Department of Radiation Oncology
Billing Compliance Plan
Reviewed December 2011
I. Billing Compliance Administrative Policies and Procedures
1.0 COMPLIANCE ASSURANCE
The Department of Radiation Oncology 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 Radiation Oncology.
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 Radiation Oncology. 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.
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.
5.4.1 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 Radiation Oncology 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 CHART DOCUMENTATION
It is the responsibility of each service provider (attending physician, resident physician, registered nurse, licensed practical nurse, nursing assistant, nurse practitioner, radiation therapist, dosimetrist, and physicist) to properly document, in the appropriate patient chart, all services provided to each patient. All chart documentation shall be appropriately signed or initialed by the service provider.
8.0 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 Teaching Physician 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.
8.1 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.
8.2 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.
8.2.1 Acceptable Documentation. The following are examples of minimally acceptable documentation of three scenarios for E/M encounters in teaching settings.
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.
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."
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."
8.2.2 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.
8.2.3 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).
9.0 RADIATION THERAPY SERVICES
Radiation therapy treatment and treatment-related services shall be documented and signed or initialed by the appropriate service provider according to the guidelines of the American College of Radiology. (See Appendix A for documentation and charge criteria.)
10.0 CONSULTATIONS (INPATIENT OR OUTPATIENT)
10.1 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.
10.2 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.
10.3 Participation and Documentation. Guidelines for Consultations and Teaching Physician participation and documentation are as outlined in Section 8.0.
11.0 CHARGE PROCESSING
11.1 Professional fees will be charged only for those services that are properly documented in the patients' medical records. Responsibilities for charge processing are assigned as follows:
11.1.1 Radiation Therapists - Enter charge information into the department IMPAC computer system on a daily basis for all chargeable simulations, daily treatments and related treatment procedures. (See Appendix A for charge criteria.)
11.1.2 Physics Assistants - Enter charge information into the department IMPAC computer system on a daily basis for fabricated shielding devices. (See Appendix A for charge criteria.)
11.1.3 Dosimetrists and Physicists - Enter charge information into the department IMPAC computer system on a daily basis for all chargeable physics services. (See Appendix A for charge criteria.)
11.1.4 Billing Office Staff - Enter all professional and technical charges into the IMPAC computer system which exports all charges to the Shands Hospital SMS computer system. Technical charges are processed in the Shands Hospital SMS computer system; the professional charges are transferred to the UF Faculty Group Practice EPIC Resolute system for processing.
11.2 Department coding staff shall code all E/M charges in accordance with Section 8.0 and the Teaching Physician Billing Policy, based on the actual dictated or handwritten reports of those services and the level of involvement and participation of the Teaching Physician.
11.3 All charges for radiation therapy treatment and treatment planning services are processed according to the guidelines of the American Society of Radiation Oncology (ASTRO)/American College of Radiology (ACR) Guide to Radiation Oncology Coding.
11.4 Upon completion of the course of radiation therapy, every patient's medical record shall be "closed out" by department coding staff to ensure that all services provided and appropriately documented are accurately charged. Any charges that were entered incorrectly during the course of radiation therapy shall be corrected during this "close-out" process. Each medical record is then audited for completeness and accuracy of charging by a different member of the billing office staff.
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Table of Appendices
Appendix A - Radiation Therapy Services Charge Criteria.
PLEASE SEE THE RADIATION ONCOLOGY DEPARTMENTAL COMPLIANCE OFFICER FOR THESE APPENDICES
Compliance main page Departmental Representative Page College of Medicine home page
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