New and Reappointment Review and Test for UNC P&A Pathologists Coding and Compliance New and Reappointment Review and Test for UNC P&A Pathologists

Course Objectives The purpose of this course and its follow-on test is to provide pathologists, who are being re-credentialed by UNC Hospitals, with important information on three issues…

Course Objectives Why coding and compliance is important to you and your practice Coding and documenting pathology services Teaching physician (TP) rules. In order to bill for services when working with residents and fellows, the teaching pathologist must abide by federal and state laws and regulations

Why coding and compliance is important to you and your practice

Reimbursement Providing good care while billing accurately and confidently requires: Doing only what is medically necessary Documenting what you do Billing what you document Understanding and applying coding and compliance conventions can improve the level of reimbursement for UNC P&A practices as well as the quality of the medical record documentation.

Why Compliance Residents are paid through the hospital by Part A Medicare. Medicare pays a portion of the residents’ salaries based on the proportionate share of Medicare at the teaching hospital. Teaching physicians are paid by Part B Medicare on a fee-for-service basis. The government, through Medicare, will pay for both resident and TP services if both participate. If the TP does not participate in a given patient service, the TP cannot bill.

Why Compliance Beginning in December, 1995 the University of Pennsylvania, Thomas Jefferson, Pittsburgh, UT San Antonio, South Carolina, Virginia, the U Cal System, Chicago and seven or eight other schools of medicine have paid fines and penalties ranging from $2M to $30M. The University of Washington recently underwent a criminal investigation. Since July 2002 , there have been at least two whistle blower faculty practice settlements -and in January 2003, the Cleveland Clinic settled with Medicare for $4M.

Why Compliance Two problems caused the refunds and penalties: The TP billed and he/she may have been present and participated in the care, but TP presence was not documented. The documentation did not support the level of evaluation and management (E&M) service billed. The billed level of service may have been provided, but it was not documented.

Coding and Documenting Pathology Services

Documentation for Cytopathology Services As appropriate the report includes: Clinical history Specimen source Type of specimen (e.g. washings, aspirate) Special stains-including positive or negative results Preparation of additional slides Preliminary results (e.g. fine needle aspiration adequacy check) Reference results of all additional studies (e.g. flow cytometry) The dx for each specimen

Documentation for Surgical Pathology As appropriate the report includes: Clinical history Itemization of each specimen received and analyzed Specimen source Gross description Microscopic description Special stains-including positive or negative results Reference results of all additional studies (e.g. decalcification) Reference/results of all consults and frozen sections The dx for each specimen

Clinical Pathology Consultations A clinical pathology consultation (CPT 80500, 80502 for comprehensive, complex) should be billed when there is a request from an attending physician in relation to test results requiring additional medical interpretive judgment. Medical interpretive judgment must be documented in addition to test result(s) CPT code 80500 is used for limited consultation. CPT 80502 is comprehensive, used for complex diagnostic problems. A review of the patient’s history and medical records must be documented by the billing pathologist.

Anatomic or Surgical Pathology Consults When pathologists refer cases to each other for second opinions on anatomic or surgical pathology tests, it is important to document appropriately The note should record whether the slides were prepared elsewhere (CPT 88321) or when new slides must also be prepared (CPT 88323) If the consulting pathologist needs to review previous medical records and specimens in addition, it must be recorded in the note and then CPT 88325 may be used. When pathologists go to the operating room to render an opinion to the surgeon during surgery and no frozen section is prepared, use CPT 88329

Diagnosis coding Tests Ordered Due to Signs and/or Symptoms If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis. If the diagnostic test did not provide a diagnosis or was normal, the interpreting physician should code the sign(s) or symptom(s) that prompted the treating physician to order the study. If the results of the diagnostic test are normal or non-diagnostic, and the referring physician records a diagnosis preceded by words that indicate uncertainty (e.g., probable, suspected, questionable, rule out, or working), then the interpreting physician should not code the referring diagnosis. Rather, the interpreting physician should report the sign(s) or symptom(s) that prompted the study.

Diagnosis coding (con’t) On the rare occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient’s medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician.

3. Teaching physician (TP) rules—supervision of residents and billing Medicare and Medicaid

Medicare TP Attestation Requirement Medicare pays for the interpretation of diagnostic tests if the interpretation is performed by or reviewed with a teaching physician. If a resident prepares and signs the interpretation, the teaching physician must indicate that he or she has personally reviewed the specimen and the resident's interpretation and either agrees with it or edits the findings. The resident may not document the participation of the teaching physician Medicare does not pay for an interpretation if the teaching physician only countersigns the resident's interpretation.

North Carolina Medicaid Requirements The degree of supervision is the responsibility of the TP and is based on the skill, level of training and experience of the resident as well as the complexity and severity of the patient's condition. Written documentation in the medical record for Medicaid patients must clearly designate the supervising physician and be signed by that physician.

Where To Get Help www.med.unc.edu/compliance/ Official regulations and scenarios from CMS: http://cms.hhs.gov/manuals/pm_trans/R1780B3.pdf UNC P&A Professional Charges 962-8391 School of Medicine Compliance Office 843-8638 Heather Scott, CPC, Compliance Officer Keishonna Carter, CPC, Compliance Review Analyst Nirmal Gulati, CPC, Compliance Auditor Lateefah Ruff, Office Assistant Confidential Help Line 800-362-2921 AMA CPT Manual