Incident To, Non Physician Practitioners, Locum Tenens and Reciprocal Billing

Transcription

1 Incident To, Non Physician Practitioners, Locum Tenens and Reciprocal Billing Presented by: Medicare Part B Provider Outreach and Education (POE) December 2015

2 Disclaimer This information release is the property of Noridian Healthcare Solutions, LLC (Noridian). It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. December

3 Acronyms APN CFR CNM CNS CP CSW MPFS NP NPI NPP PA PT OT Advanced Practice Nurse Code of Federal Regulations Certified Nurse Midwife Clinical Nurse Specialist Clinical Psychologist Clinical Social Worker Medicare Physician Fee Schedule Nurse Practitioner National Provider Identifier Non Physician Practitioner Physician Assistant Physical Therapist Occupational Therapist December

4 Incident To Overview & Coverage Supervision Agenda Non Physician Practitioners Split/Shared Services Locum Tenens Reciprocal & Substitute Physicians Resources Noteworthy Information December

5 Objective Provide a better understanding of Medicare Part B coverage guidelines Reduce paid claims error rate Protect Medicare Trust Fund Ensure quality care to beneficiaries December

6 Incident To Services

7 Definition of Incident To A service or supply that is: Integral, incidental, part of the physician s or NPP s professional service Rendered without separate charge Furnished in office or clinic Furnished under direct supervision December

8 Direct Supervision in Office Directing physician/npp Present in office suite Immediately available to provide assistance/direction December

9 Incident To Documentation Documentation Who performed the Incident To service Be able to substantiate The physician s presence in the office suite during the service/procedure Establish office process and be consistent December

10 Auxiliary Personnel Supervised by physician Employee Leased employee Independent contractor Of physician Of legal entity that employs/contracts with physician Service/supply represents expense by physician or billing entity December

11 Non Physician Practitioners (NPPs) PAs, NPs, CNSs, CNMs, CPs, CSWs, PT and OTs Have own benefit categories May provide service without direct supervision Bill directly for service Can work as auxiliary personnel Incident to rule apply Billed in name of physician or NPP supervising December

12 Incident To Services Office Setting Service provided by qualified individual Direct financial expense to practice Direct supervision required By solo practitioner By any physician group member December

13 Examples of Incident To Services: Office Setting Taking blood pressure Giving injections Changing dressings Taking height and weight Follow-up visit for established patient December

14 OIG Report Supervising Physician/NPP must assure: Licensed physician performs, or Non-physician performing has necessary training, certification and/or licensure Supervision level is appropriate Pursuant to state law and to state & Medicare regulations. December

15 Incident To Services Hospital or SNF Setting For inpatient/outpatient hospital services and Part A covered SNF stays (1862 (a)(14) of SSA Payment made to hospital/snf Not separately payable under Part B Physician fee schedule December

16 Incident To Services Clinic Setting Physician present all the time clinic is open Patient s under physician care Non-physician services under medical supervision Direct supervision responsibility of several physicians Services outside clinic require Direct supervision December

17 Incident To Services Offices in Institutions Separately identifiable space Incident to services covered Outpatients Not in covered stay or Medicare certified part of a SNF Service outside of office area Not Incident to unless physician physically present Exception Certain chemotherapy 'incident to' services December

18 Incident To Services Patient s Home Direct Supervision by physician Physically present Exceptions Homebound patients Medically underserved areas No available home health services Covered for certain limited services Pub Chapter 15 Section 60.4 (B) General supervision required December

19 Incident To Services Patient s Home Underserved Area Underserved areas General Supervision Homebound patient Integral part of physician s service Included in physician s/clinic s bill Reasonable and necessary services Cannot be furnished by Home Health Agency (HHA) December

20 Incident To Services Patient s Home Underserved Area (2) Injections Venipuncture EKGs Therapeutic exercise Insertion/sterile irrigation of catheter Changing catheter Collection of catheterized specimen December

21 Incident To Services Patient s Home Underserved Area (3) Dressing changes Replacement/insertion nasogastric tubes Removal of fecal impaction Sputum collection Paraffin bath therapy for hands and/or feet Teaching/training of patient Colostomy, ileostomy, tracheostomy, diabetic care, blood pressure monitoring December

22 NPP Services Incident To Physician Services NPPs incident to services Evaluation and Management services Minor surgery, setting casts or simple fractures, reading x-rays and other activities that involve evaluation or treatment of a patient s condition All incident to guidelines apply December

23 Physician Involvement with NPP Physician initiates course of treatment Physician ongoing involvement Residents/fellows May not supervise incident to December

24 Signature Situation Performed By Signature Requirements Incident to Ancillary Staff Signed by Supervising (billing) provider Incident to NPP May be signed by NPP or Supervising (billing) physician December

25 Billing Situation Performed By Billing Established patient with no new problem Established patient with new problem Established patient with new problem NPP (Incident to criteria met) NPP (only) NPP and Physician (Incident to criteria met) Bill under Supervising physician s NPI Bill under NPP s NPI Bill under Supervising physician s NPI Documentation face-toface with physician and that he/she initiated course of treatment Physician signs his/her entry December

26 Billing Instructions Item 19 or EDI Comments field Auxiliary provider name Item 24J NPI of supervising physician Item 31 Signature of MD/NPP providing direct supervision Item 33 NPI of rendering group (if applicable) December

27 Non Physician Practitioners

28 Medicare Guidance for NPPs CMS guidelines affect NPPs State laws dictate scope of practice State/federal law differences Stricter law prevails Noridian relies on both state and federal law December

29 NPP Services When Incident To Requirements Are Not Met NPPs can work without physician supervision Within scope of license Medically necessary Paid at percentage of physician fee schedule amount December

30 Certified Nurse Midwives (CNMs) Qualifications Currently licensed State as a registered professional nurse; and Meet one of the following requirements: Legally authorized under State as nurse-midwife Completed program of study/clinical expertise for nursemidwives as specified by State; or December

31 CNMs (2) If no State program of study/clinical expertise, must be: Certified by American College of Nurse-Midwives; Satisfactorily completed formal education program; or Completed formal RN education program Practiced as a nurse-midwife for 12 months during any 18- month period from 8/8/76-7/16/82 December

32 Scope CNMs (3) Services legally authorized to perform in Otherwise covered if furnished by physician Medical necessity rule applies Services to newborn Only to point newborn treated medically as separate individual No restrictions regarding place of service Relationship with physician Based on state law, not dictated by CMS December

33 Medicare Payment: CNM December

34 CMS Resource: CNMs CMS IOM: Chapter 15 Section180 CMS IOM: Chapter 12 Section130 December

35 Physician Assistants (PAs) Qualifications Graduated from PA education program; or Passed national certification exam, or Be licensed by the State to practice as a PA December

36 PAs (2) Scope Services legally authorized to perform All of the following requirements must be met: Type of services considered physician s services PA qualifications General supervision of MD/DO Legally authorized to perform in state Not a statutory exclusion December

37 PAs (3) Examples of services that may be covered if furnished under general supervision of MD/DO Physical exams Minor surgeries Setting casts for simple fractures Interpreting x-rays December

38 PAs (4) Relationship with Physician Physician supervisor is primarily responsible for overall direction/management of PAs Physician supervisor s physical presence is not necessarily required Except Incident To December

39 PAs (5) Payment is made only on an assigned basis to the PA s qualified employer A group of PAs is not considered a qualified employer Leasing agencies and staffing companies are not considered qualified employers Medical necessity rule applies (scope of practice does not necessarily determine coverage ) December

40 Medicare Payment: PA December

41 Nurse Practitioners (NPs) Qualifications Legally authorized as NP in State Certified as NP by national certifying body Master s degree in nursing *Some states use Advanced Registered Nurse Practitioner (ARNP) December

42 NPs (2) Nationally recognized certifying bodies: American Academy of Nurse Practitioners American Nurses Credentialing Center National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties National Certification Board of Pediatric Nurse Practitioners and Nurses Oncology Nurses Certification Corporation Critical Care Certification Corporation December

43 Clinical Nurse Specialists (CNSs) Qualifications Legally authorized as CNS in State Certified as CNS by national certifying body Master s degree in a defined clinical area of nursing December

44 CNS Certifying Entities American Academy of Nurse Practitioners American Nurses Credentialing Center National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties Pediatric Nursing Certification Board Oncology Nurses Certification Corporation AACN Certification Corporation; and National Board on Certification of Hospice and Palliative Nurses. December

45 Scope NPs and CNSs Services legally authorized to perform All of the following requirements must be met: Type of services considered physician s services NP or CNS qualifications Collaboration with MD/DO Not a statutory exclusion December

46 Collaboration With Physician by NPs and CNSs Work with one + physicians (MD/DO) Medical direction Appropriate supervision Required by state If no state law Document collaboration and relationships with physicians Physician s physical presence not required Physician s independent evaluation of patient not required December

47 NPs and CNSs Examples of services that may be covered if furnished in collaboration with MD/DO Physical exams Minor surgeries Setting casts for simple fractures Interpreting x-rays December

48 NPs and CNSs Medical necessity rule applies (scope of practice does not necessarily determine coverage ) December

49 Medicare Payment: NP and CNS December

50 Practitioner Additional Non Physician Practitioners IOM Regulations Clinical Psychologist 100-2, Chapter 15 Section , Chapter 12 Section170 Clinical Social Worker 100-2, Chapter 15 Section , Chapter 12 Section150 Physical Therapist 100-2, Chapter 15 Section Occupational Therapist 100-2, Chapter 15 Section Speech Language Pathologist 100-2, Chapter 15 Section December

51 Additional Non Physician Practitioners 2 Practitioner Clinical Psychologist Clinical Social Worker Physical Therapist Occupational Therapist Speech Language Pathologist Payments 80% of the lesser of 1) the actual charge, or 2) 100% of the fee schedule 80% of the lesser of 1) the actual charge, or 2) 75% of the fee schedule 80% of the lesser of 1) the actual charge, or 2) 100% of the fee schedule 80% of the lesser of 1) the actual charge, or 2) 100% of the fee schedule 80% of the lesser of 1) the actual charge, or 2) 100% of the fee schedule December

52 Who May Provide Services Without Direct Supervision? Name/Acronym Advanced Registered Nurse Practitioner (ARNP) Certified Nurse Midwife (CNM) Clinical Nurse Specialist (CNS) Clinical Psychologist (CP) Clinical Social Worker (CSW) Name/Acronym Speech Language Therapist (SLP) Nurse Practitioner (NP) Physician Assistant (PA) Physical Therapist (PT) Occupational Therapist (OT) December

53 Split Shared Services

54 Split/Shared E/M Services Split/shared E/M services is a medically necessary encounter with a patient where the physician and the qualified NPP each personally perform a substantive portion of an E/M visit (face-to-face) with the same patient on the same date of service December

55 Split/Shared E/M Services (2) Substantive portion: Involves all/some portion of History Exam, and/or Medical decision making IOM 100-4, Chapter 12, Sections: (B) (H) December

56 Split/Shared E/M Services (3) Applies to: Hospital inpatient Hospital outpatient Hospital observation Emergency room Hospital discharge Office and non facility clinic visits Prolonged care visits Does not apply to: Critical Care SNF/NF December

57 Split/Shared E/M Services (4) Office setting: If incident to requirements are met, services may be submitted under the physician s NPI If incident to requirements are not met, services must be submitted under the NPP s NPI December

58 Split/Shared E/M Services (5) Hospital IP, OP or ER setting Physician and NPP - same group practice Physician performs any face-to-face portion of E/M Submit service under either physician or NPP s NPI. No face-to-face with physician Physician review medical records Submit under NPP s NPI Reminder: Incident To does not apply in this setting December

59 Locum Tenens Coverage

60 Overview Locum Tenens defined as physicians who substitute for other physicians when absent for Illness Pregnancy Vacation Continuing Medical Education Sabbatical Under arrangement Physician pays locum per diem Typically no practice of their own Locums travel/move to area long term, as needed December

61 Overview (2) Within authorized scope of practice Medical necessity must be met Documentation must clarify provider of service was locum tenen Along with documenting billing provider December

62 Timeframe Under arrangement no longer than 60 continuous days Cannot take day off to restart 60 days If situation needed over 60 days Must be hired and cannot continue as Locum Utilize PECOS online enrollment December

63 Timeframe (2) When provider leaving practice With physician permission to continue using his/her NPI, then approved up to 60 days Reflect information in documentation Watch that PTAN is not deactivated December

64 Locum Tenens Billing Regular physician bills with their own NPI Locum s NPI in medical record Locums Name/NPI in Item 19 or Comments Field Use modifier Q6 Locum covering for hospice patient s attending physician Bill modifier Q6 with GV modifier All arrangements must be in writing December

65 Use of Locum Tenens Can Use Locum Tenens Medicine Osteopathy Podiatric Optometry Chiropractic Dental Surgery Cannot Use Locum Tenens Clinical Nurse Specialist Nurse Anesthetist Nurse Midwife Therapists OT, PT, SLP Psychologist Social Worker December

66 Deceased Providers Cannot use Locum Tenens Deceased Provider s Group or Executor Submit 855I and if needed 855R Include copy of death certificate Ending PTAN on date of death December

67 Reciprocal/Substitute

68 Reciprocal/Substitute Physician Arrangement between 2 physicians to substitute for one another Regular physician not available E.g. emergency visits/weekend calls Arrangements need not be in writing No more than 60 days Substitute physician name and NPI in Item 19 or Comments Field Use modifier Q5 December

69 Reciprocal/Substitute Physician (2) Applies to both same group and outside group physicians Group physician bills with his/her own NPI If hospice related, designated attending physician bills GV/GW and Q5 modifiers Global post op substitution services covered by global fee Need not be identified as substitution May have reciprocal arrangements with more than one physician December

70 Resources

71 CMS Resources Claims for CMS Guidance Incident To Services IOM, 100-2, Chapter 15, Sections 60.1B and 60.2 Split/shared E/M Services IOM, Chapter 12, Section B December

72 CMS Resources: PAs CMS IOM: Chapter 15 Section190 CMS IOM: Chapter 12 Section110 December

73 CMS Resources: NPs and CNSs NPs CMS IOM: Chapter 15, Section200 CMS IOM: Chapter 12 Section120 CNSs CMS IOM: Chapter 15 Section 210 CMS IOM: Chapter 12 Section120 December

74 Reminders & Noteworthy Information

75 Receive Part B CERT Request? CERT post pay audit review random documentation sampling on previous claims Need Part B assistance? Please Patty.Holton@noridian.com or CERTQuestion@noridian.com Follow steps: Subject line enter CERT Claim Identification (CID#) (seven-digit number starting with 1 ) Body of , provider office contact information (name, phone/fax number, CID#, city/state) December

76 Endeavor Online Provider Portal Free to providers with Internet Beneficiary Eligibility Claim Status including Reviewer Comments Payment Floor / Prior Checks Issued Single Claim / Entire Remittance Advice Reopening & Redetermination Submission Appeal Status Additional Resources include Self-Paced tutorial for Part B System availability alerts on the Medicare website User Manual; many screen images and guides Workshops and presentations Main Menu page next slide December

77 Date Time (CT/PT) Webinar Title 12/16/15 1:00 pm/11:00 am Incident To, Non Physician Practitioners 12/17/15 1:00 pm/11:00 am Chronic Care Management (CCM) 12/18/15 1:00 pm/11:00 am Screening Services 12/18/15 3:00 pm/1:00 pm Preventive Services 12/22/15 1:00 pm/11:00 am New Provider New Biller Part I 12/22/15 3:00 pm/1:00 pm Signature Requirements 12/23/15 1:00 pm/11:00 am New Provider New Biller Part II REGISTER NOW! JE JF December

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79 Paper Claim Submission Claims received by Noridian as of 10/1/2015, ICD- 9/ICD-10 indicator will be required If indicator is left blank, claim will deny Resubmit claim with indicator 9 for ICD-9 codes or a 0 (zero) for ICD-10 diagnoses Enter the ICD indicator as a single digit between the vertical, dotted lines December

80 CMS Educational Materials MLN products downloadable or free of charge/free shipping Brochures, Fact sheets Web-based training MLN dedicated web pages General Information Matters Articles es Products Web Guides December

81 CEU Reminder Attend entire workshop to earn CEU(s) Take short polling survey Pops up after closing out of webinar CEU ed 3 days after presentation Earn CEUs today No password/index number needed for AAPC PDF presentation ed again with CEU Q/A posted after 30 business days December

82 Questions Thank you