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Compliance Audits:Documentation Guidelines in

a Teaching Hospital Setting!”

The University of Tennessee

Medical Center

The University of Tennessee Medical Center is the region’s only academic medical center, Magnet® recognized hospital and Level I Trauma Center.

The 609-bed hospital also is home of the region’s only dedicated Heart Hospital, only adult and pediatric transplant center, a JointCommission/American Heart Association recognized Comprehensive Stroke Center, houses the region's only Level III private-room neonatal intensive care unit and serves as a regional perinatal center.

Our six Centers of Excellence provide comprehensive care to patients. The dedicated professionals at the medical center thrive in a fast-paced, challenging environment, where expert commitment plays a critical role in the hospital’s ongoing success.

The University of Tennessee Medical Center is part of University Health System Inc. University Health Systems is a regional health system that comprises the UT Medical Center, University Health Systems Ventures, Inc., and various partnerships and joint ventures with physicians and healthcare companies. University Health Systems is affiliated with the University of Tennessee Graduate School of Medicine and numerous regional hospitals and physician organizations. University Health Systems supports and collaborates with the UT Graduate School of Medicine and other academic endeavors as part of its commitment to excellence in education and research.

The University of Tennessee Medical Center is the first hospital in the state of Tennessee to implement a dedicated, full-time K-9 program.

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IMPORTANCE OF A COMPLIANCE PLAN

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A compliance program is not a panacea guaranteed to eliminate the risk that fraud, waste,

abuse or inefficiency will occur. Nevertheless, CMS believes that the establishment of an

effective compliance program will protect the Medicare Trust Fund by significantly reducing

the risk of unlawful or improper conduct, and will likely lead to other programmatic

efficiencies.

In order to receive “credit” for good corporate behavior, the Federal Sentencing Guidelines require that organizational defendants exercise due diligence in the design and implementation of a compliance program intended to detect and deter fraud, waste and abuse. The Federal Sentencing Guidelines Manual at §8A1.2, Application Note (k), sets forth seven steps that any compliance program must incorporate in order to demonstrate the due diligence element. These seven steps have been included in the various guidelines developed by the OIG and other compliance program authorities, and are believed to be the minimum requirement for an effective compliance program.

Compliance Program Guidance for Medicare Fee-For-Service Contractors, March 2005

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/compliance.pdf

MEDICAL NECESSITY

ESTABLISHING A FOUNDATION

• The chief complaint or the interval history is the key to

establishing the medical necessity of each encounter.

• It is important that provider work occurred during a face-to-

face encounter.

• Clinical data is the main issue in the cloned record. Patient

complaints/exam are likely to change and this must be

reflected in the note.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWEbGuide/Downloads/95Docguidelines.pdf

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THE CHIEF COMPLAINT

A common problem with provider documentation is the missing chief complaint (CC).

CPT® defines the CC as “A concise statement describing the symptom, problem,

condition, diagnosis, or other factor that is the reason for the encounter, usually

stated in the patient’s words.”

Often, providers begin their subsequent notes with symptoms the patient may not

have, or a comment pertaining to the patient’s status in relation to a procedure or

medication, but without mentioning why the patient is being treated. This shortcoming

is especially pressing when multiple providers of different specialties treat the same

patient.

The 1995 and 1997 Documentation Guidelines for Evaluation and Management

(E/M) Services specifically require, “The medical record should clearly reflect the

chief complaint.” Many electronic health records (EHRs) provide a field to enter a

chief complaint or reason for the visit, but it is often inferred from the history of

present illness (HPI). An easily identifiable chief complaint is the first step in

establishing medical necessity for services rendered. If the patient record does not

reflect a chief complaint, the service is either a preventive service, or is unbillable.

https://www.aapc.com/blog/28120-the-missing-chief-complaint/

PRINCIPAL DIAGNOSIS

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Multiple treating providers should bill with the principal diagnosis of their specialty.

• For example, a patient is admitted with an acute MI, h/o DMII, COPD

and GERD, with a cardiologist as the physician of record. The patient

also is followed by the PCP, who manages the patient’s DM II and

GERD, and a pulmonologist manages the COPD. In this case, the

admitting cardiologist would bill using the AMI as the principal

diagnosis.

• On subsequent visits, the cardiologist would continue to code the AMI

as diagnosis (along with any newly-diagnosed cardiac illness), the

PCP would continue to code the DM II and GERD, and pulmonologist

would Continue to code the COPD.

• If an admitting physician and one or two consulting providers all bill

subsequent inpatient care using the same principal diagnosis, only the

provider who gets his claim to the payer first will be paid. The others,

most likely, will be denied as duplicate services.

https://www.aapc.com/blog/28120-the-missing-chief-complaint/

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BILLING DIAGNOSIS

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Evaluation and Management coding procedure code/diagnosis

code linking. It is not enough to link the procedure code to a

correct, payable ICD-10-CM code. The diagnosis or clinical

signs/symptoms must be present for the procedure to be paid.

http://www.fmaonline.org/phys/payment_medicare.doc

WHO CAN DOCUMENT

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• HPI statement cannot be documented by anyone other than the billing provider.

• ROS can be entered from a patient form, but has to be confirmed that the

physician reviewed with the patient.

• PMH/SH/ROS can be documented by ancillary staff, but physician is

expected to review it for accuracy.

• Current problem lists should be reviewed for accuracy.

• Physicians or billing NP provider should be choosing which diagnosis (es) a

test is being ordered for. The order should be signed by the physician and/or

billing NP provider if it is not documented in their note.

• Residents dictation testing and/or other documentation require the teaching

statement that the physician examined the patient and agrees with the resident

assessment/plan and/or that they were there for the key portions of a

procedure.

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TEACHING GUIDELINES

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Payment for Physician Services in Teaching Settings

Medicare pays for services furnished in teaching settings through the

Medicare Physician Fee Schedule (PFS) if the services are:

• Personally furnished by a physician who is not a resident;

• Furnished by a resident when a teaching physician is physically present

during the critical or key portions of the service; or

• Furnished by a resident under a primary care exception within an

approved Graduate Medical Education (GME) Program.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-

Physicians-Fact-Sheet-ICN006437.pdf

BILLING GUIDELINES

FOR TEACHING PHYSICIANS

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Billing Requirements for Teaching Physicians

You must be identified as the teaching physician who involves residents in the care

of your patients on claims. Claims must comply with requirements described in the

“General Documentation Guidelines” and “E/M Documentation Guidelines” sections

on pages 5-6. Claims must include the GC modifier, “This service has been

performed in part by a resident under the direction of a teaching physician,” for each

service, unless the service is furnished under the primary care exception. When the

GC modifier is included on a claim, you or another appropriate billing provider certify

that you complied with these requirements.

If you meet the requirements described in the “Exception for E/M Services

Furnished in Certain Primary Care Centers” section on pages 6-7, you must provide

an attestation to the Medicare Administrative Contractor (MAC) which states that

you have met these requirements. Claims must include the GE modifier, “This

service has been performed by a resident without the presence of a teaching

physician under the primary care exception,” for each service furnished under the

primary care center exception.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-

Physicians-Fact-Sheet-ICN006437.pdf

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DOCUMENTATION IN EMR

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• It is the responsibility of the physician, resident, or NP to uncheck

items that are automatically checked if the entire exam template is

not performed.

• Problem lists should be updated at each visit.

• If a clinician checks "normal" for the GI system, the EMR system

may automatically fill in other descriptors such as "abdomen soft"

and "normal bowel sounds", etc. If the clinician did not listen to the

patient's bowels with a stethoscope, this potentially puts the office at

risk for quality of care issues, malpractice, etc.

• Another problem with the EMR automatically filling in documentation

is that it may lead to "over-document" which leads to selecting and

billing a higher E/M code than medically reasonable and necessary.

http://www.priorityhealth.com/provider/manual/office-mgmt/records/documentation-cloning

"Cloning" medical record documentation means cutting-and-pasting the

information entered in the Electronic Medical Record (EMR) from one

date of service to another. It can be a useful tool in providing elements of

patient history on each page of the EMR, but can also cause problems.

Cloned notes may cause:

• Inability to distinguish notes from one date of service to the other.

• Falsification of the medical record, since cloned notes may not

pertain to visits to which they are added.

• Difficulty in establishing medical necessity, which slows claims

processing.

• Failure to provide appropriate documentation to support a billed

service, resulting in recoupment of payment.

http://www.priorityhealth.com/provider/manual/office-mgmt/records/documentation-cloning12

USE OF CLONING IN EMRs

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Documentation is considered cloned when each entry in the medical record for

a beneficiary is worded exactly like or similar to the previous entries.

Cloning also occurs when medical documentation is exactly the same from

beneficiary to beneficiary. It would not be expected that every patient had the

exact same problem, symptoms, and required the exact same treatment.

Cloned documentation does not meet medical necessity requirements for

coverage of services rendered due to the lack of specific, individual information.

All documentation in the medical record must be specific to the patient and

her/his situation at the time of the encounter.

Cloning of documentation is considered a misrepresentation of the medical

necessity requirement for coverage of services.

Identification of this type of documentation will lead to denial of services for lack

of medical necessity and recoupment of all overpayments made.

http://www.priorityhealth.com/provider/manual/office-mgmt/records/documentation-cloning 13

USE OF CLONING IN EMRs

Cloning may be appropriate for elements of history when these

guidelines are followed.

Don't let an EMR select the codes for you. It is important to review the

service that was provided and bill accordingly.

Read over any cloned documentation to make sure the notes make

sense for that date of service. The chief complaint should carry through

to the exam and history and support the decisions made and medical

necessity.

http://www.priorityhealth.com/provider/manual/office-mgmt/records/documentation-cloning

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HOW TO USE CLONING APPROPRIATELY

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LEVEL 5 VISITS

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Use of Highest Levels of Evaluation and Management Codes

Contractors must advise physicians that to bill the highest levels of visit codes, the

services furnished must meet the definition of the code (e.g., to bill a Level 5 new

patient visit, the history must meet CPT’s definition of a comprehensive history).

The comprehensive history must include a review of all the systems and a complete

past (medical and surgical) family and social history obtained at that visit. In the case

of an established patient, it is acceptable for a physician to review the existing record

and update it to reflect only changes in the patient’s medical, family, and social history

from the last encounter, but the physician must review the entire history for it to be

considered a comprehensive history.

The comprehensive examination may be a complete single system exam such as

cardiac, respiratory, psychiatric, or a complete multi-system examination.

Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician

Practitioners Table of Contents (Rev. 2997, 07-25-14)

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

OBSERVATION CODES

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If a resident or nurse practitioner admits a patient to the hospital for the attending physician of

record (modifier AI), the admission history and physical bill date is the day the attending physician

examines the patient. Therefore, choose the appropriate observation code.

CPT code 99218-99220 Admitted to Observation Care for < 8 hours on the same calendar date.

CPT code 99224-99226 Subsequent observation care other than the initial or discharge date.

CPT code 99234-99236 Admit/discharge same day minimum of 8 hours.

CPT code 99217 Observation discharge only on calendar day other than initial day.

If a patient is admitted to observation status, the consulting physician should use the appropriate

office visit new patient, or established patient codes from 99201-99205 and 99211-99215.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/downloads/MM6740.pdf

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VOLUME OF DOCUMENTATION VS.

MEDICAL NECESSITY & CODE SELECTION

COMMON SETS OF CODES USED TO BILL FOR EVALUATION AND MANAGEMENT SERVICES

• When billing for a patient’s visit, select codes that best represent the services

furnished during the visit. A billing specialist or alternate source may review the

provider’s documented services before the claim is submitted to a payer. These

reviewers may assist with selecting codes that best reflect the provider’s furnished

services. However, it is the provider’s responsibility to ensure that the submitted claim

accurately reflects the services provided.

• The provider must ensure that medical record documentation supports the level of

service reported to a payer. The volume of documentation should not be used to

determine which specific level of service is billed.

The Social Security Act, Section 1862 (a)(1)(A) states: "No payment will be made ... For items or services ...not

reasonable and necessary for the diagnosis or treatment of an injury or illness or to improve the functioning of a

malformed body member." This medical reasonableness and necessity standard is the overarching criterion for the

payment for all services billed to Medicare. Providers frequently "over document" and consequently select and bill

for a higher-level E/M code than medically reasonable and necessary. Word processing software, the electronic

medical record, and formatted note systems facilitate the ...carry over... and repetitive "fill in" of stored information.

Even if a "complete" note is generated, only the medically reasonable and necessary services for the condition of

the particular patient at the time of the encounter as documented can be considered when selecting the

appropriate level of an E/M service. Information that has no pertinence to the patient's situation at that specific

time cannot be counted.https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval_mgmt_serv_guide-ICN006764.pdf

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CONSULTATIONS

CR4215 explains how to report evaluation and management (E/M) services following a

consultation service and also second opinion evaluations. In addition, it clarifies:

• An initial inpatient consultation will be reported only once per consultant per patient

per facility admission;

• In an office or outpatient setting, if an additional request for a consultation, regarding

the same or a new problem with the same patient, is received from the same or

another physician or qualified NPP and documented in the medical record, the Office

or Other Outpatient Consultation codes may be used again;

• If the consultant continues to care for the patient for the original condition following

the initial consultation, repeat consultation services will not be reported by this

physician or qualified NPP during his/her ongoing management of this condition;

Policy Clarifications/Reminders

Physicians and qualified NPPs should be aware that:

• An NPP may request and/or perform a consultation service within the scope of

practice and licensure requirements for the NPP in the State where he/she practices

and the requirements for physician collaboration and physician supervision are met;

• A consultation will not be performed as a split/shared E/M visit;

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/downloads/MM4215.pdf

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PROLONGED SERVICES

OIG WORK PLAN 2016NEW Prolonged services–reasonableness of services

We will determine whether Medicare payments to physicians for prolonged evaluation and management

(E/M) services were reasonable and made in accordance with Medicare requirements. Prolonged services

are for additional care provided to a beneficiary after an evaluation and management service has been

performed. Physicians submit claims for prolonged services when they spend additional time beyond the

time spent with a beneficiary for a usual companion evaluation and management service. The necessity of

prolonged services are considered to be rare and unusual. The Medicare Claims Process (MCP) manual

includes requirements that must be met in order to bill a prolonged E/M service code. (MCP manual, Pub.

100-04, Ch. 12, Sec. 30.6.15.1(OAS; W-00-15-35755; expected issue date: FY 2016)

http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf

TIME MUST BE DOCUMENTED

99354-99357 Prolonged Services Direct Contact

• 99356 Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first

hour (List separately in addition to code for inpatient Evaluation and Management service)

• 99357 Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each

additional 30 minutes (List separately in addition to code for prolonged service)

• 99355 Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the

primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service;

each additional 30 minutes (List separately in addition to code for inpatient evaluation and management service)

• 99354 Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the

primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first

hour (List separately in addition to code for prolonged service)

WWW.ENCODERPRO.COM19

SPLIT-SHARED VS INCIDENT-TO

http://www.mc.vanderbilt.edu/documents/CAPNAH/files/Billing%20and%20Reimbursement/Shared%20Visit%20Grid%20CMS%20guidelines.pdf 20

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SIGNATURE

REQUIREMENTS/ORDERS

MEDICAL RECORD SIGNATURE REQUIREMENTS

• Medical records submitted for review must be signed by the rendering

practitioner.

• A medical record that does not contain a valid signature may result in

claim denials or recovery of overpayments.

• Signatures added to documentation following a claim denial will not be

accepted.

This is modeled after requirements in the Centers for Medicare and Medicaid

Services (CMS) Medicare Program Integrity Manual (MPIM). Specifically, Section

3.4.1.1.D, Chapter 3 of the MPIM states:

"For medical review purposes, Medicare requires that services provided/ordered

be authenticated by the author. The method used shall be a hand written or an

electronic signature. Stamp signatures are not acceptable.“

http://www.priorityhealth.com/provider/manual/office-mgmt/records/signatures21

Sign each note. Your signature, whether actual, stamped or electronic,

indicates you agree with the information provided on that date of

service.

CMS Signature Guidelines should be followed.

• If a note is dictated by anyone other than the physician, then that

provider should sign the note. Cosigning a note is not allowed.

• If it is a resident note, then the attending physician should addend

the note with an attestation stating he/she examined the patient

and agrees with the resident’s assessment and plan. The

teaching attestation cannot be dictated by the resident.

• If a mid-level is split-sharing a visit with the attending physician,

then a face-to-face examination is required by the physician and

should be documented. 22

SIGNATURE GUIDELINES

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ACCEPTABLE DIGITIZED/

ELECTRONIC SIGNATURES

ACCEPTABLE DIGITIZED/ELECTRONIC SIGNATURES

• The responsibility for and authorship of the digitized or

electronic signature should be clearly defined in the record.

• A "digitized signature" is an electronic image of an individual's

handwritten signature. It is typically generated by encrypted software

that allows for sole usage by the practitioner.

• An electronic or digitized signature requires a minimum of a date

stamp (preferably includes both date and time notation) along with a

printed statement such as, "Electronically signed by," or

"Verified/reviewed by," followed by the practitioner's name and

preferably a professional designation. An example would be:

Electronically signed by: John Doe, M.D. 10/01/2011

http://www.priorityhealth.com/provider/manual/office-mgmt/records/signatures 23

ACCEPTABLE HANDWRITTEN

SIGNATURES

• Appear on each entry

• Are legible

• Include the practitioner's first initial and

last name

• (Recommended but not required) Include

the practitioner's credentials (P.A., D.O.,

M.D., etc.)

http://www.priorityhealth.com/provider/manual/office-mgmt/records/signatures

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UNACCEPTABLE SIGNATURES

• Signature "stamps"

• Missing signature on dictated and/or

transcribed documentation

• "Signed but not read" indicators

• Illegible lines or marks

25http://www.priorityhealth.com/provider/manual/office-mgmt/records/signatures

MISSING SIGNATURES

You may not add late signatures to medical records (beyond the

short delay that occurs during the transcription process). Medicare

does not accept retroactive orders. If the practitioner’s signature is

missing from the medical record, submit an attestation statement

from the author of the medical record. Your contractor may offer

specific guidance regarding addenda to medical records.

If an order for tests is unsigned, you may submit progress notes

showing intent to order the tests. The progress notes must specify

what tests you ordered. A note stating “Ordering Lab” is not

sufficient. If the orders and the progress notes are unsigned, your

facility or practice will be assessed an error, which may involve

recoupment of an overpayment.

Reference: CMS “Medicare Program Integrity Manual” (Pub. 100-08), Chapter 3, Section 3.3.2.4. 26

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SIGNATURE ATTESTATIONS

CMS will permit the use of an attestation form when a

signature has been inadvertently omitted. However,

patterns or consistent use of attestation in place of

signed records may lead to further investigation of

claims data.

This is consistent with the fraud referrals information on page 17 of CMS Pub 100-08, Medicare Program Integrity.

A signature attestation is a statement that must be

signed and dated by the author of the medical

record entry and must contain sufficient information

to identify the beneficiary.

Reference: CMS “Medicare Program Integrity Manual” (Pub. 100-08), Chapter 3, Section 3.3.2.4.C.

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https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf

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CMS FRAUD PREVENTION SYSTEM

CMS cutting-edge technology identifies & prevents $820 million in improper Medicare payments in first three years

The Fraud Prevention System is one part of the administration’s effort to protect the Medicare Trust Fund

After three years of operations, the Centers for Medicare & Medicaid Services (CMS) today reported that the agency’s advanced analy tics

system, called the Fraud Prevention System, identified or prevented $820 million in inappropriate payments in the program’s f irst three

years. The Fraud Prevention System uses predictive analytics to identify troublesome billing patterns and outlier claims for action, similar to

systems used by credit card companies. The Fraud Prevention System identified or prevented $454 million in Calendar Year 2014 alone,

a 10 to 1 return on investment.

"We are proving that in a modern health care system you can both fight fraud and avoid creating hassles for the vast majority of physicians

who simply want to get paid for services rendered. The key is data," said CMS Acting Administrator Andy Slavitt. "Very few investments

have a 10:1 return on taxpayer money."

The Fraud Prevention System was created in 2010 by the Small Business Jobs Act, and CMS has extensively used its tools, along with

other new authorities made possible by the Affordable Care Act, to help protect Medicare Trust Funds and prevent fraudulent payments.

For instance, last month Health & Human Services (HHS) and the Department of Justice announced the largest coordinated fraud

takedown in history, resulting in charges against 243 individuals, including 46 doctors, nurses, and other licensed medical professionals,

for their alleged participation in Medicare fraud schemes involving approximately $712 million in false billings. Over the last five years, the

administration’s efforts have resulted in more than $25 billion returned to the Medicare Trust Fund.

The Fraud Prevention System helps to identify questionable billing patterns in real time and can review past patterns that may indicate

fraud. In one case, one of the system’s predictive models identified a questionable billing pattern at a provider for podiatry services that

resulted in Medicare revoking the provider’s payments and referring the findings to law enforcement. The Fraud Prevention Sys tem also

identified an ambulance provider for questionable trips allegedly made to a hospital. During the three years prior to the system alerting

officials, the provider was paid more than $1.5 million for transporting more than 4,500 beneficiaries. A review of medical records found

significant instances of insufficient or lack of documentation. CMS also revoked the provider’s Medicare enrollment and referred the results

to law enforcement.

“The third year results of the Fraud Prevention System demonstrate our commitment to high-yield prevention activities, and our progress in

moving beyond the ‘pay and chase’ model,” said Dr. Shantanu Agrawal, CMS deputy administrator and director of the Center for Program

Integrity. “We have learned a lot in the three years since the Fraud Prevention System began, and as we learn, we continue to become

more sophisticated in detecting aberrant billing patterns and developing leads for investigations and action.”

In future years, CMS plans to expand the Fraud Prevention System and its algorithms to identify lower levels of non-compliant health care

providers who would be better served by education or data transparency interventions.

For more information, please see the Report under “Guidance and Reports” at: http://www.cms.gov/About-CMS/Components/CPI/Center-

for-program-integrity.html

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CODING GUIDELINES

The MACs, CERT, Recovery Auditors, and ZPICs shall apply coding guidelines

to services selected for review. All contractors shall determine that an

item/service is correctly coded when it meets all the coding guidelines listed in

the Current Procedural Terminology-4 (CPT) book, ICD-10, HCPCS and CMS

policy or guideline requirements, LCDs, or MAC articles.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R512PI.pdf

QUESTIONS/PRESENTER

Peggy L. Palmer, BA, CPC

Coding & Compliance Specialist, Ethics and Compliance

University of Tennessee Medical Center

Education Officer, Knoxville Chapter AAPC

Tennessee Representative, CAHABA POE Advisory Group

E-mail: knoxvillechapteraapc@utmck.edu

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