Medical coding identifies and classifies health information used in a physician’s billing process so that a physician’s payment is optimized, but not maximized. Proper documentation facilitates quality care and verifies the services that were provided. Complete and accurate documentation regarding the diagnosis and treatment in a patient’s medical record is imperative.
Medical coding identifies and classifies health information used in a physician’s billing process so that a physician’s payment is optimized, but not maximized. Proper documentation facilitates quality care and verifies the services that were provided. Complete and accurate documentation regarding the diagnosis and treatment in a patient’s medical record is imperative.
The medical record of a patient may be used to validate site of service, appropriateness of the services provided, the accuracy of the billing, and identity of the health care provider who furnished the services.
All medical records generated by all UBMD physicians must be complete and legible, and include the following elements:
CPT-4 and ICD-10-CM codes reported on all reimbursement claim forms or billing statements should be adequately supported by the documentation in the medical record, and be submitted only in the name of the provider who performed the service.
While the above principles of documentation are applicable to all UBMD providers, it is the responsibility of the individual Practice Plans to implement any documentation guidelines specific to the nature and type of service they provide. The Practice Plans are responsible for orienting all of their employees – clinicians, coders, billers, administrative staff and auditors – to the documentation guidelines. Practice Plans may ask UBMD Compliance Office for assistance with this training.
The Centers for Medicare and Medicaid Services (CMS) issue guidelines outlining how and when clinical services are coded, billed and reimbursed for those physicians teaching interns, residents, fellows, and medical students during patient treatment.
The teaching physician may verify in the medical record any student documentation of components of E/M services, rather than re-documenting the work. This is important for teaching physicians and those who provide coding services to teaching physicians. According to the Medicare Claims Processing Manual the following specifics regarding this:
It is important that there is no question that the teaching physician verified the student’s documentation and personally performed the physical examination and medical decision-making of the E/M service. To ensure that we compliantly bill for these services, the following Student Attestation must be added and signed by the supervising physician:
“I have seen, personally examined and assessed the patient to establish a plan of care. I have reviewed the medical record and verify that all student documentation or findings, including history, physical exam and/or medical decision making are accurate. I have performed or re-performed the physical exam and medical decision making activities to the extent they were conducted by a student.”
There are three (3) ways to bill for the services of non-physician practitioners (NPP).
Incident-to-services: Billed under the MD, paid at 100% of the MD fee schedule.
Direct Billing: Billed under the NPP, paid at 85% of the MD fee schedule
Shared Billing: Applies when NPP and MD are members of the same group, and the combined service is billed either under the NPP's or MD's number
Scribes are allowed by UBMD to be used by teaching/attending physicians, however there are several guidelines to follow. Anyone acting as a scribe must sign the UBMD Scribe Agreement, and the agreement should be kept on file by the practice plan.
