1. Reimbursement for Physician Assistants and Nurse Practitioners Society of Hospital Medicine March 27, 2008 Michael L. Powe, Director Health Systems & Reimbursement Policy Health Systems & Reimbursement Policy American Academy of Physician Assistants

2. Goals Any discussion of reimbursement, billing and coding is secondary to: Maintaining/improving the quality of patient care Maintaining/improving the quality of patient care Attaining practice efficiencies within the hospitalist medicine program Attaining practice efficiencies within the hospitalist medicine program

3. Understanding PA and NP Reimbursement Issues Improve physician “quality of life” Improve physician “quality of life” Maximize legitimate reimbursement and increase billable opportunities Maximize legitimate reimbursement and increase billable opportunities Avoid allegations of fraud and abuse Avoid allegations of fraud and abuse

4. Defining Terms Host of non-physician professionals who are an important part of the health care team Host of non-physician professionals who are an important part of the health care team The terms NPP or mid-level practitioners generally refer to those non-MD/DO professionals who perform physician work The terms NPP or mid-level practitioners generally refer to those non-MD/DO professionals who perform physician work Physician assistants (PAs) and advanced practice nurses (NPs), clinical nurse specialists (CNSs) Physician assistants (PAs) and advanced practice nurses (NPs), clinical nurse specialists (CNSs)

5. Granting Clinical Privileges Criteria for practice should be outlined in the medical staff bylaws Criteria for practice should be outlined in the medical staff bylaws Bylaws should include a definition of PAs and NPs that corresponds with state law Bylaws should include a definition of PAs and NPs that corresponds with state law

6. Credentialing Joint Commission’s medical staff standards require that hospitals credential and privilege PAs/NPs through the medical staff or by another “equivalent process” Joint Commission’s medical staff standards require that hospitals credential and privilege PAs/NPs through the medical staff or by another “equivalent process” Bylaws should specify a time period for the renewal and revision of privileges, and reappointment to the medical staff Bylaws should specify a time period for the renewal and revision of privileges, and reappointment to the medical staff

7. Scope of Practice Defined by state law and not typically a laundry list of duties Defined by state law and not typically a laundry list of duties Most state laws are broad and allow the supervising/collaborating physician to delegate those responsibilities for which the PA/NP is trained and capable of performing Most state laws are broad and allow the supervising/collaborating physician to delegate those responsibilities for which the PA/NP is trained and capable of performing

8. State Law Scope of Practice Example State Law Scope of Practice Example Basic Job Description Basic Job Description - Screening & evaluating patients - H&Ps - Ordering tests & procedures - Performing diagnostic & therapeutic procedures - Prescribing - Patient care & management

9. State Law Scope of Practice Example State Law Scope of Practice Example May need more formal approval for more technical procedures: May need more formal approval for more technical procedures: - Central lines - Lumbar drains - Lumbar punctures - Ventricular shunt taps - Bone marrow biopsies

10. Medicare Policies  State law and the delegation authority of the supervising/collaborating physician determine PA/NP scope of practice (PAs – medical board; NPs – nursing board)  Hospital requirements/credentialing requirements/bylaws must be met

11. Medicare’s Definition of a PA Graduate of a PA educational program accredited by the ARC-PA; or Graduate of a PA educational program accredited by the ARC-PA; or Has passed the national certification examination offered by the NCCPA; and Has passed the national certification examination offered by the NCCPA; and Is licensed (authorized) by the state to practice as a physician assistant Is licensed (authorized) by the state to practice as a physician assistant

12. Medicare’s Definition of a NP Certified to practice as a NP by the ANCC or AANP, or other recognized national certifying bodies that have established standards for NPs Certified to practice as a NP by the ANCC or AANP, or other recognized national certifying bodies that have established standards for NPs Be a registered professional nurse who is authorized by the state to practice as a nurse practitioner Be a registered professional nurse who is authorized by the state to practice as a nurse practitioner

13. Medicare’s Definition of a NPs Master’s degree required for NPs enrolling into the Medicare program Master’s degree required for NPs enrolling into the Medicare program NPs without a Master’s degree who applied for a Medicare number before 1/1/2003 are grandfathered into the program and are able to bill Medicare NPs without a Master’s degree who applied for a Medicare number before 1/1/2003 are grandfathered into the program and are able to bill Medicare

14. Medicare Payment For virtually all billable service in the hospital Medicare will cover PAs/NPs at 85% of the physician fee schedule, if the service would have been covered if performed by a physician For virtually all billable service in the hospital Medicare will cover PAs/NPs at 85% of the physician fee schedule, if the service would have been covered if performed by a physician [Medicare Transmittal AB-98-15] [Medicare Transmittal AB-98-15]

15. Medicare Payment Policy  Services are billed at the full physician rate. Use of the PA’s/NP’s Medicare provider number or National Provider Identifier (NPI) number triggers the 85% payment  Services are covered whether the PA/NP is an employee of the hospital or employed by a physician

16. Practice Settings Hospitals (inpatient, outpatient, ED, OR) Hospitals (inpatient, outpatient, ED, OR) Ambulatory Surgical Center Ambulatory Surgical Center Hospital-based office or clinic Hospital-based office or clinic Outpatient office or clinic Outpatient office or clinic Medicare Transmittal 1744; March 12, 2002 Medicare Transmittal 1744; March 12, 2002

17. National Provider Identifier (NPI)  NPI will replace PINs, UPINs and the host of other public and private payer provider numbers  NPI will not indicate the provider type  Can apply on-line at: www.nppes.cms.hhs.gov/NPPES/Welcome.do www.nppes.cms.hhs.gov/NPPES/Welcome.do

18. NPI Number PAs/NPs should have their own NPI number PAs/NPs should have their own NPI number Having an NPI number does not mean that it must be used for billing purposes for every service performed by the PA/NP Having an NPI number does not mean that it must be used for billing purposes for every service performed by the PA/NP Options exist for billing the PA’s/NP’s services under the supervising/collaborating physician Options exist for billing the PA’s/NP’s services under the supervising/collaborating physician

19. Medicare Scope of Practice PAs/NPs may perform ( as allowed by state law ): PAs/NPs may perform ( as allowed by state law ): All E/M codes (including high levels) All E/M codes (including high levels) Consultations, critical care (time-based) Consultations, critical care (time-based) Initial hospital admit & pre-surgical H&Ps (physician countersignature required) Initial hospital admit & pre-surgical H&Ps (physician countersignature required) All diagnostic tests/procedures All diagnostic tests/procedures

20. CPT Codes PAs/NPs have access to virtually all CPT codes to describe the services they deliver PAs/NPs have access to virtually all CPT codes to describe the services they deliver [2007 CPT Manual, professional edition, introduction, p. xiv] [2007 CPT Manual, professional edition, introduction, p. xiv] Beware of Medicare Local Medical Review Policy attempts to impose limitations Beware of Medicare Local Medical Review Policy attempts to impose limitations Limitations of state law must always be followed Limitations of state law must always be followed

21. If a PA/NP is Hired by the Hospital Medicare requires that medical and surgical services delivered by hospital-employed PAs/ NPs (and physicians) be billed under Medicare Part B (exception for administrative responsibilities) Medicare requires that medical and surgical services delivered by hospital-employed PAs/ NPs (and physicians) be billed under Medicare Part B (exception for administrative responsibilities) In the past, Medicare allowed hospital-employed PA/NP salaries to be covered under Part A through the hospital’s cost reports. That has changed. In the past, Medicare allowed hospital-employed PA/NP salaries to be covered under Part A through the hospital’s cost reports. That has changed.

22. Medicare Hospital Billing PAs/NPs can deliver care with the service covered at 85% whether employed by the hospital or not PAs/NPs can deliver care with the service covered at 85% whether employed by the hospital or not No need for on site physician presence under Medicare; electronic communication (telephone) meets supervision requirements (hospital bylaws/policies and state law must be followed) No need for on site physician presence under Medicare; electronic communication (telephone) meets supervision requirements (hospital bylaws/policies and state law must be followed)

23. Medicare Hospital Billing Is it a physician or PA/NP bill if both provide service to the same patient on the same visit? Is it a physician or PA/NP bill if both provide service to the same patient on the same visit? Medicare’s previous rules said that whoever provided the majority of care had to bill for the service Medicare’s previous rules said that whoever provided the majority of care had to bill for the service

24. Medicare Hospital Billing 2001 split billing policy created confusion, frustration and administrative difficulties 2001 split billing policy created confusion, frustration and administrative difficulties AAPA and others pushed CMS to adopt a more user friendly policy AAPA and others pushed CMS to adopt a more user friendly policy October 2002 - shared visit policy allowing more PA/NP patient interaction with 100% billing October 2002 - shared visit policy allowing more PA/NP patient interaction with 100% billing

25. Shared Visit Policy Ability to “combine” hospital services provided by the PA/NP and the physician to the same patient on the same calendar day (this is not “incident to” billing). Ability to “combine” hospital services provided by the PA/NP and the physician to the same patient on the same calendar day (this is not “incident to” billing). Requires that the physician provide a face-to- face portion of the E/M service to the patient Requires that the physician provide a face-to- face portion of the E/M service to the patient [Medicare Transmittal 1776, October 25, 2002] [Medicare Transmittal 1776, October 25, 2002]

26. Shared Visit Applies to evaluation and management services (not procedures, consults, or critical care as of 1/1/2006) Applies to evaluation and management services (not procedures, consults, or critical care as of 1/1/2006) PA/NP and physician must be employed by the same entity (same hospital, same group practice, PA employed by solo physician) PA/NP and physician must be employed by the same entity (same hospital, same group practice, PA employed by solo physician)

27. Medicare Payment Policy Physicians who do not contribute to the PA’s/NPs salary may not bill for/capture reimbursement from the PA’s/NPs services Physicians who do not contribute to the PA’s/NPs salary may not bill for/capture reimbursement from the PA’s/NPs services Leasing arrangements may be utilized to allow non-hospital employed physicians to bill for the services of the hospital-employed PAs Leasing arrangements may be utilized to allow non-hospital employed physicians to bill for the services of the hospital-employed PAs

28. Consultations & Shared Visits Dec. 20, 2005 transmittal officially removed consultations from shared visit billing Dec. 20, 2005 transmittal officially removed consultations from shared visit billing Transmittal 788 Transmittal 788 www.cms.hhs.gov/transmittals/downloads/R788 CP.pdf www.cms.hhs.gov/transmittals/downloads/R788 CP.pdf  AAPA/AMA lobbying CMS to include consults and will continue to try to make a policy change

29. Consultations Medicare allows PAs/NPs to order, or personally perform consultations Medicare allows PAs/NPs to order, or personally perform consultations When billed under the PA’s/NP’s name and Medicare PIN/NPI, payment will be at 85% of the physician fee schedule (bill at 100% of the physician fee schedule rate) When billed under the PA’s/NP’s name and Medicare PIN/NPI, payment will be at 85% of the physician fee schedule (bill at 100% of the physician fee schedule rate) Medicare Transmittal 1725; Sept. 27, 2001 Medicare Transmittal 1725; Sept. 27, 2001

30. Chart Co-Signature Generally, Medicare does not require chart co- signature Generally, Medicare does not require chart co- signature Exceptions are for pre-admission H&Ps, pre- surgical H&Ps, and discharge summaries Exceptions are for pre-admission H&Ps, pre- surgical H&Ps, and discharge summaries Medicare will defer to state law, if state law is more restrictive Medicare will defer to state law, if state law is more restrictive

31. Teaching Hospital Rules Any restrictions on billing apply only to first assisting at surgery, not to other services delivered in the hospital Any restrictions on billing apply only to first assisting at surgery, not to other services delivered in the hospital Resident billing rules do not apply to NPPs Resident billing rules do not apply to NPPs NPPs are statutorily authorized to bill Medicare, residents typically are not NPPs are statutorily authorized to bill Medicare, residents typically are not [Medicare Carriers Manual Section 15106] [Medicare Carriers Manual Section 15106]

32. Private Payers Most private payers cover services delivered by PAs/NPs Most private payers cover services delivered by PAs/NPs Many payers require billing for NPPs to go under the physician’s name and/or provider number or the hospital’s tax ID Many payers require billing for NPPs to go under the physician’s name and/or provider number or the hospital’s tax ID Not necessarily the same as Medicare’s “incident to” policy Not necessarily the same as Medicare’s “incident to” policy

33. Private Payers It is not fraud to bill under the physician/hospital if authorized by the payer It is not fraud to bill under the physician/hospital if authorized by the payer It is a mistake to assume that all payers follow the same billing rules It is a mistake to assume that all payers follow the same billing rules Important to know the specific policies from payers in your region Important to know the specific policies from payers in your region

34. Hospital Billing Challenges Some payers ask that PA/NP services be billed under the supervising physician. Problems may occur if the PA/NP is hospital employed, but the supervising physician is not. Some payers ask that PA/NP services be billed under the supervising physician. Problems may occur if the PA/NP is hospital employed, but the supervising physician is not. Payment might be made to the hospital’s tax ID number Payment might be made to the hospital’s tax ID number

35. Credentialing & Payment Credentialing is not necessarily directly related to payment policy Credentialing is not necessarily directly related to payment policy Credentialing and the issuance of provider numbers depend on the particular payer Credentialing and the issuance of provider numbers depend on the particular payer

36. Productivity Productivity and reimbursement are distinctly separate Productivity and reimbursement are distinctly separate Depending on utilization and payer billing requirements, NPPs may not appear to bring in large amounts of revenue under their names Depending on utilization and payer billing requirements, NPPs may not appear to bring in large amounts of revenue under their names

37. Productivity Services delivered by PAs/NPs may have been captured/billed under the physician Services delivered by PAs/NPs may have been captured/billed under the physician Non-separately billable services provided by PAs/NPs free up physicians to engage in other billable activities Non-separately billable services provided by PAs/NPs free up physicians to engage in other billable activities

38. Productivity Most billing software allows tracking of a health care professional’s billing codes, even though that information will not be sent on to the billing organization (rendering provider as opposed to billing provider) Most billing software allows tracking of a health care professional’s billing codes, even though that information will not be sent on to the billing organization (rendering provider as opposed to billing provider) Virtually every service performed can be tracked by CPT code (often with the use of modifier codes), even if the service is not submitted for billing purposes Virtually every service performed can be tracked by CPT code (often with the use of modifier codes), even if the service is not submitted for billing purposes

39. AAPA Data base Contains information on over 325 private and public payers Contains information on over 325 private and public payers  AAPA will provide details from the data base to physicians/hospitals upon request

40. Resources/Contact Information AAPA Web site: www.aapa.org AAPA Web site: www.aapa.orgwww.aapa.org Click on to Professional Practice; then click on Click on to Professional Practice; then click on Reimbursement Reimbursement Phone: 703/836-2272; ask for reimbursement department Phone: 703/836-2272; ask for reimbursement department E-mail: michael@aapa.org E-mail: michael@aapa.org

41. Resources/Information American Academy of Nurse Practitioners American Academy of Nurse Practitioners - Phone number: - Web site address: American College of Nurse Practitioners American College of Nurse Practitioners - Phone Number: - Web site address: