Billing for Non- Physician Practitioners Presented by NYU School of Medicine Office of Physician Reimbursement Compliance Gretchen L. Segado, MS, CPC, Director 316 East 30 th Street New York, NY (212) (212) fax

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 number Nurse Practitioners, Physician’s Assistants, Certified Nurse Specialists, Clinical Psychologists, Medicare reimburses on a percentage of the Physician Fee Schedule Incident-to Billing Physician 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,

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 provision Supplies, 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 necessary Physician 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 settings For 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 ( ) per MCM 15501G Other employees must bill Cannot bill based on counseling time per MCM 15501C

Incident-to vs Direct Billing Incident To No New Patients No New Problems Physician In Suite Not at Hospital or SNF Physician Directs Patient Care Full Payment Code at Any Level Direct Billing Any Patient Any Problem Who cares where Dr is? Any Place of Service NPP Directs Patient Care 85% 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 record medically 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 sections Evaluation and Management ( ) Anesthesiology ( , ) Surgery ( ) Radiology ( ) Pathology and Laboratory ( ) Medicine ( )

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: 25100Arthrotomy, wrist joint; for biopsy 25105for synovectomy Reads: 25105Arthrotomy, 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 (Chest Pain) CPT-4 represents to the carrier what was billed: Procedure (EKG)

Over 17 different Otitis Media Codes Acute? Chronic? Supportive? Serous? Mucoid? Over 28 different codes for Diabetes Type 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 Linkage Pt. for Pelvic Ultrasounduterine 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 to 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 Services Office or other Outpatient Services New and Established Patients Hospital Observation Services Initial Hospital Care Subsequent Hospital Care Hospital Inpatient Services Initial Hospital Care Subsequent Hospital Care

Categories Of E/M Services (Continued) Consultations Office 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 Patient Has not received any professional services from the physician or another physician of the same specialty, same group practice, within the past three years Established Patient Has 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 Initial Comprehensive Preventive Medicine Periodic Comprehensive Preventive Medicine

Keep Your Practice Safe Learn how to code your services Attend coding classes as specialty conferences Attend seminars given by local Medicare Contractors Educate your staff on coding and compliance Document, Document, Document Any questions?????