Faculty and Staff: For Your Benefit

Medical Compliance Service Tips of the Month

Physician Billing Compliance Tip

Teaching Physician Attestations

To bill for services in which a resident/fellow participates, the Teaching Physician must personally document that he/she was physically present during the key or critical portions of the service and his/her participation in the management of the patient. Documentation of the resident/fellow of the Teaching Physician’s presence is insufficient to bill the services by the Teaching Physician. The Teaching Physician must personally document his/her Attestation in the first person. The following Attestations are UNACCEPTABLE to establish presence and/or participation in the management of patient:

• “Patient seen and examined with team on rounds and agree with plan” and a signature

• Seen and examined and agree with resident’s note and a signature

• Agree with above, and a signature

• A co-signature, alone

• Reviewed and discussed with resident and agree with plan as written, and a signature

• As documented by resident, I agree with the history, exam and assessment/plan, and a signature

Hospital Billing Compliance Tip

Revised exceptions to “Two-Midnight Rule”

The “Two-Midnight Rule,” created in 2013, calls for Medicare’s payment and audit contractors to assume a hospital admission was legitimate if it spans two midnights. Shorter stays are assumed to be more appropriately billed as outpatient observation care. Under the revised exceptions policy (CMS-1633-F), effective Jan. 1, 2016, admissions that do not meet the two-midnight benchmark may still be paid under Part A on a case-by-case basis where the medical record supports the admitting physician’s determination that the patient requires inpatient care, despite the lack of a two-midnight expectation.

Beginning Oct. 1, 2015, Quality Improvement Organizations (QIOs) started conducting initial patient status reviews of claims for inpatient admissions. Complex medical factors will be considered in determining whether the medical record supports the need for inpatient hospital care. Recovery audit contractors may conduct patient status reviews for those providers who have been referred by the QIOs as exhibiting persistent noncompliance with Medicare payment policies including, but not limited to, consistently failing to adhere to the “Two-Midnight Rule” or failing to improve their performance after QIO educational intervention.

Clinical Laboratories Billing Compliance Tip

Submission of Diagnoses and Prohibited Practices for Clinical Laboratories

Only submit diagnoses submitted on claims to Medicare from the ordering physician. Unlike pathologists and radiologists, clinical laboratories may not alter the diagnosis based on the findings of the test or procedure. Medicare regulations require ordering physicians to include the ICD-10 codes or narrative diagnosis information with each and every order for lab tests. The Balanced Budget Act of 1997 expanded this requirements to include non-physician practitioners such as physician assistants, ARNPs and other laboratories.

Prohibited Practices given by the OIG are the following:

• Laboratories are NOT to use information provided by a physician from earlier dates of service;

NOT to create diagnosis information that has triggered reimbursement in the past;

NOT to use computer programs that automatically insert ICD-10 codes without first receiving diagnosis information from the ordering physician;

NOT “make up information for claim submission purposes.”

Research Billing Compliance Tip

Medicare Coverage Analysis

CMS Clinical Trials Policy allows for payment of routine services provided as part of a clinical trial. It allows Medicare patients to participate in clinical trials. Due to fraud and abuse concerns, it is vital that a Medicare Coverage Analysis (MCA) is performed prior to commencing a clinical trial. An MCA helps distinguish between the items and services which are allowed to be billed to Medicare (or any other insurance), based on national and local coverage determinations.

More Billing Compliance Tips can be found at www.obc.med.miami.edu