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  1. 1. School of Medicine Compliance Heather Scott May 16, 2007 Billing Non-physician Provider Services
  2. 2. Things to Consider… <ul><li>Employment </li></ul><ul><li>License </li></ul><ul><li>Payer </li></ul><ul><li>Involvement of physician </li></ul>
  3. 3. General Principles <ul><li>NC law requires payers to reimburse certain non-physician services </li></ul><ul><ul><li>How it is paid is based on payer </li></ul></ul><ul><li>Scope of practice </li></ul><ul><li>No physician co-signature required </li></ul><ul><li>No supervision of residents for Medicare and Medicaid </li></ul>
  4. 4. Employment criteria <ul><li>Salary support from physician practice. </li></ul><ul><ul><li>Percentage of salary = billable time </li></ul></ul><ul><ul><li>Direct or “incident to” billing </li></ul></ul><ul><ul><li>Exceptions for some specially designated funding </li></ul></ul><ul><li>Not included on Hospitals cost reports </li></ul>
  5. 5. Medicare in the Inpatient Setting <ul><li>Licensed non-physicians that may bill Medicare directly </li></ul><ul><ul><li>Nurse Practitioner </li></ul></ul><ul><ul><li>Physician Assistant </li></ul></ul><ul><ul><li>Clinical Nurse Specialist </li></ul></ul><ul><ul><li>Clinical Psychologist </li></ul></ul><ul><li>Reimbursed at 85% of the physician allowable </li></ul><ul><li>Services of non-physicians ineligible to bill directly are not reimbursable via Part B </li></ul>
  6. 6. Medicare Shared Visit Option <ul><li>NPP and MD make individual evaluations on the same day </li></ul><ul><ul><li>Each documents his service </li></ul></ul><ul><ul><ul><li>May bill in MD’s name combining notes for level for established patients and problems </li></ul></ul></ul><ul><ul><ul><li>May not bill consults </li></ul></ul></ul><ul><ul><ul><li>“ Shared” initial evaluations billed in NPP’s name </li></ul></ul></ul><ul><ul><ul><li>Rules are currently being reconsidered by Medicare </li></ul></ul></ul><ul><ul><li>Physician must document detail beyond a resident attestation </li></ul></ul><ul><li>NPP collaboration with an MD makes service billable as subsequent daily care, even without an MD note </li></ul>
  7. 7. “Incident to” Billing Principles <ul><li>Option for billing non-physician provider services to Medicare outpatients and Medicaid patients </li></ul><ul><li>The billing provider (usually a physician) is the only named provider on the bill </li></ul><ul><li>The third party payer does not know who rendered the service </li></ul><ul><li>The billing provider and supervising physician retain liability for all “incident to” services </li></ul>
  8. 8. “Incident to” - Medicare <ul><li>“ Incident to” services may not be billed in an inpatient setting or hospital-based clinic </li></ul><ul><li>The billing provider must perform and document the initial visit </li></ul><ul><ul><li>Thereafter, if the NPP is eligible to bill Medicare directly, the billing provider must </li></ul></ul><ul><ul><ul><li>become involved when changes occur and </li></ul></ul></ul><ul><ul><ul><li>perform subsequent services at a frequency which reflects his continuing involvement in the management of the patient </li></ul></ul></ul><ul><ul><li>For NPPs not eligible to bill directly, </li></ul></ul><ul><ul><ul><li>E&Ms may not exceed nurse visit level </li></ul></ul></ul><ul><ul><ul><li>Billing provider must perform/document every third service </li></ul></ul></ul>
  9. 9. <ul><li>No site limitations for “incident to” services </li></ul><ul><li>No difference in reimbursement (excepting mental health professions) </li></ul><ul><li>For NPs, PAs and CNMs </li></ul><ul><ul><li>No requirement for an initial evaluation </li></ul></ul><ul><ul><li>Direct supervision by billing provider </li></ul></ul><ul><ul><ul><li>available by telephone or pager </li></ul></ul></ul><ul><ul><ul><li>have a preexisting plan for emergencies </li></ul></ul></ul><ul><li>For other non-physician providers, the billing provider must </li></ul><ul><ul><li>Perform and document the initial visit </li></ul></ul><ul><ul><li>Be involved when changes occur </li></ul></ul><ul><ul><li>perform subsequent services at a frequency which reflects the billing provider’s continuing involvement in the treatment and management of the patient </li></ul></ul>“Incident to” - Medicaid
  10. 10. No “incident to” for commercial <ul><li>The concept of “incident to” billing does not exist for commercial, managed care and other third party payers </li></ul><ul><li>Billing providers may work with NPPs as appropriate to the situation </li></ul><ul><li>Must meet the standard of care </li></ul><ul><li>Patient satisfaction is always important </li></ul><ul><li>Signature always required for PAs </li></ul>
  11. 11. Direct Billing - Medicare <ul><li>Clinical psychologists, clinical nurse specialists, nurse practitioners and physician assistants may obtain a billing number and bill Medicare directly </li></ul><ul><li>May bill for anything within the state-determined scope of practice at any site </li></ul><ul><li>Generally pays 85% of physician reimbursement </li></ul><ul><li>No physician signature requirements for Medicare; however the state requires a physician signature for all PA services </li></ul>
  12. 12. Direct Billing - Medicaid <ul><li>Clinical psychologists, clinical nurse specialists, nurse practitioners, and nurse midwives, and certain other NPPs may obtain a billing number and bill Medicaid directly </li></ul><ul><li>May bill for anything within their state-determined scope of practice at any site </li></ul><ul><li>Pays 100% of physician reimbursement </li></ul>
  13. 13. Direct Billing - Medicaid <ul><li>Clinical psychologists and other non-psychiatrists cannot treat and bill Medicaid for mental health services to patients over 20 </li></ul><ul><li>PAs cannot obtain a Medicaid billing number and cannot bill directly </li></ul><ul><li>No physician signature requirements for direct billing by NPPs </li></ul>
  14. 14. Direct Billing - Commercial <ul><li>Most commercial carriers and managed care organizations do not accept direct billings by NPPs </li></ul>
  15. 15. Where To Get Help <ul><li>School of Medicine Compliance Office 843-8638 </li></ul><ul><ul><li>Heather Scott, CPC, Compliance Auditor </li></ul></ul><ul><ul><li>Wendy Smith, CPC, Compliance Auditor </li></ul></ul><ul><ul><li>Charles Foskey, Compliance Officer </li></ul></ul><ul><ul><li>Chris Agosto, Office Manager </li></ul></ul><ul><li>Confidential Help Line 800-362-2921 </li></ul>
  16. 16. In closing… <ul><li>Congratulations on recognition and increased independence </li></ul><ul><li>NPPs have increased responsibility for knowing state rules governing their respective practices </li></ul><ul><li>NPPs have increased responsibility for knowing insurance-specific billing rules </li></ul><ul><li>Leadership and communication are critical </li></ul>
  17. 17. Proper Teaching Physician Attestation <ul><li>Document seeing and/or examining patient </li></ul><ul><li>Refer to resident’s note </li></ul><ul><li>Make a summary comment about the history </li></ul><ul><li>Comment on the physical exam </li></ul><ul><li>Comment on medical decision making </li></ul><ul><ul><li>Only 2 of 3 areas need noting for established patients </li></ul></ul>
  18. 18. Teaching Physician Attestation <ul><li>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.” </li></ul>
  19. 19. 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.”