What s In Your Wallet? Houston Area Nurse Practitioners November 7, 2015 Elizabeth Ellis DNP, RN, FNP-BC, FAANP Pam Conrad, CMOM Elizabeth Knight, CPC, CCS-P, CMOM, CMIS
Disclosures Dr. Ellis has no affiliations to disclose Pam Conrad has no affiliations to disclose Elizabeth Knight has no affiliations to disclose
Objectives Define and discuss the key components of basic coding, documentation, compliance, terminology and compliance audits for the new NP graduate Discuss the components and definitions of Direct NP billing and Incident-To Billing per CMS Rules and Regulations
Objectives Cont. Discuss the basic components and how to for properly documenting a Level IV office visit. Discuss the basic components and how to for documenting Welcome to Medicare Visits Discuss the basic components of monthly productivity reports and how the NP provider can improve their performance
What Is In your Wallet? As a new and/or experienced NP there are several key areas that will increase your financial productivity Proper Coding-Know your Coding Team Proper Charting-Know your trainers Compliance-Know your representative Federal, State and Corporate Welcome to Medicare Visits/Annual visits Level IV Patient Visits
Billing Important to document NP productivity Independent and Incident To Billing Know your employers practice Be knowledgeable Implications components risk Outpatient vs Inpatient
Independent Billing Billed directly under NP National Provider Identification(NPI) Pt scheduled for the NP NP bills for: Level of Care Time Diagnosis Preventative Care Counseling http://www.napnapcareerguide.com/np-billing-coding-reimbursement
Independent Billing cont. Know regulations Work with coding team to be informed Documentation is key Obtain Coding/Compliance Review/Audits Know your resources Paid at 85% of MD reimbursement
Incident- To Billing Billed under the physicians NPI number but performed by nonphysicians To obtain full reimbursement Many regulatory components 1. MD must see Pt 2. Diagnose PT 3. Establish plan of care prior to NP visit 4. Be in suite 5. NPP must be employee 6. F/U with MD
Incident-to Billing cont. Hides/negates NP Productivity OIG has incident-to-billing top 5 audit tasks.on their radar! http://oig.hhs.gov may not meet standard of care Know state/federal law Many OIG Fines with NPs and PAs being primary target Ultimately reduces access to care
Hospital Based Employed vs non-employed Hospital Cost Report Must be removed for hospital to bill Shared Visits NPP must be employee of MD or same entity MD is an employee of Independent Billing
wrvu Work Relative Value Unit Development eliminates old usual, customary and reasonable payment system Budget Reconciliation act of 1989 devised new Medicare payment schedule Each service, procedure, act you perform for the patient is provided a relative value unit Each service contains three values Work, practice expense and malpractice expense
wrvu Cont. CMS supplies value units for each CPT/HCPCS(Healthcare common procedure coding system) code and represents the cost for providing the service. Three components make up an RVU Provider work Practice expense Malpractice overhead AAPC Advancing The Business of healthcare : https//www.aapc.com/practice-management/rvu-calculator.aspx
wrvu Cont. Medicare payments are comprised of these values multiplied by factors of conversion and geographical adjustment MGMA has also determined how many RVU s each NP (per specialty/field) should be producing to break even at 50%
wrvu Threshold rounded to nearest Primary Care- 3,067 wrvu Non primary Care Non Surgical- 2,054 wrvu Surgical (this is dependent on 25% or 50%; 25% is 700 wrvu) Additional considerations are: Credit for panel size Ramping period/pro-rated ACO Payments to Institution
Productivity Salaried- Non-Productivity Based Productivity- wrvu Based Salary + Bonus How is your bonus structured Is your bonus wrvu related? Know Qualifying factors Quality Performance Indicators
Productivity Based Plans Quality Performance Incentive Based Plans Minimum wrvu Threshold Then $ assigned to each RVU above creates bonus Maximum Threshold Payment dependent on QPI QPI may be tied to meaningful use measures or determined by entity or combination
Welcome to Medicare- IPPE-G0402 Initial Provider Performed Exam Once in a lifetime Performed in first 12 months of enrollment No hands on exam G0403 IPPE with EKG optional Once in a lifetime Performed in first 12 months of enrollment
IPPE cont Pt must bring screening form completed Risk Factor Assessment What screenings have occurred History/Family History What screenings/preventative svc. need to be performed Factors that may affect pt health Document Referrals for better health
IPPE cont A. Required components at min. 1. Medical and Social History 2. Functional Ability and level of Safety 3. Review of Risk Factors for Depression 4. Document: vitals, visual acuity, height, weight, BMI and other routine vitals 5. Provide end-of-life counseling 6. Provide education/counseling based on components of exam: written plan for preventative svcs.
IPPE Billing G0402 : 4.81wRVU $150 reimbursement?? G0403 IPPE + EKG: 0.54 wrvu G0438 Annual Wellness Visit (AWV): 4.98 wrvu G0439 Subsequent Annual Wellness:3.29 wrvu
IPPE Plus New Pt Visit If during an IPPE it is determined pt wants/needs exam/rx refilled may also charge a New Patient Visit
Level IV Patient Visit New Patient 99204 wrvu 2.43 Established Patient 99214 wrvu 1.5 NOTE: do not record unnecessary information just to solely achieve the higher level
Level IV New Patient 1. Comprehensive History 2. Comprehensive Exam 3. Medical Decision Making of Moderate Complexity or 45 min spent face-face with the patient or patient & family if coding based on time
Level IV New cont 1. Comprehensive History Chief Complaint HPI-4 descriptors ROS at least 10 systems PFSH-3 areas documented 2. Comprehensive Exam At least 8 organ systems
Level IV New cont. 3. Medical Decision Making of Moderate Complexity # of Problems: one new problem Amount/complexity: 3 points Data to be reviewed (see handout) Complexity: Pt must be Moderate Risk See Risk Complications Table Anytime you give a pt a RX they are Moderate!
Level IV Established Visit Must meet 2/3 Key Components 1. Detailed History 2. Detailed Exam 3. Medical Decision Making of Moderate Complexity 1.Detailed History Chief Complaint HPI: 4 descriptors ROS: at least 2 systems PFSH: Document 1 pertinent history area
Level IV Est. Visit cont 2. Detailed Exam: 12 Bullets 3. Medical Decision Making of Moderate Complexity: Number of problems: one new with/without a plan OR two established problems One worsening AND 1 stable OR three stable est. problems to examiner
Level IV Est. Visit cont 3. Medical Decision Making of Moderate Complexity Cont. Data: 3 points Complexity: Complexity is Moderate Put status of chronic problems
Resources https://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/MPS_QRI_IPPE 001a.pdf This is the link to the 2015 IPPE CMS Quick Reference Guide https://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/AWV_Chart_ICN 905706.pdf
Resources Cont. https://www.cms.gov/medicare/prevention/prevn tiongeninfo/downloads/mps- QuickReferenceChart-1TextOnly.pdf This is the link to the 2015 CMS Preventive Service Quick Reference Guide https://www.cms.gov/medicare/prevention/prevn tiongeninfo/health-observance-mesages-new- Items/2015-01-08-AWV-IPPE.html This is a link to CMS 2015 Preventive Service On-Line information, other links can be located and launched from this site
Resources Cont. https://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM7079.p df Link to a MedLearns Matters Article Buppert, C. (2014). 8 Things About Billing NP Hospital Services. Journal for Nurse Practitioners, 10.(3)207-208..
Resources Cont. Hull-Grommesh,L., Ellis, E.,Mackey.,(2010). Implications for Nurse Practitioner Billing: A Comparison of Hospital Versus Office Practice. Journal of The American Academy of Nurse Practitioners 22(2010) 288-291.
Questions Happy Nurse Practitioner Week November 8 14, 2015