2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Fraud, Waste, and AbuseHow to Report Fraud, Waste, and AbuseWhile true fraud involves only a small percentage ofindividuals, the costs associated with it are high.We realize that the majority of providers conducttheir practices in accordance with proper businessstandards. Presbyterian’s Special Investigative Unit(SIU) is responsible for the detection andinvestigation of any suspected fraudulent activitiesor abuse involving any members, subcontractors,providers, brokers, agents, or employer grouprepresentatives.The SIU takes a proactive approach to identifyfraud and abuse by using the claims database forresearch to detect fraudulent activities. The SIUmay contact the provider to assist with theinvestigation of any type of suspicious activity. Areview of medical records for claims validation maybe conducted at the provider’s office or facility.Medical Record DocumentationPresbyterian follows policies and procedures thatgovern the standardization and maintenance ofmedical records by its contracted providers.Presbyterian expects providers to maintain thefollowing medical record information:Physical Health Provider Medical RecordDocumentationDate of serviceType of service (for example, 99212, 99213)Medications/interventionsModalities and frequencies of treatmentfurnished with start and stop timesClinical test results and summaries of any ofthe following: diagnosis, functional status,treatment plan, symptoms, prognosis, andprogress to dateBehavioral Health Provider Medical RecordDocumentationDate of serviceType of service (for example, 90791, 90832)Medications/interventionsModalities and frequencies of treatmentfurnished with start and stop timesClinical test results and summaries of any ofthe following: diagnosis, functional status,treatment plan, symptoms, prognosis, andprogress to dateName and credentials of the provider whorendered the serviceDocumenting Timed CPT CodesHealth care professionals provide a number ofservices that are strictly time-dependent. Foraccurate coding, the provider’s documentation mustreflect the actual face-to-face time spent with thepatient. This chapter provides guidance fordocumenting timed Current Procedure Terminology(CPT) codes for the following services:Physical therapyOccupational therapyChiropractic servicesAcupunctureThese must have proper documentation for thetime or duration of each service performed, as well15-22014 Practitioner and Provider Manual - Ver. 3