COMPLIANCE RESOURCES

"Corrections to the medical record legally amended prior to claims submission and/or medical review will be considered in determining the validity of services billed. If these changes appear in the record following payment determination based on medical review, only the original record will be reviewed in determining payment of services billed to Medicare. Appeal of claims denied on the basis of an incomplete record may result in a reversal of the original denial if the information supplied includes pages or components that were part of the original medical record, but were not submitted on the initial review". Read More

This compliance program guidance for individual and small group physician practices contains seven components that provide a solid basis upon which a physician practice can create a voluntary compliance program: • Conducting internal monitoring and auditing; • Implementing compliance and practice standards; • Designating a compliance officer or contact; • Conducting appropriate training and education; • Responding appropriately to detected offenses and developing corrective action; • Developing open lines of communication; and • Enforcing disciplinary standards through well-publicized guidelines. Read more

Providers should submit adequate documentation to ensure that claims are supported as billed. Read More.

Psychotherapy for crisis should only be used for urgent assessment when
a patient is in a state of crisis. These codes (90839 and 90840) are billed based on time and may only be used when the provider documents that the patient is currently in crisis. The provider must document the total time spent. If less than 30 minutes is spent then report either code 90832 or 90833 as long as 16 minutes is
documented. The provider must devote his/her full attention to the patient during this time and cannot see other patients. The codes are to be used by providers during the time when they are trying to diffuse a crisis and restore safety.

The OIG recognizes that physicians should be able to order any tests, including screening tests, they believe are appropriate for the treatment of their patients. However, a physician practice should be aware that Medicare will only pay for services that meet the Medicare definition of reasonable and necessary. Medicare (and many insurance plans) may deny payment for a service that is not reasonable and necessary according to the Medicare reimbursement rules. Thus, when a physician provides services to a Medicare beneficiary, he or she should only bill those services that meet the Medicare standard of being reasonable and necessary for the diagnosis and treatment of a patient. A physician practice can bill in order to receive a denial for services, but only if the denial is needed for reimbursement from the secondary payor. Upon request, the physician practice should be able to provide documentation, such as a patient’s medical records and physician’s orders, to support the appropriateness of a service that the physician has provided.

Timely, accurate and complete documentation is important to clinical patient care. Examples of internal documentation guidelines a practice might use to ensure accurate medical record documentation include the following:  • The medical record is complete and legible; • The documentation of each patient encounter includes the reason for the encounter; any relevant history; physical examination findings; prior diagnostic test results; assessment, clinical impression, or diagnosis; plan of care; and date and legible identity of the observer; • If not documented, the rationale for ordering diagnostic and other ancillary services can be easily inferred by an independent reviewer or third party who has appropriate medical training; • CPT and ICD–10–CM codes used for claims submission are supported by documentation and the medical record; and • Appropriate health risk factors are identified. The patient’s progress, his or her response to, and any changes in, treatment, and any revision in diagnosis is documented. Additionally, HCFA and the local carriers should be able to determine the person who provided the services. These issues can be the root of investigations of inappropriate or erroneous conduct, and have been identified by HCFA and the OIG as a leading cause of improper payments.