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Non-Physician Practitioners Documentation and Billing March 2005 Terry L. Reeves Exec. Director of Institutional Compliance
What can they do? <ul><li>Services as outlined by state law.  The scope of practice and the reimbursement methodologies ar...
What can they do? <ul><li>Nurse Practitioner </li></ul><ul><ul><li>Physician Services </li></ul></ul><ul><ul><li>Defined b...
Who licenses and governs them? <ul><li>Nurse Practitioner </li></ul><ul><ul><li>Board of Nurse Examiners for the State of ...
Where can a non-physician practitioner perform services? <ul><li>Nurse Practitioner </li></ul><ul><ul><li>In all settings ...
Legal authority to bill for physician services performed by NPPs <ul><li>Medicare </li></ul><ul><ul><li>Authority comes fr...
What has to be in place for Medicare reimbursement? <ul><li>No other entity is billing or receiving payment for that servi...
Are protocols required? <ul><li>Nurse Practitioner </li></ul><ul><ul><li>Yes </li></ul></ul><ul><ul><li>Section 221 .1 (12...
Documentation of Collaboration <ul><li>Nurse Practitioners </li></ul><ul><li>42 CFR 410.75 3 (c) (ii).  Such collaboration...
What are Protocols? <ul><li>Nurse Practitioners </li></ul><ul><li>Written authorization to provide medical aspects of pati...
What are Protocols? (continued) <ul><li>Nurse Practitioners (continued) </li></ul><ul><li>Such protocols or other written ...
What are Protocols? (continued) <ul><li>Physicians Assistants </li></ul><ul><li>TMHP 2005 Texas Medicaid Provider  Procedu...
What are Protocols? (continued) <ul><li>Physicians Assistants </li></ul><ul><li>It is the obligation of each team of physi...
What are Protocols? (continued) <ul><li>Physicians Assistants (continued) </li></ul><ul><ul><li>a process for evaluation o...
Provider-based facility vs. Office-based facility <ul><li>Provider-Based facility </li></ul><ul><li>Designation is determi...
Provider-based facility vs. Office-based facility <ul><li>Office-based facility </li></ul><ul><li>Designation if not provi...
Medicare Reimbursement Provider-based facility <ul><li>Nurse Practitioner and Physician Assistants </li></ul><ul><li>Both ...
Medicare Reimbursement Provider-based facility <ul><li>“Incident to” billing </li></ul><ul><li>“Incident to” billing is ex...
Medicare- Shared/Split Service <ul><li>Effective October 2002, Medicare recognizes a shared service for place of service  ...
Medicare Shared Service <ul><li>The physician documents a “face-to-face” encounter with the patient </li></ul><ul><li>AND ...
Medicare Reimbursement Office-based facility <ul><li>Nurse Practitioner and Physician Assistants </li></ul><ul><li>May bil...
Medicare Reimbursement “Incident to” Billing <ul><li>What is “incident to” billing? </li></ul><ul><li>“Incident to” refers...
Medicare Reimbursement “Incident to” Billing (continued) <ul><li>Requirements for “incident to” billing </li></ul><ul><li>...
Medicare Reimbursement “Incident to” Billing (continued) <ul><li>Requirements for “incident to” billing. </li></ul><ul><li...
Medicaid Reimbursement <ul><li>Legal References </li></ul><ul><li>Texas Administrative Code </li></ul><ul><li>25 TAC Secti...
Medicaid Reimbursement <ul><li>Nurse Practitioner  </li></ul><ul><li>Option #1 Direct Billing  85% of fee schedule </li></...
Medicaid Reimbursement <ul><li>Physician Assistant  </li></ul><ul><li>Option #1 As a physician service  </li></ul><ul><li>...
Medicaid Reimbursement <ul><li>Supervision Requirements  </li></ul><ul><li>Medicaid does not require “direct” or “personal...
Other third party Reimbursement <ul><li>Private insurers generally cover medical services provided by PAs or NPs when they...
Medicare and Medicaid Documentation Requirements <ul><li>Same as a “stand alone” note for teaching physician or attending ...
Example #1 <ul><li>Physician employs NPP, who visits hospitalized patient </li></ul><ul><li>NPP performs CPT 99232 </li></...
Example #2 <ul><li>Same scenario, except physician is away and does not visit the patient </li></ul><ul><li>MD may bill CP...
Shared/split E&M service <ul><li>NPPs and MDs may conduct and bill &quot;shared&quot; visits to </li></ul><ul><ul><li>inpa...
Example #3 <ul><li>MD employs NPP (or members of same gp) </li></ul><ul><li>NPP conducts a follow-up office visit (CPT 992...
Example #4 <ul><li>Same scenario, except patient has a new problem in addition to diabetes </li></ul><ul><li>Choices: </li...
Medicare and Medicaid Documentation Requirements <ul><li>Same as a “stand alone” note for teaching physician or attending ...
Questions for hospital wanting to bill services of NPP employee to Medicare <ul><li>Are private physicians already billing...
Note that <ul><li>Under Medicare’s conditions of participation for hospitals, the care of hospitalized patients must be di...
Example #5 <ul><li>E.F., a 65-year-old woman, admitted yesterday to medicine unit with diagnosis bilateral pneumonia </li>...
Example #6 <ul><li>Same scenario (E.F., a 65-year-old woman, admitted yesterday to inpatient medicine unit for bilateral p...
Example #7 <ul><li>E.F. (same patient) c/o HA, visual disturbances. Medicine's NPP orders CT. Impression: tumor. NPP refer...
Example #8 <ul><li>Neurosurgery NPP discusses E.F. with attending on rounds. MD reviews CT scans, MRI, does focused exam, ...
Example #9 <ul><li>E.F. goes to surgery 6 weeks later. </li></ul><ul><li>Neurosurgeon bills 61607 (resection of neoplastic...
Global fee for surgery <ul><li>What is included depends on the surgery </li></ul><ul><ul><li>Major </li></ul></ul><ul><ul>...
Global fee: What is included? <ul><li>ICU visits by surgeon </li></ul><ul><li>Preoperative visits </li></ul><ul><li>Intra-...
Global fee: What is not included? <ul><li>Initial consultation </li></ul><ul><li>Services of other MDs </li></ul><ul><li>V...
Frequently asked Questions <ul><li>Q. Can a non-physician practitioner order  ancillary services? </li></ul><ul><li>A. Yes...
Frequently asked question: Whose name/provider number do we bill under? <ul><li>It depends on the circumstances  </li></ul...
Frequently asked Questions <ul><li>Q. Can a teaching physician supervise a  PA or NP in the same way as a  resident? </li>...
Frequently asked Questions <ul><li>Q. What does a physician need to write to document a shared service with a PA or NP? </...
Frequently asked Questions <ul><ul><li>Q. What do I write down when I supervise a PA or NP student? </li></ul></ul><ul><li...
Frequently asked Questions <ul><li>Q. Can a PA or NP bill upper level E&M codes, for example 99215? </li></ul><ul><li>A. Y...
Frequently asked Questions <ul><li>Q. Can a NP or PA bill new patient codes? </li></ul><ul><li>A. Yes, except when the ser...
Web Sites <ul><li>Nurse Practitioners </li></ul><ul><li>Board of Nurse Examiners </li></ul><ul><li>www.bne.state.tx.us/Def...
Web Sites <ul><li>Physician Assistants </li></ul><ul><li>Texas State Board of Medical Examiners www.tsbme.state.tx.us/ </l...
Web Sites <ul><li>Physician Assistants </li></ul><ul><li>Texas State Board of Medical Examiners www.tsbme.state.tx.us/ </l...
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Transcript of ""NPPMarch2005""

  1. 1. Non-Physician Practitioners Documentation and Billing March 2005 Terry L. Reeves Exec. Director of Institutional Compliance
  2. 2. What can they do? <ul><li>Services as outlined by state law. The scope of practice and the reimbursement methodologies are all established by state law. </li></ul><ul><li>Normally outlined in the Texas Occupation Code and in the Rules and Regulations of the Board Governing that profession. </li></ul>
  3. 3. What can they do? <ul><li>Nurse Practitioner </li></ul><ul><ul><li>Physician Services </li></ul></ul><ul><ul><li>Defined by their Scope of Practice as stated in state law BNE Rules 221.12 </li></ul></ul><ul><ul><li>Limited prescriptive authority </li></ul></ul><ul><ul><li>Cannot supervise diagnostic tests SSA § 1861 (r) </li></ul></ul><ul><li>Physician Assistant </li></ul><ul><ul><li>Physician Services </li></ul></ul><ul><ul><li>Defined by their Scope of Practice as stated in state law TSBME Board Rules 185.11 </li></ul></ul><ul><ul><li>Limited prescriptive authority </li></ul></ul><ul><ul><li>Cannot supervise diagnostic tests SSA § 1861 (r) </li></ul></ul>
  4. 4. Who licenses and governs them? <ul><li>Nurse Practitioner </li></ul><ul><ul><li>Board of Nurse Examiners for the State of Texas (BNE) </li></ul></ul><ul><ul><li>Some references to the TSBME for prescriptive authority </li></ul></ul><ul><ul><li>Various specialty organizations </li></ul></ul><ul><ul><li>UTMB Nursing Service </li></ul></ul><ul><li>Physician Assistant </li></ul><ul><ul><li>Texas State Board of Medical Examiners (TSBME) </li></ul></ul><ul><ul><li>Texas State Board of Physician Assistant Examiners </li></ul></ul><ul><ul><li>UTMB Medical Staff Office </li></ul></ul>
  5. 5. Where can a non-physician practitioner perform services? <ul><li>Nurse Practitioner </li></ul><ul><ul><li>In all settings </li></ul></ul><ul><ul><li>Inpatient hospital </li></ul></ul><ul><ul><li>Outpatient </li></ul></ul><ul><ul><li>SNF* </li></ul></ul><ul><ul><li>Patient’s Home </li></ul></ul><ul><ul><li>Nursing Home </li></ul></ul><ul><ul><li>Hospices </li></ul></ul><ul><li>Physician Assistant </li></ul><ul><ul><li>In all settings </li></ul></ul><ul><ul><li>Inpatient hospital </li></ul></ul><ul><ul><li>Outpatient </li></ul></ul><ul><ul><li>SNF* </li></ul></ul><ul><ul><li>Patient’s Home </li></ul></ul><ul><ul><li>Nursing Home </li></ul></ul><ul><ul><li>Hospices </li></ul></ul>
  6. 6. Legal authority to bill for physician services performed by NPPs <ul><li>Medicare </li></ul><ul><ul><li>Authority comes from 42 U.S.C. §1395x(s)(K) </li></ul></ul><ul><li>Medicaid </li></ul><ul><ul><li>Authority comes from 42 C.F.R. §440.166 </li></ul></ul>
  7. 7. What has to be in place for Medicare reimbursement? <ul><li>No other entity is billing or receiving payment for that service </li></ul><ul><ul><ul><li>42 CFR § 410.74 PAs </li></ul></ul></ul><ul><ul><ul><li>42 CFR § 410.75 NPs </li></ul></ul></ul><ul><li>Medicare covers the service </li></ul><ul><li>The billing entity follows the rules for physician services </li></ul><ul><ul><li>NPP codes and documents in accordance with CPT and CMS’ documentation guidelines </li></ul></ul>
  8. 8. Are protocols required? <ul><li>Nurse Practitioner </li></ul><ul><ul><li>Yes </li></ul></ul><ul><ul><li>Section 221 .1 (12) Rules and Regulations of BNE </li></ul></ul><ul><ul><li>TMHP Texas Medicaid Provider Procedures Manual 34.3 </li></ul></ul><ul><li>Physician Assistant </li></ul><ul><ul><li>Yes </li></ul></ul><ul><ul><li>Texas State Board of Medical Examiners (TSBME) </li></ul></ul><ul><ul><li>TMHP Texas Medicaid Provider Procedures Manual 34.3 </li></ul></ul>
  9. 9. Documentation of Collaboration <ul><li>Nurse Practitioners </li></ul><ul><li>42 CFR 410.75 3 (c) (ii). Such collaboration is to be evidenced by nurse practitioners documenting the nurse practitioners’ scope of practice and indicating the relationships that they have with physicians to deal with issues outside their scope of practice. </li></ul>
  10. 10. What are Protocols? <ul><li>Nurse Practitioners </li></ul><ul><li>Written authorization to provide medical aspects of patient care which are agreed upon and signed by the advanced practice nurse and the physician, reviewed and signed at least annually, and maintained in the practice setting of the advanced practice nurse. Protocols or other written authorization shall be defined to promote the exercise of professional judgment by the advanced practice nurse commensurate with his/her education and experience. </li></ul>
  11. 11. What are Protocols? (continued) <ul><li>Nurse Practitioners (continued) </li></ul><ul><li>Such protocols or other written authorization need not describe the exact steps that the advanced practice nurse must take with respect to each specific condition, disease, or symptom and may state types or categories of drugs which may be prescribed rather than just life specific drugs. </li></ul>
  12. 12. What are Protocols? (continued) <ul><li>Physicians Assistants </li></ul><ul><li>TMHP 2005 Texas Medicaid Provider Procedures Manual 34.3 </li></ul><ul><ul><li>requires protocols. </li></ul></ul>
  13. 13. What are Protocols? (continued) <ul><li>Physicians Assistants </li></ul><ul><li>It is the obligation of each team of physician(s) and PAs to ensure that: </li></ul><ul><ul><li>The PA’s scope of practice is identified; </li></ul></ul><ul><ul><li>delegation of medical tasks is appropriate to the PA’s level of competence; </li></ul></ul><ul><ul><li>the relationship between the members of the team is defined; that the relationship of, and access to, the supervising physician is defined; </li></ul></ul>
  14. 14. What are Protocols? (continued) <ul><li>Physicians Assistants (continued) </li></ul><ul><ul><li>a process for evaluation of the PA’s performance is established; and </li></ul></ul><ul><ul><li>The PA’s annual registration is current. </li></ul></ul>
  15. 15. Provider-based facility vs. Office-based facility <ul><li>Provider-Based facility </li></ul><ul><li>Designation is determined by CMS </li></ul><ul><li>Patient receives two bills: hospital and a professional fee bill </li></ul><ul><li>Hospitals bill DRGs for inpatient services and APCs for outpatient services. </li></ul><ul><li>Certain clinics are designated as provider-based </li></ul>
  16. 16. Provider-based facility vs. Office-based facility <ul><li>Office-based facility </li></ul><ul><li>Designation if not provider based then you are office-based. </li></ul><ul><li>Patient one bill: a professional fee bill </li></ul><ul><li>Office-based clinic bills the RBRVU associated with the CPT code for a “non-facility”. </li></ul><ul><li>Global or both TC and CPT code are billed. </li></ul>
  17. 17. Medicare Reimbursement Provider-based facility <ul><li>Nurse Practitioner and Physician Assistants </li></ul><ul><li>Both receive Medicare Provider numbers </li></ul><ul><li>Billed in the PA or NP name and provider number </li></ul><ul><li>Reimbursed at 85% of the fee schedule </li></ul><ul><li>Supervision requirements are as stated in state law </li></ul><ul><li>Documentation requirements are same as a “stand alone” note for an attending </li></ul>
  18. 18. Medicare Reimbursement Provider-based facility <ul><li>“Incident to” billing </li></ul><ul><li>“Incident to” billing is expressly prohibited in any provider-based setting. </li></ul>
  19. 19. Medicare- Shared/Split Service <ul><li>Effective October 2002, Medicare recognizes a shared service for place of service </li></ul><ul><li>Hospital Inpatient </li></ul><ul><li>Hospital Outpatient </li></ul><ul><li>Emergency Department </li></ul><ul><li>when the E/M is shared between the NPP and the physician AND </li></ul>
  20. 20. Medicare Shared Service <ul><li>The physician documents a “face-to-face” encounter with the patient </li></ul><ul><li>AND </li></ul><ul><li>Medical necessity for the physician’s involvement in the service. </li></ul>
  21. 21. Medicare Reimbursement Office-based facility <ul><li>Nurse Practitioner and Physician Assistants </li></ul><ul><li>May bill either in the name of the PA or NP using their provider number </li></ul><ul><li>or </li></ul><ul><li>Bill “incident to” i.e., in the name of the physician. </li></ul><ul><li>“ incident to” billing is reimbursed at 100% of the fee schedule. </li></ul>
  22. 22. Medicare Reimbursement “Incident to” Billing <ul><li>What is “incident to” billing? </li></ul><ul><li>“Incident to” refers to services or perhaps items provided after or in relation to a professional service that has already been provided by a physician. </li></ul><ul><li>Services of other healthcare professionals provided to a most commonly in an outpatient setting. </li></ul>
  23. 23. Medicare Reimbursement “Incident to” Billing (continued) <ul><li>Requirements for “incident to” billing </li></ul><ul><li>PA or NP must be an employee of the physician (for UTMB paid by MSRDP) </li></ul><ul><li>Initial visit must be performed by the physician. </li></ul><ul><li>Direct supervision: Physician must be in the office and immediately available to assist. </li></ul><ul><li>Physician has an active part in the ongoing care of the patient. Subsequent services by the physician must be of a frequency that reflects continuing active participation in, and management of the course of treatment. </li></ul>
  24. 24. Medicare Reimbursement “Incident to” Billing (continued) <ul><li>Requirements for “incident to” billing. </li></ul><ul><li>Service is typically performed in a physician’s office </li></ul><ul><li>Billed on the claim as if the billing physician had provided the services. </li></ul><ul><li>Cannot bill “incident to” for inpatient services. </li></ul>
  25. 25. Medicaid Reimbursement <ul><li>Legal References </li></ul><ul><li>Texas Administrative Code </li></ul><ul><li>25 TAC Section 29.502 </li></ul><ul><li>TMHP Texas Medicaid Provider Procedures Manual (2005) </li></ul><ul><li>Section 34.3 Benefits and Limitations </li></ul>
  26. 26. Medicaid Reimbursement <ul><li>Nurse Practitioner </li></ul><ul><li>Option #1 Direct Billing 85% of fee schedule </li></ul><ul><ul><li>NPs may apply for individual provider numbers for direct billing purposes. All covered services rendered may be billed using the NP’s direct provider number. </li></ul></ul><ul><li>Option #2 As a physician service </li></ul><ul><li>A NP may provide services as a physician service using the physician’s provider number when the physician provides “administrative supervision” and a –SA modifier is used on the CPT codes </li></ul>
  27. 27. Medicaid Reimbursement <ul><li>Physician Assistant </li></ul><ul><li>Option #1 As a physician service </li></ul><ul><li>A PA may provide services as a physician service using the physician’s provider number when the physician provides “administrative supervision” and a –U7 modifier is used on the CPT codes </li></ul><ul><li>This is the only option for a PA under Medicaid </li></ul>
  28. 28. Medicaid Reimbursement <ul><li>Supervision Requirements </li></ul><ul><li>Medicaid does not require “direct” or “personal” supervision of the NP or PA in the clinic. Medicaid does require “administrative” supervision which is defined as: </li></ul><ul><li>“ The supervision of a PA or an APN must be delivered according to protocols developed jointly with the physician and must be in accordance with the scope of practice and state law governing PAs and APNs.” </li></ul><ul><li>Settings </li></ul><ul><li>No limitations </li></ul><ul><li>Can’t double bill or “double dip” </li></ul>
  29. 29. Other third party Reimbursement <ul><li>Private insurers generally cover medical services provided by PAs or NPs when they are included as part of the physician’s bill or as part of a global fee for surgery, i.e. “Incident to”. </li></ul><ul><li>Other third party insurers normally require that the providers be credentialed and enrolled as a provider with that insurer. </li></ul>
  30. 30. Medicare and Medicaid Documentation Requirements <ul><li>Same as a “stand alone” note for teaching physician or attending </li></ul><ul><ul><li>Meet key component requirements </li></ul></ul><ul><ul><ul><li>Medical necessity </li></ul></ul></ul><ul><ul><ul><li>Chief complaint </li></ul></ul></ul><ul><ul><ul><li>History, physical exam, decision-making </li></ul></ul></ul><ul><ul><ul><li>3 out of 3 for new patient </li></ul></ul></ul><ul><ul><ul><li>2 out of 3 for established patient </li></ul></ul></ul><ul><ul><ul><li>Personal involvement should be obvious </li></ul></ul></ul><ul><ul><ul><li>Sign, date, and time the note </li></ul></ul></ul><ul><ul><ul><li>A NP or PA may not supervise a resident </li></ul></ul></ul>
  31. 31. Example #1 <ul><li>Physician employs NPP, who visits hospitalized patient </li></ul><ul><li>NPP performs CPT 99232 </li></ul><ul><ul><li>expanded problem-focused interval history </li></ul></ul><ul><ul><li>expanded problem-focused exam </li></ul></ul><ul><ul><li>medical decision-making of moderate complexity </li></ul></ul><ul><li>MD visits patient (face-to-face) later that day </li></ul><ul><li>MD may bill 99232 or 99233 (depending on how much evaluation/management physician performs) under the MD’s provider number, under shared billing rules. See Medicare Carriers Manual, Part 3, §15501 </li></ul>
  32. 32. Example #2 <ul><li>Same scenario, except physician is away and does not visit the patient </li></ul><ul><li>MD may bill CPT 99232 but must bill under the NPP’s provider number </li></ul><ul><ul><li>See Medicare Carriers Manual, Part 3, §15501 </li></ul></ul>
  33. 33. Shared/split E&M service <ul><li>NPPs and MDs may conduct and bill &quot;shared&quot; visits to </li></ul><ul><ul><li>inpatients, ER patients, outpatients </li></ul></ul><ul><li>May bill under MD's number if the MD provides any face-to-face service that day and they are employees of the same group practice </li></ul><ul><ul><li>Medicare Carriers Manual, Part 3, §15501 </li></ul></ul>
  34. 34. Example #3 <ul><li>MD employs NPP (or members of same gp) </li></ul><ul><li>NPP conducts a follow-up office visit (CPT 99214) for a patient MD has diagnosed with diabetes </li></ul><ul><li>MD is in the suite of offices </li></ul><ul><li>MD may bill CPT 99212 to 99215 under the MD’s provider number, under incident-to rules </li></ul><ul><ul><ul><ul><li>Medicare Carriers Manual, Part 3, §2050.1 </li></ul></ul></ul></ul>
  35. 35. Example #4 <ul><li>Same scenario, except patient has a new problem in addition to diabetes </li></ul><ul><li>Choices: </li></ul><ul><ul><li>Bill the visit under the NPP’s provider number </li></ul></ul><ul><ul><li>Have the patient see the MD for initial service re the new problem </li></ul></ul><ul><ul><li>Bill the service for the diabetes under the MD’s provider number, don’t bill for the NPP’s work on the new problem </li></ul></ul><ul><ul><ul><li>Source: Carrier web site – </li></ul></ul></ul><ul><ul><ul><li>http://www.noridianmedicare.com/provider/pubs/med_b/news/ </li></ul></ul></ul><ul><ul><ul><li>iowa/1097.html </li></ul></ul></ul>
  36. 36. Medicare and Medicaid Documentation Requirements <ul><li>Same as a “stand alone” note for teaching physician or attending </li></ul><ul><ul><li>Meet key component requirements </li></ul></ul><ul><ul><ul><li>Medical necessity </li></ul></ul></ul><ul><ul><ul><li>Chief complaint </li></ul></ul></ul><ul><ul><ul><li>History, physical exam, decision-making </li></ul></ul></ul><ul><ul><ul><li>3 out of 3 for new patient </li></ul></ul></ul><ul><ul><ul><li>2 out of 3 for established patient </li></ul></ul></ul><ul><ul><ul><li>Personal involvement should be obvious </li></ul></ul></ul><ul><ul><ul><li>Sign, date, and time the note </li></ul></ul></ul>
  37. 37. Questions for hospital wanting to bill services of NPP employee to Medicare <ul><li>Are private physicians already billing for the NPP’s services? </li></ul><ul><li>Is the NPP's salary on the cost report? </li></ul><ul><ul><li>If not, hospital may bill NPP's services </li></ul></ul><ul><li>If so, does the hospital receive any payments from Medicare based on the cost report? </li></ul><ul><ul><li>If so, hospital may not bill NPP's service to Medicare </li></ul></ul>
  38. 38. Note that <ul><li>Under Medicare’s conditions of participation for hospitals, the care of hospitalized patients must be directed by a doctor of medicine, dentistry, podiatry or clinical psychology </li></ul><ul><li>But MDs can delegate responsibilities to non-MDs </li></ul><ul><ul><ul><li>42 CFR 482.12 </li></ul></ul></ul>
  39. 39. Example #5 <ul><li>E.F., a 65-year-old woman, admitted yesterday to medicine unit with diagnosis bilateral pneumonia </li></ul><ul><li>Medicine team's NPP evaluates and manages E.F today through discharge. 50% of NPP's salary is paid by hospital. The hospital receives compensation from Medicare under its cost report. </li></ul><ul><li>Can NPP bill CPT 99231 daily until discharge? No. </li></ul>
  40. 40. Example #6 <ul><li>Same scenario (E.F., a 65-year-old woman, admitted yesterday to inpatient medicine unit for bilateral pneumonia) </li></ul><ul><li>NPP works for private MD Jones. </li></ul><ul><li>If NPP provides daily visits, can NPP bill CPT 99231 daily until discharge? Yes. </li></ul>
  41. 41. Example #7 <ul><li>E.F. (same patient) c/o HA, visual disturbances. Medicine's NPP orders CT. Impression: tumor. NPP refers pt. to neurosurgery team for consultation </li></ul><ul><li>NPP employed by neurosurgery team does comprehensive H&P, reviews CT, discusses findings with E.F. & medicine, orders MRI, tx. (Time spent: 80 minutes). </li></ul><ul><li>Does neurosurgery NPP bill a consultation? CPT? 99254 Yes . </li></ul>
  42. 42. Example #8 <ul><li>Neurosurgery NPP discusses E.F. with attending on rounds. MD reviews CT scans, MRI, does focused exam, discusses diagnosis and treatment options with E.F., family and PCP. (Time spent: 40 minutes). </li></ul><ul><li>What CPT would MD bill? 99252 </li></ul><ul><li>Could NPP bill 99254 and MD bill 99252? No </li></ul><ul><li>Make a choice-- bill 99254 and get 85% or bill 99252 and get 100% </li></ul><ul><li>Or, as per “shared billing” rules, bill 99255 under MD's number. </li></ul>
  43. 43. Example #9 <ul><li>E.F. goes to surgery 6 weeks later. </li></ul><ul><li>Neurosurgeon bills 61607 (resection of neoplastic lesion of cavernous sinus) </li></ul><ul><li>Can neurosurgery NPP bill 99231 for post-op visits? No. </li></ul><ul><li>If E.F. develops Herpes Zoster on post-op day 3, can NPP bill 99231? Yes . </li></ul>
  44. 44. Global fee for surgery <ul><li>What is included depends on the surgery </li></ul><ul><ul><li>Major </li></ul></ul><ul><ul><li>Minor </li></ul></ul><ul><ul><li>Diagnostic procedures may have tasks bundled into the fee, or may not </li></ul></ul><ul><ul><li>Consult CPT and the Medicare Carriers Manual for the details on a particular procedure </li></ul></ul>
  45. 45. Global fee: What is included? <ul><li>ICU visits by surgeon </li></ul><ul><li>Preoperative visits </li></ul><ul><li>Intra-operative services </li></ul><ul><li>Postoperative visits related to recovery from the surgery, for pain management, and required because of complications </li></ul><ul><li>Dressing changes; local incisional care; removal of sutures, drains, etc. </li></ul><ul><ul><ul><li>Medicare Carriers Manual, Part 3, §4821 </li></ul></ul></ul>
  46. 46. Global fee: What is not included? <ul><li>Initial consultation </li></ul><ul><li>Services of other MDs </li></ul><ul><li>Visits unrelated to the surgical diagnosis </li></ul><ul><li>Treatment for underlying condition </li></ul><ul><li>Diagnostic tests </li></ul><ul><li>Clearly distinct surgical procedures </li></ul><ul><li>Treatment for postoperative complication which requires return to OR </li></ul><ul><ul><ul><li>Medicare Carriers Manual, Part 3, §4822 </li></ul></ul></ul>
  47. 47. Frequently asked Questions <ul><li>Q. Can a non-physician practitioner order ancillary services? </li></ul><ul><li>A. Yes, if it is in their scope of practice. For a PA or NPP, yes it is allowed. NPP may not supervise diagnostic tests. May order and perform only. </li></ul>
  48. 48. Frequently asked question: Whose name/provider number do we bill under? <ul><li>It depends on the circumstances </li></ul><ul><ul><li>Where is visit conducted? </li></ul></ul><ul><ul><ul><li>In office, can bill incident-to </li></ul></ul></ul><ul><ul><ul><li>In hospital, can bill shared visit </li></ul></ul></ul><ul><ul><ul><li>In nursing facility, must bill under NPP’s provider number </li></ul></ul></ul><ul><ul><ul><li>In home, must bill under NPP’s provider number </li></ul></ul></ul><ul><ul><li>Where is the physician? </li></ul></ul><ul><ul><li>Who employs the NPP? </li></ul></ul>
  49. 49. Frequently asked Questions <ul><li>Q. Can a teaching physician supervise a PA or NP in the same way as a resident? </li></ul><ul><li>A. No. The teaching physician guidelines apply to medical residents only. </li></ul>
  50. 50. Frequently asked Questions <ul><li>Q. What does a physician need to write to document a shared service with a PA or NP? </li></ul><ul><li>A. The physician’s documentation must support a “face-to-face” encounter with the patient and the medical necessity of the physician’s involvement. </li></ul>
  51. 51. Frequently asked Questions <ul><ul><li>Q. What do I write down when I supervise a PA or NP student? </li></ul></ul><ul><li>A. The whole note. The teaching physician guidelines apply to physicians and medical residents only. They do not apply to any other type of trainee. You must perform the entire service and document the service. </li></ul>
  52. 52. Frequently asked Questions <ul><li>Q. Can a PA or NP bill upper level E&M codes, for example 99215? </li></ul><ul><li>A. Yes. A PA or NP can bill any physician service that is within their scope of practice. However, medical necessity is the driver of the level of service not the amount or content of documentation. </li></ul>
  53. 53. Frequently asked Questions <ul><li>Q. Can a NP or PA bill new patient codes? </li></ul><ul><li>A. Yes, except when the service is provided in an office based setting and billed by a physician “incident to”. If a patient has never been seen before, there is no service that a PA or NP can provide that is “incident to” another service. </li></ul>
  54. 54. Web Sites <ul><li>Nurse Practitioners </li></ul><ul><li>Board of Nurse Examiners </li></ul><ul><li>www.bne.state.tx.us/Default.htm </li></ul><ul><li>Texas Nurses Association </li></ul><ul><li>www.texasnurses.org </li></ul><ul><li>Coalition of Nurses in Advance Practice </li></ul><ul><li>www.cnaptexas.org </li></ul><ul><li>Texas Nurse Practitioners </li></ul><ul><li>www.texasnp.org/ </li></ul><ul><li>American Academy of Nurse Practitoners </li></ul><ul><li>www.aanp.org </li></ul>
  55. 55. Web Sites <ul><li>Physician Assistants </li></ul><ul><li>Texas State Board of Medical Examiners www.tsbme.state.tx.us/ </li></ul><ul><li>American Academy of Physician Assistants www.aapa.org </li></ul><ul><li>Texas Academy of Physician Assistants www.tapa.org </li></ul>
  56. 56. Web Sites <ul><li>Physician Assistants </li></ul><ul><li>Texas State Board of Medical Examiners www.tsbme.state.tx.us/ </li></ul><ul><li>American Academy of Physician Assistants www.aapa.org </li></ul><ul><li>Texas Academy of Physician Assistants www.tapa.org </li></ul>
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