Compliance
Compliance deals with the issues related to Professional Fee Reimbursement. Typically, you will have to complete compliance training annually.
Once you have completely read through the content for this section, click on the "Assessment" link on the navigation bar to the left and take the "Compliance" assessment.
Who should worry about compliance issues?
ALL HEALTHCARE PROFESSIONALS! This includes those of you planning careers in research or teaching. Compliance strives to diminish and eliminate illegal billing practices which damage the credibility and effectiveness of the healthcare system as a whole. Simply put, for your entire career you will be dealing with compliance, so the earlier you learn the better!
Office of Compliance:
Compliance Director
Robert C. Newman, MD, MSHA
The Director reports to the Dean of Medicine, and is responsible for compliance with established procedures. The Director has authority to access all documents during an audit or investigation.
In addition to the Director, the Office of Compliance includes an Assistant Dean, numerous coordinators, and a legal support system.
Mission
The critical focus for the Office of Compliance relates to professional fee reimbursement. The Office of Compliance has the responsibility of:
- Keeping abreast of the rapidly changing rules for billing
- Continually educating physicians and others on new and existing rules
- Continually monitoring compliance of physicians and others (including overseeing department reviews)
- Receiving and responding to questions related to billing issues and to reports of non-compliance
- Providing advice on disciplinary issues relating to compliance
- Working with Shands’ compliance team to coordinate compliance efforts
- Thoroughly documenting and reporting on all compliance activities
- Performing analytical review on the appropriate billing data
- Engaging external billing auditors as appropriate
The Office of Compliance:
- performs investigations / audits
- evaluates performance
- enforces disciplinary action
- conducts compliance training activities
- accepts anonymous calls to discuss possible compliance violations
Compliance Hotline
1-866-574-2867
Remember, you may remain anonymous when calling the Office of Compliance.
Compliance Codes
The purpose of a coding system is to provide a uniform language that healthcare professionals use to describe services performed that require payment.
CPT Codes (Procedural)
CPT is an acronym for Current Procedural Terminology. CPT codes are published by the American Medical Association, and the fourth edition is the most current.
A CPT code is a five digit numeric code that is used to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services of physicians, hospitals, and other health care providers. There are approximately 7,800 CPT codes ranging from 00100 through 99499. Two digit modifiers may be appended when appropriate to clarify or modify the description of the procedure.
ICD-9 Codes (Diagnosis)
ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) coding system is used to code signs, symptoms, injuries, diseases, and conditions.
E&M (Evaluation and Mangagement of Patient)
E&M codes are used by providers to describe the types of clinical activities they have performed.
The CPT, ICD-9, and E&M codes are combined to create the bill that is submitted to a third party payer.
Appropriate Compliance Plans
There are certain elements that a compliance plan must contain:
- An adminstrative framework charged with monitering and maintaining compliance
- Clearly stated and published guidelines
- Compliance education and training
- Department-specific billing plans
- A framework for reporting compliance issues
- An Investigation apparatus
- Discliplinary measure for compliance violations
- Provisions for revision to the plan
