) to promote programs and practices designed to provide reasonable assurance that all such individuals and departments will follow such laws, regulations, and policies; (3) to reduce legal and financial risks; and (4) to provide a mechanism for communication concerning compliance.
You can find more information about UCLA Health System's Professional Fee Billing Policy (HS 9100) on this site.
Evaluation and Management Coding Guidelines define the way physicians report and bill for medical services. These guidelines establish what documentation is needed to bill for medical history-taking, physical examinations and medical decision making.
The level of Evaluation and Management Service a physician chooses is based in the documentation and the services provided. The service selected is defined by the:
For more detailed information, please look at the specific links provided through this site.
In order for the teaching physician to bill for the service, the billing physician must document according to the CMS Guidelines for Teaching Physicians, Interns and Residents.
Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The record should chronologically document the care of the patient, and is an important element contributing to the quality of care. The medical record is also considered to be the basis for assessing patient health over time; appropriate utilization review and comparisons, a data source for research and education; a legal document for risk management; and establishes the supporting elements needed for professional fee billing.
As a general rule, physicians must clearly document (in legible handwriting or in a signed dictated note) their presence, and level of participation in the services provided. Medical record documentation should be completed immediately following patient services or within sufficient time to recollect the key portions of the services provided in accordance with regulations following medical staff policies and procedures. Whoever dictates a note, report, or entry, shall sign that note, report, or entry. A medical record is considered a legal document; therefore, handwritten entries must be made in ink and must be legible.
