Transcript Evaluation & Management (E/M) Services

UB School of Medicine & Biomedical Sciences
Faculty Practice Management Plan
Introduction
to Fraud & Abuse
2005
© Brigid M. Maloney, J.D., Compliance Officer
Overview
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Fraud Awareness
Medical Record Basics
E/M Documentation & Coding
Fraud Awareness
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Who Investigates Fraud?
Federal Laws and Regulations
Fines & Penalties
Billing Fraud
Unlawful Kickbacks
Stark/Prohibited Self-Referrals
Who Investigates Fraud?
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Centers for Medicare & Medicaid Services
Office of the Inspector General
Federal Bureau of Investigation
Department of Justice
U.S. Attorneys Offices
State Attorney General Offices
State Medicaid Fraud Control Units
US Postal Service
Managed Care Organizations
Intermediaries and Contractors of CMS
Private Insurance Companies
Qui Tam relators/whistleblowers
Federal Laws & Regulations
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Civil False Claims Act
Criminal False Claims Act
False Statements Act
Mail/Wire Fraud Act
Racketeer Influenced & Corrupt Organizations
Act (RICO)
Anti-kickback Statute
Stark Laws
HIPAA
Fines & Penalties
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Jail time
$$$
Revocation of provider i.d. number
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can’t diagnose, treat, prescribe medications to
patients whose care is paid for by federal
program(s)
Barred from employment with provider who
participates in federal program(s)
Billing Fraud
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Upcoding
Billing for services not rendered or provided as
claimed
Submitting claims for equipment, supplies or
services that are not medically necessary
Billing for non-covered services as if covered
Clustering/Assumption billing
Falsification of documents
Anti-kickback Law
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Prohibition against making payments in return for
patient referrals or to induce the purchasing or leasing of
equipment or services paid for by federal programs.
Includes kickbacks, bribes, etc.
Purpose of the law:
address government concerns over additional cost
loss of patient choice
factors other than quality driving decision making
competition
exercise of professional judgment.
Anti-kickback Law
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Exceptions/Safe Harbors
price discounts that are properly disclosed
and reflected in costs claimed for
reimbursement
payments made to bona fide employees
certain group purchasing vendor agreements
copayment waivers for indigent patients
Stark Law:
Prohibition Against Self-Referrals
Physicians are prohibited from referring
patients to “designated health services” to
entities in which they (or an immediate
family member) have a financial
relationship.
Stark Law:
Prohibition Against Self-Referrals
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Designated Health Services:
laboratory services
- prosthetics/orthotics
physical therapy
- home health svcs
occupational therapy - outpt. prescriptions
radiology
- inpatient/outpatient
radiation Therapy
hospital services
DME & supplies
- nutrients, equipment & supplies
Stark Law:
Prohibition Against Self-Referrals
Exceptions/Safe Harbors:
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Space/Equipment Rentals
Bona fide employment relationships
Personal service/independent contractors
Recruitment incentives
Fair market value payments for items and services
Nonmonetary compensation up to $300
Medical staff incidental benefits
Stark Law:
Prohibition Against Self-Referrals
Threshold Questions:
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Does this arrangement involve a referral of a Medicare
or Medicaid patient by a physician or an immediate
family member of a physician?
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Is the referral for a “designated health service”?
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Is there a financial relationship between the referring
physician or family member and the entity to which
the referral is being made?
Case #1
A physician group that refers many
Medicare patients to various community labs for
lab work have decided to open a lab of their own.
The plan was simple: operate an off-site lab,
refer all their patients to that lab, and enjoy
the profits from all of the business they refer to
their lab.
Unlawful referral arrangement?
Case #2
After being advised by their attorneys that
such a venture was prohibited under the
Stark laws, the same physicians decided
instead to open a lab in their spouses’
names, so they would not be implicated in
the self-referrals.
Unlawful referral arrangement?
Case #3
Dr. Jackson is employed part time as the medical
director at the UMC hospital. His job duties were described
in a 3-year employment agreement that he signed when he
was hired. He is paid a set salary of $50,000 which does not
change, regardless of the number of private patients he
refers to UMC each year. Dr. Jackson also treats patients at
a private office with three partners. Dr. Jackson routinely
refers a very large number of his patients to UMC’s
outpatient physical therapy department for treatment.
Unlawful referral or kickback?
Case #4
A physician received a research grant from a
pharmaceutical company. The grant provided for
substantial cash payments to the physician in
exchange for administering the drug company’s
product to patients and keeping brief notes about
the treatment outcome. Upon completion of a
limited number of these studies, the physician
received payment from the pharmaceutical company.
Unlawful kickback?
Medical Record Basics
The medical record facilitates:
- ability of physician and other health care professionals to
evaluate and plan the patient’s immediate treatment, and to
monitor his/her health care over time;
- Communication and continuity of care among physicians and
other health care professionals involved in the patient’s care;
- Accurate and timely claims review and payment;
- Appropriate utilization review and quality of care evaluations;
- Collection of data that may be useful for research and
education.
Medical Record Basics
Principals of Medical Record
Documentation:
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Record should be complete & legible
Documentation for each patient encounter should
include—
a. chief complaint, history, exam findings, prior
diagnostic test
results,
b. assessment, clinical impression or diagnosis,
c. plan for care, and
d. date & legible identity of the observer.
Medical Record Basics
Principals of Medical Record
Documentation, cont’d:
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If not documented, the rationale for ordering
diagnostic and other ancillary services should be easily
inferred.
Past & present diagnosis should be accessible to the
treating and/or consulting physician.
Appropriate health risk factors should be identified.
The patient’s progress, response to, and changes in
treatment, and revision of diagnosis should be
documented
Medical Record Basics
What Third Party Payors are Looking For:
- site of service
- medical necessity and appropriateness
of the diagnostic and/or therapeutic
services provided
- that services provided have been
accurately reported
Medical Record Basics
Evaluation & Management (E/M) Services:
HCFA (now CMS) released documentation
guidelines for E/M services in 1995 and 1997
to ensure accuracy in E/M code selection by
physicians.
Medical Record Basics
Evaluation & Management (E/M) Services:
What are E/M services?
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non-procedural services such as listening, counseling,
and educating
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patient visits in offices, hospitals, and nursing homes
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consultations
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certain emergency room and critical care services
Medical Record Basics
Evaluation & Management (E/M) Services:
CPT codes are assigned to E/M services
based on the level of skill, effort, time,
responsibility, and medical knowledge
that is required in each encounter.
This level is determined by the physician’s
notes and other information contained in
the medical record.
Medical Record Basics
Evaluation & Management (E/M) Services:
Document properly and thoroughly
so you can get paid for the work you
performed and avoid allegations of
fraudulent billing.
IF IT ISN’T DOCUMENTED, IT DIDN’T
HAPPEN
Medical Record Basics
Evaluation & Management (E/M) Services:
Documentation that ensures reimbursement
adequate for the level of service you provided
includes:
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Patient History
Examination
Medical Decision Making
Counseling/Coordination of Care (>50% time)
Medical Record Basics
Evaluation & Management (E/M) Services:
HISTORY
1. Chief Complaint (CC): Concise statement describing the
symptom, problem, condition, dx, or other reason for the encounter.
2. History of Present Illness (HPI): Chronological description of the
development of the patient’s present illness from the first
sign/symptom or from the previous encounter to the present.
3. Review of Systems (ROS): An inventory of body systems
obtained through a series of questions seeking to identify
signs/symptoms
4. Past, Family, and/or Social History (PFSH): past illnesses,
operations, etc; hereditary factors; age appropriate review of past
and current social activitites.
Medical Record Basics
Evaluation & Management (E/M) Services:
EXAMINATION
The levels of E/M services are based on
four types of examination:
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4.
Problem focused - a limited exam of the affected body area or
organ system
Expanded Problem Focused – a limited exam of the affected body
area or organ system and other symptomatic or related organ
systems
Detailed – an extended exam of the affected body areas and other
symptomatic or related organ systems
Comprehensive – a general multisystem examination or complete
examination of a complete organ system.
Medical Record Basics
Evaluation & Management (E/M) Services:
MEDICAL DECISION MAKING
Based on the complexity of establishing a diagnosis and/or
selecting a management option, as measured by:
- the number of possible diagnoses and/or the number of
management option that must be considered;
- the amount and/or complexity of medical records, diagnostic tests,
and other information that must be obtained, reviewed and
analyzed; and
- the risk of significant complications, morbidity and/or mortality
associated with the patient’s presenting problem, diagnostic
procedures, and the possible management options.
Medical Record Basics
Evaluation & Management (E/M) Services:
MEDICAL DECISION MAKING
To support the complexity of medical decision making, always be sure
to document in the medical record:
- Lab, X-Ray, or procedures ordered
- Review of lab, x-ray, or procedure reports
- Review of old records or gathering additional information from
other sources
- Co-morbidities/underlying diseases
Medical Record Basics
Evaluation & Management (E/M) Services:
COUNSELING/
COORDINATION OF CARE
If it dominates more than 50% of the
physician/patient encounter, time is
considered the controlling factor to qualify
for a particular level of E/M service.
Questions?
Brigid M. Maloney, J.D.
Compliance Officer
SUNY Buffalo School of Medicine
Office of the Vice President for Health
Affairs
Ph: (716) 829-3176
E-mail: [email protected]