Nurse Practitioner Billing Compliance Training

3,348 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
3,348
On SlideShare
0
From Embeds
0
Number of Embeds
9
Actions
Shares
0
Downloads
23
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Nurse Practitioner Billing Compliance Training

  1. 1. <ul><li>Billing Compliance Education </li></ul><ul><li>For </li></ul><ul><li>Nurse Practitioners </li></ul>
  2. 2. General Information <ul><li>UCD Health System Policy 1260 </li></ul><ul><ul><li>Nurse Practitioner (NP) Services: Guidelines for Professional Billing </li></ul></ul><ul><ul><ul><li>http://intranet.ucdmc.ucdavis.edu/policies/hosp/1260.htm </li></ul></ul></ul><ul><li>Reviewed Annually </li></ul><ul><ul><li>Revised </li></ul></ul><ul><ul><ul><li>Changes in Regulations or Billing Policies </li></ul></ul></ul><ul><ul><ul><li>UC Directives </li></ul></ul></ul><ul><ul><ul><li>Clarification </li></ul></ul></ul>
  3. 3. NP Policy Revision Timeline <ul><li>History </li></ul><ul><ul><li>2008 </li></ul></ul><ul><ul><ul><li>Masters Degree Required for all NPs </li></ul></ul></ul><ul><ul><li>2007 </li></ul></ul><ul><ul><ul><li>Medi-Cal Co-Signing Restrictions Lifted </li></ul></ul></ul><ul><ul><li>2006 </li></ul></ul><ul><ul><ul><li>Expanded Definitions </li></ul></ul></ul><ul><ul><ul><li>Clarification </li></ul></ul></ul><ul><ul><li>2005 </li></ul></ul><ul><ul><ul><li>Minor Changes </li></ul></ul></ul><ul><ul><li>2004 </li></ul></ul><ul><ul><ul><li>Shared/Split Visits </li></ul></ul></ul><ul><ul><li>2003 </li></ul></ul><ul><ul><ul><li>UCDHS Lifts Complexity Restrictions </li></ul></ul></ul><ul><ul><ul><li>UCDHS Consultation Policy Revised to Include NPs </li></ul></ul></ul><ul><ul><ul><li>CMS Requires Masters Degree for all NPs </li></ul></ul></ul>
  4. 4. Definitions <ul><li>Types of Clinics </li></ul><ul><ul><li>Hospital-Based Clinics </li></ul></ul><ul><ul><ul><li>Operate under license of the hospital </li></ul></ul></ul><ul><ul><ul><li>Includes all Academic Departments </li></ul></ul></ul><ul><ul><li>Free-Standing Clinics </li></ul></ul><ul><ul><ul><li>Do not operate under license of the hospital </li></ul></ul></ul><ul><ul><ul><li>Primary Care Network Clinics </li></ul></ul></ul>
  5. 5. Definitions <ul><li>Billing Components ~ Based on Location </li></ul><ul><ul><li>Hospital or Hospital-Based Clinic </li></ul></ul><ul><ul><ul><li>Two Components </li></ul></ul></ul><ul><ul><ul><ul><li>Professional Fee </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Technical ( Use of Facility ) </li></ul></ul></ul></ul><ul><ul><li>Free-Standing Clinic </li></ul></ul><ul><ul><ul><ul><li>One Global Fee </li></ul></ul></ul></ul>
  6. 6. Definitions <ul><li>Supervising Physician </li></ul><ul><ul><li>Fully Licensed Physician </li></ul></ul><ul><ul><ul><li>MD or DO </li></ul></ul></ul><ul><ul><ul><li>Not participating in an ACGME, GME or ABMS Program </li></ul></ul></ul><ul><ul><ul><ul><li>Exception – UCDHS Policy 1928, Teaching Physician Guidelines for Professional Fee Billing, Section IV, Moonlighting Residents or Fellows </li></ul></ul></ul></ul>
  7. 7. Definitions <ul><li>Types of Supervision </li></ul><ul><ul><li>Personal Supervision </li></ul></ul><ul><ul><ul><li>The physician must be present in the room when the service is provided </li></ul></ul></ul><ul><ul><li>Direct Supervision </li></ul></ul><ul><ul><ul><li>The physician must be present in the office or clinic suite and immediately available </li></ul></ul></ul><ul><ul><li>General Supervision </li></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><li>One of these types of supervision requirements apply whether billing under the name of the NP or supervising physician </li></ul></ul>
  8. 8. Minimum Qualifications <ul><li>Providing NP Services </li></ul><ul><ul><li>Registered Professional Nurse </li></ul></ul><ul><ul><li>Masters Degree </li></ul></ul><ul><ul><li>Currently Licensed in the State of California </li></ul></ul><ul><ul><ul><li>Nurse Practitioner (NP) </li></ul></ul></ul><ul><ul><ul><li>Family Nurse Practitioner (FNP) </li></ul></ul></ul><ul><ul><ul><li>Pediatric Nurse Practitioner (PNP) </li></ul></ul></ul><ul><li>Supervising NP Services </li></ul><ul><ul><li>All services billed under a NP provider number require a minimum of “General Supervision” regardless of payer source </li></ul></ul><ul><ul><li>Pay attention to Type of Supervision Required </li></ul></ul><ul><ul><ul><li>Payer Specific </li></ul></ul></ul><ul><ul><li>One supervising physician is not permitted to supervise more than the full-time equivalent of four NPs at any one time </li></ul></ul>
  9. 9. Scope of Practice <ul><li>General </li></ul><ul><ul><li>Governed by rules of RN’s and UCDHS credentialing requirements </li></ul></ul><ul><li>California Nursing Practice Act </li></ul><ul><ul><li>Allows NP to provide certain medical functions in addition to nursing </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><ul><li>Medical Functions Requiring Standardized Procedures </li></ul></ul></ul><ul><ul><ul><ul><li>Any function that is not commonly recognized as a nursing practice and that requires the NP to </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Diagnose Disease </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Furnish Medicine </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Furnish Treatment </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Penetrate or Sever Tissue </li></ul></ul></ul></ul></ul>
  10. 10. Scope of Practice <ul><li>California Nursing Practice Act, con’t </li></ul><ul><ul><ul><li>Medical Functions Requiring Standardized Procedures, con’t </li></ul></ul></ul><ul><ul><ul><ul><li>NP is allowed to furnish Schedule II-V Drugs with a Standardized Procedure </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Drugs must be consistent with the NP educational preparation </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Clinical competency has been established and maintained </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>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 </li></ul></ul></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul>
  11. 11. Terms <ul><li>Billing Terms </li></ul><ul><ul><li>“ Incident-to” </li></ul></ul><ul><ul><ul><li>Medicare term ~ Applies only to Medicare </li></ul></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><ul><li>Setting must be Freestanding/Stand Alone Setting </li></ul></ul></ul><ul><ul><ul><ul><li>UCDHS Primary Care Clinics </li></ul></ul></ul></ul><ul><ul><ul><li>Paid at 100% of the physician’s fee schedule for NP services and 85% of the physician’s fee schedule for non-physician services </li></ul></ul></ul>
  12. 12. Terms <ul><li>Billing Terms </li></ul><ul><ul><li>Split/Shared Visit </li></ul></ul><ul><ul><ul><li>Another Medicare term ~ Applies to Evaluation & Management (E/M) Services only </li></ul></ul></ul><ul><ul><ul><li>Rule allows documentation from the physician and NP note to be combined </li></ul></ul></ul><ul><ul><ul><li>Setting must be Hospital-Based </li></ul></ul></ul><ul><ul><ul><ul><li>Hospital Inpatient or Outpatient, Emergency Room & Hospital-Based Clinics </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Requires </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Two separate notes </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>NP AND supervising physician face-to-face time </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Consultations, Critical Care and Surgical Procedures are Exempt and Cannot use this Rule </li></ul></ul></ul></ul>
  13. 13. Documentation Guidelines <ul><li>Documentation </li></ul><ul><ul><li>All Payers </li></ul></ul><ul><ul><ul><li>EMR and/or Chart </li></ul></ul></ul><ul><ul><ul><ul><li>All services ordered and provided by the NP are to be personally documented, signed and dated </li></ul></ul></ul></ul><ul><ul><ul><ul><li>For billing purposes , it is strongly recommend ed that NPs identify their supervising physician in their note </li></ul></ul></ul></ul><ul><ul><ul><li>Query Process </li></ul></ul></ul><ul><ul><ul><ul><li>Request For Information (RFI) is a mechanism developed to communicate to healthcare providers when there are questions or additional information is required </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Charges are held until the RFI is answered </li></ul></ul></ul></ul>
  14. 14. Payor Specific Billing Guidelines <ul><li>Medicare - Free-Standing Clinic (PCN) </li></ul><ul><ul><li>“ Incident-to” Rules </li></ul></ul><ul><ul><ul><li>Allowed to provide any service within the scope of practice for NP/non physician employee </li></ul></ul></ul><ul><ul><ul><li>Service must be an integral part of the Physicians/NP professional services </li></ul></ul></ul><ul><ul><ul><li>Commonly included in a physician/NP bill </li></ul></ul></ul><ul><ul><ul><li>Commonly furnished in a physician/NP office or clinic </li></ul></ul></ul><ul><ul><ul><li>Furnished by a NP/non-physician under physician’s/NP’s “ Direct Supervision ” </li></ul></ul></ul><ul><ul><ul><li>Services must be billed under the name and provider number of the physician or NP providing “Direct Supervision” </li></ul></ul></ul><ul><ul><ul><ul><li>Name and UPIN of physician or NP providing “Direct Supervision” must be reported on the claim </li></ul></ul></ul></ul>
  15. 15. Payor Specific Billing Guidelines <ul><li>Medicare - Free-Standing Clinic (PCN), con’t </li></ul><ul><ul><li>“ Incident-to” Rules, con’t </li></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><li>Caution </li></ul></ul><ul><ul><ul><li>Free-Standing Clinics only (PCN) </li></ul></ul></ul><ul><ul><ul><li>Definition of “Direct Supervision” </li></ul></ul></ul><ul><ul><ul><ul><li>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 </li></ul></ul></ul></ul>
  16. 16. Payor Specific Billing Guidelines <ul><li>Medicare - Free-Standing Clinic (PCN), con’t </li></ul><ul><ul><li>Can bill under NP or Supervising Physician </li></ul></ul><ul><ul><ul><li>Reimbursement is greater for services billed under the name of the supervising physician </li></ul></ul></ul><ul><ul><ul><li>If NP is on the UCDHS Cost Report NP cannot submit a professional fee </li></ul></ul></ul><ul><ul><li>If billing under the Supervising Physician </li></ul></ul><ul><ul><ul><ul><li>Must meet “Incident-to” rules </li></ul></ul></ul></ul><ul><ul><li>Services provided by non-physicians (RN/MA) that are “Incident-to” NP services are covered and separately billable under the NP </li></ul></ul><ul><ul><ul><ul><li>Must meet “Incident-to” rules </li></ul></ul></ul></ul>
  17. 17. Payor Specific Billing Guidelines <ul><li>Medicare – Hospital Inpatient or Outpatient, Emergency Room, or Hospital-Based Clinics </li></ul><ul><ul><li>Must bill under the NP Provider Number </li></ul></ul><ul><ul><ul><li>Exceptions </li></ul></ul></ul><ul><ul><ul><ul><li>Split/Shared Visit </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Must meet Split/Shared Guidelines </li></ul></ul></ul></ul><ul><ul><ul><li>Reminder - If NP is on the UCDHS Cost Report NP cannot submit a professional fee </li></ul></ul></ul>
  18. 18. Payor Specific Billing Guidelines <ul><li>Medicare – Hospital Inpatient or Outpatient, Emergency Room, or Hospital-Based Clinics </li></ul><ul><ul><li>Split/Shared Visit Guidelines </li></ul></ul><ul><ul><ul><li>Applies to Evaluation & Management (E/M) Services provided in the hospital (inpatient or outpatient), ER, or hospital-based clinic </li></ul></ul></ul><ul><ul><ul><li>Must have two separate notes </li></ul></ul></ul><ul><ul><ul><ul><li>Supervising physician must document some face-to-face portion of the E/M Service </li></ul></ul></ul></ul><ul><ul><ul><ul><li>NP must document some face-to-face portion of the E/M Service </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Does not apply to </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Critical Care Services </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Consultation Services </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Surgical Procedures </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Cannot be used in a Free-Standing Setting (PCN) </li></ul></ul></ul></ul>
  19. 19. Payor Specific Billing Guidelines <ul><li>Medi-Cal – All Locations </li></ul><ul><ul><li>FNP and PNP </li></ul></ul><ul><ul><ul><li>Allowed to bill under their own name for any services provided within their scope of practice </li></ul></ul></ul><ul><ul><li>NP </li></ul></ul><ul><ul><ul><li>Must bill under their supervising physician name </li></ul></ul></ul><ul><ul><ul><li>There are specific HCPCS, CPT-4 and Medi-Cal only codes (NP only) </li></ul></ul></ul><ul><ul><ul><li>For a list of these codes go to </li></ul></ul></ul><ul><ul><ul><ul><li>http://files.medical.ca.gov/pubsdoco/publications/masters-MTP/Part2/nonph_m00o03o11.doc </li></ul></ul></ul></ul><ul><ul><ul><li>Difference between billable and payable </li></ul></ul></ul>
  20. 20. Payor Specific Billing Guidelines <ul><li>Commercial & Capitated Plans – All Locations </li></ul><ul><ul><li>Coverage and reimbursement varies </li></ul></ul><ul><ul><li>Most carriers cover services billed under the name of the physician providing general supervision </li></ul></ul><ul><li>Workers Compensation – All Locations </li></ul><ul><ul><li>NP may provide services to workers’ compensation patients </li></ul></ul><ul><ul><li>NP may not: </li></ul></ul><ul><ul><ul><li>Initiate new treatment </li></ul></ul></ul><ul><ul><ul><li>Report on an injured workers’ entitlement to benefits </li></ul></ul></ul><ul><ul><ul><li>Change the Primary Treating Physician (PTP) treatment plan </li></ul></ul></ul>
  21. 21. Consultation Guidelines <ul><li>Consultation Services </li></ul><ul><ul><li>UCDHS Policy 1924 </li></ul></ul><ul><ul><ul><li>http://intranet.ucdmc.ucdavis.edu/policies/hosp/1924.html </li></ul></ul></ul><ul><ul><ul><li>The 3 “R”s </li></ul></ul></ul><ul><ul><ul><ul><li>2003 - NP can be an appropriate requesting source for a consultation providing the NP has a billing provider number </li></ul></ul></ul></ul><ul><ul><li>Medicare </li></ul></ul><ul><ul><ul><li>NP can perform and bill under the NP provider number as long as all other consultation requirements are satisfied </li></ul></ul></ul><ul><ul><ul><li>Exception – NP on the Hospital Cost Report </li></ul></ul></ul><ul><ul><li>Medi-Cal </li></ul></ul><ul><ul><ul><li>NP - prohibited from performing and/or billing any consultation service </li></ul></ul></ul><ul><ul><li>Commercial & Capitated Plans </li></ul></ul><ul><ul><ul><li>Coverage varies </li></ul></ul></ul>
  22. 22. Modifiers <ul><li>Modifiers </li></ul><ul><ul><li>Medi-Cal/GMC </li></ul></ul><ul><ul><ul><li>When billing under the name of the FNP or PNP no special modifiers are required </li></ul></ul></ul><ul><ul><ul><li>When billing NP services including FNP and PNP, under the name of the supervising physician the modifier -SA is required </li></ul></ul></ul><ul><ul><ul><li>When there are multiple modifiers selected, the Billing System automatically assigns the modifier –YT to indicate there are multiple modifiers </li></ul></ul></ul><ul><ul><li>Workers Compensation </li></ul></ul><ul><ul><ul><li>When billing NP services for workers compensation, the modifier –98 is required </li></ul></ul></ul>
  23. 23. <ul><li>Pay Attention </li></ul><ul><li>Each Payer has specific rules & guidelines that vary </li></ul><ul><li>depending on: </li></ul><ul><ul><li>Type of Service Provided </li></ul></ul><ul><ul><ul><li>Office Visit </li></ul></ul></ul><ul><ul><ul><li>Consultation </li></ul></ul></ul><ul><ul><ul><li>Surgical Procedure </li></ul></ul></ul><ul><ul><li>Billing and/or Provider Name </li></ul></ul><ul><ul><ul><li>NP </li></ul></ul></ul><ul><ul><ul><li>Supervising Physician </li></ul></ul></ul><ul><ul><li>Setting </li></ul></ul><ul><ul><ul><li>Hospital-Based Setting </li></ul></ul></ul><ul><ul><ul><ul><li>Hospital Inpatient or Outpatient </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hospital-Based Clinic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Emergency Room </li></ul></ul></ul></ul><ul><ul><ul><li>Free-Standing Setting </li></ul></ul></ul><ul><ul><ul><ul><li>Primary Care Clinic (PCN) </li></ul></ul></ul></ul>
  24. 24. Questions <ul><li>Questions </li></ul><ul><ul><li>Compliance Issues </li></ul></ul><ul><ul><ul><li>Code of Conduct </li></ul></ul></ul><ul><ul><ul><li>HIPAA </li></ul></ul></ul><ul><ul><ul><ul><li>http://www.ucdmc.ucdavis.edu/compliance/ </li></ul></ul></ul></ul><ul><ul><li>General Coding Education </li></ul></ul><ul><ul><ul><li>E/M Documentation Requirements </li></ul></ul></ul><ul><ul><ul><li>UCDHS Audit Tool </li></ul></ul></ul><ul><ul><ul><ul><li>http://www.ucdmc.ucdavis.edu/cet/resources. </li></ul></ul></ul></ul>
  25. 25. Resources <ul><li>Web Resources </li></ul><ul><li>Medicare </li></ul><ul><ul><li>www.medicarenhic.com </li></ul></ul><ul><li>Medi-Cal </li></ul><ul><ul><li>www.medi-cal.ca.gov </li></ul></ul><ul><li>Workers’ Compensation </li></ul><ul><ul><li>www.dir.ca.gov </li></ul></ul>

×