2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Fraud, Waste, and Abuseclaim to verify correct coding. Providersshould record each service provided that isrepresented by a timed code regardless ofwhether or not it is billed, because the unbilledtimed services may impact the billing.Total timed code treatment minutes and totaltreatment time in minutes.Total treatment time including the minutes fortimed code treatment and untimed codetreatment. Total treatment time does notinclude time for services that are not billable(such as rest periods). The billing and the totaltimed code treatment minutes must beconsistent. See Pub. 100-04, Section 20.2 fora description of billing timed codes.Signature and professional identification of thequalified professionals who furnished orsupervised the services and a list of eachperson who contributed to that treatment(such as, the signature of Kathleen Smith,PTA, with notation of phone consultation withJudy Jones, PT supervisor, when permitted bystate and local law).These determine compliance with appropriatebilling practices and ensure appropriate chartingthat must support medical necessity and coveredservices of specific codes billed. Additionally, theseaudits may identify other problematic concernswhere greater understanding and compliance canbe achieved through education. All audits areperformed in accordance with the members’contracts and the existing Presbyterian providercontract.Throughout the auditing process a number of toolsare used to ensure accuracy and consistency. Thetools may include but are not limited toCPT, AMAInternational Classification of Diseases (ICD-9-CM and ICD-10-CM Manuals)CPT Handbook for PsychiatristsHealthcare Common Procedure CodingSystem (HCPCS) Level II code bookBenefit and contract languagePresbyterian Provider ManualPresbyterian Reimbursement GuidelinesMedical director reviewDocumentation from patient charts obtainedduring the auditClaims validation audits may be conducted eitheron site at the provider office or by desk audit andmay be announced or unannounced.For desk audits, the provider office is contacted inwriting with a request to submit the specifiedmedical record information to Presbyterian SIU.The office representative is asked to sign a formthat the records submitted are complete.When an onsite audit is conducted and completed,the auditors briefly meet with the provider or arepresentative to discuss the general findings andimpressions of the audit. The provider orrepresentative is asked to sign a form that all of thedocumentation was in the patient records at thetime of the audit and that the auditors returned thefile to the provider in the same condition that it wasprovided to the auditor.15-42014 Practitioner and Provider Manual - Ver. 3