Nurse Practitioner Billing Compliance Training

Coding Education & Training Program, HIM Department

Billing Compliance EducationFor

Nurse Practitioners


General Information

UCD Health System Policy 1260Nurse Practitioner (NP) Services: Guidelines for Professional Billing http://intranet.ucdmc.ucdavis.edu/policies/hosp/1260.htm

Reviewed AnnuallyRevised Changes in Regulations or Billing Policies UC Directives Clarification


NP Policy Revision Timeline

History2008 Masters Degree Required for all NPs2007 Medi-Cal Co-Signing Restrictions Lifted2006 Expanded Definitions Clarification2005 Minor Changes2004 Shared/Split Visits2003 UCDHS Lifts Complexity Restrictions UCDHS Consultation Policy Revised to Include NPs CMS Requires Masters Degree for all NPs


Definitions

Types of ClinicsHospital-Based Clinics Operate under license of the hospital Includes all Academic DepartmentsFree-Standing Clinics Do not operate under license of the

hospital Primary Care Network Clinics


Definitions

Billing Components ~ Based on LocationHospital or Hospital-Based Clinic Two Components

1. Professional Fee2. Technical (Use of Facility)

Free-Standing Clinic1. One Global Fee


Definitions

Supervising PhysicianFully Licensed Physician MD or DO Not participating in an ACGME, GME or

ABMS Program1. Exception – UCDHS Policy 1928, Teaching

Physician Guidelines for Professional Fee Billing, Section IV, Moonlighting Residents or Fellows


Definitions

Types of SupervisionPersonal Supervision The physician must be present in the room when

the service is providedDirect Supervision The physician must be present in the office or

clinic suite and immediately availableGeneral Supervision Services are under the physician’s overall

direction and control, but the physician’s presence is not required during the performance of the procedure or service. The physician can be available in-person or through electronic means to authorize the service

One of these types of supervision requirements apply whether billing under the name of the NP or supervising physician


Minimum Qualifications

Providing NP ServicesRegistered Professional NurseMasters DegreeCurrently Licensed in the State of California Nurse Practitioner (NP) Family Nurse Practitioner (FNP) Pediatric Nurse Practitioner (PNP)

Supervising NP ServicesAll services billed under a NP provider number require a minimum of “General Supervision” regardless of payer sourcePay attention to Type of Supervision Required Payer SpecificOne supervising physician is not permitted to supervise more than the full-time equivalent of four NPs at any one time


Scope of Practice

GeneralGoverned by rules of RN’s and UCDHS credentialing requirements

California Nursing Practice ActAllows NP to provide certain medical functions in addition to nursingIn some cases, medical functions must adhere to Standardized Procedures that are developed by the employer (UCDHS), in accordance with the California Nursing Practice Act Medical Functions Requiring Standardized

Procedures1. Any function that is not commonly recognized as a

nursing practice and that requires the NP to Diagnose Disease Furnish Medicine Furnish Treatment Penetrate or Sever Tissue


Scope of Practice

California Nursing Practice Act, con’t Medical Functions Requiring Standardized

Procedures, con’t1. NP is allowed to furnish Schedule II-V Drugs with a

Standardized Procedure Drugs must be consistent with the

NP educational preparation Clinical competency has been established and

maintained2. Schedule II or III controlled substances furnished or

ordered shall be in accordance with a patient-specific protocol approved by the treating or supervising physician

In addition to standardized procedures, other written protocols and standing orders may be developed by the supervising physician(s), subject to approval by the UCDHS Inter-Disciplinary Practices Board and the UCDHS Medical Staff Executive Committee


Terms

Billing Terms

“Incident-to” Medicare term ~ Applies only to Medicare Rule developed to allow services provided by a NP

to be billed under the supervising physician’s provider number or allows services provided by a non-physician (RN/MA) to be billed under the NP provider number

Setting must be Freestanding/Stand Alone Setting1. UCDHS Primary Care Clinics

Paid at 100% of the physician’s fee schedule for NP services and 85% of the physician’s fee schedule for non-physician services


Terms

Billing Terms

Split/Shared Visit Another Medicare term ~ Applies to Evaluation &

Management (E/M) Services only Rule allows documentation from the physician and NP

note to be combined Setting must be Hospital-Based

1. Hospital Inpatient or Outpatient, Emergency Room & Hospital-Based Clinics

2. Requires Two separate notes NP AND supervising physician face-to-face time

3. Consultations, Critical Care and Surgical Procedures are Exempt and Cannot use this Rule


Documentation Guidelines

Documentation

All Payers EMR and/or Chart

1. All services ordered and provided by the NP are to be personally documented, signed and dated

2. For billing purposes, it is strongly recommended that NPs identify their supervising physician in their note

Query Process1. Request For Information (RFI) is a mechanism

developed to communicate to healthcare providers when there are questions or additional information is required

2. Charges are held until the RFI is answered


Payor Specific Billing Guidelines

Medicare - Free-Standing Clinic (PCN)“Incident-to” Rules Allowed to provide any service within the scope of

practice for NP/non physician employee Service must be an integral part of the

Physicians/NP professional services Commonly included in a physician/NP bill Commonly furnished in a physician/NP office or

clinic Furnished by a NP/non-physician under

physician’s/NP’s “Direct Supervision” Services must be billed under the name and

provider number of the physician or NP providing “Direct Supervision”1. Name and UPIN of physician or NP providing “Direct

Supervision” must be reported on the claim



Medicare - Free-Standing Clinic (PCN), con’t

“Incident-to” Rules, con’t The supervising physician or supervising NP must

personally perform the initial service for each new condition, make an initial diagnosis and set up a treatment plan and thereafter personally perform services of a frequency reflecting their active participation in, and management of the patient’s treatment

Caution Free-Standing Clinics only (PCN) Definition of “Direct Supervision”

1. When the NPs supervising physician is away or on vacation the supervising physician noted would be the physician called that day for assistance or direction



Medicare - Free-Standing Clinic (PCN), con’t

Can bill under NP or Supervising Physician Reimbursement is greater for services billed under

the name of the supervising physician If NP is on the UCDHS Cost Report NP cannot

submit a professional feeIf billing under the Supervising Physician

1. Must meet “Incident-to” rules

Services provided by non-physicians (RN/MA) that are “Incident-to” NP services are covered and separately billable under the NP

1. Must meet “Incident-to” rules



Medicare – Hospital Inpatient or Outpatient, Emergency Room, or Hospital-Based Clinics

Must bill under the NP Provider Number Exceptions

1. Split/Shared Visit2. Must meet Split/Shared Guidelines

Reminder - If NP is on the UCDHS Cost Report NP cannot submit a professional fee



Medicare – Hospital Inpatient or Outpatient, Emergency Room, or Hospital-Based Clinics

Split/Shared Visit Guidelines Applies to Evaluation & Management (E/M)

Services provided in the hospital (inpatient or outpatient), ER, or hospital-based clinic

Must have two separate notes1. Supervising physician must document some face-to-

face portion of the E/M Service2. NP must document some face-to-face portion of the

E/M Service3. Does not apply to

Critical Care Services Consultation Services Surgical Procedures

4. Cannot be used in a Free-Standing Setting (PCN)



Medi-Cal – All Locations

FNP and PNP Allowed to bill under their own name for any

services provided within their scope of practiceNP Must bill under their supervising physician name There are specific HCPCS, CPT-4 and Medi-Cal only

codes (NP only) For a list of these codes go to

1. http://files.medical.ca.gov/pubsdoco/publications/masters-MTP/Part2/nonph_m00o03o11.doc

Difference between billable and payable



Commercial & Capitated Plans – All Locations

Coverage and reimbursement variesMost carriers cover services billed under the name of the physician providing general supervision

Workers Compensation – All Locations

NP may provide services to workers’ compensation patientsNP may not: Initiate new treatment Report on an injured workers’ entitlement to

benefits Change the Primary Treating Physician (PTP)

treatment plan


Consultation Guidelines

Consultation Services

UCDHS Policy 1924 http://intranet.ucdmc.ucdavis.edu/policies/hosp/1924.html The 3 “R”s

1. 2003 - NP can be an appropriate requesting source for a consultation providing the NP has a billing provider number

Medicare NP can perform and bill under the NP provider number

as long as all other consultation requirements are satisfied

Exception – NP on the Hospital Cost ReportMedi-Cal NP - prohibited from performing and/or billing any

consultation serviceCommercial & Capitated Plans Coverage varies


Modifiers

Modifiers

Medi-Cal/GMC When billing under the name of the FNP or PNP no

special modifiers are required When billing NP services including FNP and PNP,

under the name of the supervising physician the modifier -SA is required

When there are multiple modifiers selected, the Billing System automatically assigns the modifier –YT to indicate there are multiple modifiers

Workers Compensation When billing NP services for workers

compensation, the modifier –98 is required


Pay Attention Each Payer has specific rules & guidelines that vary depending on:

Type of Service Provided Office Visit Consultation Surgical ProcedureBilling and/or Provider Name NP Supervising Physician Setting Hospital-Based Setting

1. Hospital Inpatient or Outpatient2. Hospital-Based Clinic3. Emergency Room

Free-Standing Setting 1. Primary Care Clinic (PCN)


Questions

Questions

Compliance Issues Code of Conduct HIPAA

1. http://www.ucdmc.ucdavis.edu/compliance/

General Coding Education E/M Documentation Requirements UCDHS Audit Tool

1. http://www.ucdmc.ucdavis.edu/cet/resources.


Resources

Web Resources

Medicare

www.medicarenhic.comMedi-Cal

www.medi-cal.ca.govWorkers’ Compensation

www.dir.ca.gov

Nurse Practitioner Billing Compliance Training

Documents

Transcript of Nurse Practitioner Billing Compliance Training