Coding for Teaching Physicians and Nonphysician Practitioners

Transcription

1 Teaching physicians who accompany residents or review their notes and approve treatment plans must follow specific rules in terms of documentation and coding. Further, there are coding guidelines for physicians who are working with nonphysician practitioners (NPPs), such as physician assistants or nurse practitioners. In both of these areas, the coding and documentation regulations have changed recently. Teaching Physician Tie-in Until November 2002, practice rules required that a tie-in with the resident note by the attending physician be accompanied by relatively extensive documentation. A tie-in for key points of the history required naming of the key points, such as I was present for the key points, including discussions of congestive heart failure. The same documentation was required if the physician was present for the physical examination. Physician at Teaching Hospitals (PATH) regulations have been revised in an attempt to lighten the documentation burden on all clinicians. (See the Centers for Medicare and Medicaid Services [CMS] Medicare Transmittal #1780, November 22, 2002, revising Section of the Medicare Carrier Manual.) Statements from the teaching physician, such as, I saw and evaluated the patient. I agree with resident s notes and findings and plan of care, now are allowed to report the entire evaluation and management (E/M) service, except for a critical care service. Although the documentation rules have changed, the policy regarding teaching physician billing has not. The teaching physician must be involved in the treatment of a patient to bill for his or her services. Unless the teaching physician is involved for at least part of the face-to-face encounter that determines the service level, either with or subsequent to the resident/fellow, the physician s time cannot be billed. Simple cosigning of the resident s note is not proof of the teaching physician s presence. The teaching physician must insert notes in the record. Some of the history, review of systems, physical examination findings, and much of the assessment plan may be recorded by others, with the teaching physician tying into that documentation. However, the physician must see and evaluate the patient, document and review the resident s documentation, and note that in the record. Templates have been used for essentially all of the documentation issues up to this point in time. However, the CMS now has made it clear that because they have reduced the documentation burden significantly, they expect 2 or 3 simple sentences from the teaching physician as documentation. CMS has stated that for the present, physicians may not use a stamp, sticker, template, computer, or preprogram to meet the new regulations for a tie-in. Current Procedural Terminology 2009 American Medical Association. All Rights Reserved. 69

2 Coding and Billing for Critical Care There are specific exemptions for physician-resident interaction in certain primary care settings, including how many people the teaching physician can cover and how much information the residents may acquire. Other primary care exemptions address the difference in time between when the resident sees the patient or records the information and when the teaching physician reviews that note and whether the teaching physician actually saw the patient or provided consultation to people who were providing care to the patient, such as residents. DOCUMENTATION When the teaching physician ties into the resident note, both notes must indicate that the other clinician was present for care. The teaching physician must document that he or she agrees with the resident note and was present and evaluated the patient. The physician also can add any comments or changes to the resident note, which he or she must sign and date as separate entries. As an example, the resident notes, Patient seen with Dr. Osler. The teaching physician notes, Patient seen with Resident Jones. The resident documents a full note (history, physical examination, medical decision making), or at least 2 of the 3 if the billing is for subsequent care. The teaching physician notes, I agree with the above findings of the patient reporting shortness of breath with exertion. Physical examination reveals bilateral wheezing. I agree with the plan to discontinue or to discharge with albuterol, as noted above. Return visit in one week. A more complete note that may be more appropriate for the hospital could read: I was present with resident during all aspects of history and physical examination, was directly involved in medical decision making and management of this patient, and I agree with the resident s documentation, findings, and plan. I identify myself by name, degree, and rank. An appropriate admitting note suggested in the revised PATH regulation for noncritical care E/M services is: I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident s note and agree with the documented findings and plan of care. An appropriate notation suggested for a follow-up visit on hospital day 3 is: I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident s note. If the teaching physician personally performs all of the required elements without a resident and there is no note by a resident, the physician s note stands alone. If the resident initially sees the patient, writes a note, and the teaching physician sees the patient a few minutes or hours later, the teaching physician may tie-in with the resident s note, either agreeing or disagreeing. However, the teaching physician must include a clear statement documenting the tie-in. There is still debate about how to handle billing and documentation when the resident sees the patient at 11 PM and the teaching physician sees the patient at 6 AM (ie, on 2 separate calendar days). 70 Current Procedural Terminology 2009 American Medical Association. All Rights Reserved.

3 The teaching physician can tie-in with the medical student s notes only for a review of systems and past, family, and social history. The teaching physician must perform and document the history of the present illness, physical examination, and medical decision making independently. APPLICATION TO CRITICAL CARE There is substantial controversy over how the new PATH regulations apply to critical care codes. The new update from CMS includes a verbal commitment to allow critical care physicians who are teaching physicians to tie into the resident s note, but the note must demonstrate substantive, real-time involvement. The attending must be intimately involved with the critical care. The critical care physician may reference the house officer note as with any other note, but he or she must demonstrate physical presence either by documenting an examination or by stating, I was physically present. The physician also must state his or her personal involvement in the management during that period of time and document the time that he or she was physically present. Critical care physicians may choose to employ the tie-in with residents and fellows, but it would be appropriate for any tie-in note to include comments specifically designed to demonstrate the intensity of the physician service and the time it required at the bedside. The teaching physician must be present for all of the time for which the claims are made for critical care. Overall, the rules for major surgical procedures have not changed. The teaching physician must be present during all of the critical and key portions of the procedure and be immediately available to furnish services during the entire procedure. He or she may not have another obligation that requires his or her physical presence. Specifically, the teaching surgeon may not leave the room to begin a second case while other clinicians close the current case because that surgeon is not immediately available for the first case. Another surgeon must be immediately available for all the key portions of cases to address any potential catastrophic events. During minor procedures, the teaching physician must be present for the entire procedure to submit a bill. For endoscopic procedures, the teaching physician must be present for the entire viewing. NPP SERVICES COMBINED WITH A PHYSICIAN SERVICE New material in the Medicare Carrier Manual states that any physician or NPP authorized to bill Medicare services will be paid by the carrier at the appropriate physician fee schedule amount based on the rendering Unique Physician Identifying Number (UPIN/PIN). When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician s or the NPP s UPIN/PIN number. Current Procedural Terminology 2009 American Medical Association. All Rights Reserved. 71

4 Coding and Billing for Critical Care However, if there is no face-to-face encounter between the patient and the physician (eg, the physician participated in the service only by reviewing the patient s medical record), the service may only be billed under the NPP s UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim. The effect of this new rule is for groups currently employing physician assistants and nurse practitioners to have a means to achieve the highest E/M visit level allowed by the combined documentation of the physician and the NPP within the constraints of medical necessity. However, the physician must document some form of encounter with the patient. No specific rules have been given for the patient encounter, but it must be some form of an E/M service. Simply stating, Reviewed and agree with NPP s note does not constitute a part of an E/M service. Notes on the history, physical examination, or medical decision making are necessary, such as a restatement of the chief complaint, patient s appearance, or OK to discharge, as minimal allowable statements. A statement as simple as Patient seen face-to-face may be sufficient to document a face-to-face encounter. The extent of documentation needed to establish a portion of the E/M service has not been documented. The new shared visit policy that allows physicians to bill for inpatient and outpatient services provided in conjunction with NPPs is different from the incident to regulations that allow physicians to bill for services in an office setting (Table 16). CMS has indicated that physicians may not tie into the NPP s note for consultations, procedures, or codes and As always, the billing practitioner (eg, physician or NPP) must have provided the base critical care service (99291) to charge for it. However, the critical care times involved in the shared visit relationship are additive once a single clinician satisfies the requirements to bill 99291, and the physician and the NPP are part of the same group practice. For example, if the NPP sees a patient for 30 minutes in the morning and the physician in the same group practice as the NPP sees the patient in the afternoon for 46 minutes, the charges submitted are for the NPP (at 85%) and for the physician (at 100%). 72 Current Procedural Terminology 2009 American Medical Association. All Rights Reserved.

5 Table 16. Comparison of Incident to and Shared Visit Factor Incident To Shared Visit NPP must be an employee of Yes Yes the physician or group Service must take place in An office settin An inpatient or setting outpatient hospital Billing physician Must be in the suite Does not have to when the NPP performs be present when the service the NPP performs the service, but the physician must see the patient Face-to-face Not required by the Required and must encounter billing physician be documented on the same date of services as the NPP Visit must be part of an Yes No ongoing course of care by physician NPP may see new patients No Yes independently THE INTEGRATED TEAM OF DEDICATED EXPERTS Teamwork is one of the keys to successful intensive care unit (ICU) management. While the ICU team has remained somewhat constant throughout the decades (usually made up of physicians, nurses, pharmacists, respiratory therapists, social workers, and others), that structure is beginning to change quickly. NPPs, including physician assistants (PAs) and nurse practitioners (NPs), have been long-time members of the ICU team around the world and are becoming more prevalent at U.S. institutions, as well. Since NPPs may bill their time to Medicare independently from physicians, one only needs to peruse the Medicare billings for further proof of the increasing popularity and success of these professionals (Table 17). Current Procedural Terminology 2009 American Medical Association. All Rights Reserved. 73

6 Coding and Billing for Critical Care Table 17. Total of All Medicare Claims and Associated Payments Physician Assistants (PAs) Frequency 44,857 58,953 65,067 Allowed charges $3,036,708 $4,017,277 $5,084, Frequency 6,430 8,376 13,153 Allowed charges $1,152,418 $1,510,601 $2,389,018 Total Frequency 8,113,217 8,717,298 9,604,775 Allowed charges $459,221,468 $498,511,040 $560,314,023 Nurse Practioners (NPs) Frequency 73,663 86, ,271 Allowed charges $4,964,238 $5,873,414 $8,405, Frequency 8,358 10,734 13,168 Allowed charges $1,497,928 $1,933,338 $2,396,025 Total Frequency 13,045,812 14,018,196 15,257,956 Allowed charges $573,136,737 $643,555,718 $712,709,247 These statistics only reflect one aspect of the economic value of NPPs to the ICU team s expertise. Shared visits allow groups employing both physicians and NPPs to achieve the most appropriate E/M visits allowed by combining the services of each into a single claim. This is important to the hospital s revenue because NPPs bill at 85% of the Medicare fee schedule for physicians. However, when NPP services are combined with those of a physician, the claim bills under the physician s name/upin number at 100% of the payment schedule. This allows those physicians who employ NPPs to combine their encounters for the highest level of appropriate E/M within the constraints of medical necessity. The extent of the documentation required by the physician has not been defined by CMS. A physician should check with the local Medicare carrier. A note with information about the chief complaint, the physical examination and medical decision making would be sufficient if linked to a note by an NPP. SHARED VISITS AND CRITICAL CARE In December 2005, CMS issued a clarification on this topic, and a Contract Medical Director (CMD) shared the policy with the Society (consult CMS Transmittal 792 in 74 Current Procedural Terminology 2009 American Medical Association. All Rights Reserved.

7 reference CR4246, issued December 23, 2005). The transmittal clearly states, The split/share E/M policy does not apply to consultation services, critical care services, or procedures. These rules concerning shared visits and their potential application to critical care services ( ) are important. Billing for critical care services is based on the work of the individual physician or the NPP; it is not based on team services. Shared visit regulations provide additional revenue, helping to support the ICU team and the quality of care the team provides. When coding critical care services, however, the use of the NPP s Medicare provider number will trigger payment at 85%. The insufficient supply of ICU team members coupled with the anticipated increase in demand for critical care services because of the aging of the U.S. population, is reason for a renewed appreciation for PAs and NPs on the ICU team. The fact that NPPs joined the ICU team in larger numbers than physicians did provide one more reason to review the potential role of NPPs in the ICU. In addition to adding expertise and quality care, there is potential for NPPs to contribute to the economic viability of the integrated team of dedicated experts. NPPs generate approximately $2 to $3 for each dollar of their salary. With the constant financial pressure from administrators for departments to be selfsufficient, the revenue generated by NPPs could provide relief for all members of the ICU team. If they provide quality care that is medically necessary and code their services appropriately, the addition of NPPs to the ICU team could increase both the quality of care and the fiscal stability of the team. SUMMARY Practice rules for tie-in documentation between a teaching physician and a resident or fellow have been loosened substantially, particularly for noncritical care E/M services, allowing much less detailed documentation. However, the policy regarding teaching physician billing has not. To bill for services, a teaching physician must be involved in the treatment of the specific patient, and the documentation must indicate that the teaching physician has reviewed the resident s documentation and was present for the care. Critical care teaching physicians may employ the tie-in with residents and fellows, but the teaching physician s documentation must demonstrate the intensity of the physician service and the time required at the bedside. Shared services between a physician and an NPP may allow billing under either professional s UPIN/PIN number, but the initial critical care service (99291) must be provided by a single clinician. After that, the critical care times involved in this relationship are additive if the NPP and physician are in the same group practice. Current Procedural Terminology 2009 American Medical Association. All Rights Reserved. 75