UT Health Science Center at San Antonio CHAPTER 6–Page 6-7
Faculty Practice Compliance Manual 09/01/09
6. FACULTY PRACTICE COMPLIANCE MANUAL GLOSSARY OF TERMS AND ACRONYMS
AAMC (American Association of Medical Colleges) — A non-profit association comprising the 125 accredited U.S. Medical Schools, more than 400 major teaching hospitals, and over 90 academic and professional societies. The purpose of the AAMC is to improve the nation’s health through the advancement of academic medicine.
Authoritative Documents — Any written documentation received from or on behalf of any governmental authority including, but not limited to, the Centers for Medicare and Medicaid Services (CMS), state and regional insurance carriers and intermediaries, and other agencies authorized by law to provide interpretation of billing standards and other standards of practice.
Billing — A term used throughout this manual describing the entire process involved in obtaining appropriate reimbursement for the provision of medical services. The components of this process include, but are not limited to, the following: 1) documentation in the medical record; 2) charge capture, coding, and data entry; 3) insurance claim submission, correction, and follow-up; 4) reimbursement, payment posting, and refunds; and, 5) billing system procedures and processes involved in creating bills to be sent to third-party payors or patients.
Billing Standards — For purposes of this Program, billing standards refer to the regulations enacted by the Department of Health and Human Services (DHHS) found at 42 CFR 415.150 subpart D et seq. entitled, “Physician Services in Teaching Settings.”
CDT (Clinical Documentation Training) — Training provided by the Office of Regulatory Affairs & Compliance that sets forth the standards of practice created by reimbursement rules for providers in the teaching setting, and sets forth standards of billing practice created by laws and rules regulating the health care industry.
Clinical Department — One of the following 17 academic departments within the Health Science Center School of Medicine which includes Anesthesiology, Family & Community Medicine, Neurology, Neurosurgery, Medicine, Obstetrics & Gynecology, Ophthalmology, Orthopaedics, Otolaryngology, Pathology, Pediatrics, Psychiatry, Radiation Oncology, Radiology, Rehabilitation Medicine, Surgery, and Urology.
CMS (The Centers for Medicare and Medicaid Services) — The agency within the U.S. Department of Health and Human Services that oversees the financing of Medicare and Medicaid.
Coder Educator – Those individuals employed by the Office of Regulatory Affairs & Compliance whose duties include reviewing medical charts and prospective billing procedures to perform provider education.
Committee (Compliance & Ethics Committee) — The committee that oversees the implementation and operation of the Faculty Practice Compliance Program.
Compliance — For the purpose of this Program, compliance is the act of conducting one’s affairs in accordance with applicable rules, regulations, and laws.
Consultation — CPT defines consultation as a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. A “consultation” initiated by the patient and/or family, and not requested by a physician, is not reported using the initial consultation codes but may be reported using the codes for confirmatory consultation or office visits, as appropriate.
CPT (American Medical Association Physicians’ Current Procedural Terminology) A listing of descriptive terms identifying codes for reporting medical services and procedures. The purpose of the terminology is to provide a uniform language that accurately describes medical, surgical, and diagnostic services establishing an effective means of reliable nationwide communication among physicians, patients, and third parties.
CRNA (Certified Registered Nurse Anesthetist) – An individual who has received formal education in a nurse anesthesia program recognized by the Texas Board of Nurse Examiners and has received a license from the Board to practice in Texas.
CS (Compliance Specialists) — Those individuals employed in the Office of Regulatory Affairs & Compliance whose job duties include reviewing medical charts and retrospective billing procedures, assisting with Program development and implementation, providing clinical documentation and coding training and other specialty training as necessary, and conducting investigations of questionable practices, and completing special projects, as necessary.
CT (Compliance Technician) – Those individuals employed in the Office of Regulatory Affairs & Compliance whose job duties include reviewing medical charts and billing procedures, and conducting investigations of questionable practices.
E/M Services (Evaluation and Management Service) — A section of CPT covering non-procedural services that is divided into broad categories, such as office visits, hospital visits, and consultation services. These categories are further divided into subcategories and then divided into levels of service identified by a code number. This classification is important because the nature of physician work varies by type of service, place of service, and the patient’s status.
Entire Viewing Portion — For endoscopic procedures, CMS defines the viewing portion as starting at the time of endoscope insertion and ending at the time of removal of the endoscope.
Established Patient — CPT defines an established patient as one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the last three years.
Institutional Compliance Officer (Officer) — The individual having direct, daily responsibility for the administration, implementation, and oversight of the Program.
Faculty Practice Compliance Program (Program) — A system of policies and procedures developed to assure compliance with, and conformity to, federal and state laws, as well as internal institutional requirements governing the practice of medicine at the Health Science Center. Additional information about the Program can be found at http://facultycompliance.uthscsa.edu.
Faculty Practice Plan (Plan) — The structure under which physicians and other health care providers on the School of Medicine’s staff are able to bill for the medical services they provide to patients who choose to seek care at associated teaching hospitals or clinics. The revenue collected from these bills is placed into the university account for the School of Medicine. A portion of the fund is used to provide salaries for the physicians; some is used for general operating expenses of the medical school for the training and education of its medical students and for support of research programs.
Fellow — Under CMS guidelines, fellows are viewed the same as residents in GME programs recognized as approved for purposes of direct GME payments made by the fiscal intermediary. The fact that an individual hospital does not choose to include an eligible individual in its full-time equivalency count of residents does not change the individual’s status as a resident in an approved program.
Fiscal Intermediary — The third party designated to administer and pay claims for Medicare Part A and/or other federally funded insurance programs.
GCAT (General Compliance Awareness Training) — The Health Science Center training program designed to promote awareness of all governmental statutes, regulations, agency directives, and Health Science Center’s standards of conduct that govern an individual’s function within the Health Science Center. It also outlines the consequences, both to the individual and to the Health Science Center, that result from any violation of these requirements. Every officer, director, employee, resident, and physician of the Health Science Center must attend GCAT.
GME (Graduate Medical Education) — Additional medical training through certified programs that graduates of medical schools, schools of osteopathy, and schools of podiatry undergo to meet licensing and board certification requirements. The first year of additional training is often referred to as an internship. The second and subsequent years are usually referred to as a residency. Medicare approves selected programs for payments to defray costs for residents’ salaries and fringe benefits, as well as physician administrative costs that are not payable on a fee schedule basis (Federal Register, Vol 60, No. 236, December 8, 1995).
HCPCS (Healthcare Common Procedural Coding System, Level II) — A coding system that provides a uniform method for healthcare providers and medical suppliers to report professional services, procedures, and supplies. CPT does not contain all the codes needed to report medical services and supplies; therefore, CMS developed the HCPCS Level II codes to cover the areas not addressed in CPT.
HHA (Home Health Agency) — A public or private organization that provides skilled nursing services and other services such as physical therapy, speech-language therapy, occupational therapy, medical-social services, and home health aide services. Such services are provided in a place of residence used as a patient’s home (Medicare, CMS, Home Health Agency Manual §200, Coverage of Services, Definitions).
ICD-9 (ICD-9-CM) (International Classification of Diseases, 9th Revision (Clinical Modification) — The ICD-9 system is a statistical classification that arranges diseases and injuries into groups according to established criteria. Most ICD-9 codes are numeric and consist of three, four, or five numbers and a description. Codes are revised approximately every 10 years by the World Health Organization and annual updates are published by CMS.
IL-372 (Intermediary Letter 372) — This letter was originally issued in 1969 from CMS and outlined the guidelines for teaching physicians to follow when billing Medicare for patients they see in conjunction with a resident.
Institutional Compliance Program — The Health Science Center program is designed to prevent accidental or intentional non-compliance with applicable laws and regulations; to detect such non-compliance if it occurs; to discipline those involved in non-compliant behavior; and to prevent future non-compliance. The program promotes compliance with all applicable regulatory requirements; fosters and helps ensure ethical conduct; and provides education, training, and guidance to all faculty and staff of the Health Science Center.
Key Portions of Service — CPT defines the key portions of an E/M service to be history, examination, and medical decision making. The key portions of procedural services are determined by the teaching physician (i.e., the key portion of an endoscopy is the entire viewing portion of the service).
Level of Service (E/M) — Within each category or subcategory of E/M service, there are three to five levels of service available for reporting medical care. The descriptors for the levels of E/M services recognize seven components, six of which are used in defining the level of E/M service: 1) history, 2) examination, 3) medical decision making, 4) counseling, 5) coordination of care, 6) nature of presenting problem, and 7) time. The first three (history, examination, and medical decision making) are considered the key elements or components in selecting the level of E/M service provided. The following three components (counseling, coordination of care, and nature of presenting problem) are considered only contributory factors and may not be provided within all services. In cases where counseling or coordination of care dominate more than 50% of the service, the key or controlling factor then becomes time.
Material Billing Deficiency — Any isolated event or a series of occurrences that has a significant, adverse financial impact; significantly affects the veracity of information upon which the claim is based, even if it does not have a financial impact; or might prevent the Health Science Center from submitting a claim for reimbursement [including, but not limited to, issues relating to compliance with the anti-kickback statute (codified at 42 U.S.C. §1320a-7b) or the physician self-referral prohibition (codified at 42 U.S.C. §1395nn)]; and which claim lacks conformity with the programs’ reimbursement principles or other applicable statutes, and the regulations and written directives issued by CMS and/or its agents, or any other agency charged with administering the affected health care program and/or its agents.
MAC (Medicare Administrative Contractor) — The third party designated to administer and pay claims for Medicare Part B and/or other federally funded insurance programs.
Macro — A command in an electronic medical record or dictation application that automatically generates predetermined text that is not edited by the user.
Medicaid — A program administered by both federal and state governments designed to provide health care to those unable to afford private health insurance or private health care.
Medical Direction — For anesthesia cases, medical direction occurs when the physician medically directs two, three, or four concurrent cases involving nurse anesthetists, anesthesiologist’s assistants, interns, or residents.
Medical Student — An individual who participates in an accredited educational program (e.g., a medical school) that is not an approved GME program. A medical student is never considered a resident.
Medicare — The federal insurance program administered by the U.S. Department of Health and Human Services. Medicare provides health insurance for persons over 65 and certain other people who qualify under Social Security Disability rules.
Medicare Claims Processing Manual – A list of operating instructions, policies, and procedures for third party companies designated to pay Medicare Part B and/or other federally funded insurance program claims.
MSRDP (Medical Service Research and Development Plan) — A name under which the Health Science Center’s Faculty Practice Plan operates.
MSRDP Compliance & Ethics Committee (Committee) — The committee that oversees the implementation and operation of the Faculty Practice Compliance Program.
MSRDP Effective Date — The date that an internal Health Science Center provider number is issued. This may or may not be the date of faculty appointment.
New Patient — CPT defines a new patient as 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 last three years.
Office (Office of Regulatory Affairs & Compliance) — The office that has direct, daily responsibility for the implementation of the elements of the Faculty Practice Compliance Program.
Office of the Inspector General Work Plan (OIG Work Plan) — The annual investigative focus of the Office of the Inspector General, which operates within the Department of Health and Human Services. The OIG investigates waste, fraud, and abuse within the various HHS programs, including Medicare, Medicaid, and TRICARE/Champus.
PATH Initiative (Physicians at Teaching Hospitals Initiative) — A nationwide initiative instituted by the Department of Health and Human Services’ Office of the Inspector General in conjunction with the Department of Justice to review teaching physician compliance with Medicare billing rules. PATH actually involves an audit of the entities that submit teaching physician billings to Medicare. There are two types of PATH audits, non-voluntary (PATH I) and voluntary (PATH II).