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Healthcare Compliance

The division of healthcare compliance works in tandem with the University providers, coders, billers, and support staff to provide guidance, support, and oversight regarding state and federal healthcare provider billing regulations.

Code of Conduct (2019-2020)  

Billing Coding and Documentation

The SLUCare Coding helpline can be reached at 977-6323, or medicalcoding@health.slu.edu.

For assistance with EPIC, log in to SLU Banner with your SLU username and password, click on the "Service Now" tile, and complete a service request as needed.  

For IT help, visit myslu.slu.edu/tools, click on the IT Services tile, click the link under "The Self-Service Portal", log in and proceed.

Anthem Standards of Ethical Business Conduct

Aetna Code of Conduct

Payer Compliance Codes of Conduct

FAQ

How do I close an encounter when a provider resigns?
The University has an offboarding process that is required when a provider resigns. This process requires providers to close all of their patient encounters. Administratively closing an encounter happens, in the very rare instances, as medical leave or death. In these unfortunate instances, a mechanism to close these encounters was required. These encounters are not billable, except for the possible exception of an ancillary service where documentation does exist to support the claim that was originally authorized by the provider but, performed in a separate department. When an encounter must be administratively closed, the provider tasked with this duty (typically, the Department chairman or section leader) should amend their attestation statement to reflect that they are acting in a strictly administrative capacity and are unable to offer comment on the original provider’s findings, clinical judgment or care plan.
Is time spent in consultation with the patient’s family billable?
 In certain types of medical conditions, including when a patient is withdrawn and uncommunicative due to a mental disorder or comatose, the physician may contact relatives and close associates to secure back ground information to assist in diagnosis and treatment planning. When a physician contacts the relatives and associates for this purpose, the provider my bill for the time spent counseling and coordinating care of the patient.  In some cases, the physician will provide counseling to members of the household. Family counseling services are covered only where the primary purpose of such counseling is the treatment of the patient’s condition. 
Which date of service should be used when documentation dates differ between the teaching physician and the residents/medical students?

SLUCare has recently adjusted the SmartText Attestation to include a reference to the date of service.   This change is necessary to avoid confusion in the frequent instances where a teaching physician documents at a later date than a resident or medical student, such as a subsequent morning.  To protect the integrity of the author’s documentation and to prevent the charge from being unnecessarily down-coded or written off, the text will now include an explicit date of service on every note.

When providing an E/M visit and a procedure on the same day (modifier 25) is it necessary that each have a different diagnosis code?

No.  In many instances the diagnosis code referenced for the E/M service is different from the diagnosis code referenced for the procedure (that is, two different medical conditions). Example: A patient is seen for a scheduled follow-up visit for hypertension and complains of a sore shoulder. After evaluation of the blood pressure and the shoulder, a diagnosis of bicipital tendonitis is made, and the shoulder is injected. In this case, the appropriate E/M code for the level of service provided, as well as the procedure for injection, should be submitted. In some instances, however, the diagnosis code referenced for the E/M service and the procedure are for the same condition or illness, Example: A patient complains of a sore shoulder. After evaluation of the shoulder, a diagnosis of bicipital tendonitis is made, and the shoulder is injected. In this case, the appropriate E/M code for the level of service provided, as well as the procedure for injection, should be submitted.

Can you report an E/M visit at the time of a wellness visit?

 Yes. The E/M visit should be separate from the wellness visit.  If the physician treats and documents an acute or chronic problem during the same encounter as a wellness visit, bill for both.  If the patient’s condition is not stable, or there is an acute problem, report the E/M visit separately. The E/M visit should contain a chief complaint, HPI, Exam and assessment and treatment plan. The treatment plan should show either a change in treatment or a plan to monitor the condition. 


FAQ on Laws and Regulations Pertinent to Physician Billing 

What is HIPAA?

 This acronym stands for the Health Insurance Portability and Accountability Act, a U.S. law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

What is the Stark Law?

The Stark Law is similar to the Anti-kickback Statute, but applies only to physician relationships with entities that bill Medicare or Medicaid (CMS). The Stark Law bans certain financial arrangements between a referring physician and a covered entity that bills the Medicare or Medicaid programs.

 A financial relationship is an invested interest in, or a compensation arrangement with, another entity. An ownership or investment interest may be through equity, debt, or other means. A compensation arrangement is generally defined as any arrangement involving any remuneration between a physician (and/or their immediate family member) and an entity.

Stark Law prohibits payments for certain designated health services provided through a prohibited referral, and requires refunds for improperly billed and collected amounts. It permits CMPs (up to $15,000 per service) and exclusion from government programs when a provider submits an improper claim known, or should have been known, to have been provided through a prohibited referral, and has not refunded the payment. Physicians who violate the statute may be subject to additional fines per prohibited referral

What is the False Claims Act?

The False Claims Act (31 U.S.C. §§ 3729-3733) prohibits anyone from “knowingly” submitting false or fraudulent claims for payment, or engage in misconduct involving federal government money or property. The FCA in healthcare context imposes civil liability on persons who knowingly submit a false or fraudulent claim, which may include billing for services not rendered, billing for unnecessary medical services, double billing for the same service or equipment, or billing for services at a higher rate than provided (“up-coding”). A mere mistake, which can be remedied by returning overpayments, does not result in violations of these laws. The Office of Inspector General (OIG) oversees reviewing state FCA laws to ensure compliance with federal financial incentive standards to encourage and facilitate. Penalties for violation of FCA law are calculated through the Civil Monetary Penalty (CMP) law and range between $10,957 to $21,916 for each false claim submitted, plus three times the amount of damages (the amount of the claim).

What is the Anti-Kickback Statute?

Anti-kickback Statute states that it is a felony to knowingly and willfully offer, pay, solicit, or receive anything of value in return for a referral, or to generate reimbursable business under a federal healthcare program. Kickbacks may include bribes and rebates made directly or indirectly, overtly or covertly, or cash. Those found guilty of violating the Anti-kickback Statute may be subject to a fine of up to $50,000 per kick-back, plus three times the remuneration amount, imprisonment for up to five years, and exclusion from federal healthcare program participation for up to one year.

What is Qui tam provision or whistleblower’s law?

The Qui tam (kwee tam) provision allows for people who are not affiliated with the government (i.e., relators, whistleblowers), to file actions on behalf of the government. Persons filing under the Act may receive a portion (usually about 15–25 percent) of any recovered damages.