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3.DOCUMENTATION AND CODING GUIDELINES FOR BILLABLE SERVICES
GOAL AND POLICY
Goal
To ensure that clear written statements concerning the institution's documentation policies are available to School of Medicine Faculty Practice Plan providers, employees, and agents.
Policy
It is the policy of the UT Health Science Center at San Antonio that all charges for patient care services, including those for professional services, technical services, and durable medical equipment or supplies, are accurately submitted for reimbursement according to accepted coding and billing standards. Furthermore, the Health Science Center strives to ensure that medical record documentation meets the requirements of the Physicians at Teaching Hospitals Initiative (PATH), and that submitted charges accurately reflect such documentation.
Accepted coding practices require the use of multiple resources such as the AMA Current Procedural Terminology (CPT); the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM); and the Healthcare Common Procedure Coding System (HCPCS).
Faculty physicians provide services to patients either personally or in conjunction with residents. The revised rules for “Teaching Physician Services”(effective February 13, 2006) provides the standard for teaching physician presence, documentation, and coding of services involving residents. Resources utilized to establish this rule, as well as Medicare guidelines and policies for personally performed provider services, include the Federal Register, Medicare Claims Processing Manual, TrailBlazer Medicare Newsletters, CMS and various AAMC memos, CMS letters of clarification, and specialty society publications.
Unless a specific payor mandates a unique standard, documentation and coding standards should be uniform. This single approach significantly increases the effectiveness of education and training, decreases the complexity of monitoring, and ultimately improves compliance. To ensure consistency, the Health Science Center will require the use of the Medicare teaching physician presence and documentation standards regardless of patient or payor, unless the Compliance Ethics Committee has approved an exception (for example, use of Medicaid requirements).
Many departments utilize templates to assist them in documenting services; however, CMS requires the teaching physician to personally document his/her personal participation in a service or procedure, and include patient specific information. Templates that do not allow the teaching physician to document specific patient information are not acceptable. With the exception of unique CPT or diagnostic coding requirements by payor, Medicare coding standards will be utilized. For example, some payors require the use of unique procedure and diagnosis codes not applicable to the Medicare program. Some departments may have chosen to adopt documentation standards which are more extensive than those required by CMS. In those cases, providers are encouraged to follow their departmental guidelines, as well as those outlined in this chapter. To meet the stated goal, the Health Science Center will adopt the general policies outlined above through the use of guidelines set forth in this chapter.
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3.1ANESTHESIA SERVICES
3.1.1Major Teaching Physician Provisions for Single Cases with Residents1
The teaching physician must be present during all critical or key portions of the procedure and immediately available to furnish services during the entire procedure.
An unreduced fee schedule payment is paid if a teaching physician is involved in a single procedure with one resident.
The teaching physician’s physical presence during only the pre-operative or post-operative visits with the patient is not sufficient for payment.
If a teaching physician is involved in concurrentprocedures with more thanone resident or with a resident and a non-physician anesthetist (i.e., CRNA), the teaching physician’s services are paid as medical direction, as outlined in Section 3.1.2, of this Manual.
If a teaching physician is involved in two concurrentcases with residents on or after January 1, 2004, the teaching anesthesiologist may bill the usual base units and anesthesia time, as outlined in Section 3.1.3, of this Manual
Teaching Physician Documentation Requirements for Single Cases with Residents1
Documentation in the medical record (anesthesia record, anesthesia report) must indicate the teaching anesthesiologist’s presence or participation in the administration of the anesthesia.
The documentation must specifically state that the teaching anesthesiologist was present during all other critical or key portion(s) of the procedure, and that he/she was “immediately available” during the entire procedure.
The key or critical portion of the procedure must be referred to specifically and not just generally as the key or critical portion.
The teaching anesthesiologist’s documentation must be personally written and signed.
If the teaching anesthesiologist personally provides a pre-operative or post-operative service to the patient, then he/she should document the medical record accordingly.
Questions and Answers – Single Cases with Residents
Q:Must the teaching physician document his/her time in and time out during the critical points of the procedure?
A: A time in, time out record does not have to be kept for this purpose; however, time is a key component utilized in the charge calculation.
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Q:Must a teaching anesthesiologist personally document presence during induction, emergence, and any other portion of the procedure?
A:The teaching anesthesiologist must personally document presence during the critical or key portion(s) as well as the induction and emergence portions of the procedure. The critical or key portion(s) must be identified and the teaching anesthesiologist must also state in the medical record their immediate availability during the entire procedure.
Q:Sometimes transfer of a patient to the Post-Anesthesia Care Unit (PACU) is delayed due to bed unavailability. How does the anesthesiologist bill for post-anesthesia care time in the operating suite? That time is defined as beginning when the patient is ready to be transferred to the PACU.
A:TrailBlazer Health Enterprises states the following:
“The anesthesiologist may be permitted to bill as much as one additional time unit (15 minutes) if the anesthesiologist is present with the patient in the OR suite, while the patient is awaiting transfer. We would apply the same policy to a medically directed CRNA; that is, the CRNA must be present with the patient in the OR suite, while the patient is awaiting transfer. In either case, the anesthesiologist or medically directed CRNA can only be present with one patient; the anesthesiologist or medically directed CRNA cannot bill for anesthesia time for more than one patient simultaneously”.2
3.1.2 Major Medicare Provisions for Medically Directed Services3
Payment may be made for physician anesthesia services provided when the physician medically directs two, three, or four concurrent cases involving nurse anesthetists, anesthesiology’s assistants, interns, or residents.
In a single procedure involving a physician and the CRNA, apply the medical direction payment policy to determine payment for both the CRNA service and the physician service. In unusual circumstances such as a complicated trauma case in which it is medically necessary for the CRNA and the anesthesiologist to be involved completely and fully in a single anesthesia case, full payment could be made for the services of the two providers. Documentation must be submitted by the CRNA to support the claim for payment.
Medical direction is a covered service only if the anesthesiologist performs the following seven services:4
- Performs a pre-anesthesia examination and evaluation;
- Prescribes the anesthesia plan;
- Personally participates in the most demanding procedures of the anesthesia plan including induction and emergence;
- Ensures that any procedures in the anesthetic plan that the anesthesiologist does not perform are performed by a qualified anesthetist;
- Monitors the course of anesthesia administration at intervals;
- Remains physically present and available for immediate diagnosis and treatment of emergencies; and
- Provides indicated post-anesthesia care.
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Anesthesia time and calculation of anesthesia time units:
Anesthesia time means the time during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care. Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.
A physician who is concurrently directing the administration of anesthesia to not more than four surgical patients cannot ordinarily be involved in furnishing additional services to other patients with the following exceptions:
1.Addressing an emergency of short duration in the immediate area.
2.Administering an epidural or caudal anesthetic to ease labor pain.
3.Periodic, rather than continuous, monitoring of an obstetrical patient.
4.Receiving patients entering the operating suite for the next surgery.
5.Checking on or discharging patients in the recovery room.
6.Handling scheduling matters.
If the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physician’s services to the surgical patients are supervisory in nature.
Documentation Requirements for Medically Directed Services5
For medical direction services, the physician alone must inclusively document in the patient’s medical record that he/she:
Performed the pre-anesthetic exam and evaluation,
Provided indicated post-anesthesia care,
Was present during some portion of anesthesia monitoring, and
Was present during the most demanding procedures, including induction and emergence, where applicable.
3.1.3Two Concurrent Cases Resident
If a teaching anesthesiologist is involved in two concurrent cases, with residents on or after January 1, 2004, the teaching anesthesiologist may bill the usual base units and the amount of anesthesia time that the anesthesiologist was present during each case with the resident.
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To bill base units, the teaching anesthesiologist must be present with the resident during the pre- and post-anesthesia care included in the base units.
The teaching anesthesiologist must be present during all critical or key portions of each procedure.
Prior to January 1, 2004, if a teaching anesthesiologist is involved in concurrent cases with more than one resident, the cases are billed as medically directed, as outlined in Section 3.1.2, of this Manual.
If the teaching physician is only present during the preparation of the patient before surgery and the observation of the patient after surgery, these services cannot be billed.
Teaching Physician Documentation Requirements for Two Concurrent Cases with Residents
Documentation in the medical record must indicate the teaching anesthesiologist’s involvement in each case including presence during and/or performance of the pre- and post-anesthesia care.
Documentation must state that the teaching anesthesiologist was present during all critical or key portions of each procedure.
The teaching anesthesiologist’sdocumentation must support the amount of timethat he/she was present with each resident.
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3.2COMPLEX, HIGH-RISK AND INTERVENTIONAL PROCEDURES
Major Teaching Physician Provisions for Billable Services1
These procedures include interventional radiologic and cardiologic supervision and interpretation codes, cardiac catheterization, cardiovascular stress tests, and transesophageal echocardiography.
For each complex or high-risk procedure, the teaching physician:
Must be present with the resident when national Medicare policy, local policy or the CPT description indicates that the procedure requires personal (in person) supervision of its performance by a physician.
Is required to be present during that portion of the procedure that is usually reflected in the wording of the procedure code or in accordance with “Supervision and Interpretation” (S&I), as specified in CPT.6
- For example, in the case of a cardiac stress test, presence is required during the portion reflected by CPT 93016 – “physician supervision.” Presence would include the period during exercise or pharmacologic stress. In the case of S&I codes for radiology, presence would be required during the radiological portion of the procedure. In the case of transesophageal echo, presence would be required during the portion reflected by CPT 93313 – “placement of the probe.”7
When the description of the CPT billing code states “supervision and interpretation” (S&I), the teaching physician must be present with the patient for the entire radiologic portion of the interventional procedure, as these codes pay for both the performance and the interpretation of the findings.6
Teaching Physician Documentation Requirements1, 6
The teaching physician’s documentation must support personal presence during procedures requiring personal supervision.
The teaching physician’s must attest to reviewing the film/tracing/image and the resident’s interpretation and either agree with or have edited the findings of the report.
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3.3CONSULTATIONS
Major Teaching Physician Provisions for Billable Services1
The teaching physician must be physically present during the critical or key portion(s) of the service that determines the level of service billed.
Teaching Physician Documentation Requirements1
For E/M documentation instructions, see Medicare Claims Processing Manual, 100-04, Chapter 12, §100.1.1A - General Documentation Instructions and Common Scenarios.
Documentation of key elements above may be satisfied by combining entries into the medical record made by the resident and the teaching physician.
Major Medicare Provisions for Billing Consultations8
Effective January 1, 2006, the following guidelines apply when billing a consultation.
Consultation versus Other Evaluation and Management (E/M) Visits
The following criteria should be met when billing a consultation:
Specifically, a consultation is distinguished from other E/M visits because it is provided by a physician or qualified non-physician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source (unless it is a patient-generated confirmatory consultation);
A request for a consultation from an appropriate source and the need for consultation must be documented by the consultant in the patient’s medical records and included in the requestor’s plan of care in the patient’s medical record; and,
After the consultation is provided, the consultant prepares a written report of his/her findings and recommendations which is provided to the referring physician.
The intent of a consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.
When the referring physician will not be involved in subsequent decision-making about the problem for which the consultation was requested (i.e., has turned over the care of the patient for the specified problem to another physician), the service should be coded as a new patient or established patient, initial or subsequent non-consultative E/M service that is appropriate to the situation.10
Consultations may be billed based on time if the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter between the teaching physician or qualified NPP and the patient. When the consultation is based on time for counseling/coordination, the preceding requirements including a request, evaluation (or counseling/coordination), and written report shall also be met.
Consultation Followed by Treatment
An initial consultation may be billed if all of the criteria for a consultation are met. Reimbursement may be made regardless of treatment initiation unless a transfer of care occurs. A transfer of care occurs when the referring physician transfers the responsibility for the patient’s complete care to the receiving physician at the time of referral and the receiving physician documents approval of care in advance. The receiving physician should report a new or established patient visit depending on the situation (a new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years) and setting (e.g., office or inpatient).
A physician consultant may initiate diagnostic and/or therapeutic services at an initial or subsequent visit. Subsequent visits (not performed to complete the initial consultation) to manage a portion or all of the patient’s condition should be reported as an established patient office visit or subsequent hospital care, depending on the setting.
Consultations Requested by Members of Same Group8
A consultation may be billed if one physician or NPP in a group practice requests a consultation from another physician in the same group practice when the consulting physician or NPP has expertise in a specific medical area beyond the requesting professional’s knowledge. A consultation is not reported on every patient as a routine practice between professionals within a group practice.
Consultation for Pre-operative Clearance
Medicare will reimburse the appropriate consultation code for a pre-operative consultation for a new or established patient performed by any physician at the request of a surgeon, as long as all of the requirements for billing the consultation codes are met and the service is medically necessary and not a routine screening.