Efficiency, Growth, Financial Performance 2014 Compliance Training Billing Compliance Office Dermatology Staff Meeting 4/10/2014 BWH/BWPO Billing Compliance Office 801 Massachusetts Avenue, 5 th Floor Boston Mass Phone & (fax)

Efficiency, Growth, Financial Performance 2 Efficiency, Growth, Financial Performance Physician Billing Compliance Audit Process Overview Established Patient Definition Level 4 – Established Level 5 – Established

Efficiency, Growth, Financial Performance Audit Process Overview New Providers are added into Audit schedule as soon as they have generated professional services. Providers are scheduled for follow-up audits based on their score. –Bi-Annual Reviews – score of 0-3 –Annual Reviews – score of 4-12 – Semi-Annual Reviews – score of –Quarterly Reviews – score of 18 and over 3

Efficiency, Growth, Financial Performance 4 Selection of Encounters Encounters are randomly selected from billed services for each provider based on DOS, Procedure Billed, and Payer (Medicare/Medicaid is weighted heavier than the other payers) 10 Services are selected for each audit DOS can go back 6 months depending on the above criteria Medicare/Medicaid services will be 50% or higher (if available) Professional and Technical services are both audited

Efficiency, Growth, Financial Performance 5 Reporting Results After each audit is completed, the provider is notified by an initial . If the provider passes the audit, the will contain observations of the audit which can help decrease potential errors in future audits and attachments of the cover letter and a high level CPT-4 coding summary. A hard copy of these findings and a more detailed explanation of the review is sent via interoffice mail. If a provider does not pass the audit, an requesting a meeting is sent. The detailed report will be reviewed and discussed at this meeting.

Efficiency, Growth, Financial Performance 6 Post Audit The provider may request a review of any findings within 15 days of receipt of the audit report. If warranted, the findings will be revised and a corrected report sent. The Compliance Department will initiate appropriate refunding and rebilling of any services identified as documented incorrectly. A provider can request a meeting at any time, even if a meeting is not necessary from a scoring perspective.

Efficiency, Growth, Financial Performance 7 Established Patient Definitions Established patient has seen you, the physician or another physician of the same specialty and group (within the past three years) Regardless of problem –New diagnosis/problem does not mean new patient Regardless of whether you personally have seen the patient before –New patient to you, does not necessarily mean new patient Based on billing Tax ID number –Group Practice tax ID is a determining factor

Efficiency, Growth, Financial Performance 8 Visit Level 4 – Established Patient Established Patient Visits require that 2 of the 3 key components meet a given level in order to code at that level Level 4 visits require a Detailed History –4 or more HPI elements –2-9 Systems Reviewed –1 element in either Past, Family and Social Hx Level 4 requires a Detailed Exam –Using the Skin Exam– this means 12 exam bullets in 2+ systems Level 4 = Moderate Risk MDM

Efficiency, Growth, Financial Performance 9 Visit Level 5 – Established Patient Established Patient Visits require that 2 of the 3 key components meet a given level in order to code at that level Level 5 visits require a Comprehensive History –4 or more HPI elements –10+ Systems Reviewed –Past, Family and Social Hx (all 3) Level 5 requires a Comprehensive Exam –Using the Skin Exam– this means perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border. Level 5 = High Risk MDM

Efficiency, Growth, Financial Performance 10 Established Patient Visits (2 of 3) Code & Extent of Work Expanded Problem Focused DetailedComprehensive History HPI = 1-3 ROS = 1 HPI = 4+ ROS = 2-9 PFSH = 1 HPI = 4+ ROS = 10+ PFSH = 2 of 3 Single Exam Skin Bullets =6 At least 6 Bullets Bullets = 12 At least 12 bullets Bullets = 25 2 in 9 systems MDM Dx/mgmt = 2 Data = 2 Risk = LowLow Dx/mgmt = 3 Data = 3 Risk = ModModerate Dx/mgmt = >4 Data = >4 Risk = HighHigh

Efficiency, Growth, Financial Performance 11 Questions? Thank You !