School of Medicine Compliance Heather Scott May 16, 2007 Billing Non-physician Provider Services

Things to Consider…  Employment  License  Payer  Involvement of physician

General Principles  NC law requires payers to reimburse certain non-physician services How it is paid is based on payer How it is paid is based on payer  Scope of practice  No physician co-signature required  No supervision of residents for Medicare and Medicaid

Employment criteria  Salary support from physician practice. Percentage of salary = billable time Percentage of salary = billable time Direct or “incident to” billing Direct or “incident to” billing Exceptions for some specially designated funding Exceptions for some specially designated funding  Not included on Hospitals cost reports

Medicare in the Inpatient Setting  Licensed non-physicians that may bill Medicare directly Nurse Practitioner Nurse Practitioner Physician Assistant Physician Assistant Clinical Nurse Specialist Clinical Nurse Specialist Clinical Psychologist Clinical Psychologist  Reimbursed at 85% of the physician allowable  Services of non-physicians ineligible to bill directly are not reimbursable via Part B

Medicare Shared Visit Option  NPP and MD make individual evaluations on the same day Each documents his service Each documents his service May bill in MD’s name combining notes for level for established patients and problemsMay bill in MD’s name combining notes for level for established patients and problems May not bill consultsMay not bill consults “Shared” initial evaluations billed in NPP’s name“Shared” initial evaluations billed in NPP’s name Rules are currently being reconsidered by MedicareRules are currently being reconsidered by Medicare Physician must document detail beyond a resident attestation Physician must document detail beyond a resident attestation  NPP collaboration with an MD makes service billable as subsequent daily care, even without an MD note

“Incident to” Billing Principles  Option for billing non-physician provider services to Medicare outpatients and Medicaid patients  The billing provider (usually a physician) is the only named provider on the bill  The third party payer does not know who rendered the service  The billing provider and supervising physician retain liability for all “incident to” services

“Incident to” - Medicare  “Incident to” services may not be billed in an inpatient setting or hospital-based clinic  The billing provider must perform and document the initial visit Thereafter, if the NPP is eligible to bill Medicare directly, the billing provider must Thereafter, if the NPP is eligible to bill Medicare directly, the billing provider must become involved when changes occur andbecome involved when changes occur and perform subsequent services at a frequency which reflects his continuing involvement in the management of the patientperform subsequent services at a frequency which reflects his continuing involvement in the management of the patient For NPPs not eligible to bill directly, For NPPs not eligible to bill directly, E&Ms may not exceed nurse visit levelE&Ms may not exceed nurse visit level Billing provider must perform/document every third serviceBilling provider must perform/document every third service

 No site limitations for “incident to” services  No difference in reimbursement (excepting mental health professions)  For NPs, PAs and CNMs No requirement for an initial evaluation No requirement for an initial evaluation Direct supervision by billing provider Direct supervision by billing provider available by telephone or pageravailable by telephone or pager have a preexisting plan for emergencieshave a preexisting plan for emergencies  For other non-physician providers, the billing provider must Perform and document the initial visit Perform and document the initial visit Be involved when changes occur Be involved when changes occur perform subsequent services at a frequency which reflects the billing provider’s continuing involvement in the treatment and management of the patient perform subsequent services at a frequency which reflects the billing provider’s continuing involvement in the treatment and management of the patient “Incident to” - Medicaid

No “incident to” for commercial  The concept of “incident to” billing does not exist for commercial, managed care and other third party payers  Billing providers may work with NPPs as appropriate to the situation  Must meet the standard of care  Patient satisfaction is always important  Signature always required for PAs

Direct Billing - Medicare  Clinical psychologists, clinical nurse specialists, nurse practitioners and physician assistants may obtain a billing number and bill Medicare directly  May bill for anything within the state- determined scope of practice at any site  Generally pays 85% of physician reimbursement  No physician signature requirements for Medicare; however the state requires a physician signature for all PA services

Direct Billing - Medicaid  Clinical psychologists, clinical nurse specialists, nurse practitioners, and nurse midwives, and certain other NPPs may obtain a billing number and bill Medicaid directly  May bill for anything within their state- determined scope of practice at any site  Pays 100% of physician reimbursement

Direct Billing - Medicaid  Clinical psychologists and other non- psychiatrists cannot treat and bill Medicaid for mental health services to patients over 20  PAs cannot obtain a Medicaid billing number and cannot bill directly  No physician signature requirements for direct billing by NPPs

Direct Billing - Commercial  Most commercial carriers and managed care organizations do not accept direct billings by NPPs

Where To Get Help  School of Medicine Compliance Office Heather Scott, CPC, Compliance Auditor Wendy Smith, CPC, Compliance Auditor Charles Foskey, Compliance Officer Chris Agosto, Office Manager  Confidential Help Line

In closing…  Congratulations on recognition and increased independence  NPPs have increased responsibility for knowing state rules governing their respective practices  NPPs have increased responsibility for knowing insurance-specific billing rules  Leadership and communication are critical

Proper Teaching Physician Attestation  Document seeing and/or examining patient  Refer to resident’s note  Make a summary comment about the history  Comment on the physical exam  Comment on medical decision making  Only 2 of 3 areas need noting for established patients

Teaching Physician Attestation Unacceptable, non-specific note: “The above patient was seen concurrently with Dr. Smith (resident). I obtained a history from the patient, performed a physical exam and participated in the medical decision making.”

Teaching Physician Attestation Acceptable, specific-to-patient note: “Patient seen and discussed with Dr. Resident, whose note is available for further detail. Mr. Patient complains of intermittent chest pain. Personal findings on exam: Heart-regular, rate of 68. Chest-clear. BP remains elevated at 180/100. Will increase Inderal and proceed with remainder of treatment plan as noted above.” “Patient seen and discussed with Dr. Resident, whose note is available for further detail. Mr. Patient complains of intermittent chest pain. Personal findings on exam: Heart-regular, rate of 68. Chest-clear. BP remains elevated at 180/100. Will increase Inderal and proceed with remainder of treatment plan as noted above.”