Billing for Non-Physician Practitioners

Presented by NYU School of MedicineOffice of Physician Reimbursement

Compliance

Gretchen L. Segado, MS, CPC, Director316 East 30th StreetNew York, NY 10016

(212) 263-2446(212) 263-6445 fax

Gretchen.Segado@med.nyu.edu

Goals for This Session

Understand the difference between Direct Billing and Incident-to Billing

Understand need to learn CPT and ICD-9 coding principles

i.e. Understand E&M coding

Be aware of documentation requirements

Understand how services are reimbursed

Be aware of differences between insurance companies and their coverage

And….it is very important to remember……

Two Different Billing Scenarios

Direct Billing Certain NP Practitioners can be credentialed

and can bill under their own provider numberNurse Practitioners, Physician’s Assistants, Certified Nurse Specialists, Clinical Psychologists,

Medicare reimburses on a percentage of the Physician Fee Schedule

Incident-to BillingPhysician directed team

Service is billed under physician’s provider number

Direct Billing Criteria for Medicare

Non-Physician Practitioner bills services directly to Medicare

Must meet Medicare’s credentialing requirements

Can bill in any setting allowable under scope of practice (office, inpatient and outpatient hospital, etc)

Direct Billing Criteria for Medicare

Can provide any services allowed under their scope of practice, but will only be reimbursed for covered services.

Should have a collaborative agreement with physician or group of physicians

Refer to Non-Physician Practitioner Direct Billing Guide

Please note:

Diagnostic testing rules have a different set of regulations and supervision levels……

What Is an Incident-to Service?

When services are provided by auxiliary personnel under direct physician supervision, they may be covered as “incident-to” services

Non-physician practitioner bills for services “under physician’s name”

Incident-to Requirements

Integral though incidental part of physician’s professional service

Commonly rendered without charge or included in the physician's bill

Of a type commonly furnished in office/clinic

Furnished under direct supervision of the physician/group

Source: Medicare Carrier’s Manual, Part 3, Chapter 2, 2050.1

Part of Professional Service

Service must be medically necessary

Service must follow initial physician service

Supervision alone is not a service

Physician incurs overhead expense for service

Integral though incidental

Services and supplies commonly furnished in physician’s offices are covered

Where supplies are clearly of a type that a physician is not expected to have on hand in his/her office setting, or are of a type no considered medically appropriate to provide in the office, they are not covered under the incident-to provisionSupplies, including drugs and biologicals must be an expense to the physician or legal entity billing.

Example: if patient supplies the drug and physician administers it, only administration can be billed by physician

Service must be medically necessaryPhysician performs subsequent service to show active management and participation

Commonly furnished in Physician’s office or clinic

Place of service MUST be office/clinic

Generally no hospital or other settingsFor hospital patients and for SNF patients who are in a Medicare covered stay, there is no Medicare coverage of the services of physician-employed auxiliary personnel as services incident to physicians' services

Direct Personal Supervision

Not part of same day physician service

Not in same room

Physician or other member of group practice must be present in suite

Clinic exception

Direct Personal Supervision

Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician. Likewise, the supervising physician may be an employee, leased employee or independent contractor of the legal entity billing and receiving payment for the services or supplies.

Direct Supervision

If auxiliary personnel perform services outside the office setting, e.g., in a patient's home or in an institution (other than hospital or SNF), their services are covered incident to a physician's service only if there is direct supervision by the physician.

Example:nurse accompanied the physician on house calls and administered an injection, the nurse's services are covered. If the same nurse made the calls alone and administered the injection, the services are not covered (even when billed by the physician) since the physician is not providing direct supervision.

Supervising vs. Ordering Physician

In a group practice, where one physician orders a treatment/service to be performed by ancillary personnel under the supervision of a different physician who is a member of the group practice, the service should be billed under the provider number & name of the supervising physician who was present in the office when the service was provided NOT under the ordering physician.

Supervising vs Ordering con’t

Example:

Oncologist orders chemo to be given by a nurse while he/she is not present in the office, but under supervision of another physician member of the same group.

Service should be billed under the name of the supervising physician

Supervising vs. Ordering con’t

Example #2

Patient with high blood pressure. At first visit, treatment plan is established that the patient will come in once per week for a BP check. Patient sees a nurse for these weekly visits. This service is billed under the physician supervising the day that the patient is seen in the office.

Per Chapter 14 of Medicare Carriers Manual

A Nurse Practitioner, Physician Assistant, Nurse Midwife or Certified Nurse Specialist can bill any E&M service (99210-99499) per MCM 15501G

Other employees must bill 99211

Cannot bill based on counseling time per MCM 15501C

Incident-to vs Direct Billing

Incident ToNo New PatientsNo New ProblemsPhysician In SuiteNot at Hospital or

SNFPhysician Directs

Patient CareFull PaymentCode at Any Level

Direct BillingAny PatientAny ProblemWho cares where Dr

is?Any Place of ServiceNPP Directs Patient

Care85% of Physician

Fee Code Any Level

Private Insurance and Managed Care Companies may have different policies and requirements!!

Some insurance companies do not allow incident-to or billing under the doctor.

Know your most common payer requirements

General Principles Of Medical Record Documentation

Complete medical records for each patient

Make all entries in ink

Use drawings, illustrations & pictures when appropriate

Write legibly

General Principles Of Medical Record Documentation

For each encounter:

reason for the encounter and relevant history, exam and prior diagnostic test results

assessment, clinical impression or diagnosis

plan of care

date and legible identity of the observer

General Documentation(Continued)

Make entries promptly

Do not leave blank spaces in the patient records

Document relevant conversations between patient, responsible parties, physicians and staff

Use standard abbreviations

General Principles Of Medical Record Documentation

If not documented, the rationale for ordering and other ancillary services should be easily inferred

Past and present diagnoses should be accessible to the treating and/or consulting physician

Appropriate health risk factors should be identified

General Principles Of Medical Record Documentation

CPT and ICD-9 codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record

Basics Of Medical Reimbursement

Payers are willing to pay for services provided they are:

•covered within the patient’s policy•medically appropriate for the patient's condition•medically necessary•coded correctly

Covered services are those services:•defined as “covered” within the terms of the patient's benefit plan•documented in the medical recordmedically necessary

Variables That Affect Reimbursement Include: Individual insurance policies and regulations Patient’s coverage Federal regulations Contractual agreements Accuracy of diagnosis and procedure coding Physician office systems

What Is CPT-4?

Systematic listing of procedures & services performed by physicians

Five-digit codes for procedures or services

Used to describe the physician’s services to a patient for diagnosis and treatment of the medical condition(s)

Codes and descriptive terminology developed and copyrighted by AMA CPT Editorial Panel

Organization Of CPT Manual

Text organized in 6 major sectionsEvaluation and Management ( 99201 - 99499)

Anesthesiology ( 00100 - 01999,

99100 - 99140)

Surgery ( 10040 - 69990)

Radiology ( 70010 - 79999)

Pathology and Laboratory ( 80049 - 89399)

Medicine ( 90281 - 99199)

Format Of The CPT-4 Manual

Developed as a stand-alone descriptions of the procedures

To conserve space, some are not printed in their entirety but refer back to a common portion listed in a preceding entry

EXAMPLE:

25100 Arthrotomy, wrist joint; for biopsy

25105 for synovectomy

Reads:

25105 Arthrotomy, wrist joint; for synovectomy

Linkage Between ICD-9 & CPT (Continued)

ICD-9 represents the “WHY” component

of the procedure

CPT-4 represents the “WHAT”

component of the procedure

How Does It Differ From ICD-9?

ICD-9 represents to the carrier why a service was billed:

Medical Necessity--------- 786.50

(Chest Pain)

CPT-4 represents to the carrier what was billed:

Procedure------------------- 93010(EKG)

Over 17 different Otitis Media CodesAcute? Chronic? Supportive? Serous? Mucoid?

Over 28 different codes for DiabetesType I or II? Insulin Dependent? With complications?

Acute Upper Respiratory Tract Infections

4 codes

Disorders of Lipid Metabolism 11 codes

Establishing The Medical Necessity For Procedures

Only clinically proven effective procedures are reimbursable under the Medicare program

Medicare has a specific list of ICD-9 codes that support the medical necessity of each procedure

Medical Necessity

Diagnostic studies ICD-9-CM without established

diagnosis (i.e., rule out, probable, suspected)

Example:

Pelvic Ultrasound for R/O Ectopic Pregnancy

Report signs & symptoms

Pelvic Pain (625.9)

Medical Necessity (continued)

Diagnostic studies with confirmed or established diagnosis Report the ICD-9 Code representing the confirmed diagnosis

Example:Diagnostic Study: ICD-9 LinkagePt. for Pelvic Ultrasound uterine fibroid

(218.9)

Documentation Of Technical Detail Of Procedure

1. Pre-operative

evaluation

2. Medical Necessity

3. Separate note for the

procedure

4. Complete procedure

note itself

5. Signed and Dated by

the MD

Procedure Note

Anesthetized with 2% Lido + Epi irrigated with NS, and Explored

Laceration was subcutaneous, approx 6 cm w/ skin flap

Wound closed with #8 sutures (4-0 nylon interrupted sutures)

Signature

Evaluation And Management Services

Codes 99201 to 99499

Basic format:Unique code number is listed

Place/type of service is specified

Content of service is defined

Nature of presenting problem usually associated with a given level is described

Time typically required to provide the service is specified

Categories Of E/M ServicesOffice or other Outpatient Services

New and Established Patients

Hospital Observation Services

Initial Hospital CareSubsequent Hospital Care

Hospital Inpatient ServicesInitial Hospital CareSubsequent Hospital Care

Categories Of E/M Services(Continued)

ConsultationsOffice of Other Outpatient Consultation

Initial Inpatient Consultation

Follow-up inpatient Consultations

Confirmatory Consultations

Emergency Department Services

Critical Care Services

Categories Of E/M Services(Continued)

Neonatal Intensive Care

Nursing Facility Services

Preventive Medicine

Newborn Care

Special Evaluation and Management Services

Other Evaluation and Management Services

Is This A New Patient Visit Or An Established Patient Visit?

New PatientHas not received any professional services from the physician or another physician of the same specialty, same group practice, within the past three years

Established PatientHas received professional services from the physician or another physician of the same specialty, same group practice, within the past three years

Is This A Problem Oriented Visit Or A “Well Visit”?

Preventive Medicine Services are a special category of E&M

Code selection is based on patient’s age and status with the practice

99381-99387 Initial Comprehensive Preventive Medicine

99391-99397 Periodic Comprehensive Preventive Medicine

Keep Your Practice Safe

Learn how to code your servicesAttend coding classes as specialty conferencesAttend seminars given by local Medicare Contractors

Educate your staff on coding and complianceDocument, Document, DocumentAny questions?????