Post on 22-Dec-2015
transcript
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
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
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