Nurse Practitioner Billing Compliance Training
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Nurse Practitioner Billing Compliance Training Presentation Transcript

  • 1.
    • Billing Compliance Education
    • For
    • Nurse Practitioners
  • 2. General Information
    • UCD Health System Policy 1260
      • Nurse Practitioner (NP) Services: Guidelines for Professional Billing
        • http://intranet.ucdmc.ucdavis.edu/policies/hosp/1260.htm
    • Reviewed Annually
      • Revised
        • Changes in Regulations or Billing Policies
        • UC Directives
        • Clarification
  • 3. NP Policy Revision Timeline
    • History
      • 2008
        • Masters Degree Required for all NPs
      • 2007
        • Medi-Cal Co-Signing Restrictions Lifted
      • 2006
        • Expanded Definitions
        • Clarification
      • 2005
        • Minor Changes
      • 2004
        • Shared/Split Visits
      • 2003
        • UCDHS Lifts Complexity Restrictions
        • UCDHS Consultation Policy Revised to Include NPs
        • CMS Requires Masters Degree for all NPs
  • 4. Definitions
    • Types of Clinics
      • Hospital-Based Clinics
        • Operate under license of the hospital
        • Includes all Academic Departments
      • Free-Standing Clinics
        • Do not operate under license of the hospital
        • Primary Care Network Clinics
  • 5. Definitions
    • Billing Components ~ Based on Location
      • Hospital or Hospital-Based Clinic
        • Two Components
          • Professional Fee
          • Technical ( Use of Facility )
      • Free-Standing Clinic
          • One Global Fee
  • 6. Definitions
    • Supervising Physician
      • Fully Licensed Physician
        • MD or DO
        • Not participating in an ACGME, GME or ABMS Program
          • Exception – UCDHS Policy 1928, Teaching Physician Guidelines for Professional Fee Billing, Section IV, Moonlighting Residents or Fellows
  • 7. Definitions
    • Types of Supervision
      • Personal Supervision
        • The physician must be present in the room when the service is provided
      • Direct 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 types of supervision requirements apply whether billing under the name of the NP or supervising physician
  • 8. 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)
    • Supervising NP Services
      • All services billed under a NP provider number require a minimum of “General Supervision” regardless of payer source
      • Pay attention to Type of Supervision Required
        • Payer Specific
      • One supervising physician is not permitted to supervise more than the full-time equivalent of four NPs at any one time
  • 9. Scope of Practice
    • General
      • Governed by rules of RN’s and UCDHS 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 (UCDHS), in accordance with the California Nursing Practice Act
        • Medical Functions Requiring Standardized Procedures
          • 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
  • 10. Scope of Practice
    • California Nursing Practice Act, con’t
        • Medical Functions Requiring Standardized Procedures, con’t
          • 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 UCDHS Inter-Disciplinary Practices Board and the UCDHS Medical Staff Executive Committee
  • 11. Terms
    • Billing Terms
      • “ Incident-to”
        • Medicare term ~ Applies only to Medicare
        • Rule developed to allow services provided by a NP to be billed under the supervising physician’s provider number or allows services provided by a non-physician (RN/MA) to be billed under the NP provider number
        • Setting must be Freestanding/Stand Alone Setting
          • UCDHS Primary Care Clinics
        • Paid at 100% of the physician’s fee schedule for NP services and 85% of the physician’s fee schedule for non-physician services
  • 12. Terms
    • Billing Terms
      • 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
  • 13. Documentation Guidelines
    • Documentation
      • 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 recommend ed that NPs identify their supervising physician in their note
        • Query Process
          • Request For Information (RFI) is a mechanism developed to communicate to healthcare providers when there are questions or additional information is required
          • Charges are held until the RFI is answered
  • 14. Payor Specific Billing Guidelines
    • Medicare - Free-Standing Clinic (PCN)
      • “ Incident-to” Rules
        • Allowed to provide any service within the scope of practice for NP/non physician employee
        • Service must be an integral part of the Physicians/NP professional services
        • Commonly included in a physician/NP bill
        • Commonly furnished in a physician/NP office or clinic
        • Furnished by a NP/non-physician under physician’s/NP’s “ Direct Supervision ”
        • Services must be billed under the name and provider number of the physician or NP providing “Direct Supervision”
          • Name and UPIN of physician or NP providing “Direct Supervision” must be reported on the claim
  • 15. Payor Specific Billing Guidelines
    • Medicare - Free-Standing Clinic (PCN), con’t
      • “ Incident-to” Rules, con’t
        • The supervising physician or supervising NP must personally perform the initial service for each new condition , make an initial diagnosis and set up a treatment plan and thereafter personally perform services of a frequency reflecting their active participation in, and management of the patient’s treatment
      • Caution
        • Free-Standing Clinics only (PCN)
        • Definition of “Direct Supervision”
          • 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
  • 16. Payor Specific Billing Guidelines
    • Medicare - Free-Standing Clinic (PCN), con’t
      • Can bill under NP or Supervising Physician
        • Reimbursement is greater for services billed under the name of the supervising physician
        • If NP is on the UCDHS Cost Report NP cannot submit a professional fee
      • If billing under the Supervising Physician
          • Must meet “Incident-to” rules
      • Services provided by non-physicians (RN/MA) that are “Incident-to” NP services are covered and separately billable under the NP
          • Must meet “Incident-to” rules
  • 17. Payor Specific Billing Guidelines
    • Medicare – Hospital Inpatient or Outpatient, Emergency Room, or Hospital-Based Clinics
      • Must bill under the NP Provider Number
        • Exceptions
          • Split/Shared Visit
          • Must meet Split/Shared Guidelines
        • Reminder - If NP is on the UCDHS Cost Report NP cannot submit a professional fee
  • 18. Payor Specific Billing Guidelines
    • Medicare – Hospital Inpatient or Outpatient, Emergency Room, or Hospital-Based Clinics
      • Split/Shared Visit Guidelines
        • Applies to Evaluation & Management (E/M) Services provided in the hospital (inpatient or outpatient), ER, or hospital-based clinic
        • Must have two separate notes
          • Supervising physician must document some face-to-face portion of the E/M Service
          • NP must document some face-to-face portion of the E/M Service
          • Does not apply to
            • Critical Care Services
            • Consultation Services
            • Surgical Procedures
          • Cannot be used in a Free-Standing Setting (PCN)
  • 19. 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
          • http://files.medical.ca.gov/pubsdoco/publications/masters-MTP/Part2/nonph_m00o03o11.doc
        • Difference between billable and payable
  • 20. Payor Specific Billing Guidelines
    • Commercial & Capitated Plans – All Locations
      • Coverage and reimbursement varies
      • Most carriers cover services billed under the name of the physician providing general supervision
    • 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
  • 21. Consultation Guidelines
    • Consultation Services
      • UCDHS Policy 1924
        • http://intranet.ucdmc.ucdavis.edu/policies/hosp/1924.html
        • The 3 “R”s
          • 2003 - NP can be an appropriate requesting source for a consultation providing the NP has a billing provider number
      • Medicare
        • NP can perform and bill under the NP provider number as long as all other consultation requirements are satisfied
        • Exception – NP on the Hospital Cost Report
      • Medi-Cal
        • NP - prohibited from performing and/or billing any consultation service
      • Commercial & Capitated Plans
        • Coverage varies
  • 22. Modifiers
    • 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 –YT to indicate there are multiple modifiers
      • Workers Compensation
        • When billing NP services for workers compensation, the modifier –98 is required
  • 23.
    • Pay Attention
    • Each Payer has specific rules & guidelines that vary
    • depending on:
      • Type of Service Provided
        • Office Visit
        • Consultation
        • Surgical Procedure
      • Billing and/or Provider Name
        • NP
        • Supervising Physician
      • Setting
        • Hospital-Based Setting
          • Hospital Inpatient or Outpatient
          • Hospital-Based Clinic
          • Emergency Room
        • Free-Standing Setting
          • Primary Care Clinic (PCN)
  • 24. Questions
    • Questions
      • Compliance Issues
        • Code of Conduct
        • HIPAA
          • http://www.ucdmc.ucdavis.edu/compliance/
      • General Coding Education
        • E/M Documentation Requirements
        • UCDHS Audit Tool
          • http://www.ucdmc.ucdavis.edu/cet/resources.
  • 25. Resources
    • Web Resources
    • Medicare
      • www.medicarenhic.com
    • Medi-Cal
      • www.medi-cal.ca.gov
    • Workers’ Compensation
      • www.dir.ca.gov