Billing Standards, Guidelines, and FAQ

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Professional Fee Billing

I. Clinical Fellow Policy

At UCSD, physician trainees who have completed residency training and enroll in subsequent programs leading to a certificate of special competence in a specific medical subspecialty are referred to as "clinical fellows".

The Medicare program has specifically stated that it is inappropriate to submit bills for services rendered exclusively by a Clinical Fellow unless qualified to do so under a "moonlighting" agreement. "Clinical Fellow" refers to individuals enrolled in a graduate medical education training program that is approved and recognized by the Accreditation Council for Graduate Medical Education (ACGME), or the American Board of Medical Specialties (ABMS) as an "approved and recognized" graduate medical education program or where a certificate of added qualifications (CAQ) is possible.

A "clinical fellow", who is enrolled in a departmental training program that is not recognized by the ACGME or ABMS as an "approved" graduate medical education program and/or where a CAQ is not expected, may be eligible to bill for professional services providing the individual has the necessary approval from UCSD Health’s Graduate Medical Education Office; credentials and attending physician privileges of UCSD Health’s Medical Staff Administration; credential and enrollment with UCSD Medical Group (provider enrollment); and the appropriate clinical appointment via the UCSD School of Medicine.

"Moonlighting" agreement refers to an approved contract for separate, identifiable services that may qualify for professional fee billing, if certain conditions are met.

VI. General Policies and Procedures

The following policies and procedures are to be used at this institution when documenting professional services.

  1. Documentation Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The record should chronologically document the care of the patient, and is an important element contributing to the quality of care. As a general rule, physicians must clearly document (in legible handwriting or in a signed dictated / electronic note) their presence and level of participation in the services provided. Medical record documentation should be completed immediately following patient services or within sufficient time to recollect the key portions of the services provided. Whoever dictates a note, report, or entry, shall sign that note, report, or entry. A medical record is considered a legal document.
    • Macros. Teaching physicians may use a macro, a command in a computer or dictation applications in an electronic medical record that automatically generates predetermined text that is not edited by the user, as the required personal documentation, if the teaching physician personally adds it in a secured or password protected system. In addition to the teaching physician’s macro, the teaching physician must provide customized information that is sufficient to support a medical necessity determination. The note in the electronic medical record must sufficiently describe the patient specific services furnished to the specific data. If both the resident and the teaching physician use only macros, this is considered insufficient documentation by Medicare.
  2. Record Retention Because the mission of the University includes clinical research, as well as patient care and teaching, UCSD Health’s medical record retention policy mandates that medical records are to be kept 10 years for adults, 25 years for minors (under age 18), and 30 years beyond experiment for any human experimentation (experimental drugs and devices). UCSD Medical Group billing records for professional fee services shall be retained for a minimum of 10 years.
  3. Signatures Either the full physician signature, or the first initial of the physician and a complete physician last name is required. Practitioners using a computerized signature to authenticate entries must sign a statement they alone will use it. Whoever dictates a note, report, or entry, shall sign that note, report, or entry – including residents and clinical fellows.
  4. Billing Codes
  1. CPT codes. "Current Procedural Terminology, Fourth Edition" (CPT-4) is a five-digit numeric code that is used to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation and management services of physicians, hospitals, and other health care providers. CPT codes range from 0100 through 94499. There are three types of CPT codes: Category 1, Category 2 and Category 3. Note: CPT copyright of the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
    1. Category 1: Procedures and contemporaneous medical practices that are widely performed.
    2. Category 2: Clinical Laboratory Services, supplementary tracking codes that are used for performance measures. Use of this code set is optional and not a substitute for Category 1 codes.
    3. Category 3: Emerging technologies, services, and procedures (temporary codes).
  2. ICD-10 codes. "International Classification of Diseases and Related Health Problems, 10th Revision" (ICD-10), is a numeric coding system describing diseases, symptoms, conditions, complications, external causes, as well as drugs and chemicals. ICD-10 diagnosis codes are a medical classification list maintained by the World Health Organization (WHO).
  3. HCPCS codes. Healthcare Common Procedure Coding System (HCPCS) is a set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT). Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT-4 codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not identified by CPT-4 codes, the level II HCPCS codes were established for submitting claims for these items.
  4. Modifier codes. Two-digit/character code modifiers help further describe a procedure code without changing the definition of the code. Certain modifiers indicate that a service or procedure that was performed has been altered in some manner. Modifiers can be found in the CPT, HCPCS and payer billing manuals, such as Medicare and Medi-Cal. Utilizing the above coding systems, the UCSD Health is committed to submitting only compliant bills for professional fee services; and further, strives to provide reasonable assurance concerning compliance with conditions of payment and encounter data reporting under managed care plans.
  1. Refunds and Fines As is current practice, amounts identified as a result of inaccurate billing are to be reported and returned as soon as possible – and no later than 60 days from the date that an over-payment is identified through a reasonable and diligence period has concluded.

VII. Teaching Physician Guidelines

The Centers for Medicare and Medicaid Services (CMS) have published specific guidelines and requirements that need to be met when seeking payment from Medicare. These regulations speak to the services furnished by not only the teaching physician, but the resident and medical student.

The "general rule", as described by the American Association of Medical Colleges (AAMC), is "if a resident participates in a service furnished in a teaching setting, a physician fee schedule payment is made only if a teaching physician is present to perform or observe the resident perform the key portion of any service or procedure for which payment is sought."

For billing purposes, the medical record information must also support the presence and direct participation of the teaching physician during the critical/key (most important treatment-determining, interpretation making, defining technology or technique) portion of the service or procedure, and medical decision making.

Through the link below, you will find information involving general documentation guidelines including those for Evaluation and Management Services that will help guide in the process of patient care and properly coding and billing for all medical services provided at UCSD Health.

  1. Payment for Attending Physician Services in Teaching Settings Medicare pays for services furnished in teaching settings if the services are:
    1. Personally furnished by a physician who is not a resident; or
    2. Furnished by a resident when a teaching physician is physically present during the critical or key portions of the service; or
    3. Furnished by a resident under a primary care exception within an approved Graduate Medical Education (GME) Program.

    Information recorded within the medical record must demonstrate the teaching physician's presence and level of participation in the service. For billing purposes, the medical record information must also support the presence of the teaching physician during the critical/key (most important treatment-determining, interpretation making, defining technology or technique) portion of the service or procedure, and his/her participation. The following sections are a composite of jointly developed medical record documentation guidelines for Teaching Physicians by the American Medical Association (AMA) and the Centers for Medicare/Medicaid Services (CMS), as well as professional interpretations of Medicare teaching physician regulations.

    A UCSD Medical Group teaching physician is an attending physician, (other than a resident or fellow in an approved GME program), who has clinical privileges at UCSD Medical Center, a faculty appointment at the UCSD School of Medicine, credentialed as a billing provider with UCSD, and who involves residents in the care of his/her patients. Teaching physician services must include the GC modifier for each CPT code billed as a professional fee service.

    • Modifier GC indicates services provided in part by a resident under the direction of a teaching physician. When the GC modifier is included on a claim, you or another appropriate billing provider certify that you complied with these requirements.
    • Modifier GE. If you meet the requirements for primary care exception billing, append modifier GE to each eligible service code (CPT code). Modifier GE indicates “this service has been performed by a resident without the presence of a teaching physician under the primary care exception.” Contact the UCSD Health - Compliance Office for approval and for guidance on permitted CPT codes and attestation documentation.
  2. Services Furnished by an Intern or Resident within the Scope of an Approved Training Program. A “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). For DGME and IME payment purposes, a resident means an intern, resident, or fellow who is formally accepted, enrolled, and participating in an approved medical residency program. Medical and surgical services furnished by an intern or resident within the scope of his or her training program are covered as provider services and Medicare pays for them through Direct Graduate Medical Education (DGME) and Indirect Medical Education (IME) payments. These services may not be billed or paid under the Medicare PFS. Refer to CMS guidance for services furnished by an intern or resident outside the scope of an approved training program (“moonlighting”).
  3. Services Furnished by a Student. A 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. The student may document services in the medical record; however, the teaching physician may only refer to the student’s documentation of an E/M service that is related to the review of systems (ROS) and/or past, family and social history (PFSH). Teaching physician may not refer to a student’s documentation of physical examination findings or medical decision making in the teaching physician’s note. If the student documents E/M services, the teaching physician must verify and redocument the history of present illness (HPI) and perform and redocument the physical examination and medical decision making activities of the service.
  4. Evaluation and Management (E/M) Services. At a minimum, medical record notes for E/M services should include: (1) relevant history of present illness and prior diagnostic tests; (2) major findings of physical examination; (3) assessment, clinical impression or diagnosis; and (4) plan of care. When a patient is re-admitted for subsequent hospital care or for established patient visits, the teaching physician's personal note must highlight at least two of the following three components: (1) relevant history; (2) major findings of physical examination; (3) medical decision-making (assessment, impression, diagnosis, or plan of care). When the teaching physician is performing services with a resident(s), the teaching physician may document brief summary comments that tie into each resident's entry, which either confirm or revise each KEY element of the service(s) provided.

    For billing purposes the teaching physician must personally document at least the following:
    1. That the teaching physician performed the service or was physically present during the critical or key portions of the service furnished by the resident; and
    2. Teaching physician’s participation in the management of the patient.

    On medical review, the combined entries in the medical record by the teaching physician and the resident constitute the documentation for the service and together must support the medical necessity of the service. Documentation by the resident of the teaching physician’s presence and participation in an E/M service is insufficient to establish such presence and participation.

    For a given encounter, the selection of the appropriate level of E/M service code is determined according to the definitions of the code in AMA Current Procedural Terminology (CPT®) books, medical necessity and any applicable documentation guidelines.

  5. Anesthesia Services Furnished in Teaching Settings. Effective January 1, 2010, Medicare pays for the following procedures if the teaching anesthesiologist is involved in:

     

    1. Training the resident in a single anesthesia case;
    2. Two concurrent anesthesia cases involving residents; or
    3. Single anesthesia case involving a resident that is concurrent to another case paid under medical direction rules.

    The following requirements must be met to qualify for a teaching physician payment:

    1. The teaching anesthesiologist or different anesthesiologist(s) in the same anesthesia group must be present during all critical or key portions of the anesthesia service or procedure; and
    2. The teaching anesthesiologist or another anesthesiologist must be immediately available to provide anesthesia services during the entire procedure.

    The patient’s medical record must reflect the following documentation:

    1. The teaching anesthesiologist’s presence during all critical or key portions of the anesthesia procedure;
    2. The immediate availability of the teaching anesthesiologist (or another teaching anesthesiologist as necessary).

    When different teaching anesthesiologists are present with the resident during the critical or key portions of the procedure, report the National Provider Identifier (NPI) number of the teaching anesthesiologist who started the case on the claim. Submit teaching anesthesiologist claims using the following modifiers:

    • Modifier AA: Anesthesia services performed personally by attending anesthesiologist; or
    • Modifier GC: This service has been performed in part by a resident under the medical direction of a teaching anesthesiologist.

    The teaching anesthesiologist must be available to furnish services throughout the entire procedure. In order to bill for professional services, CMS guidelines mandate that the teaching physician be present for induction, emergence, and all other critical or key portions of care. Documentation of care must be provided. The anesthesia record should include the signatures of all participants in the care of the patient, including the resident, CRNA and attending anesthesiologist. The teaching anesthesiologist must document the preoperative evaluation, presence and participation during the administration of anesthesia, including those portions of the service for which they are present and the extent of postoperative care.

  6. Diagnostic Tests. The teaching physician shall either personally perform or review test results or materials and agree with or make changes and additions to the resident's interpretation. If a resident prepares and signs the interpretation, the teaching physician must indicate that he/she personally reviewed the material or results and the resident's interpretation and either agrees with it or edits the findings.
  7. Endoscopies. For diagnostic endoscopy procedures, the medical record must document the teaching physician's presence during the procedure. For billing purposes, the teaching physician must be present for the entire viewing, which includes the scope insertion, diagnostic viewing, and scope withdrawal. (Note: The presence requirement is for diagnostic endoscopy, and does not refer to therapeutic (surgical) procedures performed endoscopically.)

     

  8. Surgical Services. "Physical Presence" is one of the basics for surgical procedure documentation. The physician must assure documentation of his/her personal involvement and presence during the surgical procedure. If the teaching physician is present throughout the entire procedure, a personal notation of "key portions" by the teaching physician is not required; however, if the operative report is dictated by a resident, it should be noted that the teaching physician was present for the entire procedure. If the teaching physician is not present for the entire procedure then the teaching physician must: (1) personally document the key portion(s) of the procedure for which he/she was present; and (2) be immediately available throughout the entire event; and/or designate another physician to be immediately available.

     

    The presence or level of involvement by the teaching physician may be recorded in notes to the record by the teaching physician, resident, or operating room nurse. The teaching physician signature is required on operative notes.

    Overlapping Surgeries require the teaching physician to document the key portions of each operation, and his/her presence and participation during those key portions. When all of the key portions of the initial procedure have been completed, the teaching physician may become involved in a second procedure. The teaching physician bill only for operations during which they were physically present for all of the key portions.

  9. Psychiatry. For psychiatric services, the requirement for the presence of the teaching physician (psychiatrist) during the service must either be "in-person" or by concurrent observation, e.g., one-way mirror or video equipment.
  10. Time-Based Services. Physicians must document time-based services that reflect the actual amount of time spent with the individual patient (e.g., face-to-face for office visits and unit/floor for inpatient hospital visits). The documentation must also summarize what services were performed during that time and the medical necessity for physician attendance throughout the time reflected.
  11. Discharge Day Management. Generally on the day of a patient's discharge, the physician spends an added amount of time with the patient and the family communicating instructions to be followed upon discharge, future medical visits, and medication management. In addition to any final reviews of progress notes and the patient's physical condition, the amount of time spent with the patient and family discussing discharge instructions should be noted.
  12. Maternity. The presence of the teaching physician during maternity procedures follows the same guidelines previously noted for surgical services. The physical presence requirement is applied to the delivery (key portion), and the teaching physician must document his/her involvement, presence, and availability at the time of delivery.

Hospital Billing

The Hospital Billing Compliance component is designed to incorporate compliance activities occurring in multiple hospital system departments into a comprehensive integrated program.  The program is designed to reduce the potential for fraud and abuse in hospital coding and billing programs, along with ensuring compliance with multiple other regulatory requirements that impact hospital and hospital-based licensed areas including compliance with federal privacy and security regulations, EMTALA regulations, and other regulatory mandates.  The program integrates compliance activities in specialized areas including Laboratory and Pathology, Pharmacy, Health Information Management, Reimbursement, Coding and Billing.

Important Guidelines:

  • Inpatient Admission & Medical Necessity
  • Observation Services: Observation care is a well defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.
  • APC - Status Indicator "C" List
  • "Inpatient Only": List of procedures that may only be performed in an inpatient setting
  • Government Guidelines: Guidance and Medicare Conditions of Participation.  The Center for Medicare and Medicaid Services (CMS) develop Condition of Participation (CoPs) that health care organizations must meet in order to participate in the Medicare and Medicaid programs. These minimum health and safety standards are the foundation for improving quality and protecting the health and safety of the patients. Refer to Title 42 – Part 482.

Factsheets