9/11/15. Reimbursement for Non- Physician Providers Real Life Practice Objectives

Transcription

1 Reimbursement for Non- Physician Providers Real Life Practice 2015 John F. Bishop, PA, CPC, CPMA, CGSC, CPRC AAPA National Chair Reimbursement and ICD-10 Work Groups Principle, John Bishop and Associates, LLC Private Consultant Tampa, Florida Objectives * Get managed care and private carrier companies to recognize and pay for NPPs services * Bill properly for a shared visit * Supervision requirements * Identify what physician supervision rules apply to NPPs performing diagnostic tests * List the modifiers to use for NPPs * Discover whether NPPs can perform consults * Incident to one more time! * Skilled Nursing Facility billing for NPP s 1

2 Coding- Caveats If you didn t write it down- you didn t do it If you did write it down but incorrectly- you didn t do it If you can t produce a dictated copy of whatever you said you did (OR, ER,ASC)- you didn t do it If you didn t do it, don t bill it. That s called FRAUD!! If you can t justify the medical necessity of what you dictated or wrote down- you didn t do it If you code it incorrectly- you still didn t do it If you did code it correctly- just maybe you ll get paid! If you did get paid, doesn t mean you get to keep it!! If you did get paid, be prepared to give it back!! Incident- To Services 2

3 Non- Physician Providers? * Allowed by state and federal laws to provide physician services and procedures and direct bill (Medicare/ Medicaid/Tricare) * Physician Assistants- PA s * Nurse Practitioners- NP s * Clinical Nurse Specialists- CNS s * CRNA s Non- Physician Providers? * The other group * RNFA s * Physical Therapists- PT * Occupational Therapists- OT * Speech/Audiology Therapists * Surgical Techs- CST * Psychologists * LCSW Billing for Non- physician Professionals * Medicare usually defers to state laws Scope of Practice * Hospitals CANNOT bill for those considered auxilliary personnel services (on payroll) * Require UPIN/PIN * File CMS form # 855- Medicare Part B * Services must be considered Physician Services * Hospital based NPP s charges may be billed IF NOT INCLUDED ON THE COST REPORT 3

4 Non- Physician Providers? * Must have national certification/license * Must have state license/registration * Must have hospital (s) privileges * If employed by hospital, must still have a supervising physician of record (most states) * PA s tied to physicians by law * NP s may be independent in some states * Reimbursement is totally dependent upon carrier discretion and interpretation!! * Must be considered Revenue generators**** Medicare Incident To Rule- 100% Reimbursed * NPP s can get reimbursed for seeing patients in the office * Physician must be in Office suite * MD must maintain direct supervision * MD does not have to see patient * NPP can see established, (not new patient or new problem) for incident to * Bill in MD s PIN number- 100% reimbursed * If No MD NPP bills 85% with NPP PIN * NPP can see new patient or new problem- just bill under NPP NPI number Incident To * Only Medicare Part B * Not commercial carriers or Medicaid * Bill at 100% of physician fee schedule in physician s provider number * Must be established patient * Service must be within Physician s plan of care- (not a new problem) * Physician must be in office suite * ARNP/PA must be employee/leased back to practice 4

5 Billing for Non- physician Professionals * Medicare usually defers to state laws Scope of Practice * Hospitals CANNOT bill for those considered auxilliary personnel services (on payroll) * Require UPIN/PIN/NPI * File CMS form # 855- Medicare Part B * Services must be considered Physician Services * Hospital based NPP s charges may be billed IF NOT INCLUDED ON THE COST REPORT Physician Supervision Requirements * CMS defines 3 levels * General (level 1) procedure is furnished under physician s overall direction and control (ie, is available by telephone or beeper)- does NOT need to be present * Direct** (level 2) physician must be physically present in office suite (laboratory suite) and immediately available to furnish assistance and direction throughout the performance of the procedure * Personal supervision** (level 3) - physician must be in attendance in the room during procedure ** Apply equally to all places of service (office/clinic and hospital facility) Physician Supervision Requirements * Level 1 - Most diagnostic pulmonary function tests require general supervision * Level 2 Direct supervision involves * administering an inhaled medication * 94060, 94070, * Breathing unusual gas mixture- carbon dioxide * * Low percentage oxygen , 94452, * And exercise 94621, 94680, * Pulmonary stress testing only requires level 1 supervision 5

6 Setting Supervision Requirements For Reimbursement Rates and Services for PA s and NP s * Office/Clinic when physician is not on site- 85% of physician s fee schedule * All services PA is legally authorized to provide that would have been covered if provided personally by a physician in Office/Clinic when physician is on site * Physician must be in the suite of offices for 100% of physician s fee schedule * Home visit/ House Call- 85% of physician s fee schedule * Skilled Nursing Facility & Nursing Facility * 85% of physician s fee schedule * Hospital- 85% of physician s fee schedule * First assisting at surgery in all settings- 85% of physician s first assist fee schedule * Federally Certified Rural Health Clinics- Cost- based reimbursement. * HMO- Reimbursement is on capitation basis. All services contracted for as part of an HMO contract Using carrier guidelines for "incident to" services. Incident To NPP s Provider # Direct Supervision Doctor must see all new Medicare patients and established patients with exacerbations or new conditions 100% of physician fee schedule Must indicate point of doctor s involvement Doctor should sign all notes General Supervision Doctor doesn t have to see new patients or exacerbated or new conditions 85% of physician fee schedule Not required Not required Obvious Advantages * Indirectly- MD time is freed up for other uses- office, surgery, hospital rounds, golf course, home, family/ children, exercise, reading * MD efficiency, accuracy and skills * MD bill all carriers for NPP services * MD can set a base salary plus give performance bonus based on either productivity, percentage of their monthly A/R or overall practice A/R * Prescription writing (DEA) * Work for your practice (not Hospital) * NPPs are Revenue Generators 6

7 OIG FRAUD and ABUSE * 7

8 New: OIG WORK PLAN FOR 2013 * Physician- owned distributors of spinal implants * Physicians: Place of service errors in ASC and outpatient locations * Evaluation and Management Services: Trends in Coding of Claims * We will review E&M claims to identify trends in coding of E&M services from * E&M services during Global Surgery periods * E&M services: Use of modifiers during global surgical periods***** New: OIG Work Plan 2013 * E&M services: * We will review multiple E&M services for the same providers and beneficiaries to identify EHR documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across all services, Medicare requires providers to select the code for the service based upon the content of the services and have documentation to support the level of service reported New: Incident- To services * Incident to Services- medical necessity, documentation, quality of care. Determine whether payment for such services had a higher error rate than that for non- incident to services. We will also assess CMS s ability to monitor services billed as incident to. Medicare Part B pays for certain services billed by physicians that are performed by nonphysicians incident- to a physician office visit. They found that over half of services in 24 hours were being performed by nonphysicians. Also found unqualified nonphysicians performed 21% of the services that physician did not perform personally. Incident- to services represent a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record. 8

9 OIG WORK PLAN FOR 2013 * Excessive dosages monitoring high volume, high cost drugs for acceptable therapeutic levels for patient condition * Wound Care Services * Incident to Services- medical necessity, documentation, quality of care * Physical Therapy and OT providers * Place of Service Errors- services provided in ASC and outpatient locations * E/M during global surgery periods * Consults * Home Calls OIG WORK PLAN FOR 2013 * Services by Social Workers * Medicare payments for Interventional Pain Management procedures * Geographic areas with high utilization of Ultrasound services * Geographic areas with high density of Independent Diagnostic Testing Facilities * Psychiatric Services inpatient setting * Polysomnography reimbursement * Medical necessity * Violation of assignment rules- improper balance billing * Business relationships with Advance Imaging Service in Physician office New: OIG WORK PLAN FOR * Medicare payments for Interventional Pain Management procedures * Geographic areas with high utilization of Ultrasound services and other Imaging services * Geographic areas with high density of Independent Diagnostic Testing Facilities * Business relationships with Advance Imaging Service in Physician office * Polysomnography reimbursement * Medical necessity * Appropriateness of the study; payments have increased from $ million in 8 years * Wound Care 9

10 Below are the top ten errors RAC has identified: 10. Debridement Coding - Errors in coding surgical debridement versus active wound care management. 9. Duplicate Billing - Filing claims more than once for the same service. 8. Stark Violations - Physicians referring patient to services in which they have a financial interest or in which a family member has a financial interest. 7. Pharmaceutical Coding in Physician Offices - Incorrect use of codes or units in billing of injections. 6. Social Work Services in Facilities - Some clinical social worker services provided to inpatients in hospitals or skilled nursing facilities cannot be billed under Part B. Below are the top ten errors RAC has identified: * 5. Psychiatric Services - Over utilization of psychiatric services provided in outpatient setting. 4. Medical Necessity - Documentation not supporting the level of service provided in the outpatient setting. 3. E/M Billed During Global Periods - Use of modifier - 24 in billing services that should have been included in the global package. 2. Place of Service Errors - Physicians performing services in ASCs or outpatient facilities but when billing applying a place of service code indicating the service was performed in the physician office. 1. Incident- to Errors - Physician assistants and nurse practitioners performing services for a physician but not following billing- specific guidelines related to the physician's relationship to the patient and the physician's presence in the office. Salaries by Specialty PAs * Cardiology $109,030 * Dermatology $107,727 * ED $103,489 * Surgery $102,760 * Hospital based $97,680 * House Calls $94,383 * Family Practice $90,528 * Pediatrics $86,894 * Oncology $85,851 * Academia $95,215 NPs * Oncology $98,327 - $90,574 * ED - $104,549 * Hospital - $93,943 * Surg. Specialties - $91,511 * Women s Health- $76,483 * Gerontology- $93,668 * Cardiology- $100,881 * Int. Med- $88,287 * Family Practice- $86,518 * Academia- $80,400 10

11 Billing for Time * If more than 50% of visit is spent in counseling the patient * Document total visit and counseling time * Document what was discussed * Can use time as overriding factor on those categories where time is a factor * Must make sense for the diagnosis/reason for visit Visit Codes Do Not Use Alone Add-on Code** * Prolonged Services * Office * * 30 minutes to 1 hour additional time (above the time designated for the base visit code) * * each additional 30 minutes additional time (above the time designated for the base visit code and after the first hour of additional time (99354) Visit Codes Do Not Use Alone Add-on Code** * Prolonged Services * Hospital * * 30 minutes to 1 hour additional time (above the time designated for the base visit code) * * each additional 30 minutes additional time (above the time designated for the base visit code and after the first hour of additional time (99356) 11

12 Scribing NPPs are highly educated licensed health care providers Federal and State agencies do not find it credible that an NPP would refrain from providing health care services or making their own observations to solely report the work of a physician NPPs can (and should) be better utilized!! They are revenue generators!!! Medical Necessity Issues Medicare only allows coverage for services and items which are medically reasonable and necessary for treatment/diagnosis of a patient. * Medical necessity may be determined according to several factors including the following: * Items or services provided to the patient must be appropriate for that patient s treatment/diagnosis * Documentation (When identified as required or when requested) supports the medical need. * The frequency of service or dispensing of an item is within the accepted standards of medical practice. ICD- 9 CM/ICD- 10 Working diagnosis must match the ICD- 9/ICD- 10 description Close doesn t count Do not up- code Fraud Do not down- code Fraud Do not not code-???? Don t code from the index Always verify and check the book! Then run it through your CCI and NCCI edits 60-70% of first denials come from wrong/not specific/ ICD- 9 12

13 First Surgical Assisting First Surgical Assisting Physician bills 25% of CPT Medicare- PA s can charge. 85% x 16% = 13.6% of surgeon s fee Medicaid- same 3rd party- either 100% 75% Reimbursement depends on IF a surgeon assistant is required/allowed and NO Resident is available Check each carrier reimbursement schedule for all reimbursable cases Surgical Assisting If physician- modifier- 80 Minimal assistance- modifier- 81 In teaching institution- modifier- 82 (Resident not available) Medicare- PA/NP- modifier AS Blue Cross/Blue Shield doesn t recognize Non-physician PIN codes- state specific 13

14 Surgical Assisting * If physician- modifier- 80 * Minimal assistance- modifier- 81 * In teaching institution- modifier- 82 (Resident not available) * Medicare- PA/NP- modifier AS * Blue Cross/Blue Shield doesn t recognize Non-physician PIN codes- state specific Carrier Reimburse Bill under MD 1 st Assist Modifier Aetna 100% Yes 12% Assurant Health 100% Yes 20% BC/BS 100% Yes 13.6% AS Cigna 100% Yes 13.6% AS GHI 100% Yes 13% AS Humana 100% Yes 10-20% AS School Insurance of FL United Healthcare 100% Yes Pasco Co-13.6% 100% Yes 14% AS AS or 80 Shared/Split Billing- Hospital Inpatient only The PA and the physician must work for the same employer. The regulation applies only to E/M services delivered in the hospital and not to procedures. The physician must provide some face- to- face portion of the E/M services on same day. Simply reviewing or signing the patient s chart is not sufficient. Incident to billing has never applied to the hospital setting and still does not apply Bill 100% under physician PIN 14

15 Overlooked CPT Codes- NPP s Medical Nutrition Therapy Medical Genetics/Counseling Services Education/training for Self management established pts using standardized guidelines (CHF, Coumadin, Genetics, Immune, Transplant Svc) Home Services (E&M) Home Health procedures (Postnatal, Resp. Tx, Hemodialysis Preventive Medicine- Counseling, Risk factor reduction , with modifier GT to signify Teleconsultation via interactive video/audio Non face- to- face Telephone E&M Online ( ) E&M assessment and management Smoking Cessation * Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes * intensive, greater than 10 minutes * INCLUDES: Administration and analysis of a health risk assessment (99420) Face- to- face services for new and established patients based on time increments of 15 to 60 minutes Issues such as a healthy diet, exercise, alcohol and drug abuse Services provided by a physician or other qualified healthcare professional for the purpose of promoting health and reducing illness and injury Smoking Cessation * EXCLUDES: Counseling and risk factor reduction interventions included in preventive medicine services ( ) Counseling services provided to patient groups with existing symptoms or illness (99078) Code also distinct evaluation and management services when performed in addition Do not report with heath and behavioral services provided on the same day ( ) 15

16 Obesity Counseling * CPT code G0447, a 15- minute face- to- face behavioral counseling for obesity, has been assigned total non- facility RVUs of The 2011 conversion factor is $ Screening and counseling coverage is effective as of the decision date, so when contractors are ready to process the claims, physicians will be able to submit claims for service back to the date of coverage, according to the spokeswoman. Patients with Medicare will not be charged for the screening or counseling, according to CMS. Screening for obesity and counseling for eligible beneficiaries by primary care providers are covered under this new benefit. For a beneficiary who screens positive for obesity with a body mass index greater than 30, the benefit includes one face- to- face counseling visit each week for 1 month and one face- to- face counseling visit every other week for an additional 5 months, according to CMS. The beneficiary may receive one face- to- face counseling visit every month for an additional 6 months (for a total of 12 months of counseling) if he or she has achieved a weight reduction of at least 6.6 pounds during the first 6 months of counseling. Summary * Why is the patient being seen? * Does the level of visit make sense? * Does the documentation support the level indicated? * Could it support a different (higher or lower) level of E&M? * Too much, too little or just right? * Has Medical Necessity been met? * Is this visit justifiable? * Is this visit defensible from an outside audit or worse, an ALJ hearing? Conclusion * Teach your doctors, PA s and other providers to understand what medical necessity is from the payer s perspective, NOT the provider s * Teach them what is required for documentation per payer * Teach them to dictate/write the proper justification- OP note, procedure note, lab/radiology orders, etc. * Finally, don t bill it, if it s not documented and justifiable. 16

17 Conclusion NPP s very cost effective NPP s accepted just about every clinical environment NPP s billing and reimbursement has improved significantly NPP s will be around for quite a while! Reimbursement is totally dependent upon carrier discretion and interpretation!! Must be considered Revenue generators**** Learn how to get them reimbursed!! Resources * Medicare Part B (Medical Insurance) covers: * Abdominal aortic aneurysm screening * Alcohol misuse screenings & counseling * Bone mass measurements (bone density) * Cardiovascular disease screenings * Cardiovascular disease (behavioral therapy) * Cervical & vaginal cancer screening * Colorectal cancer screenings * Depression screenings * Diabetes screenings * Diabetes self- management training * Nutrition therapy services * Obesity screenings & counseling Resources * * practice-management/reimbursement/68- articles/326- medicare-update * * practice-management/reimbursement/68- articles/325- medicare-reimbursement * * and-screening- services.html 17

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