presentation covers physician practice compliance

November 14, 2014

Prepared for Physician Practice Management Forum

Compliance in the

Physician Practice

2014 Georgia HFMA

Physician Practice Management Forum

Southern Regional Medical Center

November 14, 2014

November 14, 2014


Agenda

• The importance of having a compliance plan

• “60-Day Rule” Environment

• Methods of coding and billing monitoring

• Recent compliance issues in physician coding audits

– Non-Physician Practitioner (NPP) utilization

– ICD-10-CM Crosswalks

– Time-Based Coding

November 14, 2014


Mandatory Compliance Plans

• No longer voluntary

– 2010 Affordable Care Act

• Current Guidance:

– Office of Inspector General Compliance

Guidance

– Federal Sentencing Guidelines for corporate

entities (Chapter 8)

– Use also recent Corporate Integrity Agreements

November 14, 2014


Compliance Plans

• Minimally include:

– Policies and Procedures; Billing and Collections, HIPAA, and OSHA

– Consider vendor contracting, HR, and physician compensation

– Supports due-diligence in the midst of an audit

• Plan with reviews and response = more trust from gov’t

• Otherwise will more likely be penalized more heavily

• Typically 1.5x overpayment in self-disclosure, less likely other penalties

November 14, 2014


Methods of Coding

and Billing Monitoring

• Audit schedules

– The 10 chart review

– Data analytics

– Not more than you can do

– Budget planning

• Provider expectations and disciplinary plan

– Set up to win

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“60-Day Rule” Environment

• Recent case against Mount Sinai Health

System

• ACA guidance ambiguous

• Response to findings is the focus

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Response to Complaints

• Are you creating a whistleblower?

• Could be a misunderstanding

• Complaints must be vetted

• Plan for audit and repayment activity

• An effective Compliance Plan is active in

identifying risks and errors and resolving

them

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Hospital versus Physician Practice

• Noted differences in how hospitals and practices

are auditing and monitoring

• High level of risk management

Detection

• Identify potential issue

• Review and confirm issue exists

Response

• Confirm overpayment or extent of error

• Refund overpayments with or without self-disclosure

Monitoring

• Education

• High frequency audit and monitoring of focus area

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Demonstrating a Commitment to

Compliance for Small Organizations• 2.(C)(iii) Small Organizations.—In meeting the requirements of this guideline, small

organizations shall demonstrate the same degree of commitment to ethical conduct and

compliance with the law as large organizations. However, a small organization may meet

the requirements of this guideline with less formality and fewer resources than would be

expected of large organizations. In appropriate circumstances, reliance on existing

resources and simple systems can demonstrate a degree of commitment that, for a large

organization, would only be demonstrated through more formally planned and implemented

systems.

• Examples of the informality and use of fewer resources with which a small organization

may meet the requirements of this guideline include the following: (I) the governing

authority's discharge of its responsibility for oversight of the compliance and ethics program

by directly managing the organization's compliance and ethics efforts; (II) training

employees through informal staff meetings, and monitoring through regular "walk-arounds"

or continuous observation while managing the organization; (III) using available personnel,

rather than employing separate staff, to carry out the compliance and ethics program; and

(IV) modeling its own compliance and ethics program on existing, well-regarded compliance

and ethics programs and best practices of other similar organizations. (Federal Sentencing

Guidelines, 2014)

November 14, 2014


Recent compliance issues

in physician coding audits

• Non-Physician Practitioner (NPP) utilization

• ICD-10-CM Crosswalks

• Time-Based Coding

November 14, 2014


NPP Utilization –

Georgia Rules and Laws

• Advance Nurse Practitioner Protocol Requirements

• Physician Assistant Protocol Requirements

Common Risk

• Physician used as Nurse Practitioner

• NPP utilized beyond scope delegated

• Private payer supervision requirements typically

default to State guidance

– Some will reference Medicare guidance

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“Other Qualified Healthcare

Professional”

• A “physician or other qualified healthcare professional” is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional services. These professionals are distinct from “clinical staff.” A clinical staff member is a person who works under the supervision of a physician or other qualified healthcare professional, and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specific professional service, but does not individually report that professional service. Other policies may also affect who may report specific services.

CPT Coding Guidelines, Introduction, Instructions for Use of the CPT Codebook

November 14, 2014


Professional Services –

Supervision vs. Incident to

• Supervision:

– Most private payers allow NPPs to provide professional services under State supervision guidelines and bill under their number

• Professional service provided Incident to a physician is a Medicare provision

– Not recognized by Georgia Medicaid

– Not recognized in the hospital setting

• Includes Outpatient Department of the Hospital = Provider-based Clinics

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Incident to vs. Shared Visit

• Medicare provision

• Office Setting

• Hospital Setting

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• Office Setting

– Incident to

• NPP provides services to an established patient with established diagnoses without the physician = Bill under Physician

– Shared Visit

• NPP provides services during the same date of service as a physician

– Visit meets incident to guidelines = Bill under Physician

– Visit does not meet incident to guidelines = Bill under NPP

November 14, 2014


Professional Services -


• Hospital Setting

– Shared Visit

• Documentation should reflect the services of two

providers on one date of service

• Cahaba GBA silent on requirements

• Some carriers requiring a “substantial portion”

threshold

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NPP Utilization –

Insurance Payer Credentialing

• Non-credentialed providers and Medicaid

• Clinical staff providing professional services;

E/M services

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General Medical Record Documentation

• Methods

– Handwritten

– Scribe

– Dictation (Dictaphone, Dragon)

– EHR

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Templates

• Overall

– Treated as a checklist

• Handwritten

– Checkboxes

• Scribe

– Knowledgebase

• Dictation (Dictaphone, Dragon)

– Errors

– Conflicts

• EHR

– Dictation/Scribe/Dragon

– Over-documentation

– Conflicts

– Copy/Paste

November 14, 2014


Electronic Health Record

Documentation

Copy Forward

– Limit sections that can be copied forward in

system

– Select ROS and Exam elements that are

pertinent positives and negatives performed

– Select diagnoses assessed during that encounter

– Ensure all documentation is current or dated and

not conflicting from one section to the next

November 14, 2014


General Medical Record Guidelines

• Documentation

– Should Be Complete and Legible

• Handwritten: Office or Facility with no EHR

• EHR: Missing required elements (ROS, Signature)

– The documentation/note/record for each date of service should support (alone or by reference) the CPT and ICD-9-CM codes reported on the claim form or billing statement.

• Dictation and EHR templates missing DOS

• DOS not dictated

November 14, 2014


General Medical Record Guidelines

• Documentation should Include:

– Reason for encounter and relevant history

– Physical examination findings and prior diagnostic test results

– Assessment, clinical impression, or diagnosis

– Plan for care

– Date and legible identification of the observer (handwritten or electronic signature; no stamps)

– Rationale for ordering diagnostic and other ancillary services

– Past and present diagnoses

– Appropriate health risk factors

– The patient's progress, response to and change in treatment, and revision of diagnosis

November 14, 2014


ICD-10-CM is here

• Payment is increasing link to the diagnosis

and complexity of the visit and accurate

documentation related

– Medicare Advantage plans, risk-based payment

– Good outcomes

– PQRS/P4P

• Include ICD-10 in 2015 audit and training

plan for diagnosis coding and documentation

November 14, 2014


ICD-10-CM Risk

• Language from ICD-10 descriptions used in

place of ICD-9 descriptions in the medical

record

• ICD-9 crosswalks are inaccurate based on

documentation

• ICD-9 crosswalked to an unspecified code

November 14, 2014


ICD-10-CM Risk Mitigation

• Confirm all diagnoses selected are accurate

and supported in the record

• Provide education and resources to providers

and staff

• Confirm an understanding of correct

utilization of ICD-10-CM codes prior to

October 1, 2015

November 14, 2014


Time-Based Coding

• Time may be the key or controlling factor to qualify the use of a particular E/M service provided certain conditions have been met

• Necessary Criteria

– Counseling and/or coordination of care dominates (more than 50%) the patient encounter

– Applies to E/M services only

– Must be face-to-face time in office; floor time in the hospital or nursing home setting

– Documentation supports counseling/COC

– Documentation of total visit time and time spent in counseling or coordination of care

November 14, 2014


Time: Risk

• Using time as a work-around to documenting

• Combining E/M time with the time spent

performing other procedures/services

– Psychiatric codes

• Not documenting time

– Assuming time captured in EHR

– Too difficult to keep up with

November 14, 2014


References

• Office of Inspector General Compliance Guidance

– https://oig.hhs.gov/compliance/compliance-guidance/compliance-resource-

material.asp

• Federal Sentencing Guidelines, Chapter 8, §8B2.1. Effective Compliance

and Ethics Program

– http://www.ussc.gov/guidelines-manual/2014/2014-chapter-8

• ICD-10-CM Manual

• 2010 Affordable Care Act

• Georgia Composite Medical Board

• http://medicalboard.georgia.gov/frequently-asked-questions-professionals

https://oig.hhs.gov/compliance/compliance-guidance/compliance-resource-material.asp

http://www.ussc.gov/guidelines-manual/2014/2014-chapter-8

http://medicalboard.georgia.gov/frequently-asked-questions-professionals

November 14, 2014


Questions?

November 14, 2014


Thank You!

Valerie Rock, CHC®, CPC®, ACS-EM

Pershing Yoakley & Associates, P.C.

(404) 266-9876

[email protected]

www.pyapc.com