August 10, 2010 CIDP Leadership Meeting UCSF Medical Group and Medical Center Nurse Practitioner as Billing Provider POLICY Business and Finance Nurse Practitioners as Billing Providers Issued: April 2009

1 UCSF Medical Group General Information UCSF Medical Center Policy Nurse Practitioner (NP) Services: Guidelines for Professional Billing anual/IndividualPolicies/NursePractitionersasBil lingProviders.pdf anual/IndividualPolicies/NursePractitionersasBil lingProviders.pdf Reviewed Every Two Years Proposed for next revision: Inclusion of Physician Assistants under policy

2 UCSF Medical Group Definitions Types of Clinics Hospital-Based Clinics Operate under license of the hospital Includes all Academic Departments Two Billing Components —Professional Fee —Technical (Use of Facility) NPs employed by the Medical Center must be removed from the Medicare Cost Report once they start to bill. This has implications in terms of AB915 revenue. Free-Standing Clinics Do not operate under license of the hospital Currently none operating at UCSF One Global Fee

3 UCSF Medical Group Definitions Supervising Physician Fully Licensed Physician MD or DO Not participating in an ACGME, GME or ABMS Program Types of Supervision Direct Supervision The physician must be present in the room when the service is provided Indirect Supervision The physician must be present in the office or clinic suite and immediately available General Supervision Services are under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure or service. The physician can be available in-person or through electronic means to authorize the service One of these supervision requirements apply whether billing under the name of the NP or supervising physician

4 UCSF Medical Group Minimum Qualifications Providing NP Services Registered Professional Nurse Masters Degree Currently Licensed in the State of California Nurse Practitioner (NP) Family Nurse Practitioner (FNP) Pediatric Nurse Practitioner (PNP) Must have active UCSF Medical Center Medical Staff Privileges which includes national certification (for NPs hired after 1992). Supervising NP Services All services billed under a NP provider number require a minimum of “General Supervision” regardless of payer source Services not billed under a NP provider number require “Indirect Supervision” as part of a shared visit methodology. One supervising physician is not permitted to supervise more than the full-time equivalent of four NPs at any one time

5 UCSF Medical Group Scope of Practice General Governed by rules of RN’s and UCSF credentialing requirements California Nursing Practice Act Allows NP to provide certain medical functions in addition to nursing In some cases, medical functions must adhere to Standardized Procedures that are developed by the employer (UCSF), in accordance with the California Nursing Practice Act Medical Functions Requiring Standardized Procedures/Protocols —Any function that is not commonly recognized as a nursing practice and that requires the NP to —Diagnose Disease —Furnish Medicine —Furnish Treatment —Penetrate or Sever Tissue

6 UCSF Medical Group Scope of Practice California Nursing Practice Act, cont’ Medical Functions Requiring Standardized Procedures, cont’ —NP is allowed to furnish Schedule II-V Drugs with a Standardized Procedure —Drugs must be consistent with the NP educational preparation —Clinical competency has been established and maintained —Schedule II or III controlled substances furnished or ordered shall be in accordance with a patient-specific protocol approved by the treating or supervising physician In addition to standardized procedures, other written protocols and standing orders may be developed by the supervising physician(s), subject to approval by the UCSF Committee on Inter-disciplinary Practice (CIDP).

7 UCSF Medical Group Terms Billing Terms “Incident-to” Medicare term ~ Allows services provided by a NP to be billed under the supervising physician’s provider number. Setting must be Freestanding/Stand Alone Setting —None of which currently exist at UCSF Split/Shared Visit Another Medicare term ~ Applies to Evaluation & Management (E/M) Services only Rule allows documentation from the physician and NP note to be combined Setting must be Hospital-Based —Hospital Inpatient or Outpatient, Emergency Room & Hospital-Based Clinics —Requires —Two separate notes —NP AND supervising physician face-to-face time —Consultations, Critical Care and Surgical Procedures are Exempt and Cannot use this Rule

8 UCSF Medical Group Documentation Guidelines All Payers EMR and/or Chart All services ordered and provided by the NP are to be personally documented, signed and dated. For billing purposes, it is strongly recommended that NPs identify their supervising physician in their note. —When the NPs supervising physician is away or on vacation the supervising physician noted would be the physician called that day for assistance or direction. If NP is on the UCSF Cost Report, the NP cannot submit a professional fee and must use the split/shared visit methodology.

9 UCSF Medical Group Payor Specific Billing Guidelines Medi-Cal – All Locations FNP and PNP Allowed to bill under their own name for any services provided within their scope of practice NP Must bill under their supervising physician name There are specific HCPCS, CPT-4 and Medi-Cal only codes (NP only) For a list of these codes go to — cal.ca.gov/pubsdoco/DocFrame.asp?wURL=publications%2Fm asters-mtp%2Fpart2%2Fnonph_m00o03o11.doc Difference between billable and payable

10 UCSF Medical Group Payor Specific Billing Guidelines Workers Compensation – All Locations NP may provide services to workers’ compensation patients NP may not: Initiate new treatment Report on an injured workers’ entitlement to benefits Change the Primary Treating Physician (PTP) treatment plan

11 UCSF Medical Group Modifiers Medi-Cal/GMC When billing under the name of the FNP or PNP no special modifiers are required When billing NP services including FNP and PNP, under the name of the supervising physician the modifier -SA is required When there are multiple modifiers selected, the Billing System automatically assigns the modifier –99 to indicate there are multiple modifiers Workers Compensation When billing NP services for workers compensation, the modifier –98 is required

12 UCSF Medical Group Considerations Additional requirements/considerations under this policy include: A face to face meeting between the Nurse Practitioner and the Supervising Physician occurring the year between credentialing cycles. The purpose of this meeting is to ensure that the Nurse Practitioner is continuing to practice within the scope of the protocol on file. Nurse Practitioners, whether billing independently or otherwise, cannot supervise Residents. Residents will continue to require a physician in attendance to supervise their activities. Currently many departments receive State of California AB-915 reimbursement to for the facility costs related to clinic operations. Nurse Practitioners who bill independently can no longer qualify to be included in these facility costs. It is up to the department manager’s discretion whether a Nurse Practitioner can bill independently as there may be workflow issues within the clinic.

13 UCSF Medical Group Process For Enrollment As an Independent Biller A web page is under construction at the following address: Contained at this site will be: Application Form Educational presentation Link to current UCSF policy Link to current Medi-Cal coding guidelines List of active NPs credentialed to bill independently