Understanding Medicare Billing Issues

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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

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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

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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.

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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 physicians name

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Incident To

• Office only
• Billed under the physicians name
• Doctor must be in the office suite at the time
  - document I was present in the office suite
  when the service was provided__________________(si
  gnature)
• Contact by telephone or the MDs presence
  somewhere else in the building is not sufficient
  
  within human voice distance
  

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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

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Incident To

• What EM codes can be billed for incident to
  services?
• If ancillary personnel other than a Nurse
  Practitioner or Physician Assistant perform
  incident to services only 99211 can be billed

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What Is the Physicians 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
  providers active participation in the patients
  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 employees work and the physicians service.

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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.

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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
• www.trailblazerhealth.com/Publications/Training20
  Manual/incident_to.pdf

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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 eithers name
• The physician should reference the NPPs note in
  his/her documentation if billing in the MDs name
• The NP should reference the MD documentation if
  billing in the NPPs name

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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 MDs name

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NPP

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

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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.

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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 professionals knowledge.

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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.

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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

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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 physicians own management of, or
  decision making about, the patient.

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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 patients 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.

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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 (9923199233) should be reported for
  additional follow-up services.

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Consultations

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

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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 consultants
  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.

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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
  patients condition required a significant,
  identifiable E/M service

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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

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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.

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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
  physicians fee, the fee schedule or the price
  paid for the service.

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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.

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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)

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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.

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Purchased Diagnostic Tests

• A physicians office cannot purchase a diagnostic
  test from a lab
• If a physicians 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. 

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Questions?