AHLA. S. Mid-Level Providers Maximizing Clinical, Billing, and Compliance Opportunities in the Hospital and Physician Office Setting

Transcription

1 AHLA S. Mid-Level Providers Maximizing Clinical, Billing, and Compliance Opportunities in the Hospital and Physician Office Setting Marissa W. Arreola Baker Donelson Bearman Caldwell & Berkowitz PC Houston, TX Tami Reinglass Horton General Counsel and Chief Compliance Officer Illinois Bone & Joint Institute LLC Des Plaines, IL Physicians and Hospitals Law Institute February 2-4, 2015

2 Mid Level Providers Maximizing Clinical, Billing, and Compliance Opportunities in the Hospital and Physician Office Settings Marissa Arreola Baker, Donelson, Bearman, Caldwell & Berkowitz, PC 1301 McKinney Street, Suite 3700 Houston, TX Tami Horton Illinois Bone and Joint Institute, LLC 900 Rand Road, Suite 300 Des Plaines, IL (847) Nonphysician Practitioners Overview NPPs are sometimes referred to as physician extenders, midlevel providers, or simply, midlevels. The term nonphysician practitioner or NPP is fluid, often applied to many different disciplines. We will focus on: Physician Assistants ( PAs ); Nurse Practitioner ( NPs ); Certified Registered Nurse Anesthetists ( CRNAs ); and Certified Nurse Midwives ( CNMs ). 2 1

3 DISCLAIMER Each state may have regulations regarding scope of practice and level of supervision required. These materials contain information as related to the general qualifications and requirements of each practice provided by CMS and Medicare/Medicaid. Each general description contained herein should be confirmed for a particular jurisdiction. 3 TOPICS COVERED DETAILED CASE STUDIES DEMONSTRATING: physician extender risk management issues (e.g., delegation of authority, prescriptive authority, required proximity of MD, etc.); Medicare coverage and billing requirements affecting NPPs physician extender billing and collections/ compliance issues in the hospital and physician office setting: appropriate documentation in medical record; appropriate modifiers for services personally performed by physician extenders; definition of incident to and appropriate billing use operational policies and procedures which can maximize revenue generation from physician extenders 4 2

4 MLN Reference 5 MLN Reference (cont d) 6 3

5 MLN Reference (cont d) 7 MLN Reference (cont d) 8 4

6 MLN Reference (cont d) 9 MLN Reference (cont d) 10 5

7 MLN Reference (cont d) 11 Scenario 1 Frost E. Snowman slips on the ice, hurting his back and cutting his leg. He immediately goes to his doctor s office. After looking at his leg, the doctor calls the PA into the office to do stitches in the leg and complete the appointment. The PA stitches Mr. Snowman s leg, examines his back and refers him to physical therapy for a back strain. 12 6

8 Questions: Who is the rendering provider? Who is the billing provider? Are the billing and rendering provider the same for the stitches and for the back examination? The patient asks for a prescription for pain medication, who may prescribe the pain medication? 13 Analysis Might the patient be eligible for incident to billing? 1. Determine the provider: Billing provider: the practitioner under whom the services are billed Rendering provider: The practitioner who renders the services The billing and rendering provider are not always the same individual. 2. Was the current plan of care established by a physician? 3. Was the plan of care followed without change? 4. Is there an onsite supervising physician? 14 7

9 Risk Areas Risk areas: New patient visits cannot be performed by an NPP as incident to services. A physician must maintain responsibility for the management of the patient s medical conditions and furnish sufficient professional services to demonstrate continued participation in the case. When a patient raises a new issue with an NPP during the course of treatment, because the physician has not seen the patient with regard to the new condition, all services in connection with such condition are categorically excluded from incident to services. 15 Risk Areas (cont d) Prescriptive Authority: If there is a current written Prescriptive Authority Form/Agreement completed and on file with the appropriate authorities (as set forth in state law) designating scope of prescriptive authority for the PA and signed by both parties, then the PA may prescribe for the patient within the scope of that authority. If there is not a Form/Agreement on file, the PA may not prescribe Delegation of Services Agreement: There must be a delegation of services Agreement. The required elements of this Agreement will vary by state and the type of mid level Provider. Medical tasks which are delegated by a supervising physician may only be those that are usual and customary to the physician's practice. 16 8

10 Risk Areas (cont d) Even if a PA is the billing and rendering provider (e.g. not billing incident to a physician), a PA may not collect directly from Medicare. A PA s services may only be billed by a PA s employer or contractor, provided that the employer or contractor uses the PA s NPI for identification purposes when billing for a PA s services. Other NPPs are permitted to collect directly from Medicare for his or her services 17 Analysis The stitches and treatment for the leg wound are a new patient treatment and must be billed under the physician s number Assuming that the PA is acing within the scope of his/her authority, the back injury was a new injury treated only by the PA and the PA is the billing and rendering provider (therefore the services are paid at 80% of the lesser of the actual charge, or 85% of what a physician is paid under the physician fee schedule) 18 9

11 Scenario 2 A Medicare patient has been previously treated by a physician and diagnosed with hypertension. On a subsequent visit to the physician s office, a PA saw the patient. May the PA bill incident to the physician? What is the reimbursement rate for the incident to services? 19 Risk Areas After the initial visit, what role should the MD have in the patient s care while the PA sees the patient incident to the physician? The medical record should reflect that the MD has ongoing involvement in the patient s care

12 Analysis Yes, the PA may bill incident to the physician for the follow up hypertension care. The fee for these incident to services is 100% of the Medicare physician fee schedule. If the hypertension patient saw the PA and complained of a new condition, the two complaints need to be separated: (a) The hypertension visit is billed at 100% as incident to services; (b) the PA may treat the patient for the new condition and bill this and subsequent visits under his own NPI, or PA can have the MD see the patient for the new condition and then also bill this incident to for follow up care for this new condition. 21 Split/Shared Incident to Services In the event of a shared or split visit between a physician and an NPP in a noninstitutional setting involving Evaluation and Management services ( E&M Services ), an NPP may assist a physician and bill his or her services as incident to the physician s services. In these instances, the NPP can perform part of the visit before the patient s face to face encounter with the physician, and still bill the services as incident to. However, if any of the incident to requirements are not satisfied, the NPP will have to bill his or her services under his or her own NPI, and will be paid accordingly at the 85 percent rate. When a shared or split visit occurs in a hospital setting, the services are covered by Medicare, but are not considered incident to under the statute. In such hospital settings, the Medicare instructions allow the physician to bill for the complete service associated with the E&M Services even though the service is not covered as an incident to service

13 Scenario #3 Dr. Jones does major spine surgery on Ms. Patient. Dr. Jones asks his Nurse Practitioner, Mr. Helpful to Assist in the Surgery. Dr. Jones relies heavily on Mr. Helpful during the surgery and Mr. Helpful plays an active part in Ms. Patient s surgery. How should Dr. Jones code Mr. Helpful? What kind of reimbursement will Dr. Jones receive for Mr. Helpful s assistance? Would the answer change if Mr. Helpful was a PA instead of an NP? 23 Analysis Mr. Helpful should be designated as an assistant at surgery as long as he delivers services during the surgery that are more than ancillary Medicare pays for a NP assistant at surgery services at the standard NP assistant at surgery payment rate (80% of actual or 85% of Medicare physician fee schedule). Because Medicare reimburses physicians who perform assistant atsurgery services at 16% of the surgical payment amount under the Medicare physician fee schedule, the actual payment amount for assistant at surgery services performed by an NP is equal to 13.6% of the amount paid to a physician (i.e., 85% of the 16% payment amount). This same payment rate and designation apply to a PA acting as an assistant at surgery delivering more than ancillary services 24 12

14 Scenario #4 A cardiology practice with seven physician owners leases nurse practitioners. One of the physician owners sees a patient in the clinic and develops a plan of care for hypertension ( Original Treating Physician ). The patient returns two weeks later for a follow up appointment with one of the leased nurse practitioners. The follow up appointment relates to the previously diagnosed hypertension. At the time of the follow appointment, two physicians are present in the clinic ( Follow Up Physicians ). Neither of the Follow Up Physicians is the Original Treating Physician. On the day of the follow up appointment, one of the Follow up Physicians is supervising installation of the practice s new EMR system and is not performing professional medical services. 25 Issue How can the clinic situation be optimized to ensure appropriate incident to billing? 26 13

15 Analysis The patient is under the care of a clinic physician for hypertension. Direct physician supervision may be provided by a group physician other than the Original Testing Physician. The physician ordering a particular service need not be the physician who is supervising the service. The physician supervising EMR installation and not performing medical services may not supervise the NPPs at that time. 27 Analysis (cont.) The non physician services must be under medical supervision, so all medical testing must be done at the clinic with supervising physicians. It is appropriate for leased, employed or contracted NPPs to participate in incident to billing arrangements, but if the NPP is not an employee, leased employee, or contractor of the practice, then then incident to billing is not appropriate

16 Analysis (cont.) Also note that if the NPP decided to catheterize the patient in the office as part of the hypertension plan of care, incident to billing is not appropriate if catheterization is not a type of service furnished in physician offices or clinics. In order to effectively operationalize incident to billing, office staff should be trained in addressing patient concerns that bills reflect services rendered by a physician provider who did not treat the patient, because the NPP billed incident to a provider who may not have been present in the office that day. 29 Scenario #5 A commercial pay patient previously has been treated by a physician for injury to his arm due to excessive slot machine play. The prior treatment occurred while the patient was a hospital inpatient. A hospital employed nurse practitioner treats the same patient for the injury during another hospital inpatient stay. The physician who previously treated the patient is present in the emergency room. A physician assistant works as a scribe to document the service and to diagnose an eye disorder developed as a result of watching the Blue Man Group show 100 times

17 Issues Identify issues associated with attempting to bill these services as incident to the original treating physician s services. 31 Analysis Note applicable billing rules. Unlike other CMS rules which are generally followed by commercial payors, many commercial payor have not adopted CMS incident to billing rules. Moreover, Medicaid can also adopt its own incident to billing rules. Make sure that you are aware of and operationalize the correct incident to billing rules for each patient/payor. Note place of service. Incident to billing is not permitted in a hospital inpatient setting. Please also note that billing for shared services is different than billing incident to services. Shared services billing may be permissible in the hospital environment

18 Analysis (cont.) It is irrelevant that the prior treating physician is present, because incident to billing cannot occur in the hospital inpatient setting. In a hospital inpatient setting, if the MD does not personally perform the professional service, he is not entitled to reimbursement. Even if incident to billing were permissible, the NPP needs to be an employee or contractor of the practice/physician billing the incident to service and not of a hospital A scribe is only permitted to document what is dictated to them and must be identified as a scribe. Diagnosing a new injury is outside the scope of scribe duties. Utilizing a workflow checklist can keep all of these billing requirements organized and at the forefront of clinic operations. 33 Checklist If the answer is "no" to any of the questions, it is not appropriate to bill the service incident to the physician. DOCUMENTATION TASK Location Does the place of service (POS) fall within the definition of an office or a physician directed clinic? YES NO The service is not performed in the institutional setting (i.e. inpatient hospital or skilled nursing facility)? Employment relationship Supervision Services performed Does the physician or group incur an expense and meet the employment requirements for the auxiliary staff? OR Does the auxiliary staff include employees, leased employees, or independent contractors of the physician or the entity that employs or contracts with the physician? Is there direct supervision by the physician? (Present in the office suite to assist, if necessary. The physician does not need to be physically present in the patient's treatment room for these services.) Is there a documentation link between auxiliary staff and the physician when the incident to service was performed? (Records of when the supervising physician was in the office suite, i.e. physician schedules, etc. or documentation in the medical record by the physician.) Did the physician personally perform the initial service and develop the plan of care? (Non physician practitioners (NPPs) cannot see new patients or established patients with new problems incident to). Is the service a part of the patient's normal course of treatment? Auxiliary staff services Qualified Staff Is the physician actively involved in the course of treatment? Is the physician's involvement documented in order to prove physician involvement on an "active" level? If service is performed by auxiliary staffs, who are not NPPs, is only a level 1 visit (CPT 99211) billed? (NPPs can bill for whatever established patient evaluation and management level that is documented) If the review of systems (ROS) and past family and social history (PFSH)? were performed by auxiliary staff is there documentation to support that the physician and/or NPP personally reviewed this documentation by confirming and/or supplementing to it in the medical record? Are auxiliary personnel performing physician services qualified non physician practitioners (NPP)? This includes Physician Assistants, Nurse Practitioners, and Clinical Nurse Specialists. Is the NPP licensed and certified to practice in the state in which they are practicing? Scribing The NPPs salary is excluded from the facility's cost report? If a scribe was used, did they only document what was dictated to them by the physician and is the scribe identified as such? (Scribes do not act on their own) Incident to? 100% of each. Yes or No? If "incident to" requirements are not met, the services may be billed under the NPP's own provider number and paid at 85% of the Medicare physician fee schedule if the NPP is working within his/her scope of practice, license, and meets all other state guidelines