Effective Utilization of Nonphysician Providers– Billing & Scope of Practice

Restrictions

John F. Bishop, PA, CPC, CPMA, CGSC, CPRCPresident John Bishop and Associates, LLC

Physician, Provider Coding, Auditing Compliance andReimbursement Consulting

Tampa, FL

Reimbursement for Non-Physician Providers Real Life Practice 2014

John F. Bishop, PA, CPC, CPMA, CGSC, CPRCAAPA National Chair Reimbursement Work Group

Principle, John Bishop and Associates, LLCPrivate Consultant

Tampa, Florida

Get managed care and private carrier companies to recognize and pay for NPPs services

Bill properly for a shared visit Supervision requirements Identify what physician supervision rules apply to

NPPs performing diagnostic tests List the modifiers to use for NPPs Discover whether NPPs can perform consults “Incident to” – one more time! Skilled Nursing Facility billing for NPP’s

Objectives

• If you didn’t write it down-you didn’t do it• If you did write it down but incorrectly-you didn’t do it• If you can’t produce a dictated copy of whatever you

said you did (OR, ER,ASC)-you didn’t do it• If you didn’t do it, don’t bill it. That’s called FRAUD!!• If you can’t justify the medical necessity of what you

dictated or wrote down-you didn’t do it• If you code it incorrectly-you still didn’t do it• If you did code it correctly-just maybe you’ll get paid!• If you did get paid, doesn’t mean you get to keep

it!!• If you did get paid, be prepared to give it back!!

Coding-Caveats

OIG

http://oig.hhs.gov/fraud/fugitives/index.asp

FRAUD and ABUSE

Physician-owned distributors of spinal implants

Physicians: Place of service errors in ASC and outpatient locations

Evaluation and Management Services: Trends in Coding of Claims◦ We will review E&M claims to identify trends

in coding of E&M services from 2000-2009 E&M services during Global Surgery

periods E&M services: Use of modifiers during

global surgical periods*****

New: OIG WORK PLAN FOR 2013

E&M services:◦ We will review multiple E&M services for the

same providers and beneficiaries to identify EHR documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across all services, Medicare requires providers to select the code for the service based upon the content of the services and have documentation to support the level of service reported.

New: OIG Work Plan 2013

“Incident to” Services-medical necessity, documentation, quality of care. Determine whether payment for such services had a higher error rate than that for non-incident to services. We will also assess CMS’s ability to monitor services billed as “incident to.” Medicare Part B pays for certain services billed by physicians that are performed by nonphysicians incident-to a physician office visit. They found that over half of services in 24 hours were being performed by nonphysicians. Also found unqualified nonphysicians performed 21% of the services that physician did not perform personally. Incident-to services represent a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record.

2013 New: Incident-To services

Excessive dosages…monitoring high volume, high cost drugs for acceptable therapeutic levels for patient condition

Wound Care Services “Incident to” Services-medical necessity, documentation,

quality of care Physical Therapy and OT providers Place of Service Errors-services provided in ASC and

outpatient locations E/M during global surgery periods Consults Home Calls

OIG WORK PLAN FOR 2013

Services by Social Workers Medicare payments for Interventional Pain Management

procedures Geographic areas with high utilization of Ultrasound

services Geographic areas with high density of Independent

Diagnostic Testing Facilities Psychiatric Services – inpatient setting Polysomnography reimbursement –

◦ Medical necessity Violation of assignment rules-improper balance billing Business relationships with Advance Imaging Service in

Physician office

OIG WORK PLAN FOR 2013

10. Debridement Coding - Errors in coding surgical debridement versus active wound care management.9. Duplicate Billing - Filing claims more than once for the same service.8. Stark Violations - Physicians referring patient to services in which they have a financial interest or in which a family member has a financial interest.7. Pharmaceutical Coding in Physician Offices - Incorrect use of codes or units in billing of injections.6. Social Work Services in Facilities - Some clinical social worker services provided to inpatients in hospitals or skilled nursing facilities cannot be billed under Part B.

Below are the top ten errors RAC has identified:

5. Psychiatric Services - Over utilization of psychiatric services provided in outpatient setting.4. Medical Necessity - Documentation not supporting the level of service provided in the outpatient setting.3. E/M Billed During Global Periods - Use of modifier -24 in billing services that should have been included in the global package.2. Place of Service Errors - Physicians performing services in ASCs or outpatient facilities but when billing applying a place of service code indicating the service was performed in the physician office.1. Incident-to Errors - Physician assistants and nurse practitioners performing services for a physician but not following billing-specific guidelines related to the physician's relationship to the patient and the physician's presence in the office.

Below are the top ten errors RAC has identified:

Incident-To Services

Allowed by state and federal laws to provide physician services and procedures and direct bill (Medicare/Medicaid/Tricare)

Physician Assistants-PA’s Nurse Practitioners-NP’s Clinical Nurse Specialists-CNS’s CRNA’s

Non-Physician Providers?

The “other” group◦ RNFA’s◦ Physical Therapists-PT◦ Occupational Therapists-OT◦ Speech/Audiology Therapists◦ Surgical Techs-CST◦ Psychologists◦ LCSW

Non-Physician Providers?

Medicare usually defers to state laws Scope of Practice

Hospitals CANNOT bill for those considered auxilliary personnel services (on payroll)

Require UPIN/PIN File CMS form # 855-Medicare Part B Services must be considered Physician

Services Hospital based NPP’s charges may be billed

IF NOT INCLUDED ON THE COST REPORT

Billing for Non-physician Professionals

Must have national certification/license Must have state license/registration Must have hospital (s) privileges If employed by hospital, must still have a

supervising physician of record (most states)◦ PA’s tied to physicians by law◦ NP’s may be independent in some states

Reimbursement is totally dependent upon carrier discretion and interpretation!!

Must be considered Revenue generators****

Non-Physician Providers?

NPP’s can get reimbursed for seeing patients in the office

Physician must be in Office suite MD must maintain direct supervision MD does not have to see patient NPP can see established, (not new patient or new

problem) for “incident to” Bill in MD’s PIN number-100% reimbursed If No MD—NPP bills 85% with NPP PIN NPP can see new patient or new problem-just bill

under NPP NPI number

Medicare “Incident To” Rule-100% Reimbursed

Only Medicare Part B Not commercial carriers or Medicaid Bill at 100% of physician fee schedule in

physician’s provider number Must be established patient Service must be within Physician’s plan of

care-(not a new problem) Physician must be in office suite ARNP/PA must be employee/leased back to

practice

“Incident To”

Billing Under Incident-To indicates:

The physician was directly involved in the patients care

Services were provided in an office setting The patient was not new, nor had new

conditions You expect 100% of the allowed fee

schedule

Billing Under the NPP’S Number indicates that:

There was general supervision (physician NOT in office)

The patient had a new or exacerbated condition (NPP deviated from plan of care)

Expect to receive 85% of the allowed fee schedule

Think of NPPs as Revenue Generators!!

Medicare usually defers to state laws Scope of Practice

Hospitals CANNOT bill for those considered auxilliary personnel services (on payroll)

Require UPIN/PIN/NPI File CMS form # 855-Medicare Part B Services must be considered Physician

Services Hospital based NPP’s charges may be

billed IF NOT INCLUDED ON THE COST REPORT

Billing for Non-physician Professionals

CMS defines 3 levels◦ General (level 1) – procedure is furnished under

physician’s overall direction and control (ie, is available by telephone or beeper)-does NOT need to be present

◦ Direct** (level 2) – physician must be physically present in office suite (laboratory suite) and immediately available to furnish assistance and direction throughout the performance of the procedure

◦ Personal supervision** (level 3) - physician must be in attendance in the room during procedure** Apply equally to all places of service (office/clinic

and hospital facility)

Physician Supervision Requirements

Level 1 - Most diagnostic pulmonary function tests require general supervision

Level 2 – Direct supervision involves◦ administering an inhaled medication

94060, 94070, 94664◦ Breathing unusual gas mixture-carbon dioxide

94400 Low percentage oxygen-94450, 94452, 94453 And exercise 94621, 94680, 94681

◦ Pulmonary stress testing 94620 only requires level 1 supervision

Physician Supervision Requirements

Office/Clinic when physician is not on site-85% of physician’s fee schedule

All services PA is legally authorized to provide that would have been covered if provided personally by a physician in Office/Clinic when physician is on site

Physician must be in the suite of offices for 100% of physician’s fee schedule

Home visit/  House Call- 85% of physician’s fee schedule Skilled Nursing Facility & Nursing Facility

◦ 85% of physician’s fee schedule Hospital-85% of physician’s fee schedule First assisting at surgery in all settings- 85% of physician’s

first assist fee schedule Federally Certified Rural Health Clinics- Cost-based

reimbursement. HMO-  Reimbursement is on capitation basis. All services

contracted for as part of an HMO contract Using carrier guidelines for "incident to" services.

Setting Supervision  Requirements For Reimbursement Rates and Services for PA’s

and NP’s

• “Direct” Supervision• Doctor must see all

new Medicare patients and established patients with exacerbations or new conditions

• 100% of physician fee schedule

• Must indicate point of doctor’s involvement

• Doctor should sign all notes

• “General” Supervision• Doctor doesn’t have to

see new patients or exacerbated or new conditions

• 85% of physician fee schedule

• Not required• Not required

“Incident To” NPP’s Provider #

Indirectly-MD time is freed up for other uses-office, surgery, hospital rounds, golf course, home, family/children, exercise, reading

MD efficiency, accuracy and skills MD bill all carriers for NPP services MD can set a base salary plus give

performance bonus based on either productivity, percentage of their monthly A/R or overall practice A/R

Prescription writing (DEA) Work for your practice (not Hospital) NPPs are Revenue Generators

Obvious Advantages

PAs

Cardiology $109,030 Dermatology $107,727 ED $103,489 Surgery $102,760 Hospital based $97,680 House Calls $94,383 Orthopaedics $91,491 Family Practice $90,528 Pediatrics $86,894 Oncology $85,851 Academia $95,215

NPs

Oncology $98,327 - $90,574

ED - $104,549 Hospital - $93,943 Surg. Specialties - $91,511 Women’s Health- $76,483 Gerontology-$93,668 Cardiology-$100,881 Int. Med-$88,287 Family Practice- $86,518 Academia- $80,400

Salaries by Specialty-2013

Burn Wound Dressing changes under anesthesia 1st Assist in the OR VAC changes Compartment measurements-Wick catheter ALL Central lines, Triple lumens, A-line, Hickman’s,

Ports, Use of US and Fluoro w/interp I&D’s, NG tubes under guidance, Intubation, Trach’s Consults Admission H&P Daily subsequent visits (not related to Burn injury) Counseling and Coordination of care Joint injections/aspirations Discharge summaries $$$

Reimbursable Burn Services and Procedures for NPP’s

99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

99407 intensive , greater than 10 minutes

INCLUDES: Administration and analysis of a health risk assessment (99420)

Face-to-face services for new and established patients based on time increments of 15 to 60 minutes

Issues such as a healthy diet, exercise, alcohol and drug abuse

Services provided by a physician or other qualified healthcare professional for the purpose of promoting health and reducing illness and injury

Smoking Cessation

EXCLUDES: Counseling and risk factor reduction interventions included in preventive medicine services (99381-99397)

Counseling services provided to patient groups with existing symptoms or illness (99078)

Code also distinct evaluation and management services when performed in addition

Do not report with heath and behavioral services provided on the same day (96150-96155)

Smoking Cessation 99406-99407

Surgery Day-Surgical Assisting◦ THR (27130) x 3=37.70 x 36.07=$4271.07

4271.07 x 13.6% = $580.87****◦ TKR (27447) x 2=40.38 x36.07=$3051.62

3051.62 x 13.6% = $415.02****◦ Arthroscopy, knee

Menisectomy 29881x3:16.38 x 36.07=$1834.50 1834.50 x 13.6% = $249.49****

TOTAL generated $ 9157.19 TOTAL paid $1,244.88

36

RVU Examples-Ortho

Office Day-Dr. in office (“Incident To”)◦ PA schedule 40 patients

30 follow-up = 99213=1.70 x 36.07=$1813.50 10 new pt/new problems=99204=3.93 x

36.07=$1203.18 (85%) 5 Trigger points injected= 20550=1.49 x

36.07=$273.30 3 Large joint injections=20610=1.94 x

36.07=$211.65 2 Med. Joints injected=20605=1.50 x

36.07=$109.12 TOTAL $3610.75

◦ ALL charges go under supervising physician’s billing number except new patients. Then they go under PA’s NPI number (expect 85% return) 3

7

RVU Examples

If more than 50% of visit is spent in counseling the patient

Document total visit and counseling time Document what was discussed Can use time as overriding factor on those

categories where time is a factor Must make sense for the diagnosis/reason

for visit

Billing for Time

Prolonged Services◦Office

9935430 minutes to 1 hour additional time (above the time designated for the “base” visit code)99355 each additional 30 minutes additional time (above the time designated for the “base” visit code and after the first hour of additional time (99354)

Visit CodesDo Not Use Alone – Add-on Code**

Prolonged Services◦Hospital

9935630 minutes to 1 hour additional time (above the time designated for the “base” visit code)99357 each additional 30 minutes additional time (above the time designated for the “base” visit code and after the first hour of additional time (99356)

Visit CodesDo Not Use Alone – Add-on Code**

• NPPs are highly educated licensed health care providers

• Federal and State agencies do not find it credible that an NPP would refrain from providing health care services or making their own observations to solely report the work of a physician

• NPPs can (and should) be better utilized!!

• They are revenue generators!!!

Scribing

• Medicare only allows coverage for services and items which are “medically reasonable and necessary” for treatment/diagnosis of a patient. ◦ Medical necessity may be determined according

to several factors including the following: Items or services provided to the patient must be

appropriate for that patient’s treatment/diagnosis Documentation (When identified as required or

when requested) supports the medical need. The frequency of service or dispensing of an item is

within the accepted standards of medical practice.

Medical Necessity Issues

• Working diagnosis must match the ICD-9 description

• Close doesn’t count• Do not up-codeFraud• Do not down-codeFraud• Do not not code-????• Don’t code from the index• Always verify and check the book!• Then run it through your CCI and NCCI

edits• 60-70% of first denials come from

wrong/not specific/ ICD-9

ICD-9 CM

Fracture coding in ICD-10-CM requires:◦ documentation of site, ◦ laterality, ◦ type of fracture, ◦ whether it is displaced or nondisplaced, ◦ and the stage of healing (or encounter), which

includes open fracture classification. This resource is to assist in the

understanding of the classification system utilized in ICD-10-CM for open fractures.

Fracture Classification in ICD-10-CM

The procedure for evaluation and management of open fractures is basically a set of principles that involve initial management and subsequent surgical interventions. The purpose of any fracture classification system in the clinical setting is to allow communication that infers fracture morphology and treatment parameters.

Open fractures

Grade I: • wound less than 1 cm with minimal soft tissue injury; • wound bed is clean; • bone injury is simple with minimal comminution; • with intramedullary nailing, average time to union is 21–28 weeks Grade II: • wound is greater than 1 cm with moderate soft tissue injury; • wound bed is moderately contaminated; • fracture contains moderate comminution; • with intramedullary nailing, average time to union is 26–28 weeks Grade III: The following fracture types automatically results in classification as type III: • segmental fracture with displacement • fracture with diaphyseal segmental loss; • fracture with associated vascular injury requiring repair; • farmyard injuries or highly contaminated wounds; • high velocity gun shot wound; • fracture caused by crushing force from fast moving vehicle;

Gustilo Classification for Open Fractures

Grade IIIA fracture: • wound less than 10 cm with crushed tissue and contamination; • soft tissue coverage of bone is usually possible; • with intramedullary nailing, average time to union is 30–35

weeks; Grade IIIB fracture: • wound greater than 10 cm with crushed tissue and

contamination; • soft tissue is inadequate and requires regional or free flap; • with intramedullary nailing, average time to union is 30–35

weeks;

It is important to educate providers on the use of this scale for the specific documentation necessary in ICD-10-CM.

This will ensure that proper code assignment can be made without multiple queries to the provider.

Gustilo Classification for Open Fractures

“Arthritis” 715.16 Primary localized

osteoarthrosis, lower leg

715.00 Generalized osteoarthrosis, unspecified site

M17.0 Bilateral primary osteoarthritis of knee

M17.10 Unilateral primary osteoarthritis, unspecified knee

M17.11 Unilateral primary osteoarthritis, right knee

M17.12Unilateral primary osteoarthritis, left knee

M15.0 arthritis of multiple sitesbilateral involvement of single joint (M16-M19)

ICD-9-CM 719.47 - Pain in joint; ankle and foot, Ankle joint,

Digits [toes], Metatarsus, Phalanges, foot, Tarsus, Other joints in foot

ICD-10-CM M25.571 Pain in right ankle M25.572 Pain in left ankle M25.579 Pain in unspecified ankle M79.671 Pain in right foot M79.672 Pain in left foot M79.673 Pain in unspecified foot M79.674 Pain in right toe(s) M79.675 Pain in left toe(s) M79.676 Pain in unspecified toe(s)

Ortho/Sports Medicine

ICD-9-CM 726.12 - Bicipital tenosynovitis ICD-10-CM M65.811 Other synovitis and tenosynovitis, right shoulder M65.812 Other synovitis and tenosynovitis, left shoulder M65.819 Other synovitis and tenosynovitis, unspecified shoulder   ICD-9-CM 729.5 - Pain in limb   ICD-10-CM M79.601 Pain in right arm M79.602 Pain in left arm M79.603 Pain in arm, unspecified M79.604 Pain in right leg M79.605 Pain in left leg M79.606 Pain in leg, unspecified M79.609 Pain in unspecified limb

Ortho/Sports Medicine

Chapter 19 Injury, Poisoning and certain other consequences of External causes

What ICD-9 looked like: 945.39 What ICD-10 looks like: T24.309A-

unspecified site T24.312-D-left thigh, subsequent visit T24.321A-right knee T24.332S-sequela left lower leg

ICD-10 for Burns

First Surgical Assisting

• Physician bills 25% of CPT• Medicare-PA’s can charge . 85% x 16% =

13.6% of surgeon’s fee • Medicaid-same• 3rd party-either 100%75%• Reimbursement depends on IF a surgeon

assistant is required/allowed and NO Resident is available

• Check each carrier reimbursement schedule for all reimbursable cases

First Surgical Assisting

• If physician-modifier-80• Minimal assistance-modifier-81• In teaching institution-modifier-82 (Resident

not available)• Medicare-PA/NP-modifier AS• Blue Cross/Blue Shield doesn’t recognize

Non-physician PIN codes-state specific

Surgical Assisting

If physician-modifier-80 Minimal assistance-modifier-81 In teaching institution-modifier-82 (Resident

not available) Medicare-PA/NP-modifier AS Blue Cross/Blue Shield doesn’t recognize

Non-physician PIN codes-state specific

Surgical Assisting

Carrier Reimburse Bill under MD

1st Assist Modifier

Aetna 100% Yes 12% 80-81

Assurant Health

100% Yes 20% 80-81

BC/BS 100% Yes 13.6% AS

Cigna 100% Yes 13.6% AS

GHI 100% Yes 13% AS

Humana 100% Yes 10-20% AS

School Insurance of FL

100% Yes Pasco Co-13.6%

AS or 80

United Healthcare

100% Yes 14% AS

• The PA and the physician must work for the same employer.

•  The regulation applies only to E/M services delivered in the hospital and not to procedures.

• The physician must provide some face-to-face portion of the E/M services on same day. Simply reviewing or signing the patient’s chart is not sufficient.

• “Incident to” billing has never applied to the hospital setting – and still does not apply

• Bill 100% under physician PIN

Shared/Split Billing-Hospital Inpatient only

• 97802-97804Medical Nutrition Therapy• 96040Medical Genetics/Counseling Services• 98960-98962Education/training for Self management

established pts using standardized guidelines (CHF, Coumadin, Genetics, Immune, Transplant Svc)

• 99341-99350Home Services (E&M)• 99500-99600Home Health procedures (Postnatal,

Resp. Tx, Hemodialysis• 99401-99429Preventive Medicine-Counseling, Risk

factor reduction• 99241-99245, 99251-99255 with modifier –GT to

signify Teleconsultation via interactive video/audio• 98966-98968→ Non face-to-face Telephone E&M• 98969→ Online (email) E&M assessment and

management

Overlooked CPT Codes-NPP’s

CPT code G0447, a 15-minute face-to-face behavioral counseling for obesity, has been assigned total non-facility RVUs of 0.74. The 2011 conversion factor is $33.9764.

Screening and counseling coverage is effective as of the decision date, so whencontractors are ready to process the claims, physicians will be able to submitclaims for service back to the date of coverage, according to the spokeswoman.

Patients with Medicare will not be charged for the screening or counseling,according to CMS. Screening for obesity and counseling for eligiblebeneficiaries by primary care providers are covered under this new benefit. Fora beneficiary who screens positive for obesity with a body mass index greaterthan 30, the benefit includes one face-to-face counseling visit each week for 1month and one face-to-face counseling visit every other week for an additional 5months, according to CMS.

The beneficiary may receive one face-to-face counseling visit every month for anadditional 6 months (for a total of 12 months of counseling) if he or she hasachieved a weight reduction of at least 6.6 pounds during the first 6 months ofcounseling.

Obesity Counseling

Why is the patient being seen? Does the level of visit make sense? Does the documentation support the level

indicated? Could it support a different (higher or

lower) level of E&M? Too much, too little or just right? Has Medical Necessity been met? Is this visit justifiable? Is this visit defensible from an outside audit

or worse, an ALJ hearing?

Summary

Teach your doctors, PA’s and other providers to understand what medical necessity is from the payer’s perspective, NOT the provider’s

Teach them what is required for documentation per payer

Teach them to dictate/write the proper justification-OP note, procedure note, lab/radiology orders, etc….

Finally, don’t bill it, if it’s not documented and justifiable.

Conclusion

• NPP’s very cost effective• NPP’s accepted just about every clinical

environment• NPP’s billing and reimbursement has

improved significantly • NPP’s will be around for quite a while!• Reimbursement is totally dependent upon

carrier discretion and interpretation!!• Must be considered Revenue

generators****• Learn how to get them reimbursed!!

Conclusion

email: bishopjf@aol.com