The following Frequently Asked Questions are derived from questions previously submitted to the Compliance Office. Please note that these answers may not be appropriate to your specific situation and the may require further research by the Compliance Office.

Professional Services

If the emergency department physician requests that another physician evaluate a given patient, that physician should bill an emergency department visit code.  Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description).  It is not required that the physician be assigned to the emergency department.

If the patient is admitted to the hospital by the second physician performed the evaluation, he or she should bill an initial hospital care code and not an emergency department visit code.

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The underlying difference between a consultation and a referral is the intent of the visit.  If the requesting provider expects you to provide only your opinion on the best course of treatment for the condition, it's a considered a Consult (even if you prescribe medication).  If, on the other hand, the requesting provider knows the patient's condition will require treatment beyond his or her scope of care and expects you to take over treatment of that condition, it's a Referral.

You're doing a consultation if:

  • Another provider or appropriate source requests your services,
  • The reason for the request is documented and
  • You provide a report on your findings the requesting provider.


It is recommended that the clinicians avoid words like "referral" or "referred by" when documenting the request for consultation services.  Some payers may deny consultation codes based on the use of these words or phrases.

The recommended language for consultations is "The patient was seen in consultation at the request of Dr. XXX for (what the provider is rendering an opining on)".
  • The request as well as the subsequent opinion must be documented in the medical record.
  • In an academic setting, a consult may be requested by a faculty physician or a community-based physician.
  • If the consultant assumes care of patient, do not use consultation codes for subsequent visits.



A new patient is one who has not received any professional services, such as an E&M service or other face -to face service (e.g., surgical procedure), from the physician or physician group practice (same physician specialty) within the previous three years.  For example, if a professional component of a previous procedure is billed in a three year period (e.g., a lab interpretation is billed and no E&M service or other face-to face service with the patient is performed), then this patient remains a "new" patient for the initial visit.

An interpretation of a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E&M service or other face-to face with the patient, does not affect the designation of a new patient.




Compliance Operations

Please contact us!  We need to ensure:

  • That the department is set up correctly within APeX
  • Validate that Regulatory Affairs is aware and the service is licensed appropriately
  • The service can be billed correctly
  • Research any unknown concerns

 We want to partner with you so services aren't delayed down the road due to missing a step in the process.

Medicare uses a network of contractors called Medicare Administrative Contractors to process Medicare claims, enroll health care providers in the Medicare program, and educate providers on Medicare billing requirements. MAC’s also handle claims appeals and answer beneficiary and provider inquiries.  For California the MAC’s are as follows:

  • Noridian: Part A, Part B, Durable Medical Equipment (DME)
  • Palmetto: Railroad Retirement
  • Novitas: Indian Health Services
  • NGS: Home Health & Hospice

Ask the person for their ID.  Show them to a quiet room, and let them know someone will be with them shortly.  Call your manager and contact the Compliance department at 415-502-2790.


Only a physician can write an order for an Inpatient admission. If a Resident, PA, or NP writes an order for a patient to be admitted, it must be co-signed by an Attending physician before the patient is discharged.

Clinical Research Billing Compliance

Refer to Clinical Research Contact Directory tab located under Resources

A formal coverage analysis is a tool used to coordinate the study information of a clinical trial and review of pertinent trial documents; including but not limited to, protocol, informed consent form (ICF) and study budget. The analysis identifies each service and documents the supporting reason of the final billing designation, i.e.: insurance, sponsor or internal funding source.

Effective 6/1/2013, every new clinical trial at UCSF must have a formal CA performed to identify all items and services within the trial protocol, and document the final billing designations per service. This analysis proactively validates the accurate billing designations, regardless of funding source, prior to subject accrual.

Government Audit Guidance

No. Call the Compliance Office so that someone from our office can talk to the representative to ascertain the purpose of the visit. The contact telephone number is (415) 514-2573.

Please forward the letter to the External Audits & Investigations Manager who will review the letter, explain what it is for and either respond on your behalf or forward it to the correct answering entity within UCSF.

It is important to promptly and accurately act upon correspondence from governmental entities.  If a Provider or Department employee receives this type of correspondence, it should be presented promptly to the Department Manager for reporting and forwarding to the Compliance Office.

Examples of government entities include:

  • CMS (Centers for Medicare and Medicaid Services)
  • HealthDataInsights (the Medicare Recovery Audit Contractor or RAC)
  • Palmetto GBA (the Medicare Administrative Contractor or MAC)
  • Noridian (the UCSF MAC of Fall 2013)
  • Medi-Cal or HMS
  • CERT (Comprehensive Error Rate Testing Contractor)
  • Department of Justice
  • The Compliance Office will provide coordination and processing of the response as well as perform an internal review. Compliance will appeal any request for repayment, as supported by our internal review. The Compliance Office will also provide overall guidance for the response, including:

    • review of billing processes and documentation
    • drafting of cover letters and other appropriate correspondence
    • facilitation of timeline extensions, as needed
    • communication with the payor for any clarification needed