Medical Compliance Plan

Approval by the University Billing Compliance Committee on March 19, 2002

Introduction

The Department of Medicine at Creighton University is comprised of 11 divisions. The divisions including Allergy/Immunology, Cardiology, Dermatology, Endocrinology, Gastroenterology, General Internal Medicine, Hematology/Oncology, Infectious Diseases, Nephrology, Pulmonary/Critical Care and Rheumatology. Each division provides inpatient and outpatient medical care for Medicare recipients. Inpatient and outpatient services are provided at a number sites, please see Appendix A. In addition, outpatient services are provided at a number of regional outreach sites.

A complete list of the Licensed Individual Practitioner’s (LIP’s) in the Department of Medicine who provide patient care is attached as Appendix B. The Department of Medicine operates an Internal Medicine residency training program and a Medicine-Pediatrics residency training program. The Department of Medicine currently has approximately 66 residents, 22 are preliminary or categorical first year residents. There are 12 categorical residents in the 2nd year, 12 categorical residents in the 3rd year, and 16 med-peds residents. In addition, there are 4 chief residents. The Department also has fellowship programs in Cardiology, Pulmonary/Critical Care, Allergy/Immunology, and Infectious Disease, with a total of approximately 19 fellows. Of these residents and fellows, 48 resident providers and 17 fellow providers are federally funded. Approximately 45% of all patients admitted to Saint Joseph Hospital are under the care of Department of Medicine faculty and house staff.

Compliance Oversight and Involvement

The compliance liaison physician to the University Compliance Committee for the Department of Medicine is appointed by the Chair of the Department of Medicine and serves under the direction of the Associate Chair for Clinical Affairs. The compliance liaison physician for the Department of Medicine will attend at least 60% of the compliance liaison physician meetings. Associate Chair for Clinical Affairs maintains compliance oversight for the Department of Medicine, with the compliance liaison physician reporting to the Creighton University Compliance Liaison Committee.

There shall be a Department Compliance Committee charged with direction and oversight of all billing related compliance activities. The Committee shall be chaired by the Associate Chair of Clinical Affairs. The following individuals shall be members of the committee:

Ø      Associate Chair for Clinical Affairs

Ø      University Compliance Liaison Physician

Ø      Billing Manager

Ø      Department Administrator

Ø      Clinical Center Administrators

Ø      Clinical Operations Managers

Ø      Clinical Nursing Administrators

Ø      Department Compliance Coordinator

The Department of Medicine employs a department compliance coordinator to oversee and monitor billing compliance according to federal and state laws and regulations. The department compliance coordinator will conduct chart reviews annually for each Licensed Individual Practitioner (LIP). Further individual LIP chart reviews will be conducted in accordance with the Creighton University School of Medicine Department Audit Guidelines Policy and the Corrective Action Plan Policy. A report of the findings of these reviews is provided to the faculty of each division on a monthly basis. The non-compliant findings are reviewed by the Associate Chair for Clinical Affairs and the Compliance Liaison Physician for the Department of Medicine. The final chart audit results will be provided to the faculty for review. A summary report will be reviewed and approved by the Committee.

The Committee meets at least quarterly and more frequently as needed. Regular meetings are held with the House Staff and Faculty by the compliance liaison physician, to discuss issues relative to Medicare billing, compliance, appropriate documentation and coding of clinical services. The Chairman of the Department of Medicine Compliance Committee will submit quarterly status reports to the Compliance Officer as required in the Creighton University Compliance Plan.

In addition, faculty profiles on level of charges will be distributed on a quarterly basis, when available, and reviewed by the Department of Medicine Compliance Committee. Audits will be conducted for faculty with high profiles. The findings obtained by the audits will determine if additional training is necessary due to inadvertent over billing. These findings will be included in the Department report to the Creighton University Compliance Officer.

Policy Guidelines

1.         Documentation Guidelines – Policies for documentation and incorporation of the most current Centers for Medicare and Medicaid Services (CMS) documentation guidelines: 

Documentation of E&M services and procedures may be either handwritten or transcribed with some procedures in cardiology having computer interpretation which are overread and signed. Medical records are regularly monitored for LIP signatures and documentation of level of service.

Nurses, medical assistants, residents/fellows, medical students, and LIP’s may provide documentation of E/M services. For example, nurses or medical assistants often record vital signs (temperature, pulse, respiratory rate, blood pressure, weight and height) before the LIP sees patients. Residents/Fellows often document all of the elements of the history and physical exam, but the faculty must document personal participation in the History, Physical Exam and Medical Decision Making.

Any changes or revisions to the medical record may be made by LIP’s or residents/fellows using standard practice for documentation of the revisions with no removal of any information from the record. Faculty members who involve residents in patient care must abide by the requirements for documentation as stated in the University’s Policies for Teaching Physician Requirements.

Each outpatient clinic unit maintains separate medical records. The chart organization is uniform within each clinic; however, there may be some variances from clinic to clinic. At a minimum, all medical records are organized to include sections on progress notes, correspondence, and laboratory data.

Medical necessity for E&M services is documented in the history and physical examination or the progress notes and documentation for procedures is a standard part of the procedure note, whether it be written or dictated.

2.         Teaching physician presence and documentation rules: 

The teaching physician must be present during or perform the key portions of any E&M service or procedure. For Primary Care resident outpatient E&M services at levels 1-3 for new and established patients at identified Primary Care outpatient clinics, the teaching physician must be immediately available (on premises) and document their involvement. Charts are audited for documentation of resident services/plan of care and the teaching physician’s involvement in the E&M service provided and billed (99201, 99202, 99203, 99211, 99212, 99213).

The documentation of presence and level of service is the responsibility of the teaching physician. In all cases, the teaching physician must review and sign procedure reports. If residents/fellows perform procedures without a teaching physician being present, the procedures will not be billed.

3.         A written list of commonly used abbreviations and anachronyms is provided as Appendix C.

4.         Written policies and procedures for coding and billing:

All coding questions are handled by the coding staff, compliance office, and the Billing Manager. The Creighton University Helpline (402-280-5846) is also available for assistance in this area.

The History of Present Illness, Exam, or Medical Decision Making by medical students, nurses, or medical assistants shall not be relied upon to determine the level of E/M service to bill. In addition, residents/fellows must personally document their own History of Present Illness, Exam and Medical Decision-Making.

The LIP is responsible for determining the appropriate billing code and diagnosis. If there is disagreement among the faculty and the Department Compliance Committee, the services will not be billed until mutual resolution.

The Department of Medicine Compliance Committee will review these plans and policies annually. Revisions may be made at any time if there are regulatory changes.

5.                  Templates

Templates utilized in the Department of Medicine clinics must be approved by the Creighton University Compliance Department prior to implementation of the template for clinical usage.

Proposed templates should be forwarded to the department compliance coordinator. Following review by the Billing Manager and compliance coordinator, the template will be forwarded to the Creighton University Compliance Department for approval.

Departmental Education and Training

Mandatory training

1.                  Initial Orientation

LIP’s - All LIP’s are required to complete a compliance orientation.

1.      Initial training.

2.      Read the University Compliance Plan.

3.      Review policies, the Department Compliance Plan, and any unique divisional policies and procedures.

Residents & Fellows

1.      House Officer Orientation

2.      Residents/Fellows with mid year entry will view the videotaped copy of the house officer orientation.

Staff - all employees

1.      All employees must attend compliance orientation as a part of the Creighton University New Employee orientation.

2.      Employees transferring to the Department of Medicine from other departments will also be required to have initial compliance orientation.

2.      Continuing Education

LIP’s, Residents & Fellows

1.      Annual refresher training provided by the University Compliance Officer.

2.      Remedial training as required by the University compliance procedures.

Staff

1.      Department coding staff: annual refresher training provided to faculty.

2.      All certified coders: maintain annual certification by obtaining CEU’s.

All educational and training materials utilized by or developed for Department of Medicine are reviewed and approved by the Associate Chair for Clinical Affairs, the Compliance Liaison Physician, the Departmental Compliance Committee, and the Creighton Compliance Officer.

Corrective Action Tracking (Monitoring)

The audit will track the status for each LIP as they proceed through the School of Medicine Billing Deficiency Corrective Action Plan.

The status results are reported to the Department of Medicine Compliance Committee.

The auditor will provide a corrective action monitoring report to the Department of Medicine Compliance Committee on a quarterly basis. This report will include:

Non-compliant LIP

Corrective Action Plan level

Training needs assessed

Training plan

LIP Notification

Concurrent/Re-audit plan

A corrective action summary report will be forwarded to the Creighton University Compliance Officer.

Reporting and Investigation of Non-compliant Conduct

Members of the Department of Medicine are instructed to report any problems or non-compliant conduct to any member of the Department of Medicine Medicare Compliance Committee. Appropriate investigation and action will be taken to resolve the problems. If these problems are felt to be serious and cannot be resolved by the Department of Medicine, alone, they will be reported to Creighton Compliance Officer directly or through the liaison physician. A University Hotline (402-280-2107) is available for any staff or faculty to report possible compliance violations.

The Creighton Compliance Officer or General Counsel, assisted by the Department Liaison Physician and the Associate Chair for Clinical Affairs, will investigate suspected non-compliant conduct. Other members of the Departmental Compliance Committee may be utilized in the investigative activities.

Creighton University Billing Compliance Policies and Procedures for the School of Medicine can be accessed on the Internet at http://www.creighton.edu/billingcompliance/mspp.htm

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