1:35. NPP April Young Medical Consulting, LLC. Non-Physician Practitioner Coding and Billing. Disclaimer

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1 Non-Physician Practitioner Coding and Billing Jill Young - CPC, CEDC, CIMC, East Lansing, Michigan 1 Disclaimer This material is designed to offer basic information for coding and billing. The information presented here is based on the experience, training, and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This handout is intended as an educational a guide and should not be considered a legal/consulting opinion 2 1:35 Two Kinds 3 1

2 CPT - Time When counseling and/or coordination of care constitute more than 50% of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or unit/floor time in the hospital or nursing facility) time may be considered the key or controlling factor to qualify for a particular level of E/M service. 4 CPT Assistant August 2004 Counseling is a discussion with a patient and/or family concerning one or more of the following areas: Diagnostic results, impressions and/or recommended diagnostic studies Prognosis Risks and benefits of management (treatment) options Instructions for management (treatment) and/or follow-up Importance of compliance with chosen management (treatment options) Risk factor reduction Patient and family education 5 PHYS The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling. 6 2

3 The Other Kind of Time Prolonged Care 7 Prolonged Physician Services For use when patient contact is beyond the usual service. Codes are to report total duration of time spent by physician on a date May not be continuous Used for any primary E&M service code with a typical or specified time published in CPT 8 Prolonged Physician Services Office Prolonged physician service office or other outpatient setting: first hour each additional 30 minutes Face to Face time (CPT & CMS) List separately in addition to code for office or other outpatient Evaluation and Management service RVU 2.69 and 2.65 respectively Threshold for use of code 30 minutes 9 3

4 Prolonged Physician Services Hospital Prolonged physician service inpatient setting: first hour: first hour each additional 30 minutes Face to Face time (CMS) Unit Floor (CPT) List separately in addition to code for office or other outpatient Evaluation and Management service RVU 2.38 for both Threshold for use of code 30 minutes 10 Documentation Requirements MCM Chapter 12:Sec 30:6:1D Documentation is required in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services billed. The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. 11 Documentation Requirements MCM Chapter 12:Sec 30:6:1D The start and end times of the visit shall be documented in the medical record along with the date of service. 12 4

5 Prolonged Physician Services 13 TYPICAL TIME THRESHOLD TO BILL PROLONGED CPT CODE Office New Patient Office Established Patient TYPICAL TIME THRESHOLD TO BILL PROLONGED CPT CODE Hospital Initial Care Subsequent Hospital Care Prolonged Physician Services Procedure time may not be used as part of the E&M time or Prolonged Service time If the dominant service is counseling and time is the basis of the code selection prolonged service (total 4.25 RVU) vs just bump up the code (3.46 RVU) 14 Prolonged Service MCM e 15 5

6 Office Services Previously Consultations Consider Prolonged Care codes where appropriate Bullet points determine code (i.e ) Time spent determines prolonged care NOT same concept as counseling & coordination of care 16 Office 45 Minute Service If the dominate service has traditional elements of History, Exam and Medical Decision making (1.82) + prolonged service (2.69) = 4.51 RVU Bill If the dominant service is counseling and time is the basis of the code selection TOTAL 3.68 RVU Based on Documentation 17 Hospital 60 or 80 Minute Service If the dominate service has traditional elements of History, Exam and Medical Decision making (2.64 ) + prolonged service (2.38) = 5.02 RVU Published time 30 minutes (3.58) + prolonged care (2.38) = 5.86 RVU Published time 50 minutes Consultation RVU BILL BASED ON DOCUMENTATION 18 6

7 Non Physician Practitioner (NPP) Mid Level Providers Physician Extenders Nurse Practitioner (NP) Physician Assistant (PA) Certified Nurse Specialist (CNS) 19 License Requirements and Scope of Practice State scope is frequently mentioned throughout the Medicare Manuals. Each state is responsible for mandating and enforcing specific requirements for licensure and for defining the Scope of Practice. 20 How do You learn? What are your references? Medicare(CMS) Publications: Local Coverage Provisions (LCD) National Coverage Provisions (NCP) Medlearn Matters MPFSDB BCBSM Record Other payer publications Pre and Post Payment Audits 21 7

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9 25 General Information A Physician Assistant (PA) is prepared, both academically and clinically, to provide health care services with the direction and responsible supervision of a Doctor of Medicine (MD) or Osteopathy (DO). PA functions include: Performing diagnostic services, Therapeutic services, Preventive services, and Health maintenance services. A Nurse Practitioner (NP) is a nurse with a graduate degree in advanced practice nursing. This allows him or her to provide a broad range of health care services, including: Taking the patient's history, performing a physical exam, and ordering appropriate laboratory tests and procedures Diagnosing, treating, and managing acute and chronic diseases Providing prescriptions and coordinating referrals Promoting healthy activities in collaboration with the patient 26 General Information PAs practice in a variety of settings in nearly every medical and surgical specialty area. The majority practice within primary care areas and in family practice. Other practice areas include general surgery, surgical subspecialties, and emergency medicine. The remainder are involved in teaching, research, administration, or other nonclinical roles. Like many other professions, PAs are regulated at two different levels. Licensure takes place at the state level according to specific state laws. In contrast, certification is established through a national organization, with requirements for minimal practice standards being consistent across all states. Laws specific to PA licensure may vary somewhat among the states. However, nearly all states require national certification prior to licensure. NP specialties include family practice, women's health, pediatrics, geriatric, neonatology, school health, emergency, oncology and primary care. Some NPs work in clinics without physician supervision, and others work together with physicians as a joint health care team. Their scope of practice and authority depends on state laws. For example, some states allow NPs to write prescriptions, while other states do not. Like many other professions, NPs are regulated at two different levels. Licensure is a process that takes place at the state level in accordance with specific state laws. In contrast, certification is established through national organizations with requirements for minimal professional practice standards being consistent across all states. 27 9

10 Collaboration Collaboration is a process in which a PA works with one or more physicians (MD/DO) to deliver health care services, with medical direction and appropriate supervision as required by the law of the state in which the services are furnished. The PA s physician supervisor (or a physician designated by the supervising physician or employer as provided under state law or regulations) is primarily responsible for the overall direction and management of the PA s professional activities and for assuring that the services provided are medically appropriate for the patient. The physician supervisor (or physician designee) need not be physically present with the PA when a service is being furnished to a patient and may be contacted by telephone, if necessary, unless state law or regulations require otherwise. MBPM Ch 15 Pub , C15, S Employment Relationship Payment for PA auxiliary personnel (under direct physician supervision) services may be made only to the actual qualified employer of the PA that is eligible to enroll in the Medicare program under existing Medicare provider/supplier categories whether the PA is employed as a W-2 employee or as a 1099 employee. While a PA has an option in terms of selecting employment arrangements, only the employer can bill a carrier for the PA s services. If the employer of the PA is a professional corporation (or other duly qualified legal entity), as the employer that corporation/entity may bill for PA services. The professional corporation or duly qualified legal entity (such as a limited liability company or a limited liability partnership) must be properly formed, authorized and licensed under state laws and regulations that permits PA ownership in such corporation or entity as a stockholder or member. This applies even if a PA is a stockholder or officer of the entity, as long as the entity is entitled to enroll as a provider of services or a supplier of services in the Medicare program. MBPM Ch 15 Pub , C15, S190.D 29 Employment Relationship PAs may not otherwise organize or incorporate and bill for their services directly to the Medicare program, including as, but not limited to sole proprietorships or general partnerships. Accordingly, a qualified employer is not a group of PAs that incorporate to bill for their services. A leasing agency and staffing company do not qualify under the Medicare program as a provider of services or supplier of services. Payment for PA services is made only to the PA s employer, whether the PA is employed as a W-2 employee or as a 1099 employee. While a PA has an option in terms of selecting employment arrangements, only the employer can bill a carrier for the PA s services

11 State Of Michigan Public Health Code Sec (1) Except in an emergency situation, a physician's assistant shall provide medical care services only under the supervision of a physician or properly designated alternative physician, and only if those medical care services are within the scope of practice of the supervising physician and are delegated by the supervising physician. 31 State Of Michigan Public Health Code PUBLIC HEALTH CODE (EXCERPT) Act 368 of Responsibilities of physician supervising physician's assistant. Sec (2) Subject to section 17048, a physician who supervises a physician's assistant may delegate to the physician's assistant the performance of medical care services for a patient who is under the case management responsibility of the physician, if the delegation is consistent with the physician's assistant's training. (3) A physician who supervises a physician's assistant is responsible for the clinical supervision of each physician's assistant to whom the physician delegates the performance of medical care service under subsection (2)... (6) Notwithstanding any law or rule to the contrary, a physician is not required to countersign orders written in a patient's clinical record by a physician's assistant to whom the physician has delegated the performance of medical care services for a patient. 32 Incident To Services 33 11

12 Can the following scenario be billed under the "incident to" guidelines? A physician establishes a plan of care for his patient. A nonphysician practitioner (NPP) sees the patient for a follow-up visit and determines she needs to change the patient's dosage of medication. The NPP discusses the situation with the physician outside of the examining room, and the NPP then returns to the examining room to carry out the change of treatment plan. The conversation is documented in the medical records to reflect the conversation between the NPP and the physician. 34 No. The NPP speaking with the physician about a change in dosage of medication does not meet the guidelines for billing the service as "incident to." To review the guidelines for billing services incident to the professional services of a physician or NPP, please see IOM Publication , Chapter 15Adobe Portable Document Format, Section

13 Q6. If the physician is not in the office, but available by phone, can the NPP bill under the incident to guidelines? A6. No. If the physician is not in the office suite, the service does not qualify under the incident to guidelines. The NPP would bill for the service under his/her provider number. 37 Q7. Both the physician and the NPP performed part of the Evaluation and Management (E/M) service for the patient. The doctor left the documentation of the visit to the NPP. Is this a shared/split visit? A7. No. To bill a shared/split visit, both the physician and the NPP must document the work they performed and sign their part of the medical record. 38 Q8. What are you looking for to prove that the doctor had a face-to-face with the patient for share/split visits? A8. The doctor must document his/her work and sign the medical record 39 13

14 Q10. Can we bill inpatient subsequent visits as a shared/split visit? A10. Yes. You can bill a shared/split visit only if the visit meets the documentation requirements for facility services. For a shared/split visit, both the MD/DO and the NPP must document and sign the portion of the visit they performed

15 43 Medicare Benefit Policy Manual Chapter Incident To Services Incident to a physician s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. 44 Medicare Benefit Policy Manual Chapter 15 Direct Personal Supervision Direct supervision in the office setting means the physician must be present in the office suite and immediately available and able to provide assistance and direction throughout the time the service is performed. Direct supervision does not mean that the physician must be present in the same room with his or her aide

16 Medicare Benefit Policy Manual Chapter 15 Services of Non-physician Personnel A. There must have been a direct, personal professional service furnished by the physician to initiate the course of treatment of which the service being performed by the non-physician is an incidental part; and B. There must be subsequent services by the physician of a frequency that reflects his or her continuing active participation in and management of the course of treatment; and C. The physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary. 46 Incident To Care Reference in NPP care s documentation a link between today s visit/service and the plan of care and service to which their service in incidental. The date and location of the plan of care and any other documentation that supports the active involvement of the physician. Write legibly 47 DOCUMENTATION 1. The progress note must substantiate the service performed and be signed by the person performing it. 2. When the physician is involved with a particular service, his or her contribution to the care must be documented. This will assist in substantiating his or her continued involvement in the patient's care. 3. The extent of physician involvement should reflect the patient's condition, increasing with instability and uncertainly of the situation. 4. All documentation should support the level of care provided

17 NPP Service - Medicare Incident to Incident to a physician s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician s personal professional services in the course of diagnosis or treatment of an injury or illness WPS Q&A For a physician s note to qualify as a plan of care, it would need to contain at least: The patient s diagnosis Long term treatment goals And the type, amount, duration and frequency of services It must be established before treatment has begun and may be adjusted by the appropriate provider 49 NPP Service - Medicare Q7. What information in a physician's note for a clinic/office visit would constitute a plan of care? A7. A plan of care identifies the patient's diagnosis, the longterm treatment goals, and the type, amount, duration, and frequency of services. The physician establishes the plan prior to treatment and makes adjustments as needed for changes in the patient's condition. Page Last Updated: Friday, 05-Jun :10:34 CDT 50 Physician Supervision for Physician s Assistant The PA s physician supervisor (or a physician designated by the supervising physician or employer as provided under State law or regulations) is primarily responsible for the overall direction and management of the PA s professional activities and for assuring that the services provided are medically appropriate for the patient. The physician supervisor (or physician designee) need not be physically present with the PA when a service is being furnished to a patient and may be contacted by telephone, if necessary, unless State law or regulations require otherwise. MCM Chapter 15 Sec

18 Physician s Assistant - State Scope - Michigan (1) Except in an emergency situation, a physician's assistant shall provide medical care services only under the supervision of a physician or properly designated alternative physician, and only if those medical care services are within the scope of practice of the supervising physician and are delegated by the supervising physician. (2) Subject to section 17048, a physician who supervises a physician's assistant may delegate to the physician's assistant the performance of medical care services for a patient who is under the case management responsibility of the physician, if the delegation is consistent with the physician's assistant's training. 52 Differing Billing Models Medicare / Commercial Direct Billing Supervising physician Indirect Billing or Incident To Split Shared 53 Direct Billing PA bills under their own NPI/billing numbers Carrier allows for credentialing of PA and pays for their services Work independently Seeing new patients, new problems, established patients, established problems 54 18

19 Supervision Medicare BIG S Physician names in PA s collaboration agreement May be delegated to another if needed Little s Supervisor who is in the office at the time of care May not be the patient s physician Special billing considerations 55 CIGNA Physician Assistant Physician assistants (PAs) are health professionals who practice medicine under a doctor's supervision in medical and surgical settings. They can perform routine exams, order lab work and X-rays, prescribe medicines, and counsel people about their health. Nurse Practitioner Nurse practitioners (NPs) are registered nurses (RNs) who have advanced education and clinical training. They can perform physical examinations, diagnose and treat health problems, order lab work and X-rays, prescribe medicines, and provide health information. 56 NPP Service - Medicare Q7. What information in a physician's note for a clinic/office visit would constitute a plan of care? A7. A plan of care identifies the patient's diagnosis, the long-term treatment goals, and the type, amount, duration, and frequency of services. The physician establishes the plan prior to treatment and makes adjustments as needed for changes in the patient's condition. Page Last Updated: Friday, 05-Jun :10:34 CDT 57 19

20 Incident To Commercial Carriers Policy Manual Indicates Medicare Rules Carrier s Own definition No definition 58 Incident To at a Glance Incident To Does not apply in hospital Must be expense to physician or group Requires physician supervision (Dr In Suite) Reflected on claim form Cannot See New Patients Cannot diagnose/treat new problem Physician initiates treatment plan Has a documented plan of care PA references physician and date of plan of care at beginning of note Physician actively participating in patient s in ongoing care Bill any level of E&M service Bill under physician s name and PIN Big S and Little s supervision considerations No reduction in payment 59 Split Shared Visit - Medicare Hospital Inpatient/Outpatient/Emergency Department Setting When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient s medical record) then the service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim. MCM Chapter b 60 20

21 MCM - Chapter Split/Shared E/M Visit (Skilled Nursing/Nursing Facility) A split/shared E/M visit cannot be reported in the SNF/NF setting. A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit faceto-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer. 61 MCM - Chapter Split/Shared E/M Visit (Skilled Nursing/Nursing Facility) [cont d] The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to consultation services, critical care services or procedures. 62 MCM Chapter b Split/Shared Visit Office/Clinic Setting In the office/clinic setting when the physician performs the E/M service the service must be reported using the physician s UPIN/PIN. When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed incident to if the requirements for incident to are met and the patient is an established patient. If incident to requirements are not met for the shared/split E/M service, the service must be billed under the NPP s UPIN/PIN, and payment will be made at the appropriate physician fee schedule payment

22 64 WPS Medicare Both the physician and the NPP must each personally perform part of the visit, and both the physician and the NPP must document the part(s) that he or she personally performed. When the supporting documentation does not demonstrate that the physician "performed a substantive portion of the E/M visit face-to-face with the same patient on the same date of service" as the portion of service performed by the NPP, a service billed under the physician's Provider Transaction Access Number (PTAN) will be denied. 65 Inappropriate Documentation Split Shared All were signed by the attending physician I have personally seen and examined the patient independently, reviewed the PA's Hx, exam and MDM and agree with the assessment and plan as written Patient seen Seen and examined Documentation by the NPP stating "The patient was seen and examined by myself and Dr. X., who agrees with the plan" with a co-sign of the note by Dr. X. No comment at all by the physician, or only a physician signature at the end of the note

23 Split Shared at a Glance Service must be provided in Hospital (Inpatient, Outpatient, Emergency Department) Physician and NPP must EACH perform a part* of the E&M service and document as such New or established patients New or established problems Bill any level of E&M service CANNOT do procedures/surgery split shared Billed under physician number No reduction in payment 67 Split Shared Commercial Carriers Policy Manual Indicates Medicare Rules Carrier s Own definition No definition 68 Researching Carrier Policy Carrier Policy Manual Internet Google Bing Contact insurance directly In writing 69 23

24 BCBSM - After April 1, 2008 Use indirect method if any of following criteria met: Any service where the physician delivers any component of the service Services for which the physician has provided specific clinical direction to the non-physician practitioner Services for which the PA or CNP has presented pertinent clinical findings and obtained approval of evaluation and management by the physician prior to the end of the day following the service.* April 2008 Record 70 WPS - Medicare Q14. The physician reviews the documentation from the PA, but does not see the patient. Is this a shared/split visit? The PA documents the physician reviews and agrees. Does it make a difference if this is a new or established patient visit charge? 71 WPS - Medicare A14. If the physician is not performing any of the E/M services, it is not a shared/split visit. If the service is performed in a facility setting, only the NPP may submit a charge for the service. If the service is performed in an office setting, the physician may submit a charge for the service if the incident to requirements are met. One requirement is that it is the physician who has established the plan of care. Therefore, if the patient is new, only the NPP may bill the service 72 24

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26 Physician Supervision of Diagnostic Procedures 01 = Procedure must be performed under the general supervision of a physician. 02 = Procedure must be performed under the direct supervision of a physician physician. 03 = Procedure must be performed under the personal supervision of physician. 04 = Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist; otherwise must be performed under the general supervision of a physician. 05 = Physician supervision policy does not apply when procedure is furnished by a qualified audiologist; otherwise must be performed under the general supervision of a physician. 06 = Procedure must be performed by a physician or a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiological clinical specialist and is permitted to provide the procedure under State law. 09 = Concept does not apply 76 What to do if a payer doesn t credential PA s? Decide to only use one method to simplify? Which? Effect of direct billing by PA on Copays & deductibles 77 WPS Medicare Guidelines for the Use of Scribes in Medical Record Documentation "Scribe" situations are those in which the physician utilizes the services of his, or her, staff to document work performed by that physician, in either an office or a facility setting. In Evaluation and Management (E/M) services, surgical, and other such encounters, the "scribe" does not act independently, but simply documents the physician's dictation and/or activities during the visit 78 26

27 WPS Medicare Guidelines for the Use of Scribes in Medical Record Documentation The physician who receives the payment for the services is expected to be the person delivering the services and creating the record, which is simply "scribed" by another person. 79 WPS Medicare Guidelines for the Use of Scribes in Medical Record Documentation Record entry notes the name of the person "acting as a scribe for Dr. X." Physician co-signs the note indicating the note is an accurate record of both his/her words and actions during that visit. 80 EMTALA 81 Note: Be aware that there is an EMTALA policy affecting PAs and Consultations in the ED. While your patient may not be a Medicare patient, any institution participating in the Medicare program and receiving Medicare funding must comply with EMTALA. "The decision as to whether the on call physician responds in person or directs a non-physician practitioner (physician assistant, nurse practitioner, orthopedic tech) as his or her representative to present to the dedicated ED is made by the responsible on call physician." For EMTALA purposes, the physician would have to be called or contacted to delegate the Consultation to a PA. 27

28 Hospital Employed Physician Scope of License Supervision Physician Billing Hospital Inurnment 82 FINAL QUESTIONS & COMMENTS Thank you!! 83 28

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