It is the mission of our Hospital Billing Compliance program to integrate compliance as a fundamental part of the business and clinical operations of UCI Health, with the goal of minimizing organizational risk and reducing hospital system vulnerability for fraud and abuse.
The quality of care provided to patients has become an increased focus of governmental scrutiny; therefore, the accurate reporting of quality-of-care measures has become more important to healthcare facilities.
The compliance program aims to integrate and enhance the compliance activities that are already integral to hospital departments and clinics to ensure applicable regulations, laws and standards are met, and that specific risk areas are addressed.
Our objectives are designed to:
- Enhance education and training programs relating to the complex rules and regulations impacting hospitals
- Conduct monitoring and auditing activities for the purpose of identifying potentially troublesome issues, monitor implementation of corrective and preventative actions, and foster effective interdepartmental communication on common compliance issues
- Assess existing policies and procedures that address potential risk areas
Our areas of focus are:
- Inpatient and outpatient facility coding and billing for the hospitals and hospital-based clinics
- Quality-of-care reporting
- Charge master review
- Emergency Medical Treatment and Active Labor Act (EMTALA)
- Medical necessity
- Provider-based outpatient facilities designations
Guidance & Policies
It is the mission of our Professional Billing Compliance program to ensure that all UCI Health physicians document their services according to federal and state guidelines, and that documentation supports the services and quality of care provided to patients.
The objectives of the professional billing compliance program goals are to:
- Enhance education and training programs for physicians, NPP’s, residents, medical students and coding staff
- Conduct monitoring and auditing activities according to federal and state guidelines of potential high-risk areas identified by the Office of the Inspector General and various other programs
- Ensure that only the services that are provided are billed to the appropriate third party payer, accurately documented and medically necessary
Our areas of focus are:
- Inpatient and outpatient physician services
- All physician’s practices
- UCI Health Douglas Hospital emergency room
- Radiology services
- Pathology professional services
Teaching Physician Guidelines
The clinical research billing compliance program goals are to:
- Provide an internal mechanism for quality assurance, quality improvement and education, pursuant to regulations governing research financial compliance, research revenue integrity and research coordinators
- Conduct monitoring and auditing activities according to all institutional policies and federal and state laws and regulations of potential high-risk protocols defined as high volume of clinical services or mixture of services billed to the study and services billed to the third party payers
- Ensure that only the clinical research claims that are provided are: billed to the right payer, accurately documented and medically necessary
Learn more about research compliance ›
Significant changes are coming to E/M Coding in 2021 for ambulatory/outpatient patient visits.
The Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) have published the 2021 Medicare Physician Fee Schedule with significant changes to E/M documentation and payment. The new AMA CPT E/M changes are specific to new and established office (99201-99205 and 99211-99215) codes and will take effect Jan. 1, 2021.
Under the new guideline, new and established Office codes will include a medically appropriate history and/or examination but code selection will be based on the MDM level or total time spent on that date.
Changes will include:
Resources for UCI Health staff ›
- The 99201 level of care will be deleted
- The work RVUs assigned to new and established office visits will be increasing
- Code selection will be driven by time spent OR the medical decision making
- History and physical exam will no longer affect the level of care selected but still be required to some degree
- There will be a new table to calculate the medical decision-making
- Number and complexity of problems addressed
- Amount and/or complexity of data to be reviewed and analyzed
- Risk of complications and/or morbidity or mortality of patient management
- There will be new time thresholds and a new definition of total time spent for selecting the level of care
- There will be a new prolonged services code for each 15 minute increment of prolonged E/M services