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Navigating ARNP Billing Issues

Angela Mann, MS, ARNP, NP-C

I have nothing to disclose

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Objectives

The attendee will be able to:Describe the qualifications needed for Medicare, Medicaid and commercial insurance billingExplain Medicare rules related to NP-physician collaboration, coverage and restrictions for inpatient and outpatient visitsExplain Medicare and Medicaid billing for ARNPs related to direct billing and billing under a physician

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The NPI number HIPPA Unique health care provider identifier Required for billing for services using electronic billing The NPI number is permanent and remains with the

provider regardless of job or location changes NPI numbers are required to bill for Medicare or

Medicaid, they are commonly used by commercial insurance companies as well.

NPIs may be required for ARNPs, certified nurse midwives, certified registered nurses, CRNAs, and clinical nurse specialists

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Medicare rulesMust be a registered professional nurse

authorized by the state in which services are furnished. Practices as an in NP in accordance with state law and meet one of the following:Obtained Medicare billing privileges as an NP for the

first time on or after January 1, 2003Obtained Medicare billing privileges as an NP for the

first time before January 1, 2003 and meet certification requirements

Obtained Medicare billing privileges as an MP for the first time before January 1, 2001

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Medicare rules

Is certified as an NP by a recognized national certifying body that has established standards for NPs; and

Has a Masters degree in nursing or a Doctorate of nursing practice degree

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Absolute Medicare rules1.Services must be medically reasonable and necessary2.Services must have been provided as billed, as supported by the

medical record3.The clinician providing the service must have a Medicare

provider number4.The entity seeking payment must submit a Centers for Medicare

and Medicaid services CMS 1500 form appropriately completed5.The entity seeking payment must accept Medicare’s rates6.Providers may not provide kickbacks for referrals7.Services must be billed under the provider number of the

clinician performing the service, unless ‘incident-to’ or ‘shared visit’ rules are followed

8.Medicare will pay only certain parties

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Billing

• NPs are expected to submit claims under their own NPI number.

• NPs may assign numbers to a group practice for purposes of billing.

• There are no limitations on CPT codes, as long as they are recognized by Medicare and have reimbursement codes

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Incident-to

1.They must be an a integral, although incidental, part of the physicians professional service

2.They must be commonly rendered without charge or included in the physician’s bills

3.They must be of the type that is commonly furnished in physicians offices or clinics

4.They must be furnished by the physician or by auxiliary personnel under the physicians direct supervision

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Shared visit

• NPS with their own billing number providing shared visit with physicians and hospitals may bill 100% as long as the physician has also seen the patient. The same day in a “face-to-face” encounter. Billing will take place under the physicians billing number

• It is not required to have a physician counter signature for hospital admission

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In-Patient Billing

• NP salary vs. reimbursement billing

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Medicaid

• Services provided by an ARNP under direct supervision of the physician may be billed by the physician, instead of the ARNP. Direct physician supervision means the physician:– Is on the premises when the services are

rendered, and– Reviews, signs and dates the medical record

Content and Documentation

Level of exam Perform and document

99212 1-5 elements

99213 At least six elements

99214 At least 12 elements

99215 Perform all elements

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E/M Documentation and Billing

• HPI – Brief 1-3– Extended-four or more

elements or associated comorbidities

– OLDCART

• ROS– Pertinent-1– Extended 2-9– Complete 10 or more

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• PFSH– Pertinent-1– Complete-2 or more– Initial visits require at

least one item from all three PFSH areas• Past medical• Family history• Social history

Reimbursement

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99212 99213 99214Medicare $42.50 $70.65 $104.45Medicaid $21.84 $26.61 $41.46

Est. patient Average time99211 5 min.99212 10 min.99213 15 min.99214 25 min.99215 40 min.

New patient99201 10 min.99202 20 min.99203 30 min.

99204 45 min.99205 60 min.

Subsequent hospital care99231 15 min.99232 25 min.99233 35 min.

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Review of systems (ROS)• For purposes of ROS, the following systems are recognized:– Constitutional symptoms– Eyes– Ears, nose, mouth, throat– Cardiovascular– Respiratory– Gastrointestinal– Genitourinary– Musculoskeletal– Integumentary ( skin and/or breast)– Neurological– Psychiatric– Endocrine– Hematologic/lymphatic– Allergic/immunologic

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ROS

• A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI– The patient’s pertinant positive responses and

pertinent negatives for the system related to the problem should be documented

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ROS

• An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.– The patient’s pertinent positive responses and

pertinent negatives for 2-9 systems should be documented

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ROS

• A complete ROS inquires about the system(s) directly related to the problem(s) identified in HPI plus all additional body systems– At least 10 organ systems must be reviewed. The

assistance with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation at least 10 systems must be individually documented.

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Constitutional

Measurements of any three of the following seven vital signs:

1. Sitting or standing blood pressure

2. Supine blood pressure3. Pulse rate and

regularity4. Respiration

5. Temperature6. Height7. Weight8. General appearance of

patient (development, nutrition, body habitus, deformities, attention to grooming)

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Eyes Neck

• Inspection of conjunctiva and lives

• Examination of pupils and irises(PERRL)

• Ophthalmoscopic examination of optic discs

• Examination of the neck• Examination of thyroid

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Ears, nose, mouth and throat

• External inspection of ears and nose• Otoscopic examination of external auditory

canals and tympanic membranes• Assessment of hearing• Inspection of nasal mucosa, septum and

turbinates• Inspection of lips, teeth and gums• Examination of the oropharynx

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Respiratory Cardiovascular

• Assessment of respiratory effort

• Percussion of chest• Palpation of chest• Auscultation of lungs

• Palpation of heart• Auscultation of heart• Examination of– Carotid arteries– Abdominal aorta– Femoral arteries– Pedal pulses– Extremities for edema

and/or varicosities

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Chest Gastrointestinal

• Inspection of breasts• Palpation of breast and

axilla

• Examination of abdomen• Examination of liver and

spleen• Examination for presence or

absence of hernia• Examination of anus,

perineum, and rectum• Obtain stool sample for

occult blood when indicated

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Male Female

• Examination of scrotal contents

• Examination of penis• Digital rectal

examination of prostate gland

• Pelvic examination– Examination of external

genitalia– Examination of urethra– Examination of bladder– Examination of Cervix– Examination of Uterus– Examination of

Adnexa/parametria

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Musculoskeletal• Examination of gait and

station• Inspection and/or palpation

of digits and nails• Examination of joints, bones

and muscles of one or more of the following six areas:– Head and neck– Spine, ribs and pelvis– Right upper extremity– Left upper extremity– Right lower extremity– Left lower extremity

• Examination of the area includes:– Inspection and/or

palpation– Assessment of range of

motion– Assessment of stability– Assessment muscle

strength and tone

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Lymphatic Skin

• Palpation of lymph nodes in two or more areas:– Neck– Axillae– Groin– other

• Inspection of skin and subcutaneous tissue

• Palpation of skin and subcutaneous tissue

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Neurologic Psychologic

• Test cranial nerves• Examination of deep

tendon reflexes• Examination of

sensation

• Description of patients judgment and insight

• Recent assessment of mental status including:– Orientation to time,

place and person– Recent and remote

memory– Mood and affect

Medical decision-making• Review/order of clinical labs and tests• Review/order of tests and radiology• Review/order tests in medicine• Discuss test with performing/interpreting physician• Decision to obtain old records or obtained history

from someone other than patient• Review and summary of old records and/or obtaining

history from someone other than patient• Discussion of case with another health care provider

and documentation of relevant findings• Independent visualization of image, tracing or

specimen itself ( not simply reviewing report) 30

Established patient

99211 99212 99213 99214 99215

Minimal Prob Focused Exp Prob Focused Detailed Comprehensive

HPI N/A Brief 1-3 Brief 1-3 Extended 4 or more Extended 4 or more

ROS N/A N/A Pertinent problem -1 Extended 2-9 systems Complete 10 systems

PSSH N/A N/A N/A Problem pertinent 1 of 3 areas Complete

Medical decision-making

Straightforward: options-minimal; complexity-minimal; risk of complications- minimal,

Straightforward: options-minimal; complexity-minimal; risk of complications- minimal,

Low complexity: options-limited; complexity-

limited; risk of complications-low;

Moderate complexity: options-multiple; complexity-moderate risk

of complications-moderate;-

Hi complexity: options-extensive; complexity-extensive; risk of

complications-high

General multisystem exam

Perform and document 1-5 elements in one or more systems or body areas

Perform and document at least six elements in one or more systems or body areas

Perform and document at least two elements from at least six systems or body areas, or at least 12 elements from two or more body systems or body areas

Perform all elements from at least nine systems/body areas and document at least two elements from each selected area

Single organ system exam

Perform and document 1-5 elements

Perform and document at least six elements

Perform and document at least 12 systems (except for eye and psych exam, which should be at least nine bulleted elements)

Perform all elements; document every element in each.

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New patient 99201 99202 99203 99204 99205

Problem focused Expanded problem Detailed Comprehensive moderate Comprehensive high

HPI Brief 1-3 Brief 1-3 Extended 4 or more Extended 4 or more Extended 4 or more

ROS N/A Problem pertinent Extended 2-9 systems Complete 10 systems Complete 10 systems

PSSH N/A N/A Problem pertinent Complete all 3 areas Complete all 3 areas

Medical decision-making

Straightforward: options-minimal; complexity-minimal; risk of complications- minimal,

Straightforward: options-minimal; complexity-minimal; risk of complications- minimal,

Low complexity: options-limited; complexity-limited; risk of complications-low;

Moderate complexity: options-multiple; complexity-moderate

risk of complications-moderate;-

Hi complexity: options-extensive; complexity-

extensive; risk of complications-high

General multisystem exam

Perform and document 1-5 elements in one or more systems or body areas

Perform and document at least six elements in one or more systems or body areas

Perform and document at least two elements from at least six systems or body areas, or at least 12 elements from two or more body systems or body areas

Perform all elements from at least nine systems/body areas (unless specific directions limit content) and document at least two elements from each selected area

Single organ system exam

Perform and document 1-5 elements, whether in shaded or unshaded box

Perform and document at least six elements, whether initiated her unshaded box

Perform and document at least 12 systems (except for IE and psych exam, which should be at least nine elements)

Perform all elements document every element in each.

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Consultation 99241 99242 99243 99244 99245

Problem focused Expanded problem

Detailed Comprehensive moderate

Comprehensive high

HPI Brief 1-3 Brief 1-3 Extended 4 or more

Extended 4 or more

Extended 4 or more

ROS N/A Problem pertinent

Extended 2-9 systems

Complete 10 systems

Complete 10 systems

PSSH N/A N/A Problem pertinent

Complete all 3 areas

Complete all 3 areas

Medical decision-making

Straightforward: options-minimal; complexity-minimal; risk of complications- minimal,

Straightforward: options-minimal; complexity-minimal; risk of complications- minimal,

Low complexity:

options-limited;

complexity-limited; risk of complications-

low;

Moderate complexity:

options-multiple; complexity-

moderate risk of complications-

moderate;-

Hi complexity: options-

extensive; complexity-

extensive; risk of

complications-high

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Document Document Document

• Avoid words such as “maybe”, “perhaps”, “probably”, or “rule out”.

• Record specific signs and symptoms• Right legibly• Always clearly document chief complaint,

”follow-up” is insufficient

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ICD-9

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Hierchical Condition Catagories (HCC)

• Must be captured in documentation every 12 months

• Risk adjustment diagnosis must be based on clinical medical record documentation from a face-to-face encounter

• Coding according to ICD-9 guidelines• Medical record documentation must support

unassigned HCC

HCC Hypertension

• Hypertensive CKD, w/CKD stage I-IV

• Hypertensive CKD, w/CKD stage V

• Hypertensive heart & CKD w/HF &CKD Stage 1-IV

• Hypertensive heart & CKD w/HF &CKD Stage V

• Hypertensive heart, & CKD w/o HF w/CKD Stage 1-IV

• Hypertensive heart, & CKD w/o HF w/CKD Stage V

• Hypertensive heart disease

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Risk Adjustment

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Meaningful Use

• Computerized provider order entry

• Electronic prescriptions• Record demographicsand

vital signs• Record smoking status• Clinical decision support• Patient assess ability to

health information• Clinical summaries• Protected EHR

• Lab interface• Grouping patients• Reminder systems• Patient education• Medication reconciliation• Or referral summary of care• Immunization• Secure electronic messaging

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Healthcare Effectiveness Data and Information Set (HEDIS)

• Asthma medication use• Persistence of beta

blocker treatment after a heart attack

• Controlling high blood pressure

• Comprehensive diabetes care

• Breast cancer screening• Antidepressant

medication management

• Childhood and adolescent immunization status

• Childhood and weight/BMI assessment

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Healthcare Effectiveness Data and Information Set (HEDIS)

• Prevention and screening

• Respiratory conditions• Cardiovascular

conditions• Musculoskeletal

conditions• Diabetes• Behavioral health

• Medication management

• Access/availability of care

• Experience of care• Utilization• Relative resource use• Health plan descriptive

information

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Modifiers

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Barriers

• Third-party reimbursement• Hospital privileges• Inconsistent and restrictive prescriptive

authority• Statutory limitations to NP scope of practice

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Medicare fraud

• Red flags• Affordable Care Act• Exclusion statute• Federal fraud and abuse laws:– False Claims Act (FCA)– Anti-Kickback Statute– Physician Self Referral Law (Stark Law)– Social Security Act– U.S. criminal code

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Improper claims• Billing for services that you did not actually

render• Billing for services that were not medically

necessary• Billing for services that were performed by

improperly supervised or unqualified employee

• Billing for services that were performed by an employee who is been excluded from participation in the federal health care programs

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What to do if you think you have a problem

• Immediately cease filing the problematic bills• Seek knowledgeable legal counsel• Determine what money you collect it in error from

your patients and from the federal health care programs and report and return overpayments

• Undo the problematic investment by taking all necessary steps to free yourself from your involvement in the investment

• Disentangle yourself from the suspicious relationship

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What to do if you have information about fraud and abuse

• http://www.stopmedicarefraud.gov• 1-800-HHS-TIPS• E-mail HHSTips@oig.hhs.gov

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Billing home visits

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Billing nursing home visits

• An NP may not perform the initial comprehensive visit, unless the following requirements are met:– The NP is performing the service for patients in a nursing

facility ( as compared with the skilled nursing facility)– ENP is not an employee of the nursing facility– State law permits an NP to perform the service– The services within the scope of practice of the NP

understate law– A physician has delegated the service to the NP– The NP is working in collaboration with the physician

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Clinical Nurse Specialists

• Services or supplies must be medically reasonable and necessary

• All of the following must be met

– Services are performed in collaboration with a physicianServices of the type considered physician services if furnished by an M.D. or aD.O.

– Services are not otherwise precluded due to statutory exclusion

– He or she is legally authorized and qualified to furnish the services in the state where they are performed

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Clinical Nurse Specialists

• Clinical nurse specialist may bill the Medicare program directly for services using his or her NPI number or under an employer or contractor’s NPI. Incident to services. Claims must be submitted under the supervising physician’s NPI and identified on provider filed by specialty code 89. Payment is made only on assignment basis, the outpatient mental health transition limitation applies, services repeated 85% of the PFS amount and when services furnished the hospital inpatients and outpatients are billed directly, payment is unbundled and make the CNS

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Certified Nurse-Midwives• Services or supplies must be medically reasonable

and necessary• Here she must be legally authorized qualified first

services in the state in which they were acquired• Services are covered in all settings, including:– Offices– Clinics– Birthing centers– Patient’s homes– HospitalsIncident to services and supplies may be covered

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Certified Nurse-Midwives• Build the Medicare program directly for services using his or

her NPI number• Or

• Under an employer or contractor’s NPI number Incident to service claims must be submitted under the supervising physician’s NPI

• Use billing modifier 52 to report that all services covered by the global allowance were not provided by the billing provider( should not be used when billing for split/shared evaluation and management visits)

• Identified on provider filed by specialty code 42

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ICD-10

• Everyone covered by HIPPA must transition to ICD 10

• Change in format• ICD 10-CM & ICD 10-PCS• ICD 10 will not affect CPT coding for

outpatient procedures

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Thank you

Questions?

• NPI number application process can be done online or with paper application, https://www.cms.gov/nationalprovidentstand/

• http://medicare.fcso.com/EM/175804.pdf

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