NonPhysician Practitioners Documentation and Billing March 2005

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Non-Physician PractitionersDocumentation and
BillingMarch 2005

• Terry L. ReevesExec. Director of Institutional
  Compliance

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What can they do?

• Services as outlined by state law. The scope of
  practice and the reimbursement methodologies are
  all established by state law.
• Normally outlined in the Texas Occupation Code
  and in the Rules and Regulations of the Board
  Governing that profession.

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What can they do?

• Nurse Practitioner
• Physician Services
• Defined by their Scope of Practice as stated in
  state law BNE Rules 221.12
• Limited prescriptive authority
• Cannot supervise diagnostic testsSSA 1861 (r)

• Physician Assistant
• Physician Services
• Defined by their Scope of Practice as stated in
  state law TSBME Board Rules 185.11
• Limited prescriptive authority
• Cannot supervise diagnostic tests SSA 1861 (r)

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Who licenses and governs them?

• Nurse Practitioner
• Board of Nurse Examiners for the State of Texas
  (BNE)
• Some references to the TSBME for prescriptive
  authority
• Various specialty organizations
• UTMB Nursing Service

• Physician Assistant
• Texas State Board of Medical Examiners (TSBME)
• Texas State Board of Physician Assistant
  Examiners
• UTMB Medical Staff Office

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Where can a non-physician practitioner perform
services?

• Nurse Practitioner
• In all settings
• Inpatient hospital
• Outpatient
• SNF
• Patients Home
• Nursing Home
• Hospices

• Physician Assistant
• In all settings
• Inpatient hospital
• Outpatient
• SNF
• Patients Home
• Nursing Home
• Hospices

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Legal authority to bill for physician services
performed by NPPs

• Medicare
• Authority comes from 42 U.S.C.1395x(s)(K)
• Medicaid
• Authority comes from 42 C.F.R. 440.166

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What has to be in place for Medicare
reimbursement?

• No other entity is billing or receiving payment
  for that service
• 42 CFR 410.74 PAs
• 42 CFR 410.75 NPs
• Medicare covers the service
• The billing entity follows the rules for
  physician services
• NPP codes and documents in accordance with CPT
  and CMS documentation guidelines

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Are protocols required?

• Nurse Practitioner
• Yes
• Section 221 .1 (12) Rules and Regulations of BNE
• TMHP Texas Medicaid Provider Procedures Manual
  34.3

• Physician Assistant
• Yes
• Texas State Board of Medical Examiners (TSBME)
• TMHP Texas Medicaid Provider Procedures Manual
  34.3

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Documentation of Collaboration

• Nurse Practitioners
• 42 CFR 410.75 3 (c) (ii). Such collaboration is
  to be evidenced by nurse practitioners
  documenting the nurse practitioners scope of
  practice and indicating the relationships that
  they have with physicians to deal with issues
  outside their scope of practice.

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What are Protocols?

• Nurse Practitioners
• Written authorization to provide medical aspects
  of patient care which are agreed upon and signed
  by the advanced practice nurse and the physician,
  reviewed and signed at least annually, and
  maintained in the practice setting of the
  advanced practice nurse. Protocols or other
  written authorization shall be defined to promote
  the exercise of professional judgment by the
  advanced practice nurse commensurate with his/her
  education and experience.

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What are Protocols? (continued)

• Nurse Practitioners (continued)
• Such protocols or other written authorization
  need not describe the exact steps that the
  advanced practice nurse must take with respect to
  each specific condition, disease, or symptom and
  may state types or categories of drugs which may
  be prescribed rather than just life specific
  drugs.

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What are Protocols? (continued)

• Physicians Assistants
• TMHP 2005 Texas Medicaid Provider Procedures
  Manual 34.3
• requires protocols.

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What are Protocols? (continued)

• Physicians Assistants
• It is the obligation of each team of
  physician(s) and PAs to ensure that
• The PAs scope of practice is identified
• delegation of medical tasks is appropriate to the
  PAs level of competence
• the relationship between the members of the team
  is defined that the relationship of, and access
  to, the supervising physician is defined

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What are Protocols? (continued)

• Physicians Assistants (continued)
• a process for evaluation of the PAs performance
  is established and
• The PAs annual registration is current.

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Provider-based facility vs.Office-based facility

• Provider-Based facility
• Designation is determined by CMS
• Patient receives two bills hospital and a
  professional fee bill
• Hospitals bill DRGs for inpatient services and
  APCs for outpatient services.
• Certain clinics are designated as provider-based

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Provider-based facility vs.Office-based facility

• Office-based facility
• Designation if not provider based then you are
  office-based.
• Patient one bill a professional fee bill
• Office-based clinic bills the RBRVU associated
  with the CPT code for a non-facility.
• Global or both TC and CPT code are billed.

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Medicare ReimbursementProvider-based facility

• Nurse Practitioner and Physician Assistants
• Both receive Medicare Provider numbers
• Billed in the PA or NP name and provider number
• Reimbursed at 85 of the fee schedule
• Supervision requirements are as stated in state
  law
• Documentation requirements are same as a stand
  alone note for an attending

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Medicare ReimbursementProvider-based facility

• Incident to billing
• Incident to billing is expressly prohibited in
  any provider-based setting.

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Medicare- Shared/Split Service

• Effective October 2002, Medicare recognizes a
  shared service for place of service
• Hospital Inpatient
• Hospital Outpatient
• Emergency Department
• when the E/M is shared between the NPP and the
  physician AND

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Medicare Shared Service

• The physician documents a face-to-face
  encounter with the patient
• AND
• Medical necessity for the physicians involvement
  in the service.

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Medicare ReimbursementOffice-based facility

• Nurse Practitioner and Physician Assistants
• May bill either in the name of the PA or NP using
  their provider number
• or
• Bill incident to i.e., in the name of the
  physician.
• incident to billing is reimbursed at 100 of
  the fee schedule.

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Medicare ReimbursementIncident to Billing

• What is incident to billing?
• Incident to refers to services or perhaps items
  provided after or in relation to a professional
  service that has already been provided by a
  physician.
• Services of other healthcare professionals
  provided to a most commonly in an outpatient
  setting.

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Medicare ReimbursementIncident to Billing
(continued)

• Requirements for incident to billing
• PA or NP must be an employee of the physician
  (for UTMB paid by MSRDP)
• Initial visit must be performed by the physician.
• Direct supervision Physician must be in the
  office and immediately available to assist.
• Physician has an active part in the ongoing care
  of the patient. Subsequent services by the
  physician must be of a frequency that reflects
  continuing active participation in, and
  management of the course of treatment.

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Medicare ReimbursementIncident to Billing
(continued)

• Requirements for incident to billing.
• Service is typically performed in a physicians
  office
• Billed on the claim as if the billing physician
  had provided the services.
• Cannot bill incident to for inpatient services.

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Medicaid Reimbursement

• Legal References
• Texas Administrative Code
• 25 TAC Section 29.502
• TMHP Texas Medicaid Provider Procedures Manual
  (2005)
• Section 34.3 Benefits and Limitations

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Medicaid Reimbursement

• Nurse Practitioner
• Option 1 Direct Billing 85 of fee schedule
• NPs may apply for individual provider numbers
  for direct billing purposes. All covered
  services rendered may be billed using the NPs
  direct provider number.
• Option 2 As a physician service
• A NP may provide services as a physician
  service using the physicians provider number
  when the physician provides administrative
  supervision and a SA modifier is used on the
  CPT codes

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Medicaid Reimbursement

• Physician Assistant
• Option 1 As a physician service
• A PA may provide services as a physician
  service using the physicians provider number
  when the physician provides administrative
  supervision and a U7 modifier is used on the
  CPT codes
• This is the only option for a PA under Medicaid

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Medicaid Reimbursement

• Supervision Requirements
• Medicaid does not require direct or personal
  supervision of the NP or PA in the clinic.
  Medicaid does require administrative
  supervision which is defined as
• The supervision of a PA or an APN must be
  delivered according to protocols developed
  jointly with the physician and must be in
  accordance with the scope of practice and state
  law governing PAs and APNs.
• Settings
• No limitations
• Cant double bill or double dip

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Other third party Reimbursement

• Private insurers generally cover medical services
  provided by PAs or NPs when they are included as
  part of the physicians bill or as part of a
  global fee for surgery, i.e. Incident to.
• Other third party insurers normally require that
  the providers be credentialed and enrolled as a
  provider with that insurer.

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Medicare and MedicaidDocumentation Requirements

• Same as a stand alone note for teaching
  physician or attending
• Meet key component requirements
• Medical necessity
• Chief complaint
• History, physical exam, decision-making
• 3 out of 3 for new patient
• 2 out of 3 for established patient
• Personal involvement should be obvious
• Sign, date, and time the note
• A NP or PA may not supervise a resident

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Example 1

• Physician employs NPP, who visits hospitalized
  patient
• NPP performs CPT 99232
• expanded problem-focused interval history
• expanded problem-focused exam
• medical decision-making of moderate complexity
• MD visits patient (face-to-face) later that day
• MD may bill 99232 or 99233 (depending on how much
  evaluation/management physician performs) under
  the MDs provider number, under shared billing
  rules. See Medicare Carriers Manual, Part 3,
  15501

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Example 2

• Same scenario, except physician is away and does
  not visit the patient
• MD may bill CPT 99232 but must bill under the
  NPPs provider number
• See Medicare Carriers Manual, Part 3, 15501

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Shared/split EM service

• NPPs and MDs may conduct and bill "shared" visits
  to
• inpatients, ER patients, outpatients
• May bill under MD's number if the MD provides any
  face-to-face service that day and they are
  employees of the same group practice
• Medicare Carriers Manual, Part 3, 15501

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Example 3

• MD employs NPP (or members of same gp)
• NPP conducts a follow-up office visit (CPT 99214)
  for a patient MD has diagnosed with diabetes
• MD is in the suite of offices
• MD may bill CPT 99212 to 99215 under the MDs
  provider number, under incident-to rules
• Medicare Carriers Manual, Part 3, 2050.1

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Example 4

• Same scenario, except patient has a new problem
  in addition to diabetes
• Choices
• Bill the visit under the NPPs provider number
• Have the patient see the MD for initial service
  re the new problem
• Bill the service for the diabetes under the MDs
  provider number, dont bill for the NPPs work on
  the new problem
• Source Carrier web site
• http//www.noridianmedicare.com/provider/pubs/med_
  b/news/
• iowa/1097.html

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Medicare and MedicaidDocumentation Requirements

• Same as a stand alone note for teaching
  physician or attending
• Meet key component requirements
• Medical necessity
• Chief complaint
• History, physical exam, decision-making
• 3 out of 3 for new patient
• 2 out of 3 for established patient
• Personal involvement should be obvious
• Sign, date, and time the note

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Questions for hospital wanting to bill services
of NPP employee to Medicare

• Are private physicians already billing for the
  NPPs services?
• Is the NPP's salary on the cost report?
• If not, hospital may bill NPP's services
• If so, does the hospital receive any payments
  from Medicare based on the cost report?
• If so, hospital may not bill NPP's service to
  Medicare

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Note that

• Under Medicares conditions of participation for
  hospitals, the care of hospitalized patients must
  be directed by a doctor of medicine, dentistry,
  podiatry or clinical psychology
• But MDs can delegate responsibilities to non-MDs
• 42 CFR 482.12

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Example 5

• E.F., a 65-year-old woman, admitted yesterday to
  medicine unit with diagnosis bilateral pneumonia
• Medicine team's NPP evaluates and manages E.F
  today through discharge. 50 of NPP's salary is
  paid by hospital. The hospital receives
  compensation from Medicare under its cost report.
• Can NPP bill CPT 99231 daily until discharge? No.

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Example 6

• Same scenario (E.F., a 65-year-old woman,
  admitted yesterday to inpatient medicine unit for
  bilateral pneumonia)
• NPP works for private MD Jones.
• If NPP provides daily visits, can NPP bill CPT
  99231 daily until discharge? Yes.

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Example 7

• E.F. (same patient) c/o HA, visual disturbances.
  Medicine's NPP orders CT. Impression tumor. NPP
  refers pt. to neurosurgery team for consultation
• NPP employed by neurosurgery team does
  comprehensive HP, reviews CT, discusses findings
  with E.F. medicine, orders MRI, tx. (Time
  spent 80 minutes).
• Does neurosurgery NPP bill a consultation? CPT?
  99254 Yes.

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Example 8

• Neurosurgery NPP discusses E.F. with attending on
  rounds. MD reviews CT scans, MRI, does focused
  exam, discusses diagnosis and treatment options
  with E.F., family and PCP. (Time spent 40
  minutes).
• What CPT would MD bill? 99252
• Could NPP bill 99254 and MD bill 99252? No
• Make a choice-- bill 99254 and get 85 or bill
  99252 and get 100
• Or, as per shared billing rules, bill 99255
  under MD's number.

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Example 9

• E.F. goes to surgery 6 weeks later.
• Neurosurgeon bills 61607 (resection of neoplastic
  lesion of cavernous sinus)
• Can neurosurgery NPP bill 99231 for post-op
  visits? No.
• If E.F. develops Herpes Zoster on post-op day 3,
  can NPP bill 99231? Yes.

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Global fee for surgery

• What is included depends on the surgery
• Major
• Minor
• Diagnostic procedures may have tasks bundled into
  the fee, or may not
• Consult CPT and the Medicare Carriers Manual for
  the details on a particular procedure

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Global fee What is included?

• ICU visits by surgeon
• Preoperative visits
• Intra-operative services
• Postoperative visits related to recovery from the
  surgery, for pain management, and required
  because of complications
• Dressing changes local incisional care removal
  of sutures, drains, etc.
• Medicare Carriers Manual, Part 3, 4821

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Global fee What is not included?

• Initial consultation
• Services of other MDs
• Visits unrelated to the surgical diagnosis
• Treatment for underlying condition
• Diagnostic tests
• Clearly distinct surgical procedures
• Treatment for postoperative complication which
  requires return to OR
• Medicare Carriers Manual, Part 3, 4822

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Frequently asked Questions

• Q. Can a non-physician practitioner order
  ancillary services?
• A. Yes, if it is in their scope of practice.
  For a PA or NPP, yes it is allowed. NPP may not
  supervise diagnostic tests. May order and perform
  only.

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Frequently asked question Whose name/provider
number do we bill under?

• It depends on the circumstances
• Where is visit conducted?
• In office, can bill incident-to
• In hospital, can bill shared visit
• In nursing facility, must bill under NPPs
  provider number
• In home, must bill under NPPs provider number
• Where is the physician?
• Who employs the NPP?

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Frequently asked Questions

• Q. Can a teaching physician supervise a PA or NP
  in the same way as a resident?
• A. No. The teaching physician guidelines apply
  to medical residents only.

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Frequently asked Questions

• Q. What does a physician need to write to
  document a shared service with a PA or NP?
• A. The physicians documentation must support a
  face-to-face encounter with the patient and
  the medical necessity of the physicians
  involvement.

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Frequently asked Questions

• Q. What do I write down when I supervise a PA or
  NP student?
• A. The whole note. The teaching physician
  guidelines apply to physicians and medical
  residents only. They do not apply to any other
  type of trainee. You must perform the entire
  service and document the service.

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Frequently asked Questions

• Q. Can a PA or NP bill upper level EM codes, for
  example 99215?
• A. Yes. A PA or NP can bill any physician
  service that is within their scope of practice.
  However, medical necessity is the driver of the
  level of service not the amount or content of
  documentation.

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Frequently asked Questions

• Q. Can a NP or PA bill new patient codes?
• A. Yes, except when the service is provided in an
  office based setting and billed by a physician
  incident to. If a patient has never been seen
  before, there is no service that a PA or NP can
  provide that is incident to another service.

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Web Sites

• Nurse Practitioners
• Board of Nurse Examiners
• www.bne.state.tx.us/Default.htm
• Texas Nurses Association
• www.texasnurses.org
• Coalition of Nurses in Advance Practice
• www.cnaptexas.org
• Texas Nurse Practitioners
• www.texasnp.org/
• American Academy of Nurse Practitoners
• www.aanp.org

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Web Sites

• Physician Assistants
• Texas State Board of Medical Examinerswww.tsbme.
  state.tx.us/
• American Academy of Physician Assistants
  www.aapa.org
• Texas Academy of Physician Assistantswww.tapa.or
  g

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Web Sites

• Physician Assistants
• Texas State Board of Medical Examinerswww.tsbme.
  state.tx.us/
• American Academy of Physician Assistants
  www.aapa.org
• Texas Academy of Physician Assistantswww.tapa.or
  g