University of California, Riverside

UCR School of Medicine Compliance



Professional Compliance


Important Policies and Guidelines

Professional Fee Billing Policy

The University of California Health Sciences Campus System Wide Professional Fee Billing Compliance Plan Guidelines were adopted by The Regents of the University of California for implementation at all University of California Schools of Medicine. In adopting our compliance plan, the School of Medicine at UC Riverside affirms the philosophy of university compliance with applicable laws, regulations, and university policies that impact professional fee billing.

The UC Riverside Health (UCRH) Professional Fee Billing Compliance Program is designed to accomplish the following objectives:

  1.  To familiarize physicians and non-physician employees involved with professional fee billing about applicable laws, regulations, and university policies regarding professional fee billing;
  2. To promote programs and practices designed to provide reasonable assurance that all such individuals and departments will follow such laws, regulations, and policies;
  3. To reduce legal and financial risks; and
  4. To provide a mechanism for communication concerning compliance.

The full UC Riverside Health Policies and Procedures for Teaching Physician Billing Compliance document is available for download.

Evaluation & Management Coding Guidelines

Evaluation and Management Coding Guidelines define the way physicians report and bill for medical services.  These guidelines establish what documentation is needed to bill for medical history-taking, physical examinations and medical decision making.

The level of evaluation and management service a physician chooses is based in the documentation and the services provided.  The service selected is defined by the:

  • type of service (consult or new patient);
  • type of patient (new or established); and
  • location of service (inpatient or outpatient).

For more detailed information, please visit the following links:

In order for the teaching physician to bill for the service, the billing physician must document according to the CMS Guidelines for Teaching Physicians, Interns and Residents.

Coding Links from the Center for Medicare and Medicaid Services

Billing

Billing and Documentation Guidelines

Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The record should chronologically document the care of the patient, and is an important element contributing to the quality of care. The medical record is also considered to be the basis for assessing patient health over time; appropriate utilization review and comparisons, a data source for research and education; a legal document for risk management; and establishes the supporting elements needed for professional fee billing.

As a general rule, physicians must clearly document (in legible handwriting or in a signed dictated note) their presence, and level of participation in the services provided. Medical record documentation should be completed immediately following patient services or within sufficient time to recollect the key portions of the services provided in accordance with regulations following medical staff policies and procedures. Whoever dictates a note, report, or entry, shall sign that note, report, or entry. A medical record is considered a legal document; therefore, handwritten entries must be made in ink and must be legible.

Billing Links

More Information 

General Campus Information

University of California, Riverside
900 University Ave.
Riverside, CA 92521
Tel: (951) 827-1012

Department Information

UCR School of Medicine Compliance
900 University Avenue
SOM Education Building
Riverside, CA 92521

Tel: (951) 827-3257
Fax: (951) 263-7271
E-mail: paul.hackman@ucr.edu

Related Links

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