AAPC Annual Conference Nashville, Tennessee April 13-16, Incident-to Billing and Scope of Practice: Staying Compliant with Both is no Easy Task!

Transcription

1 AAPC Annual Conference Nashville, Tennessee April 13-16, 2014 Incident-to Billing and Scope of Practice: Staying Compliant with Both is no Easy Task! Presented by Jean Acevedo, LHRM, CPC, CHC, CENTC Agenda Understanding the incident to provision The impact of State laws and regulations The Shared Visit concept Microsoft PowerPoint Step by Step 11-1

2 CPT Instructions When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same subspecialties as the physician..these professionals are distinct from clinical staff. a clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service... [emphasis added] Especially important because 2014 MPFS rule revision to the incident to definition: Specifically, we are amending (a)(7), which defines auxiliary personnel to add and meets any applicable requirements to provide the services, including licensure, imposed by the State in which the services are being furnished. CMS-1600-FC, page 585 Microsoft PowerPoint Step by Step 11-2

3 Medical Assistant Scope of Practice (Florida) Per the FL DOH (FS ) Under the direct supervision and responsibility of a licensed physician, a medical assistant may undertake the following duties: (a) Performing Clinical Procedures, to include: 1. Performing aseptic procedures. 2. Taking vital signs. 3. Preparing patients for the physician s care. 4. Performing venipunctures and non-intravenous injections. 5. Observing and reporting patients signs or symptoms. (b) Administering basic first aid. (c) Assisting with patient examination or treatments. Microsoft PowerPoint Step by Step 11-3

4 FL DOH on MAs, Cont d.under direct physician supervision.. (d) Operating office medical equipment. (e) Collecting routine laboratory specimens as directed by the physician. (f) Administering medication as directed by the physician. (g) Performing basic laboratory procedures. (h) Performing office procedures including all general administrative duties required by the physician. (i) Performing dialysis procedures, including home dialysis. Non-Physician Practitioners Microsoft PowerPoint Step by Step 11-4

5 Nurse Practitioners Work in collaboration with a physician Typically do not need a physician on-site to be able to treat patients May have a specialty designation (e.g.., ARNP- Pediatrics) If so, State may not allow the NP to practice outside that specialty area. If caring for a Medicare patient, must enroll in Medicare MLN/MLNProducts/APNPA.html Physician Assistants Work under the supervision of a physician Typically do not need a physician on-site to be able to treat patients General supervision If caring for a Medicare patient, must enroll in Medicare MLN/MLNProducts/APNPA.html Microsoft PowerPoint Step by Step 11-5

6 And then the NPP s or clinical staff s scope of practice bumps up against Medicare coverage criteria.. Medicare Benefit Categories Microsoft PowerPoint Step by Step 11-6

7 Medicare Benefit Categories Immunizations Supervision of Diagnostic Services Therapy and Rehabilitation Incident to Preventive & screening services Others Immunizations* Pneumococcal Pneumonia Influenza Virus Vaccine Hepatitis B Vaccines Medicare does not require, for coverage purposes, that a Doctor of medicine or osteopathy order the vaccine. Therefore, the beneficiary may receive the vaccine upon request without a physician s order and without physician supervision. *Medicare Benefit Manual, Section Microsoft PowerPoint Step by Step 11-7

8 Supervision of Diagnostic Tests Nurse practitioners, clinical nurse specialists, and physician assistants are not defined as physicians under 1861(r) of the Act. Therefore, they may not function as supervisory physicians under the diagnostic tests benefit 1861(s)(3) of the Act). However, when these practitioners personally perform diagnostic tests as provided under 1861(s)(2)(K) of the Act, 1861(s)(3) does not apply and they may perform diagnostic tests pursuant to State scope of practice laws and under the applicable State requirements for physician supervision or collaboration. *Ch. 15, CMS Benefit Policy Manual, and Section 1861(r) of the Social Security Act Screening Services: Fecal Occult Blood Testing Screening FOBT has been covered only when ordered by a physician MPFS rule changed to include Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists who are acting within their scope of practice and are the patient s attending NPP. As an attending they are responsible for using the test results in the overall management of the beneficiary s medical care. Microsoft PowerPoint Step by Step 11-8

9 The Incident-to Benefit The burning question. What are the circumstances that must be met for me (the doctor) to be able to bill using my NPI for services provided by a member of my staff (whether MA, technician or PA/ARNP)? Microsoft PowerPoint Step by Step 11-9

10 Why all the interest? MD/DO paid at full physician fee schedule amount PA/ARNP services are usually allowed at 85% of the MPFS amount. Incident to Benefit Its own benefit category Under 1861(s) of the Social Security Act: Medicare pays for certain services and supplies furnished incident to a physician s/npp s services and for which payment is not made under a separate benefit category. Microsoft PowerPoint Step by Step 11-10

11 Incident to Requirements The services/supplies are an integral, although incidental, part of the physician s/npp s professional services. Course of treatment initiated by physician Physician involvement reflected as continuing active participation in the patient s management/care The services/supplies are of a type that are commonly furnished in a physician s office or clinic. Rules out services performed in the hospital Incident to Requirements, cont d The services/supplies are furnished under the physician s direct personal supervision. A member of the group who is physically in the office suite The services/supplies are furnished by an individual who qualifies as an employee of the physician. W2, 1099 or leased employee Cannot bill for the hospital s PA/ARNP Microsoft PowerPoint Step by Step 11-11

12 Documentation must: Identify who rendered the service Indicate supervision requirement is met Show physician s initiation and continued involvement in treatment Reasonable and necessary Within scope of practice for the NPP Personnel Who Can Perform Services Incident-to a Physician* Auxiliary Personnel RNs LPNs MAs Technicians PAs NPs PTs OTs CPs These can always be direct billed! LCSWs *Services must be within their scope of practice Microsoft PowerPoint Step by Step 11-12

13 Non-Physician Practitioners Can supervise auxiliary personnel for incident-to purposes Must meet all other requirements for billing Billed as if NPP performed the service MA supervised by PA/ARNP Paid at NPP rate (e.g., 85%) PTA supervised by the RPT No payment differentiation from physician Unique Signature Situations: Incident to: Incident to a physician s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician s personal professional services in the course of diagnosis or treatment of an injury or illness. Only the Past, Family, and Social History (PFSH) and Review of Systems (ROS) may be documented by ancillary personnel incident to and incorporated in to the E/M documentation, which must be reviewed and signed by the billing provider. Microsoft PowerPoint Step by Step 11-13

14 Unique Signature Situations, cont d Services of non-physician practitioners ordinarily performed by the physician such as minor surgery, setting casts or simple fractures, reading x-rays*, and other activities that involve evaluation or treatment of a patient s condition are also covered as services incident to a physician s professional services. *as long as the services are within the NPP s scope of practice Unique Signature Situations, cont d Split/shared services: Office setting: When an E/M service in an office setting is a shared/split encounter between a physician and a nonphysician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed 'incident to' if the requirements for 'incident to' are met and the patient is an established patient. The service is reported using the physician s billing number. The physician must sign. If 'incident to' requirements are not met for the shared/split E/M service, the service must be billed under the NPP s billing number, and payment will be made at the appropriate physician fee schedule payment. The billing NPP provider must sign. Microsoft PowerPoint Step by Step 11-14

15 NPPs and Incident to Never bill incident-to New patients or consultations Established patient with a new problem In any inpatient setting or at home Can bill incident-to Established patient, without a new problem, and with direct physician supervision Never assume a 3 rd party payer recognizes an NPP s services as incident-to Verify whether the payer includes NPPs as covered providers. BCBS UHC A Note on Documentation Done By Scribe The situation should be clearly delineated so the reviewer can identify the provider who performed the service, and The record should be signed by both parties the scribe and the physician (or NPP). Scribed by A.J. Smith, MA for Dr. Steven Johnson <Dr. Johnson s signature> Microsoft PowerPoint Step by Step 11-15

16 First Coast Service Options on Scribing (April 28, 2006) If a nurse or non-physician practitioner (PA, NP) acts as a scribe for the physician, the individual writing the note (or history or discharge summary, or any entry in the record) should note written by xxxx, acting as scribe for Dr. yyyy. Then, Dr. yyyy should co-sign, indicating that the note accurately reflects work and decisions made by him/her. It is inappropriate for an employee of the physician to make rounds at one time and make entries in the record, and then for the physician to make rounds several hours later and note agree with above, unless the employee is a licensed, certified provider (PA, NP) billing Medicare for services under his/her own name and number. FCSO on Scribing (April 28, 2006) Record entries made by a scribe should be made upon dictation by the physician, and should document clearly the level of service provided at that encounter. This requirement is no different from any other encounter documentation requirement. Medicare pays for medically necessary and reasonable services, and expects the person receiving payment to be the one delivering the services and creating the record. There is no carrier Part B incident to billing in the hospital setting (inpatient or outpatient). Thus, the scribe should be merely that, a person who writes what the physician dictates and does. This individual should not act independently, and there is no payment for this activity. It is acceptable for a physician to use a scribe, but current documentation guidelines must be followed. The physician is ultimately accountable for the documentation, and should sign and note after the scribe s entry the affirmation above that the note accurately reflects work done by the physician.. Microsoft PowerPoint Step by Step 11-16

17 Incident-To Scenarios #1 Mrs. Jones, a new patient, calls and asks for a same day appointment because of pain that she experiences when walking. Your schedule is full, but your NP has a time slot open, so she handles the visit. Can you bill her work as incident-to? Microsoft PowerPoint Step by Step 11-17

18 #1 No. You haven t satisfied the incident-to requirement that a physician initiate the course of treatment. Medicare wants you to see the patient first. Then you re free to delegate incidental services to a staffer and bill them as incident-to. So, in Mrs. Jones case, submit the claim under the NP s provider number. #2 Two weeks ago, you diagnosed Mr. Smith with a osteoarthritis, and today he s in the office with your PA, who s determining whether the medication you prescribed is working. Meanwhile, you re walking a golf course with a cell phone on your belt. You instructed the PA to ring you if he has any questions. Can you bill Mr. Smith s visit with the PA as incident-to? Microsoft PowerPoint Step by Step 11-18

19 #2 Nope. Better bill this one under the PA s Medicare number. You must be somewhere in the office, immediately available for consultation. Being reachable by telephone doesn t count, even though that may satisfy state requirements for supervision. #3 Three months ago, you diagnosed Mr. Hillary with RA, and put him on a regimen of medication and therapy. Today, your NP is assessing his progress. You re out of town attending a medical convention, but one of your partners is in the office. Is the visit with the NP eligible for incident-to billing? Microsoft PowerPoint Step by Step 11-19

20 #3 Yes. Medicare states that the doctor who initiates the course of treatment doesn t need to be the same physician who oversees a staffer performing an incidental service. So your partner can do the supervising. Remember, however, that you bill this work under the supervising doctor s Medicare number. Incident To Checklist If you answer no to any of these questions, the services cannot be billed as incident to. Are the incident to services incidental to the physician s/npp s professional services? Did the physician/npp initially see the patient and establish a plan of treatment? If this is an established patient being seen for a new problem, has the physician examined the patient? Microsoft PowerPoint Step by Step 11-20

21 Incident To Checklist If you answer no, continued Are the services/ supplies typically provided in the practice? Were the services provided in our office or a leased office in an institution? Was the supervising physician/npp physically present within the office suite while services were rendered? Is the individual an employee of the practice? Shared/Split Visits E&M services (note: concept cannot be used for procedures) provided in the inpatient hospital, outpatient hospital or emergency department only Microsoft PowerPoint Step by Step 11-21

22 Split/Shared Visits IOM Publication , Chapter 12, Section (H) states that, "A split/shared E/M visit is defined by Medicare Part B payment policy as where the physician and a 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. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service." medically necessary encounter with a patient Split/Shared E/M Services Physician and NPP both perform face-to-face visits with the patient Excludes consultations, critical care, SNF/NF services and procedures If NPP provides, must bill under his/her NPI Microsoft PowerPoint Step by Step 11-22

23 Split/Shared E/M Services May occur at same or separate times of the day No Medicare supervision requirement for NPP Must be w/in the NPP s scope of practice Split/Shared E/M Services Both MD/DO and NPP must render a face-to-face service Select code based on combined content of service documented by both providers Applies ONLY to E&M services Any other service in the hospital or ED must be billed under the NPI of the individual who performed the service Microsoft PowerPoint Step by Step 11-23

24 Cannot be Shared/Split Consultation services Critical Care services Procedures E/M services performed in the skilled nursing facility(snf)/nursing facility (NF) Sharing Limited to NPPs PAs NPs CNSs CNMs Microsoft PowerPoint Step by Step 11-24

25 Shared/Split Documentation Clearly identify both physician and NPP who are sharing the service Each must document own personally performed portion of the visit Each must sign their entry Be within the scope Unacceptable Documentation of Split/Shared E/M Service "I have personally seen and examined the patient independently, reviewed the PA's Hx, exam and MDM and agree with the assessment and plan as written" signed by the physician Seen and examined" signed by the physician "Seen and examined and agree with above (or agree with plan)" signed by the physician "As above" signed by the physician Documentation by the NPP stating "The patient was seen and examined by myself and Dr. X., who agrees with the plan" with a co-sign of the note by Dr. X No comment at all by the physician, or only a physician signature at the end of the note Microsoft PowerPoint Step by Step 11-25

26 Who bills? Service shared between physician and NPP, Both are from the same group practice, and Physician performs and documents his/her face-toface portion. May bill under the physician or the NPP Final Notes on Split/Shared Services There must be documentation of the face-to-face portion of the E/M encounter between the patient and the physician. Medical record should also clearly identify the part(s) of the E/M service which were personally provided by the physician, and which were provided by the NPP. In the absence of such documentation, the service may only be billed under the NPP's provider number. This applies to the initial history and physical examination, discharge day management visits, and subsequent hospital and emergency department visits. Microsoft PowerPoint Step by Step 11-26

27 Questions? Jean Acevedo, LHRM, CPC, CHC, CENTC Acevedo Consulting Incorporated Microsoft PowerPoint Step by Step 11-27