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SLU Compliance Trainings

The Saint Louis University Office of University Compliance offers seminars and individual trainings on compliance-related issues.

If you would like to request an individual training, contact the Office of University Compliance.

View the Mid-Level Providers Seminar Video

Billers' Meetings

Date Time Location
 
December 11, 2018 10 a.m. Law Clinic Annex
January 8, 2019 10 a.m. Law Clinic Annex
February 12, 2019 10 a.m. Law Clinic Annex
March 12, 2019 10 a.m. Law Clinic Annex

 


Fraud, Waste, and Abuse Training Modules

The Office of University Compliance has now made various training modules available for your review.  Click on the title to view the PDF.

FAQs

Physician Billing

What are common billing terms?
  • Physician: A teaching or attending physician is a licensed provider who involves residents in the care of his or her patients. Generally, for the service to be payable under the Medicare PFS, he or she must be present during all critical or key portions of the procedure and immediately available to furnish services during the entire service.
  • Non Physician Provider (NPP):  CMS defines the Advanced Practice Nurse (APN) as a professional licensed medical staff who is allowed, under both state and federal law, to practice medicine under the supervision of a collaborating physician. These APN’s include other practitioners such as advanced practice registered nurses (APRN) and physician assistants (PA), Nurse practitioners (NP), Clinical nurse specialists (CNS), Certified registered nurse anesthetists (CRNA), Certified nurse-midwives (CNM), Clinical social workers (CSW), Clinical psychologists (CP), Registered dietitians (RD) or speech therapists (SLP), and other non-physician practitioners on the medical staff.

Housestaff

  1. An intern or resident is an individual who participates in an approved GME Program or a physician who is not in an approved GME Program, but who is authorized to practice only in a hospital setting (for example, has a temporary or restricted license or is an unlicensed graduate of a foreign medical school). A resident is an intern, resident, or fellow who is formally accepted, enrolled, and participating in an approved medical residency program including programs in osteopathy, dentistry, and podiatry as required to become certified by the appropriate specialty board.
  2. A fellow is a physician who has completed their residency and elects to complete further training in a specialty. The fellow is a fully credentialed physician who chooses to pursue additional training, in the fellowship.  This additional training is optional is not required to practice medicine, but is necessary for training in a subspecialty.

Trainees

  1. A medical student is an individual who participates in an accredited educational program (for example, medical school) that is not an approved GME Program and who is not considered an intern or resident. Medicare does not pay for any services furnished by these individuals.
  2. A fellow is a physician who has completed their residency and elects to complete further training in a specialty. The fellow is a fully credentialed physician who chooses to pursue additional training, in the fellowship.  This additional training is optional is not required to practice medicine, but is necessary for training in a subspecialty.

Patient

  1. new patient is considered new to a specialty group (i.e. cardiology, internal medicine, etc.) only once within a three-year period. A claim for a new patient visit may be submitted once by the group within a three-year period; this visit may be performed and billed by either a physician or a non-physician provider member of the group, but may not be submitted by both group members.
  2. An established patient is defined as Individual who has received any professional services, E/M service or other face-to-face service (e.g., surgical procedure) from a provider or another provider (same specialty or subspecialty) in the same group practice within the previous three years.

Other Terms

  1. A medical scribe is a trained medical paraprofessional who specializes in charting physician-patient encounters in real-time during medical examinations, patient encounters. SLUCare’s Scribe Policy requires the scribe to be signed into the electronic medical record under the approved scribe security template. Scribed documentation must clearly support the name of the scribe, the role the individual documenting the service and the provider of the service.  The scribed documentation must be authenticated by the provider.
  2. A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). The NPI has replaced the unique provider identification number (UPIN) as the required identifier for Medicare services, and is used by other payers, including commercial healthcare insurers.
  3. Scope of practice describes the procedures, actions, and processes that a healthcare practitioner is permitted to undertake in keeping with the terms of their professional license. The scope of practice is limited to that which the law allows for specific education and experience, and specific demonstrated competency. Each state and/or jurisdiction has laws, licensing bodies, and regulations that describe requirements for education and training, and define scope of practice.
  4. Collaborative Practice Agreement is a written statement that defines the joint practice of a physician and an advanced practice nurse (APN) in a collaborative and complementary working relationship. It provides a mechanism for the legal protection of the APN and sets out the rights and responsibilities of each party involved. All APNs, regardless of practice setting, should be knowledgeable about aspects of a collaborative practice agreement before they sign one.
  5. A teaching hospital is a facility where residents train in an approved GME Residency Program in medicine, osteopathy, dentistry, or podiatry.
  6. Centers for Medicare and Medicaid Services (CMS): In 1965, President Lyndon B. Johnson signed into law legislation that established the Medicare and Medicaid programs. CMS has been providing health and wellness to millions of American families ever since it’s inception. Though Medicare and Medicaid started as basic insurance programs for Americans who didn’t have health insurance, they’ve changed over the years to provide more and more Americans with access to the quality and affordable health care they need. Since this is a program paid for by the American tax payer, the government sets regulations to be followed and monitors participants in the program to prevent fraud and abuse.
What are common documentation and billing terms?
  1.  Physically Present Requirement is an expectation that the teaching physician is located in the same room as the trainee and patient (or a room that is subdivided with partitioned or curtained areas to accommodate multiple patients) and/or performs a face-to-face service.
  2.  Primary Care Exception is a billing exception within an approved GME Program that applies to limited situations when the resident is the primary caregiver and the faculty physician sees the patient only in a consultative role (that is, those residency programs with requirements that are incompatible with a physical presence requirement). In such programs, it is beneficial for the resident to see patients without supervision to learn medical decision making. Medicare may grant a primary care exception within an approved GME Program in which the Department is paid for certain E/M services the resident performs when the teaching physician is not present. The services furnished in a primary care exception center must be located in the outpatient department of a hospital or another ambulatory care entity, such as a Resident Clinic, where the time spent by residents in patient care activities is included in determining Direct GME payments to a teaching hospital.
  3.  A Sensitive Note contains sensitive information that is defined as data that is protected against unwarranted disclosure. Access to sensitive information should be safeguarded. Protection of sensitive information may be required for legal or ethical reasons, for issues pertaining to personal privacy, or for proprietary considerations.  Psychotherapy notes would be examples of “sensitive notes”.
  4.  Valid Attestation Statement is the act of verifying a document and bearing witness to its authenticity, by signing one's name to it to affirm that it is genuine. In order for an attestation statement to be considered valid for Medicare medical review purposes, the statement must be signed and dated by the author of the medical record entry and contain the appropriate beneficiary information.
  5. The Medical Necessity of a service is the overarching criterion for payment. Do not submit a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which the service is submitted. Select the code for the service based upon the content of the service. The service furnished and submitted must meet the definition of the code.
How do I close an encounter when a provider resigns?
The University has an offboarding process that is required when a provider resigns. This process requires providers to close all of their patient encounters. Administratively closing an encounter happens, in the very rare instances, as medical leave or death. In these unfortunate instances, a mechanism to close these encounters was required. These encounters are not billable, except for the possible exception of an ancillary service where documentation does exist to support the claim that was originally authorized by the provider but, performed in a separate department. When an encounter must be administratively closed, the provider tasked with this duty (typically, the Department chairman or section leader) should amend their attestation statement to reflect that they are acting in a strictly administrative capacity and are unable to offer comment on the original provider’s findings, clinical judgment or care plan.
Is time spent in consultation with the patient’s family billable?
 In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental disorder or comatose, the physician may contact relatives and close associates to secure back ground information to assist in diagnosis and treatment planning. When a physician contacts the relatives and associates for this purpose, the provider my bill for the time spent counseling and coordinating care of the patient.  In some cases, the physician will provide counseling to members of the household. Family counseling services are covered only where the primary purpose of such counseling is the treatment of the patient’s condition. 
Can copy-paste be used in documentation of patient encounters?
In 2018, SLUCare revised our Billing and Reimbursement Compliance Policy to prohibit copy, paste, or cloned documentation within the medical record. The CMS expectation is that the medical record must contain documentation showing the difference and the needs of the patient for each visit or encounter. It is unacceptable for multiple encounter notes within a patient’s medical record to be identical except for the date of service, as the notes should reflect what actually occurred during each visit. There are infrequent times when copying forward information is efficient, for example, copying a medical device number, an extensive medication list, or a difficult spelling. To further support the need to copy forward information, the provider is encouraged to note, “I have copied Mr. Brown’s medication list, reviewed and updated it. This list is accurate as of today’s visit.”
What is critical portion or key portion of service?
The part or parts of a service the teaching physician determines are a critical or key portion.
Which date of service should be used when documentation dates differ between the teaching physician and the residents/medical students?

SLUCare has recently adjusted the SmartText Attestation to include a reference to the date of service.   This change is necessary to avoid confusion in the frequent instances where a teaching physician documents at a later date than a resident or medical student, such as a subsequent morning.  To protect the integrity of the author’s documentation and to prevent the charge from being unnecessarily down-coded or written off, the text will now include an explicit date of service on every note.

Which codes should be used for the last patient exam prior to discharge?

 The last patient exam, discussing the hospital stay, instructions for ongoing care as it relates to all pertinent caregivers, as well as preparing the medical discharge records, prescriptions, and/or referrals as applicable. Time reported should be for the total duration of time spent by the provider even when the time spent on that date is not continuous. For hospital discharge duration of 30 minutes or less, report 99238; for duration of greater than 30 minutes, report 99239. It is only necessary to state the time, either total time spent or from ____ to ____, when billing 99239. If time is not documented, the 99238 code should be billed.

When providing an E/M visit and a procedure on the same day (modifier 25) is it necessary that each have a different diagnosis code?

No.  In many instances the diagnosis code referenced for the E/M service is different from the diagnosis code referenced for the procedure (that is, two different medical conditions). Example: A patient is seen for a scheduled follow-up visit for hypertension and complains of a sore shoulder. After evaluation of the blood pressure and the shoulder, a diagnosis of bicipital tendonitis is made, and the shoulder is injected. In this case, the appropriate E/M code for the level of service provided, as well as the procedure for injection, should be submitted. In some instances, however, the diagnosis code referenced for the E/M service and the procedure are for the same condition or illness, Example: A patient complains of a sore shoulder. After evaluation of the shoulder, a diagnosis of bicipital tendonitis is made, and the shoulder is injected. In this case, the appropriate E/M code for the level of service provided, as well as the procedure for injection, should be submitted.

Can you report an E/M visit at the time of a wellness visit?

 Yes. The E/M visit should be separate from the wellness visit.  If the physician treats and documents an acute or chronic problem during the same encounter as a wellness visit, bill for both.  If the patient’s condition is not stable, or there is an acute problem, report the E/M visit separately. The E/M visit should contain a chief complaint, HPI, Exam and assessment and treatment plan. The treatment plan should show either a change in treatment or a plan to monitor the condition.

Can any physician use emergency room codes?

Yes, any physician seeing a patient registered in the emergency department may use emergency department codes 99281 – 99285 (for services matching the code description). It is not required that the physician be assigned to the emergency department.

Is "Incident-To" billing (split shared billing) allowed?

No. SLUCare recently revised our Billing and Reimbursement Compliance Policy to prohibit billing Incident To services. “Incident To” is the scenario in which an M.D. and a non-physician provider (NPP) from the same provider group each perform individual E/M services for the same patient on the same calendar day. CMS previously allowed these visits to be combined and reported as a single service under the M.D.’s identifier if certain criteria were met and appropriately documented. As of 9/15/2018, CMS no longer allows inpatient split-shared billing.

What is “linking to a note” and how is it documented?

 The combined entries in the medical record by the attending physician and the resident or medical student constitute the documentation required for the service.  Together the documentation must support the medical necessity of the service. Documentation by the resident or medical student of the attending’s presence and participation is not sufficient to establish such presence and participation.

  1.  Linking to a resident's note: “I have seen and examined the patient with the resident. I agree with the findings and plan of care as documented by the resident." Date of residents note: ___. Signed and dated by the attending physician.
  2. Linking to a medical student's note: "I have verified the documentation in the medical students note, including all history, exam and medical decision making details. I have personally performed a physical exam and have personally reviewed the data to support my medical decision making as outlined in the medical students note, and I arrive independently at the same conclusion." The medical student should perform the patient’s exam in the physical presence of a resident or the attending physician.
  3. Linking to both a resident and a medical student’s note: “I saw and examined the patient with both the medical student and the resident. I have verified all the details of the medical students note and agree with the resident’s documentation” Signed and dated by the attending physician.
  4. Linking to a residents note on a different date of service then attending: “Patient seen and examined on date of service_____. I have reviewed the resident's note dated _________. I have discussed this patient and his note with the resident and confirm his findings as documented.”  Signed by the attending physician.

It is expected that if the attending does not agree with specifics of documentation, he/she would write “Patient seen and examined with the resident. I agree with the resident’s documentation except for ___________. I have discussed this with the resident.” Signed by the attending physician.

Can the teaching physician use medical student documentation or must he/she re-document?

Any contribution or participation of a medical student in the performance of a billable service must be performed in the physical presence of a teaching physician or physical presence of a resident. Students may document services in the medical record. The teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed. As of 3/5/2018, the teaching physician may verify any student documentation or findings for components of E/M services included in the medical record rather than re-documenting the work.

What does the scope of practice for an NPP (Non Physician Provider) include?

A health care professional licensed to provide healing services that complement or supplement those provided by a physician. CMS Non-Physician Practitioner definition: Anesthesiology Assistant (AA), Audiologist, Certified Nurse Midwife (CMN), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Clinical Social Worker (CSW),  Nurse Practitioner (NP), Occupational Therapist (OT) in Private Practice,  Physical Therapist (PT) in Private Practice, Physician Assistant (PA), Psychologist, Clinical, Psychologist billing independently, Registered Dietician (RD) or Nutrition Professional, Speech Language Pathologist. Non Physician Providers are expected to bill for their services under their own NPI number.

Does the collaborating physician have to review all of the NPP’s records?

No, only 10% of the NPP’s records have to be reviewed, 20% if the NPP is prescribing controlled substances.

Does the collaborating physician have to be the one reviewing the records, or can the delegating physicians assist in the process?

A percentage of the NPP’s records have to be reviewed every two weeks.  A rotation can be put into place for collaborating and delegating physicians according to your agreement and departmental needs.

Must I have different diagnosis codes when billing an E/M and a procedure (using the 25 modifier) on the same visit?

In many instances the diagnosis code referenced for the E/M service is different from the diagnosis code referenced for the procedure (that is, two different medical conditions); Example: A patient is seen for a scheduled follow-up visit for hypertension and complains of a sore shoulder. After evaluation of the blood pressure and the shoulder, a diagnosis of bicipital tendonitis is made, and the shoulder is injected. In this case, the appropriate E/M code for the level of service provided, as well as the procedure for injection, should be submitted. In some instances, however, the diagnosis code referenced for the E/M service and the procedure are for the same condition or illness; Example: A patient complains of a sore shoulder. After evaluation of the shoulder, a diagnosis of bicipital tendonitis is made, and the shoulder is injected. In this case, the appropriate E/M code for the level of service provided, as well as the procedure for injection, should be submitted.

Does the release of psychotherapy notes require special authorization?

Psychotherapy and/or sensitive notes are the personal notes of a mental health care provider documenting or analyzing the contents of a counseling session, that are maintained separate from the rest of the patient’s medical record. See 45 CFR 164.524(a)(1)(i) and 164.501. 

Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. This documentation is put into a regular progress note that can be accessed by ancillary personal.

Keeping in mind that the psychotherapy note is separate from the rest of the individual’s medical record, patients do not have access rights to this documentation.  The provider is not prohibited from releasing psychotherapy notes, although the Privacy Rule requires a covered entity to obtain a patient’s authorization prior to a disclosure of psychotherapy notes for any reason, including a disclosure for treatment purposes to a health care provider other than the originator of the notes. See 45 CFR 164.508(a)(2)

SLUCare’s HIM requires review and approval by Psychiatry before releasing a psychotherapy note and always requires a signed authorization specific for any psychotherapy notes.

Can the attending bill for a hospital admit by a resident, if so what date would be used?

In the scenario where the resident admits a patient to the hospital and the attending is called to ok the admission and give orders for the patient’s care, if the attending physician sees the patient within the next 24 hours, takes the history and performs an examination, yes, the attending can bill for the admission. It should be charged on the day the attending actually saw the patient. The CPT description of the hospital admission (99221-99223) requires that the physician is to complete a history and an examination. Even if the resident is the one to admit the patient, the attending cannot code the admission until he/she has had a face-to-face encounter with the patient. In this case, it would be the next day (within the next 24 hours.) CMS Medicare Claims Processing Manual. If the attending see’s the patient later than 24 hours, the attending physician can bill the service weighted solely on the attending physician documentation. If the attending physician documentation does not support a initial hospital care charge, then he/she would report a subsequent hospital care code 99231-99233.

Are SLUCare added standards still required?

SLUCare has recently discontinued the institutional expectation for additional documentation from teaching physicians linking to a resident’s note. Years ago we implemented the “Added Standards Guidance” which required a teaching physician to comment on three out of three key components (history, exam, medical decision making) for a new patient, and two out of three key components for an existing patient. The added standards are no longer required to bill E/M services, as they go above and beyond CMS requirements and cause unnecessary confusion among billers, coders, and providers.

What are teaching physician billing rules, and where can I find additional information about them?

The teaching physician rules describe a payment method by which Medicare pays an attending physician or teaching physician for services performed jointly with an intern, resident or fellow, in an approved graduate medical education program. 

Learn More

Can I report an E/M visit at the time of a wellness visit?

The E/M visit should be separate from the wellness visit. If the physician treats and documents the acute or chronic problems during the same encounter as a wellness visit, you may bill for both. If the patient’s condition is not stable, or there is an acute problem, report the E/M visit separately. The E/M visit should contain a chief complaint, HPI, Exam and assessment and treatment plan. The treatment plan should show either a change in treatment or a plan to monitor the condition.

 

Where to Get Help

How can I obtain help with documentation?

 If you have questions about documentation required to report a service, SLUCare has developed a help line and email address for billing and coding questions. During normal business hours, a coding supervisor is available to answer your coding questions 314-577-5613. In the event that you have coding questions during the off hours, you may leave a detailed message with your question. The coding supervisor will respond to you as soon as possible the next business day or you may email the coding help desk and medialcoding@health.slu.edu.

Where can I find help with EPIC?

Log in to slu.service-now.com with your SLU username and password. Choose from the self-service menu: “Knowledge,” select the “SLUCare Clinical IT Training Library.”

How do I access IT Training Help?

 

Visit IT Services, click the link under “The Self-Service Portal,” log in and proceed.
Who do I report security and privacy incidents to?
  1. Information Security Team at 314-977-5499 or infosecurityteam@slu.edu.
  2. Privacy Officer at  314-977-5545 or HIPAA@health.slu.edu.
How do I report compliance concerns?
A toll-free Compliance Hotline is available 24 hours a day, seven days a week. The calls are answered by a trained interview specialist who is not directly affiliated with Saint Louis University. Callers may remain anonymous and are protected from discrimination, retaliation and intimidation through stringent University policies. Contact them at 877-525-KNOW or 877-525-5669.

 

Laws and Regulations Pertient to Physician Billing

What is HIPAA?

 This acronym stands for the Health Insurance Portability and Accountability Act, a U.S. law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

What is the Stark Law?

The Stark Law is similar to the Anti-kickback Statute, but applies only to physician relationships with entities that bill Medicare or Medicaid (CMS). The Stark Law bans certain financial arrangements between a referring physician and a covered entity that bills the Medicare or Medicaid programs.

 A financial relationship is an invested interest in, or a compensation arrangement with, another entity. An ownership or investment interest may be through equity, debt, or other means. A compensation arrangement is generally defined as any arrangement involving any remuneration between a physician (and/or their immediate family member) and an entity.

Stark Law prohibits payments for certain designated health services provided through a prohibited referral, and requires refunds for improperly billed and collected amounts. It permits CMPs (up to $15,000 per service) and exclusion from government programs when a provider submits an improper claim known, or should have been known, to have been provided through a prohibited referral, and has not refunded the payment. Physicians who violate the statute may be subject to additional fines per prohibited referral

What is the False Claims Act?

The False Claims Act (31 U.S.C. §§ 3729-3733) prohibits anyone from “knowingly” submitting false or fraudulent claims for payment, or engage in misconduct involving federal government money or property. The FCA in healthcare context imposes civil liability on persons who knowingly submit a false or fraudulent claim, which may include billing for services not rendered, billing for unnecessary medical services, double billing for the same service or equipment, or billing for services at a higher rate than provided (“up-coding”). A mere mistake, which can be remedied by returning overpayments, does not result in violations of these laws. The Office of Inspector General (OIG) oversees reviewing state FCA laws to ensure compliance with federal financial incentive standards to encourage and facilitate. Penalties for violation of FCA law are calculated through the Civil Monetary Penalty (CMP) law and range between $10,957 to $21,916 for each false claim submitted, plus three times the amount of damages (the amount of the claim).

What is the Anti-Kickback Statute?

Anti-kickback Statute states that it is a felony to knowingly and willfully offer, pay, solicit, or receive anything of value in return for a referral, or to generate reimbursable business under a federal healthcare program. Kickbacks may include bribes and rebates made directly or indirectly, overtly or covertly, or cash. Those found guilty of violating the Anti-kickback Statute may be subject to a fine of up to $50,000 per kick-back, plus three times the remuneration amount, imprisonment for up to five years, and exclusion from federal healthcare program participation for up to one year.

What is Qui tam provision or whistleblower’s law?

The Qui tam (kwee tam) provision allows for people who are not affiliated with the government (i.e., relators, whistleblowers), to file actions on behalf of the government. Persons filing under the Act may receive a portion (usually about 15–25 percent) of any recovered damages.