Reimbursement Update MAPA Tricia Marriott, PA-C, MPAS, DFAAPA AAPA Director of Reimbursement on Twitter

Transcription

1 Reimbursement Update MAPA 2012 Tricia Marriott, PA-C, MPAS, DFAAPA AAPA Director of Reimbursement on Twitter

2 Disclaimer This presentation was current at the time it was submitted. It does not represent payment or legal advice. Medicare policy changes frequently, so be sure to keep current by going to Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The American Medical Association has copyright and trademark protection of CPT.

3 Why should I care about billing rules? I just want to take care of patients. Who is responsible/liable for compliance? My office uses a billing company; I don t have anything to do with it.

4 Fraud And Abuse Revenue Audit Contractors (RAC) Office of Inspector General (OIG) HealthCare Fraud Prevention and Enforcement Action Team (HEAT) Zone Program Integrity Contractors (ZPIC) Comprehensive Error Rate Testing (CERT)

5 Civil Monetary Penalties (CMP) The OIG may seek CMPs for a wide variety of conduct. [42 CFR ]. For example, the OIG may seek CMPs against any person who: Presents or causes to be presented claims to a Federal health care program that the person knows or should know is for an item or service that was not provided as claimed or is false or fraudulent. 42 U.S.C. 1320a-7a(a)(1)(A) and (B).

6 How Much? In a case of false or fraudulent claims, the OIG may seek a penalty of up to $10,000 for each item or service improperly claimed, and an assessment of up to three times the amount improperly claimed. 42 U.S.C. 1320a-7a(a).

7 Office of the Inspector General

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9 Exclusion The effect of an OIG exclusion from Federal health care programs is that no Federal health care program payment may be made for any items or services furnished by an excluded individual or entity, or directed or prescribed by an excluded physician. (42 CFR ). In many instances, the practical effect of an OIG exclusion is to preclude employment of an excluded individual in any capacity by a health care provider that receives reimbursement, indirectly or directly, from any Federal health care program.

10 Fraud & Abuse If your name is on the claim, you are likely to be the first point of contact. Through the investigation/audit process, it may be shown that you were not at fault for the error.

11 Myths PAs cannot see new patients. PAs cannot bill Level 4 or 5 visits. PAs cannot see patients with new problems.

12 Myth Busters CPT AMA Manual Medicare Manual Payer Policy

13 PAs can bill all levels of E/M CPT CPT 2012 AMA states: Any procedure or any service in this book may be used to designate the services rendered by any qualified physician or other qualified healthcare professional. (Introduction, Instructions for Use of the CPT Code Book, pg x)

14 PAs can bill all levels of E/M Medicare Medicare Benefit Policy Manual: Chapter 15, 190 Physician Assistant(PA) Services states: PAs may furnish services billed under all levels of CPT evaluation and management codes, and diagnostic tests if furnished under the general supervision of a physician.

15 New Patients/New Problems PAs may provide evaluation and management services to new patients and established patients with new problems in the Medicare program. When they do, the encounter should be billed under the PA s NPI; reimbursement will be at 85% of the physician rate.

16 *Caveat While there are no restrictions in CPT AMA or Medicare payment rules, private payers may restrict any code as they see fit. Examples: There are some workers comp policies that do not allow PAs to see patients on the initial visit. This may be based in WC statute Arkansas BCBS limits codes that PAs/NPs may bill to the lower level codes.

17 Levels of Services Medical Necessity must support the level of service billed. (The Chief Complaint and History/ROS drives the Examination and the Medical Decision-Making). Documentationmust support the level of service billed. (If it is not written, it was not done.)

18 Medicare Claims Processing Manual Chapter 12, Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.

19 Global Package: Pre-OP H&P There must be medical necessity in order to bill for a Pre-op H+P, under Medicare. It is considered part of the global package. Typically, the surgeon/surgeon s team is not the clinician who addresses the medical management. The hospital requires it does not make it billable/reimbursable.

20 Global Surgical Package-Medicare Each procedure has a defined number of days of follow-up included. The components of this package include the following services. INTRAOPERATIVE WORK=69% POSTOPERATIVE WORK=21% PRE-OP WORK=10%

21 Global Surgical Package-CPT From the AMA- Q: Are preoperative visits billable? A: If the decision for surgery occurs on the day of surgery or day before and includes the preop evaluation and management services, then the visit is reportable. Modifier -57, Decision for Surgery, is appended to indicate that this is the decision-making service, not the History and Physical (H&P) alone.

22 Global Surgical Package-CPT If the surgeon sees the patient and makes a decision for surgery, and then the patient returns for a visit where the intent of the visit is the pre-operative H&P, and this visit occurs between the decision-making visit and the day of surgery, regardless of when the visit occurs ( 1 day, 3 days or 2 weeks) the visit is not separately billable as it is included in the surgical package. Source: AMA CPT Assistant, May 2009/Volume 19 Issue 5, pp. 9, 11

23 Pre-op H&P For the record, it is never a good idea to trick the system and schedule an H&P more than 24 hours prior to surgery just to get paid. Laura Evans Evans, L ; Pre-op H&P: often required, usually not separately billable, MGMA Connexion, July 2010, p.11-12

24 Pre-op H&P RAC Audits Announced ISSUE: E&M services are not allowed to be billed prior to a major surgical service without the proper modifiers. Therefore, an issue may exist when these services are billed and reimbursed under Medicare Part B without these modifiers. DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT Date Posted: June 17, 2010 Dates of service: October 1, 2007-present

25 Incident-to Billing Incident to is a Medicare billing provision that allows reimbursement for services delivered by PAs at 100 percent of the physician fee schedule, provided that all incident to criteria are met. Incident to billing only applies in the office or clinic.

26 Incident-to billing Make sure you know and understand the rules for Medicare s Incident-to billing. Some payers do not enroll PAs. Claims are submitted under the physician s number. This is NOT incident-to billing. There is no on- site or first visit rule attached.

27 Incident-to Rules The physician must have personally treated the patient on his or her initial visit for the particular medical problem and established the diagnosis and treatment plan.. The physician is within the suite of offices when the PA renders the service. The service is within the PA s scope of practice and in accordance with state law.

28 Incident-to Rules The physician must have some ongoing participation in the patient s care. This must be reflected in the medical record somehow, in the event of an audit. Not required if billed under the PA s NPI.

29 OIG Report The Office of the Inspector General released a report Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services August pdf Incident to billing coming under increasing scrutiny.

30 Incident-to Under Scrutiny The Office of the Inspector General (OIG) has published itswork Plan for FY 2012, which includes a focus on Incident-To Services. w/item.aspx?id=2981 The Office of the Inspector General was created to protect the integrity of HHS programs and operations and the wellbeing of beneficiaries by detecting and preventing fraud, waste, and abuse; identifying opportunities to improve program economy, efficiency, and effectiveness; and holding accountable those who do not meet program requirements or who violate Federal laws.

31 References for Incident-to Medicare Benefit Policy Manual, Chapter 15, Section ds/bp102c15/pdf Transmittal oads/r1764b3.pdf.

32 Remember PAs may see new patients and patients with new problems. When they do, they must be billed under the PA s NPI number. The physician is not required to see the patient or be on-site; must be consistent with state law and scope of practice.

33 Shared Visit Billing-Hospital Shared visit billing can be used when the following criteria are met: Both the PA and the physician work for the same entity (i.e., same practice, same hospital, etc.). Both the PA and the physician see the patient on the same calendar day.

34 Split/Shared Visit-Office When an E/M service is a shared/split encounter between a physician and a nonphysician 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. Medicare Claims Processing Manual, Ch 12, (B)

35 Shared Visit Billing The service performed was an evaluation and management (E/M) service and neither a procedure nor a critical care service. The physician provided some face-to-face portion of the E/M service with the patient (did not simply review and agree with the PA s description on the patient s chart.) The physician must document his/her contribution to the E/M service.

36 Shared Visit Billing Shared visits are not allowed in SNFs. see (H) More info: Transmittal

37 Medicare Hot Topics

38 SNF Certification: New in 2011 The Affordable Care Act included a provision to allow PAs to perform the initial certification and periodic re-certification required for the skilled nursing facility (SNF) level of care. Does NOT include the initial comprehensive exam however. Previously, the list of practitioners allowed to "certify" SNF care included only physicians, nurse practitioners and clinical nurse specialists. The provision was published in the Federal Register November 29, 2010, (H. Section 3108, page 219) and became effective January 1, 2011.

39 Home Health: New in 2011 The Affordable Care Act mandates a face-to-face encounter with a patient prior to the certification of home health services. Although a physician must certify, re-certify and sign the plan of care for home health patients, nonphysician practitioners including PAs, NPs, CNSs and CNMs may provide the newly required face-toface encounter. PAs may continue to provide care plan oversight services for home health patients. In approved rural sites, the face-to-face encounter may occur via tele-health.

40 Home Health To assist home health providers, the agency has developed a CMS MLN Matters Article: Home Health Face-to-Face Encounter A New Home Health Certification Requirement wnloads/se1038.pdf

41 PECOS All providers should be verifying their enrollment on the CMS on-line enrollment systems known as Internet-based PECOS. CMS has posted a PECOS Ordering/Referring Filewhere you can easily check to see if you are current. If you are not listed in this file, you will need to update your information in the PECOSsystem. If you do not know your NPI number, it is easily accessed from the NPI Registry. *Beginning January 2011 claims were to be denied for services ordered by non-pecos enrolled providers. This has been delayed.

42 Re-Validation Beginning March, 2011, providers will be asked to re-validate their information through the PECOS system. You will receive a letter from your administrative contractor. Wait for the letter. wnloads/se1126.pdf nice summary

43 Links PECOS Ordering/Referring File penroll/downloads/orderingreferringreport. pdf PECOS NPI Registry ysearch.do

44 Primary Care Services Incentive Bonus 10% of allowed charges PAs are eligible providers Primary care services must be at least 60% of allowed charges for Medicare. To be eligible for the incentive payment, qualifying services must be rendered between January 1, 2011, and December 31, CPT codes include , , included (outpatient office, nursing facility, patient home visit, etc.)

45 Primary Care Incentive Program wnloads/mm7060.pdf PCIP Eligibility file-michigan entive-programs/pcip-program.shtml Search for your NPI; if you are listed, you are eligible for the 10% bonus. Be sure to let your practice know that the practice will receive this payment.

46 Other Medicare Incentive Programs Electronic Health Records (EHR) E-Prescribing How to Get Startedhttp:// o_get_started.asp#topofpage Physician Quality Reporting System(PQRS ) (formerly known as PQRI) t_started.asp

47 Electronic Health Record Goal is to have everyone on interoperable/integrated electronic health records by Incentives built in based on Implementation, Adoption, and Meaningful use criteria. If not implemented by 2015, penalties of 2% of Medicare charges will be applied. First incentive year 2011.

48 Electronic Health Records Who is eligible for what? $44,000-$63,500 for the early adopters Physicians are eligible under both Medicare and Medicaid programs. Nurse practitioners are eligible under the Medicaid program only. Physician assistants are only eligible under the Medicaid program, and onlyif practicing in a PA-led RHC or FQHC.

49 PA-led RHC or FQHC 1) When a PA is the primary provider in a clinic; (for example, an RHC with a part-time physician and a full-time PA would be considered PA-led ) 2) When a PA is a clinical or medical director at a clinical site of practice; or 3) When a PA is an owner of an RHC.

50 Medicaid EHR Incentive Additionally, for the Medicaid incentive, there is a percentage volume requirement. Eligible Professionals must have a minimum of 30% of their visits as unique encounters. Pediatricians may have 20%.

51 EHR Incentive bill-action ALERT! HR 2729 The Health IT Modernization for Underserved Communities Act has been introduced by Karen Bass (D-CA) and Lee Terry (R-NE); This act will extend the Medicaid EHR incentive to PAs.

52 Contact Your Congressman! Starts in Energy and Commerce Committee: Fred Upton (R-MI) is Chairman! Mike Rogers and John Dingell also on Committee. =

53 E-prescribing Program already in place, authorized by MIPAA in While an element of electronic health records, it is a stand-alone program as well. Eligible providers include physicians, nurse practitioners, and physician assistants. DEA getting on board for controlled substance prescribing. If you are not already e-prescribing, you are being penalized unless you have filed for an exemption.

54 E-prescribing Incentives/Penalties Year Incentive Penalty % % % % 1% % 1.5% 2014 and beyond 2%

55 PQRI/PQRS Physician Quality Reporting Initiative is already in place: (see 2012 Implementation Guide) Eligible providers include physician assistants. ACA has increased the number of measures, decreased the threshold from 80% to 50, and made it easier for group practices to participate. Voluntary, but posted on Physician Compare website. Penalties if not reporting by 2013!

56 Resources 2012 PQRI Implementation Guide PhysQualRptg_ImplementationGuide_Measur eslist_ zip Medicare EHR Incentive Program, Physician Quality Reporting System and e-prescribing Comparison /EHRIncentivePayments-ICN pdf

57 Resources Watch your PA Advocate weekly s Tricia Marriott, AAPA Director of Reimbursement Policy, 571/ Follow me on Click on Your PA Practice >Reimbursement