1. Understanding Medicare Billing Issues
Sponsored by the MSBA Health Law Section
Presented by:
Edith Sunderland
Director of Compliance and Coding
University Physicians, Inc.
April 8, 2008

2. Understanding Medicare Billing issues (Part B)
“Incident to” billing
Billing for physician extenders (physician assistants, CRNPs)
Consultations
Billing for visits with procedures
Purchased diagnostic tests
Other reimbursement issues

3. Non Physician Practitioners (NPP)
Must be employees (includes leased and contracted employees) of the practice to bill –or for the physician to bill the services under “incident to” or split/shared visits.
When billing under attending name in the office setting– “incident to” rules may apply.

4. What Does “Incident To” Mean?
The service was provided in the office setting by an employee (includes leased/contracted employee) of the practice under the direct supervision of the physician and billed in the physician’s name

5. “Incident To” … Office only Billed under the physician’s name
Doctor must be – in the office suite at the time - document “I was present in the office suite when the service was provided__________________(signature)
Contact by telephone or the MD’s presence somewhere else in the building is not sufficient within human voice distance

6. “Incident To”….
Non physician personnel must be an “employee” of the practice
NPP in Maintenance mode
MD must see all new patients –
MD must see all patients with new problems –

7. “Incident To” What E&M codes can be billed for “incident to” services?
If ancillary personnel other than a Nurse Practitioner or Physician Assistant perform “incident to” services only can be billed

8. What Is the Physician’s Role in “Incident To” Services?
The billing provider must see the patient for an initial visit and develop a treatment plan.
There must be documentation to support the provider’s active participation in the patient’s care.
If the condition for which the provider is treating the patient changes, the provider must personally see the patient.
The record of services performed “incident to” a physician service demonstrates the link between the employee’s work and the physician’s service.

9. “Incident To”
Does the “incident to” provision apply to inpatient services?
The services must be those that are commonly performed in an office setting. The split/shared visit rules apply in an inpatient setting.

10. “Incident To”
Please refer to the “Incident To” manual for complete information. This manual can be downloaded free of charge from the TrailBlazer Web site at:

11. Split/Shared Visits
Both the physician and the NPP see the patient during the same day
Both the physician and the NPP document their portion of the visit
Bill the level of care that the combined notes will allow
Bill the service in either’s name
The physician should reference the NPP’s note in his/her documentation if billing in the MD’s name
The NP should reference the MD documentation if billing in the NPP’s name

12. Split/Shared Visits NPP must be an employee of the faculty practice
The record of services split/shared by a physician and non-physician practitioner must demonstrate the face-to-face encounter and contribution to patient management by each practitioner involved.
Consultations for Medicare patients cannot be shared visits and billed in the MD’s name

13. NPP Cannot supervise residents and bill.
Cannot use documentation of students to bill.
The only part of a student’s note that can be counted is the ROS and PFSH if it is reviewed and noted.

14. E & M New Patient Rule
New patient is someone who has not been seen by the physician or another physician in the same practice (same specialty) for three years, regardless of the reason or location.

15. Consultation
The intent of a consultation is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, an opinion, recommendation, suggestion, direction or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.

16. Consultations…
A consultation is distinguished from a visit because it is done at the request of a referring physician and the consultant prepares a report of his/her findings which is provided to the referring physician for his or her use in the treatment of the patient.
A consultant may initiate diagnostic and/or therapeutic services and the service still remains as a consultation.
If the referring physician transfers complete responsibility for all medical care to the physician the service as not a consultation.

17. Consultations… The Rule of the Four Rs for a Consultation Referral
Request for an opinion
Report to the referring physician
Referring provider must document the request

18. Consultations…
The service is not simply a continuation of care by the consultant for an established clinical problem of an established patient in a different clinical setting.
The opinion rendered is of such a nature that it will be used by, and in some manner will affect, the requesting physician’s own management of, or decision making about, the patient.

19. Consultations…
Consultations rendered for the purpose of preoperative medical clearance are covered Medicare services. However, the record of such a consultation should very clearly demonstrate that the preoperative medical evaluation is reasonable and necessary, given the patient’s medical condition and the nature of the proposed surgical procedure. Additionally, it should be clear that the opinion of the consultant will be used by the requesting surgeon in the post-operative management of the patient.

20. Consultations…
Medicare does not reimburse consultations rendered as “split/shared services.”
The initial inpatient consultation may be reported only once per consultant per patient per facility admission.
In the hospital setting, following the initial consultation service, the Subsequent Hospital Care codes (99231–99233) should be reported for additional follow-up services.

21. Consultations…
A second-opinion E/M service initiated by a patient and/or family is not reported using the consultation codes.

22. Consultations…
Consideration of the following points will assist in correct billing of consultations. In instances where you may be unsure whether the services rendered meet the criteria of a consultation, ask the following questions:
Did the doctor receive a referral or order to provide a consultation?
Does the documentation of the service clearly demonstrate the order or referral?
Was a written report of the consultant’s opinion/advice provided to the referring provider?
Though the referring physician may have asked for “consultation,” is the E/M service provided truly a consultation (i.e., not better characterized by another E/M service code)?
If the answer to any of the previous questions is “no,” the service is not a consultation CPT code.

23. Visit and Minor Procedures -Same Day
Evaluation and Management (E/M) services reported on the same day as a procedure must be clearly documented, medically necessary, significant and separate from the procedure.
The 25 modifier is appended to the E/M service to indicate a significant, separately identifiable E/M service above and beyond the other service provided, or services beyond the usual preoperative and postoperative care associated with the procedure that was performed by the same physician on the same day of a minor procedure or service. It is used to indicate that the patient’s condition required a significant, identifiable E/M service

24. Closer Look at Modifier 25
Significant separately identifiable evaluation and management service by the same physician on the same day of a minor procedure or other service

25. What Are Purchased Diagnostic Tests?
The entity billing for the diagnostic test did not perform all components of the test but purchased part of the test from another source.
If the technical portion of the test was purchased, check the “Yes” box and enter the purchase price under “Charges.”
There is no need to enter the purchase price for the purchased interpretation.

26. Purchased Diagnostic Tests…
Purchased Technical Components
A physician/practitioner may bill for the technical component of a diagnostic test that he purchases from another physician, medical group or supplier if:
The physician or supplier that furnished the technical component of the test is enrolled in the Medicare program. And,
The physician/practitioner purchasing the test performed the interpretation.
Payment is based on the lower of the billing physician’s fee, the fee schedule or the price paid for the service.

27. Purchased Diagnostic Tests…
Purchased Interpretations
An entity that provides the technical portion of a diagnostic test may submit the claim, and payment can be made for the diagnostic test interpretations that it purchases from an independent physician or medical group if:
The tests are ordered by a physician/practitioner or medical group that is independent of the entity providing the technical portion of the test and of the physician or medical group providing the interpretation.
The purchaser performs the technical component of the test.
The interpreting physician/practitioner is enrolled in the Medicare program.
The interpreting physician/practitioner does not see the patient. And,
The purchaser keeps on file the name, provider identification number and address of the interpreting physician.

28. Purchased Diagnostic Tests…
Providers may not submit a global billing code when one component of the service has been purchased.
Example: A physician may see a patient and send him to a testing facility for an MRI. The testing facility then sends the MRI to be interpreted by another physician. The testing facility may bill Medicare the technical and professional components of the MRI if purchasing the interpretation from the physician. This is acceptable because the testing facility is independent of the physician who referred the patient to it and of the physician who interpreted the service
71010 – TC (chest x-ray technical component)
71010 – 26 (chest x-ray professional component)

29. Specific Instructions for Filing Claims for Purchased Services
Providers may not submit a global billing when one component of the service has been purchased. To determine the correct payment jurisdiction and price services correctly, the technical and professional components of the service must be submitted on separate detail lines or on separate claims, depending on how the claim is filed (paper or electronic).
Paper Claims: The technical component and the professional component must be submitted on separate claim forms. The physical address of the location where the specific test component was rendered should be entered in Item 32 on the claim form.

30. Purchased Diagnostic Tests…
A physician’s office cannot purchase a diagnostic test from a lab
If a physician’s office sends laboratory services to an outside laboratory, the outside laboratory should bill for the tests. It is the responsibility of the outside laboratory to bill for the services rendered. 

31. Questions?