E/M Compliance Cheryl Rasbach, Compliance Auditor



E/M Compliance Cheryl Rasbach, Compliance Auditor

Presentation Outline Health First Health Plans

Introduction/Compliance 101

- HFHP Medicare Advantage Plan: What does this mean?

- HFHP obligations to comply with Federal/State Regulations

General E/M Compliance

- “If it isn’t documented, it hasn’t been done” – CMS

- Clear and concise representation of treatment

- Meet medical necessary guidelines

- 1995/1997 Documentation Guidelines

- Medical decision making – level of complexity

- Documentation: volume versus content

- E/M Documentation checklist

- Signature requirements

- ICD-10 – effective October 2013

Regulator/Payer - Provider Oversight

- Federal oversight of Mandated Compliance Programs

- State regulations – Special Investigations Unit

- Obligated to monitor/audit providers: safeguard the Medicare program

Auditor’s Perspective

- Key Components of E/M codes: history, physical exam, medical decision making

- Examples of Medical Decision Making: minimal, low, moderate, high

- Table of Risk

- Face-to-face time requirements

- Consultations – documentation requirements

- Incident-To requirements

- Electronic Medical Records – pro’s and con’s

- Documentation is the “Key to Success”

Preparing for an E/M audit

- Provider Self Audits

- Importance of participation

- Responding to overpayments: your rights as a provider

- Examples of provider’s non-compliance

- Coming Soon - Provider Mandated Compliance Programs

- Resources:

o CMS manuals/publications

o FCSO website/listservs

o OIG Annual Work Plan

o Semi-Annual Report to Congress

o Contracted Health Plans Carriers

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