COM Compliance Policy No. 3 THE UNIVERSITY OF ILLINOIS AT CHICAGO NO.: 3 UIC College of Medicine DATE: 8/5/10 Chicago, Illinois PAGE: 1of 7 UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE CODING AND DOCUMENTATION POLICY AND PROCEDURE NO.: 3 DATE: 8/5/2010 SUBJECT HEALTHCARE CODING AND DOCUMENTATION COMPLIANCE OBJECTIVE The purpose of this policy is to affirm the College of Medicine s commitment to ethical, complete, accurate, and consistent coding and documentation practices. DEFINITIONS Advance Beneficiary Notice: Written notice, given prior to a medical service, which informs a beneficiary that Medicare may not pay for an item or service. Current Procedure Terminology Codes (CPT Codes): Numeric (5-digit) codes developed by the AMA used to report medical services and procedures performed by providers. CPT codes types include Medical, Surgical, Diagnostic Services, Anesthesia and Evaluation & Management Codes. Diagnostic Related Group (DRG): Method to determine reimbursement from payors according to a diagnosis on a prospective basis. It evolved from the Medicare program. Evaluation and Management Codes (E&M Codes): Codes which describe providerpatient encounters. These encounters are translated into 5 digit CPT codes to facilitate billing. Health Care Financing Administration Common Procedure Coding System (HCPCS): Codes developed and maintained by the federal government used to report professional services, procedures and supplies. International Classification of Dieseases-9 th Revision Codes (ICD-9-CM Codes): Numeric codes that describe the diagnosis, symptom, complaint, condition or problem for which a service or procedure is being performed by the physician or other health professional. Medical Coding: A system that translates services/procedures/supplies/drugs into CPT/HCPCS codes and/or ICD-9-CM diagnosis codes. 1
UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE COMPLIANCE-CODING AND DOCUMENTATION GUIDELINES Medically Necessary Services: Services rendered to a patient are reasonable and necessary according to the standards for Medicare/Medicaid reimbursement set forth in applicable statutes and regulations and supported by adequate documentation. Medicare Secondary Payer (MSP): A list of questions used to determine if a Medicare Beneficiary has additional health insurance and if Medicare is the primary or secondary payer for services rendered. Medicare Teaching Physician Rules: Regulations that govern professional services billing to Medicare for patient care provided with the involvement of residents (60 Federal Register 63124 and Il-372 Guidelines). This rule requires the physical presence of the teaching physician in order to Bill for services. Only in specific circumstances is an exception permitted to the physical presence requirement. Modifiers: A set of numbers and/or letters used to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed the definition of the CPT or HCPCS code. 72 Hour Window Rule: Medicare Rule that identifies certain outpatient services that must be included with an inpatient stay, if the patient is admitted (becomes an inpatient) within 72 hours of the outpatient visit. POLICY All COM personnel who may directly or indirectly influence documentation and coding of medical records must at all times adhere to the University of Illinois College of Medicine s Mission and the University s Code of Conduct. Services performed are documented in an accurate, organized, legible and timely manner in order to ensure appropriate billing and claims submission (See UIMC Electronic Medical Record Documentation Guidelines G4.1-G 4.8). In order for a service to be billable, it must meet the teaching physician physical presence requirements, as well as chart documentation and coding requirements. PROCEDURES APPENDIX A: GENERAL PRINCIPLES OF MEDICAL DOCUMENTATION APPENDIX B: GUIDELINES FOR USING THE INTERNATIONAL CLASSIFICATION OF DISEASES (ICD-9-CM) APPENDIX C: GUIDELINES FOR USING CURRENT PROCEDURAL TERMINOLOGY-CPT APPENDIX D: 1995 E&M GUIDELINES AND 1997 E&M GUIDELINES 2
UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE COMPLIANCE-CODING AND DOCUMENTATION GUIDELINES REFERENCES 60 Federal Register, 63124 IL-372 Guidelines CMS Manual Instructions: Supervising Physicians in a Teaching Setting Policy #1 College of Medicine Compliance Program Policy #2 Billing and Claims Reimbursement 1995 and 1997 E&M Guidelines REVIEWERS Departmental Compliance Liaisons Chief Compliance Officer, UIMC Director of Compliance, UIMC MSP Executive Board RESPONSIBLE PARTY(S) Director of Compliance, COM POLICY UPDATE SCHEDULE This policy will be updated every five years or more often as appropriate. APPROVAL PARTY(S): Joseph Flaherty, MD. Dean, College of Medicine Arnim Dontes, MBA Associate Dean for Fiscal Affairs, CFO Date Date 3
APPENDIX A: GENERAL PRINCIPLES OF MEDICAL DOCUMENTATION A. The medical record should be complete and legible. B. The documentation should support the intensity of the patient evaluation and/or treatment, including thought processes and the complexity of medical decision making. C. The entry should include the reason for the encounter, the relevant history and physical exam as appropriate, any prior diagnostic tests results, assessment/impression and plan for care, date of service and legible identity of the provider. D. All entries to the medical record should be timed, dated and signed by the provider of service. The signature can be hand written or electronic. Signature stamps are not acceptable. E. The patient s progress, including responses to treatment, change in treatment, change in diagnosis and patient compliance with treatment should be documented. F. Review of lab, x-ray data, and other ancillary services should be documented. G. The documented plan of care should include, when appropriate, treatments and medication-specifying frequency and dosage, referrals and consultations, patient/family education, and specific instructions for follow-up. H. The medical record should be completed by the provider following UIMC Guidelines G-4.1 to G-4.8. In order to maintain an accurate record, document during or shortly after rendering the service. I. The provider of the services is responsible to ensure that documentation is accurate whether it is hand written, transcribed or entered into an Electronic Medical Record. J. Documentation must support CPT and ICD-9 Codes utilized for billing purposes. K. Medical necessity is the overall criterion for payment in addition to the individual requirements of CPT codes. L. When a resident is involved in a patient s care, Teaching Physician Rules require the physical presence of the teaching physician and an attestation confirming the physician s involvement in order to bill for the service provided. 4
APPENDIX B: GUIDELINES FOR USING THE INTERNATIONAL CLASSIFICATION OF DISEASES (ICD-9-CM) A. Code the primary diagnosis first, followed by the secondary, tertiary etc. The primary diagnosis should reflect the current, most significant reason for the services or procedures provided; it is the main reason for care and should be the first diagnosis listed. B. Do not code a diagnosis that was treated in the past and is no longer applicable. C. Code the diagnosis to highest degree of specificity; use 4 th and 5 th digits as indicated in the ICD-9 guidelines. D. Identify services or circumstances other than disease or injury, such as follow-up care, chemotherapy or routine physical exams with V codes provided for this purpose. When only ancillary services are provided, list the V Code first and the problem second. E. For surgery, code the diagnosis applicable to the procedure i.e. the pre-operative diagnosis. Once the diagnosis is confirmed (the postoperative diagnosis is different than the pre-operative diagnosis) use the post-operative diagnosis. F. Do not code diagnoses that are probable, suspected, questionable or rule out. Instead code the symptoms, signs, abnormal test results or other reason for the visit. G. E-Codes are never used as a primary code. These codes are used as additional codes which give a more detailed analysis and the nature of the condition. NOTE: Details on how to use the International Classification of Diseases-9 th Revision, Clinical Modification (ICD-9-CM) Volumes 1&2 can be found in the current ICD-9-CM Coding Manual. 5
APPENDIX C: GUIDELINES FOR USING CURRENT PROCEDURAL TERMINOLOGY (CPT) A. Upon reviewing the medical information, identifying services and procedures performed, select the appropriate name (key term) of the procedure or service that accurately identifies the service performed. B. Locate the key terms in the index section of CPT. C. Locate the code within the tabular section of CPT. D. Read the code usage notes and select the most appropriate code. NOTE: Details on how to use the Current Procedural Terminology can be found in a current CPT manual. 6
APPENDIX D: 1995 E&M GUIDELINES AND 1997 E&M GUIDELINES 1995 and 1997 Documentation Guidelines can be found at the following Link: https://www.cms.gov/mlnedwebguide/25_emdoc.asp 7