Billing Compliance Education

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• Billing Compliance Education
• For
• Nurse Practitioners

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General Information

• UCD Health System Policy 1260
• Nurse Practitioner (NP) Services Guidelines for
  Professional Billing
• http//intranet.ucdmc.ucdavis.edu/policies/hosp/12
  60.htm
• Reviewed Annually
• Revised
• Changes in Regulations or Billing Policies
• UC Directives
• Clarification

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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

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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

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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

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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

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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 physicians overall
  direction and control, but the physicians
  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

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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

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Scope of Practice

• General
• Governed by rules of RNs 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

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Scope of Practice

• California Nursing Practice Act, cont
• Medical Functions Requiring Standardized
  Procedures, cont
• 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

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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 physicians
  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 physicians fee schedule for
  NP services and 85 of the physicians fee
  schedule for non-physician services

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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

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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 recommended
  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

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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
  physicians/NPs 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

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Payor Specific Billing Guidelines

• Medicare - Free-Standing Clinic (PCN), cont
• Incident-to Rules, cont
• 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
  patients 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

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Payor Specific Billing Guidelines

• Medicare - Free-Standing Clinic (PCN), cont
• 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

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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

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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)

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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

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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

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Consultation Guidelines

• Consultation Services
• UCDHS Policy 1924
• http//intranet.ucdmc.ucdavis.edu/policies/hosp/19
  24.html
• The 3 Rs
• 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

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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

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• 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)

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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.

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Resources

• Web Resources
• Medicare
• www.medicarenhic.com
• Medi-Cal
• www.medi-cal.ca.gov
• Workers Compensation
• www.dir.ca.gov