UCLA Medical Sciences Compliance and Privacy Office 2010

Transcription

1 UCLA Medical Sciences Compliance and Privacy Office 2010

2 Background AHP Defined General Scope of Practice Supervising Physician Requirements How the AHP Can Be Utilized and When Services Can Be Billed Billable Services Medicare Independent Billing Split/Shared Services Incident-To Billing Examples of Billing Scenarios Medi-Cal Other Services AHP s Can Provide to Assist a Practice Appendix 1 How UCLA Defines AHPs Appendix 2 Reference for Licensing and Scope of Practice for Physician Assistants Appendix 3 Reference for Licensing and Scope of Practice for Nurse Practitioners Appendix 4 References for Licensing and Scope of Practice for Other AHPs (Clinical Nurse Specialists, Certified Registered Nurse Anesthetists and Certified Nurse Midwifes) 2

3 An Allied Health Professional (AHP) is defined as: A health provider qualified by training and frequently by licensure to assist, facilitate, or compliment the work of physicians, dentists, podiatrist, nurses and other specialists in a health care system. Joint Commission Medical Staff Bylaws and Rules and Regulations typically define and specify the categories of AHPs authorized to provide services. (See Appendix 1 for how UCLA defines AHPs) Medicare identifies certain AHPs* as Non-Physician Practitioners (NPP) and only these can bill Medicare for services. Medi-Cal identifies certain AHPs* as Non-Physician Medical Practitioners (NMP) and only these can bill Medi-Cal for services. *Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists and Certified Registered Nurse Anesthetists are an example of AHPs authorized by Medicare and Medi-Cal. 3

4 The scope of practice must be consistent with: Applicable licensing laws (California Business and Professions Code) and regulations (Title 16 of the California Code of Regulations). Practice protocols, standardized procedures and other relevant procedures developed, reviewed and approved in accordance with Title 22; and Payor requirements if payment sought. In the Hospital setting, the Interdisciplinary Practice Committee (IDPC) is responsible for reviewing AHP practices. Applicable protocols and procedures must be readily available for review. At UCLA Hospitals, the Medical Staff Office maintains these documents. CONTACT INFORMATION: Quality Management Services, Medical Staff Office, Phone: See Appendix 2-5 for specific requirements for PAs, NPs, CNSs and CRNAs. 4

5 The scope of services may be limited to less than the maximum scope allowed by law by: CPT/HCPCS codes if billing for services; The Medical Director of the Clinic/Unit where the AHP works; The Hospital s Bylaws, Rules and Regulations and Policies; The practice privileges which AHPs are granted; A job description, if employed by the Hospital; or The AHP s supervising physician. 5

6 AHP services typically require the general supervision of a physician who is: A member of the medical staff (inpatient or outpatient department) and in good standing with the Medical Board; and Not a resident, fellow or intern. General supervision means: Under the physician s overall direction and control. Physician s physical presence not required. May be available by electronic means. However the level of supervision depends on the services the AHP is providing and the protocols defining that service. There may be additional supervision requirements to bill such as the direct supervision requirements needed for Medicare Incident to Billing (Slide 20-22) * Certain independent licensed AHPs, such as acupuncturists, clinical psychologists and optometrists, are not subject to the general supervision requirements. 6

7 Before authorizing an AHP to perform any medical procedure, the supervising physician is responsible for evaluating the AHP s education, experience, knowledge, and ability to perform the procedure safely and competently as validated in the credentialing process. The supervising physician must also be familiar with the laws and payor guidelines specifying the number of AHPs a physician can supervise. For example: A single physician is limited to supervising four PAs at any moment in time under California law. A single physician is also limited to supervising four NPs if the NPs are furnishing drugs or devices. (If not, there is no limit under California law). The supervising physician should also know the supervision level needed for billing a particular way. 7

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9 AHPs can be utilized by: Providing billable services, such as Independent services Medicare Split/Shared Visits for Hospital Settings which includes Hospital-based Clinics Medicare Incident to services for Freestanding Clinics and Offices Medi-Cal Other Payors Providing other services Providing Triage Providing Outreach Acting as a Resource 9

10 When billing for AHP services, it is important to pay attention to the different Payor Rules and Guidelines as they can vary in regards to: The type of services AHPs can provide (office visit, consult) The name of the billing provider The level of supervision required The setting where service can be performed Some payors do not recognize AHP services This presentations focuses on the requirements for Medicare and Medi-Cal billing. 10

11 AHPs may bill independently for their services only after: Practice Protocols or standardized procedures are developed by the AHP in conjunction with the supervising physician, and approved by the IDPC, when appropriate. Authorization is provided by the sponsoring Department. Enrollment in Government and Commercial payors (i.e., obtaining NPI). Enrollment and issuance of Internal Billing Number through the Faculty Practice Group (FPG) Physician Billing Office (PBO). Medi-Cal also require documentation showing that: The medical/surgical services provided by the AHP and the supervising physician are integrated and consistent with acceptable medical practice; and Issues outside the AHP s scope of practice are appropriately addressed.* *These requirements can be incorporated into standardized procedures for advanced practice nurses and practice protocols for physician assistants. 11

12 Examples of the types of services AHPs can provide which are billable (will depend on their scope of license/protocols and on the payor): E/M services, such as: New/Established Office Visits ( ) Subsequent Hospital Care ( ) Discharge Services ( ) Procedures such as insertion of lines, injections, venipuncture, EKG s, nasogastric tube replacement, immunosuppression therapy 12

13 In the Hospital Setting which includes inpatient, outpatient, the emergency department and hospital based clinics: Certain AHPs*, such as NPs can bill independently for their services if they are not employees of the hospital. General Medicare Rule is: If the AHP performs the service in the hospital, the AHP is the billing provider for the service, if the service is billable. Some services are not billable, such as services provided during the global surgery period. * Not all AHPs credentialed by UCLA are recognized by payors as billing providers. 13

14 AHP services may not be covered if they are otherwise excluded from coverage even though an AHP may be authorized by State law to perform them. Examples: Routine foot care Routine physical exams Services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member These services are precluded from coverage even though they may be within a AHP s scope of practice under State law.

15 Qualified AHPs can provide assistant-at-surgery services and bill if: The surgical procedure is within the scope of licensure and is defined under approved policies and protocols and laws and regulations and payor requirements; The surgical procedure is recognized as requiring a surgical assistant; and No qualified resident/fellow is available and clearly reflected in the operative report. (In the teaching setting, it is expected that surgical assistance will be performed by residents.) Separate documentation is not required by the AHP if the physician s note indicates that the AHP assisted and no qualified resident was available. If this is not documented, the AHP assisting cannot bill for the service REMINDER: Make sure the surgeon appends the appropriate assistant surgeon modifier. For Medicare and other payors, modifier AS must be appended to the surgical procedure to reflect that an AHP assisted. For Medi-Cal, refer to Slide

16 What is the Split/Shared Rule in Hospitals/Hospital Based Clinics? For Medicare patients, the Split/Shared Rule allows physicians to provide and document some E/M services and an authorized AHP to do the rest of the visit and document the services provided. The visits can then be combined and the physician can bill for the service. What are the benefits of this Rule? The Split/Shared Rule would allow a physician in a hospital or hospital based clinic to attend to other matters after he/she has provided some of an E/M service for a Medicare patient. 16

17 Does the Medicare Split/Shared Rule Pertain to All Services in Hospitals/Hospital Based Clinics? No, it does not pertain to Consultations, Critical Care and Surgical Procedures. Also for an initial hospital visit where patient is new to group, the visit cannot be split. Applies only to E/M Services, such as non-global discharge services. Are there other restrictions? It is not sufficient for a physician to document seen and agreed or countersign the AHP s note to bill for the service*. The physician must document the portion of the E/M service provided. If no face-to-face encounter by the physician, the AHP is the billing provider and the AHP must sign to verify the services. * A physician can countersign an AHP s note or document seen and agreed to demonstrate that he/she reviewed the care provided by the AHP when required by law or Hospital policies, Medical Staff Bylaw or Rules and Regulations. Countersigning or documenting seen and agreed however, is not sufficient for Medicare billing purposes. 17

18 Example: In the Hospital and Hospital-Based Clinic setting, when the service is split/shared between a physician and an AHP 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 AHP s NPI.* Remember: If there were 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 AHP s NPI. * Remember does not pertain to initial hospital visit where patient is new to group, critical care or surgery. 18

19 Independent Billing: Authorized AHPs can bill independently for their services in non hospital based clinics and office setting. Medicare Incident To * Billing: AHPs can provide services under the supervision of the physician in which case the physician can bill if services meet the Incident to requirements for Medicare as set forth on next slide. In certain situations, AHPs may be able to supervise the services of others and bill for these services if they meet the Medicare Incident to requirements. For Medicare Incident to rules to apply, services must be provided in freestanding settings (not operated under license of hospital), such as: CPNs Practice Based Clinics Incident to is really a Medicare term and includes the specific requirements addressed on slides However this term is often used to describe services performed by a NP or PA under the general supervision of physician which can be very confusing. 19

20 Services performed by AHPs incident to a physician s professional services can include: Services ordinarily performed by the physician, such as minor surgery, setting casts, reading x-rays and other activities that involve the evaluation or treatment of a patient s condition. 20

21 The Medicare Rules require: The physician must first see the patient and initiate a plan of care. The AHP then provides services based on this plan of care. The AHP s services can be at the same visit or at a subsequent visit; The physician must remain involved in the management of the patient s treatment and documentation must reflect this continued involvement; The services must be considered integral to the plan of care, medically appropriate and the type provided in an office setting; The AHP must be employed by the physician or group billing for the service; and There must be direct supervision by the supervising physician. (See next slide) 21

22 Medicare Direct Supervision Requirements: Doesn t require the physician to be in same room, but must be present in the office suite and immediately available to provide assistance and direction. Not sufficient to be available by electronic means for incident to billing. Not sufficient to be somewhere in the building. It doesn t matter that the AHP is allowed by law and office protocol to perform these services without supervision. To meet incident to billing requirements, direct supervision is necessary. If no direct supervision, the AHP must bill for the service, not the physician. In the clinic setting, the physician who ordered the service, need not be the physician who provides the supervision (see next slide). 22

23 In highly organized clinics, particularly those that are departmentalized, direct physician supervision may be the responsibility of several physicians as opposed to an individual attending physician. In this situation, medical management of all services provided in the clinic is assured. Example: When the physician who outlined the treatment plan is away on vacation and can not be physically present in the clinic to supervise the AHP. Whoever is designated on that day to provide direct supervision would sign and document the medical record and bill for the service. Reference: 23

24 In certain situations, authorized AHPs may be able to bill for services that a qualified RN or LVN provides, if the AHP (as the supervising provider) is present in the office suite and immediately available to provide assistance and direction throughout the time the RN or LVN is performing services, assuming the other incident to requirements are met. AHP saw the patient and initiated plan of care; and AHP remained involved with the patient s treatment; and Services provided were integral to the plan of care, medically appropriate and the type provided in an office setting; and The qualified staff member performing the service must be an expense to the group. * To bill in this manner, the matter should be discussed with the UCLA Medical Sciences Compliance and Privacy Office and the Physician Billing Office. 24

25 Medicare Requirements Definitions Allowed Settings/Services Non-allowed Settings/Services General Requirements Incident To Office Services 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. Practice based Office/Clinic Patient s Home Institution (such as a nursing or convalescent home) Designated office area in a SNF/NF or hospital Hospital Inpatient/Outpatient/Hospital based clinics Emergency Department SNF Ambulance/EMT services performed under telephone supervision AHP must be employee of or independent contractor to physician, physician s group or physician s employer. Supervising physician must be physically present (direct supervision) Physician has performed initial & subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment. Professional identity of the staff furnishing the service must be Split/Shared A medically necessary encounter with a patient where the physician and a qualified AHP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. Hospital Inpatient/Outpatient Emergency Department Hospital Observation Hospital Discharge Hospital Based Clinic SNF/NF Setting Consultation Services Critical Care Services Procedures Patient s Home and Domiciliary Sites Physician and AHP are from same group practice OR employed by same employer. Physician provides any face-to-face portion of E/M encounter with patient. (NOTE: if physician only participated in the service by reviewing the patient s medical record, then service may only be billed under the AHP s UPIN/PIN) Not sufficient for MD to note seen 25

26 Documentation Requirements for AHP to bill: The AHP should fully document the service provided. E/M Services reported by an AHP must be based solely on the services documented by the AHP unless services meets the Split/Shared requirements. (Slides 16-18)* AHPs should not be relying on a note from a resident or intern. *A supervising physician should be careful not to treat an AHP as he/she would a resident. It is inappropriate for a supervising physician to amend an AHP s note and then bill for the service. 26

27 Examples of Billing Scenarios AHP and Physician: If the physician provides part of the service sufficient to substantiate a billable service and the AHP has independently performed a similar level, either the AHP or the physician may submit the claim (NOT BOTH). Guidelines should be established. If the physician and AHP are present for the entire visit, the physician should submit the claim. 27

28 Examples of Billing Scenarios Hospital Visit If the physician and AHP (from the same specialty) provide hospital visits on the same day (even at different times), only the physician should bill. The level of service documented by the physician should be used to report the appropriate E/M service code. It should not be combined with the AHP s documentation. 28

29 Examples of Billing Scenarios Separate Surgical Procedure: If the physician provides an E/M service (even if the service involved a resident) AND the AHP performs a separate surgical procedure, both the physician and AHP may bill for their services. (Each provider must personally document the service that they are billing. Modifier 25 should be appended to E/M code. If the physician services involves a resident, the Teaching Physician rules apply. ) 29

30 Examples of Billing Scenarios AHP and Resident/Fellow: If a resident or fellow sees a patient with an AHP and no teaching physician is involved, only the AHP can bill AND only for their own services rendered. The AHP must personally document the level of service he/she provided to support the service or procedure reported. (It is not appropriate for the AHP to amend the resident s note or act as a teaching physician.) 30

31 Examples of Billing Scenarios AHP, Resident and Teaching Physician: If a teaching physician, resident or fellow, and an AHP sees a patient, the case is billed by the teaching physician. All Teaching Physician guidelines apply. The AHP documentation should not be used to support the level of service billed by the Teaching Physician. 31

32 Examples of Billing Scenarios Medicare Incident To Example A physician evaluates a patient, and diagnoses hypertension. The physician initiates treatment. The physician employs an NP. The NP conducts follow up visits with the patient, monitoring and treating the hypertension over months. The physician sees the patient every third visit, under a policy adopted by the practice. The NP's work may be billed under the physician's provider number, and the practice will receive 100% of the physician's fee schedule rate for the services performed by the NP. 32

33 Medi Cal Billing Medi Cal will reimburse for services provided by: Physician Assistants Nurse Practitioners Certified Nurse Midwives Certified Nurse Midwives and Family and Pediatric Nurse Practitioners can also enroll as individual providers. 33

34 Medi Cal Billing General Requirements May only bill Medi Cal if: Provider enrolled with Medi Cal Appropriate supervision requirements are met Medi Cal provider who employ/use services of Non Physician Medical Practitioners (NMP) must ensure patient is initially informed he may be treated by NP, PA etc. Interface document developed by Medi Cal provider who employs/uses NMP. This document establishes means by which medical treatment services provided by physicians and NMP are integrated and made consistent with accepted medical practice. This document must be kept on file in physician s office and available for review. There are specific requirements for this document based on the type of NMP.* Reimbursement is typically made to the employing physician, organized outpatient clinic or hospital outpatient department. Exceptions for certain Certified Family and Pediatric Nurse Practitioners. *See specific requirements for PA, NP and CNM included in attached Appendices. 34

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36 AHPs can support a Clinic or Division/Department by serving as the front line to: Talk with patients seeking an appointment or service; Discuss a case with a referral center or referring physician; and, Assist in care coordination of the patient to improve patient access and customer satisfaction. 36

37 AHPs can support a Clinic or Division/Department by supporting the Outreach Efforts of a Physician by: Serving as the coordinator of the Outreach Activities; Being the initial primary contact for the patient and assisting them with accessing the UCLA system; and, Ensuring medical record documentation and HIPAA requirements are met for clinical records. NOTE: Patients must be informed that services are being provided by an AHP, not a MD. 37

38 AHPs can support a Clinic or Division/Department by being a primary access/resource for the patients and referring providers by: Being available to respond to questions, answer phone calls from families/patients and referring physicians; and, Supporting the physicians through effective communication to create a seamless practice to improve access to our Clinics and services. Practices have found that AHPs are well received by patients and referring physicians because of increased accessibility to the practice. 38

39 UCLA Medical Sciences Office of Compliance and Privacy (310) Medicare Claims Processing Manual, Chapter 12, Sections and &sortByDID=1&sortOrder=ascending&itemID=CMS018912&intNumPerPage=10 Medicare Benefits Manual, Chapter 15, Sections and UCLA Compliance Office Professional Compliance Policies and Guidelines Medi-Cal Non-Physician Medical Practitioners, March Medicare Learning Network Advanced Practice Nurses/Physician Assistants 39

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41 Ronald Reagan UCLA Medical Center Medical Staff Bylaws defines an AHP as: a dependent practitioner who is qualified to provide specified patient care services in the Medical Center but is not eligible for Medical Staff Membership. Licensed Dependent Practitioners granted practice prerogatives under Supervising Physician includes: Physician Assistants Nurse Practitioners Nurse Midwives Nurse Anesthetists Licensed independent practitioners granted privileges with no direct supervision requirements: Acupuncturists, Clinical Psychologists Optometrists 41

42 Santa Monica UCLA Medical Center and Orthopedic Hospital s (Santa Monica) Medical Staff Bylaws defines an AHP as an individual who is neither a physician, dentist or podiatrist... and who is privileged to assist members of the Medical Staff in the care of patients within the limits and scope of a lawful practice. Categories of AHPs eligible for practice privileges at Santa Monica include: Physician Assistants Nurse Practitioners Non-Hospital Scrub Personnel Certified Registered Nurse Anesthetists Registered Nurse First Assistant Clinical Licensed Psychologists REMINDER: Just because the AHP has practice privileges DOES NOT mean that they can bill and be paid for services. 42

43 The Resnick Neuropsychiatric Hospital s Medical Staff Bylaws states that the AHP staff shall be individually assigned to an appropriate Clinical Division, and shall carry out their activities therein subject to Clinical Division, program and/or service policies and procedures and in conformity with all applicable provisions... 43

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45 A PA is a licensed and highly skilled health care professional, trained to provide patient evaluation, education, and health care services. A PA works with a physician to provide medical care and guidance needed by a patient. The Delegation of Services Agreement between the PA and the supervising physician defines what tasks and procedures a physician is delegating to the PA. These tasks and procedures must be consistent with the supervising physician's specialty or usual and customary practice and with the patient's health and condition. Title 16 of the California Code of Regulations, Section

46 A PA in conjunction with the supervising physician is responsible for establishing written guidelines for adequate supervision of the PA. This can be done by establishing protocols which meet the following requirements: A protocol governing diagnosis and management must include at a minimum, the presence or absence of symptoms, signs, and other data necessary to establish a diagnosis or assessment, any appropriate tests or studies to order, drugs to recommend to the patient, and education to be provided to the patient. A protocol governing procedures must specify the information to be provided to the patient, the nature of the consent to be obtained from the patient, the preparation and technique of the procedure, and the followup care. Protocols must be developed by the supervising physician, or adopted from, or referenced to, texts or other sources. All Protocols must be signed and dated by the supervising physician and the PA. California Business and Professions Code Section

47 The supervising physician may supervise by: Seeing the patient the same day the patient is treated by the PA; Reviewing, signing and dating the medical record of every patient treated by the PA within 30 days of the treatment; or Adopting written protocols which specifically guide the actions of the PA. The physician must select, review, sign and date at least 10% of the medical records of patients treated by the PA according to these protocols within 30 days. The supervising physician shall select for review those cases that pose the most significant risk to the patient. (based on the diagnosis, problem, treatment, or procedure). California Business and Professions Code Section

48 Unless limited by Hospital protocols or the Delegation of Services Agreement, the PA is authorized to perform the following: Take a patient s history or perform a physical examination and diagnose Initiate and revise treatment Order x-rays, other studies, diets, PT, OT, RT and nursing services Order, perform or assist in the performance of laboratory procedures, screening procedures and therapeutic procedures Instruct and counsel pertaining to a patient s physical and mental health Initiate arrangements for admissions, complete forms/records 48

49 Initiate and facilitate the referral of patients to appropriate health facilities, agencies and community resources Administer or provide medication in accordance with B&P Section Perform surgical procedures without the personal presence of the supervising physician which are customarily performed under local anesthesia. Supervising physician must review documentation which indicates that the physician assistant is trained to perform the surgical procedures. Act as a first or second assistant in surgery under the supervision of an approved supervising physician Title 16 of the California Code of Regulation, Section

50 The services of an appropriately licensed PA may be covered under Part B if: They are the type that is considered a physician service and within the PA s scope of practice in the state where services are provided; Performed under the general supervision of a physician who is primarily responsible for the overall direction and management of the PA s professional activities and for assuring that services provided are medically appropriate; and Not otherwise precluded from coverage because of a statutory exclusion. A PA may practice in any setting where a physician provides care. Only an employer can bill for the PA s services. 50

51 PAs are employed by a Medi-Cal provider, but are never independent Medi-Cal providers. Covered Services: Services performed within scope of practice if a covered benefit. To bill Medi-Cal for services of a PA: PA must be enrolled in Medi-Cal General supervision of a physician who must be available in person or through electronic means to provide: Supervision required by California law Necessary instruction in patient management Consultation Referral for appropriate specialist 51

52 To bill Medi-Cal for services of a PA (continued): Patient must be informed treatment provided by PA Interface document must meet requirements of California Business and Professions Code Section 3502, , 3516, and Welfare and Institution Code Section Written protocols must be issued in collaboration between physician and PA. Interface document must also include written standing orders. Supervising physician must review, countersign and date a sample of records, consisting of at minimum 5 percent of records within 30 days of treatment. (7 days for all Schedule II drugs. Supervising physician is limited to supervising 4 PAs. 52

53 Reimbursement for services of a PA can be made only to the employing physician or clinic/department Supervising physician number entered as the rendering physician on each applicable claims but in Remarks field (BOX 80) include PA name and provider number and type PA Modifier U7 53

54 Modifiers 99 = U are used to bill for a Physician Assistant (PA) who serves as first assistant in surgery under an approved supervising physician. The PA s services must be billed by the supervising physician and the appropriate surgical procedure code. 54

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56 Advanced Practice Nurses recognized under California law includes, Nurse Practitioners, Clinical Nurse Specialists and Certified Registered Nurse Anesthetists. Advanced Practice Nurses must be licensed and certified by the Board of Registered Nurses (BRN). The scope of practice for advanced practice nurses is not specifically defined under California Law. As such, APN must rely on the development of standardized procedures (SP) for authorization to perform overlapping medical functions. SP must specify the functions which the advanced practice nurse may perform and under what circumstances. 56

57 SP must include all of the following: Written, dated and signed by personnel authorized to approve; Functions to be provided and under what circumstances; Requirements which must be followed in performing the SP; Experience, training and education required to perform the SP; A method for initial and ongoing evaluation of the competencies to perform SP as well as written record of those authorized to perform; Scope of supervision required (i.e. immediate); Any circumstances which must be immediately communicated to the physician; Any limitations on setting where SP may be performed; Patient record keeping requirements; and Method for periodic review. California Code of Regulations, Title 16, Section

58 A NP is a registered nurse who possesses additional preparation and skills in physical diagnosis, psycho-social assessment, and management of health-illness needs in primary health care, who has been prepared in a program that conforms to Board of Registered Nurses (BRN) standards. There are three methods to qualify for certification as a NP with the BRN. See California Business and Professions Code Sections Physician countersignature of a NP s chart is not a requirement under California law. See BRN web site for additional information: 58

59 Medicare will pay for services of an appropriately licensed and credentialed NP if: They are the type that is considered a physician service and within the NP s scope of practice in the state where services are provided; Performed in collaboration with physician (Protocols); and Not otherwise precluded from coverage because of a statutory exclusion. (Example: Services not medically necessary routine foot care) NPs are authorized to bill Medicare directly for their services when furnished in any area or setting. However, no separate payment will be made when a facility or other provider charges or is paid any amount. 59

60 NP can be employed by a Medi-Cal provider, or if a Certified Pediatric NP (CPNP) or a Certified Family NP (CFNP) can be an independent Medi-Cal provider. Covered Services: Medi-Cal provides a list of services that are covered by Medi-Cal assuming within the NP s license and allowed in the Physician Practitioner Interface. ( To bill Medi-Cal for services of a NP: NP must be enrolled in Medi-Cal* General supervision of a physician who must be available in person or through electronic means to provide: Supervision required by California law Necessary instruction in patient management Consultation Referral for appropriate specialist * CFNP and CPNP would be enrolled as an independent practitioner. 60

61 To bill Medi-Cal for services of a NP (continued): Patient must be informed treatment provided by NP Interface document must meet requirements of California Code of Regulation, Title 16, Article 7, Chapter 14 (Section 1470 et seq.). Written protocols must be issued in collaboration between physician and NP. Interface document must also include written standing orders. No limit on number of NP supervising physician may supervise, except if NP ordering or furnishing drugs or devices, supervising physician is limited to 4 NPs. *Co- signature is not required 61

62 Unless independent providers (CFNP, CPNP), reimbursement for services can be made only to the employing physician, organized outpatient clinic or hospital outpatient department. Supervising physician number entered as the rendering physician on each applicable claims but in Remarks field (BOX 80) include NP s name and provider number and type Add Modifier SA (NP rendering services in collaboration with a physician). CPNP and CFNP providers billing with their own provider number must not use this modifier. 62

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64 The CNS is an advanced practice nurse providing expert clinical practice, research, education, consultation and clinical leadership with an identified patient population and certified by the BRN. There are three methods to qualify for certification as a clinical nurse specialist with the BRN. See California Business and Professions Code Sections See California BRN web cite for additional information on Clinical Nurse Specialists: 64

65 The services of an appropriately licensed and qualified CNS may be covered under Part B if: They are the type that is considered a physician service and within the CNS s scope of practice in the state where services are provided; The CNS is appropriately licensed and meets qualifications; They are furnished in collaboration with a physician as required by state law (Interface); and Not otherwise precluded from coverage because of a statutory exclusion. Payment made be made to the CNS or the employer. 65

66 The nurse anesthetist is a registered nurse who provides anesthesia services under the direction of a physician, dentist, or podiatrist, and is certified by the BRN in this specialty. See California Business and Profession Code Section See California BRN web cite for additional information on CRNA: 66

67 Medicare will pay for services of an appropriately licensed and credentialed CRNA. Anesthesia services of the CRNA may be furnished under the medical direction of a physician and in some instances without medical direction.* Payment may be made to the CRNA who furnished the anesthesia services, or to a hospital, an Ambulatory Surgical Center, or a physician with which the CRNA has an employment or contractual relationship. The supervising physician can be paid for the medical direction of up to four concurrent anesthesia procedures.* When billing, the following modifiers should be utilized by the CRNA. QS monitored anesthesiology care (can be billed by a CRNA or a physician) QX CRNA with medical direction by a physician QZ CRNA without medical direction by a physician * The Hospital or Department may have different standards. 67

68 A certified nurse-midwife is an individual educated and licensed in the disciplines of registered nursing and nurse-midwifery who possesses evidence of certification issued by the California Board of Registered Nursing. 68

69 Under the general supervision of a licensed physician and experience in the field, CNW are authorized to: Attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family care and immediate care of the newborn. Assist a woman in childbirth so long as progress meets criteria accepted as normal. Perform and repair episiotomies and laceration and order drugs and devices pursuant to protocols developed in accordance with law. All complications shall be referred to a physician immediately. The practice of nurse-midwifery does not include the assisting of childbirth by any artificial, forcible, or mechanical means, nor the performance of any version. Physician supervision does not require the physical presence of the supervising physician. California Business and Professions Code Sections , and

70 Medicare will pay for services of an appropriately licensed and credentialed CNW if: They are the type that would otherwise be covered if furnished by a physician, including obstetrical and gynecological services and within the CNW scope of practice in state where services are provided: and Not otherwise precluded from coverage because of a statutory exclusion. (Example: Services not medically necessary routine foot care). Services and supplies furnished incident to a nurse midwife s service are covered if they would have been covered when furnished incident to the services of a physician. Coverage of service to the newborn continues only to the point that the newborn is or would normally be treated medically as a separate individual. Items and services furnished the newborn from that point are not covered on the basis of the mother s eligibility. CNW are authorized to bill Medicare for their services when furnished in any area or setting. 70

71 Certified Nurse Midwife (CNM) can be employed by a Medi-Cal provider, or an independent Medi-Cal provider. Covered Services: Medi-Cal provides a list of services that are covered by Medi-Cal assuming authorized in the Physician Practitioner Interface. ( ) To bill Medi-Cal for services of a CNM: CNM must be enrolled in Medi-Cal General supervision of a physician who must be available in person or through electronic means to provide: Supervision required by California law Necessary instruction in patient management Consultation Referral for appropriate specialist 71

72 To bill Medi-Cal for services of a CNM (continued): Patient must be informed treatment provided by CNM Interface document must meet requirements of California Code of Regulation, Title 16, Article 7, Chapter 14 (Section 1470 et seq.). Written protocols must be issued in collaboration between physician and CNM. Interface document must also include written standing orders. No limit on number of CNM supervising physician may supervise, except if ordering or furnishing drugs or devices, supervising physician is limited to 4 NPs. *Co- signature is not required 72

73 Reimbursement will depend on status of CNW. Services can be billed by and reimbursed to supervising physician, organized outpatient clinic or hospital outpatient department. Or can be billed to the Medi-Cal program directly if independent provider. Supervising physician number entered as the rendering physician on each applicable claims but in Remarks field (BOX 80) include NP s name and provider number and type Physician hospital outpatient departments, or organized outpatient clinics that bill CMW services add SB modifier. CNM utilizing own provider number must not use this modifier. 73

74 Resources Medicare Benefit Provider Manual, Pub , Chapter 15, Section CMS Medicare Learning Network, Advanced Practice Nursing/Physician Assistants California BRN Practices Medi-Cal Provider Manual, Non-Physician Medical Practitioner, March