Incident To and Locum Tenens. Presented by: Noridian Part B Medicare Provider Outreach and Education (POE) June 2014

Transcription

1 Incident To and Locum Tenens Presented by: Noridian Part B Medicare Provider Outreach and Education (POE) June 2014

2 Workshop Protocol Cannot register with WebEx using mobile device Must use desktop or laptop Entering workshop Attendee lines muted Presentation slides ed Adobe PDF format (with printing instructions) 3 days before webinar Throughout workshop Questions pertinent to workshop slide addressed Address Q & A to all panelists ; not to host directly All other questions, call Part B Provider Contact Center Workshop conclusion Asking questions aloud? Use raise/lower hand feature MUTE phones never place on HOLD June

3 Continuing Education Units (CEU) Process When registering, add additional attendees First and last names Attend entire workshop Take short polling survey After closing out of webinar CEU ed 3 days after presentation Earn between.5 and 1.5 CEUs No password or index number needed All providers may use CEU certificate Certificate of Attendance no longer available June

4 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. 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 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 2014 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. June

5 Agenda Incident To Overview & Coverage Supervision Billing Locum Tenens Reciprocal & Substitute Physicians Noteworthy Information Resources June

6 Acronyms Acronym Description Purpose E/M Evaluation/Management Office visit IOM Internet Only Manual Medicare rules NPI National Provider Number 10 digit enroll ID NPP Non-Physician Practitioner Not MD/DO PECOS PTAN Provider Enrollment Chain & Ownership System Provider Transaction Access Number Online enrollment Medicare billing # linked to NPI June

7 OVERVIEW & COVERAGE June

8 Incident To Overview Physician means practitioners (physician) or NPPs authorized to receive payment direct or incident to Physician Assistant (PA) Nurse Practitioner (NP) Clinical Nurse Specialist (CNS) Certified Nurse Midwife (CNM) Clinical Psychologist (CP) Clinical Social Worker (CSW) All must accept claim assignment June

9 Incident To Overview 2 Patient seen first by supervising practitioner Plan developed and integral part of physician services Part of diagnosis/treatment of injury/illness Included in physician/npp bills Furnished in physician/npp s office/clinic Within state scope of clinical practice law Includes non self-administered drugs and biologicals June

10 Sharing Office Visits E/M services may be shared/split encounter between physician and NPP Established patient in office setting when: NPP performs portion of E/M Physician completes E/M If Incident to requirements met Physician s NPI reports service June

11 Incident To Table Specialty MD/DO NP CNM/CNS/ CP/PA Column Heading MD, NP, PA, CNM, CP, CSW, CNS Auxiliary staff* NP, CNM, CP, CSW, CNS Auxiliary staff* NP, CNM, CP, CSW, CNS Auxiliary staff* *Auxiliary staff includes nurses, technicians, therapists and any other licensed/certified to perform incident to June

12 Common Procedures/Services* Incident to services include procedures and services ordinarily performed by physicians Minor surgery Chemotherapy administration Setting casts or simple fractures X-ray interpretation/readings Anti-coagulation monitoring or other activities involving treatment of patient's condition *Not an all inclusive list June

13 Place of Service Physician Directed Clinics: Bill under NPI of supervising practitioner Hospital clinic billing = POS 22, not 11 Homebound Patient: Still under direct supervision rules Unless in a rural area, then modified to general supervision Patient must be confined to their home Homebound reflected Item 19 narrative Not an alternative to Home Health (HHEH) benefits paid by another contractor June

14 Who May Bill Independently? NPPs may provide services without direct supervision Bill their NPI and Medicare PTAN Name/Acronym Certified Nurse Midwife (CNM) Clinical Nurse Specialist (CNS) Clinical Psychologists (CP) Clinical Social Worker (CSW) Name/Acronym Occupational Therapist (OT) Physical Therapist (PT) Physician Assistant (PA) Speech Language (SLP) Nurse Practitioner (NP) June

15 MD to MD Incident To Physician may bill incident to to another physician, if criteria met New physician to practice Enrollment/reassignment process with Medicare must be in place and has NPI Bill with supervising MD s NPI Supervising MD liable for all services Must sign off notes/reports/charts 42 CFR Ch IV June

16 Outpatient Therapy Services Therapist services "incident to" physician All services furnished same day, regardless whether services are provided in one therapy discipline or multiple disciplines (OT, PT, SLP) Not covered as incident to Services performed by non-employees Not contracted Not under physician direct supervision Aides or PT Assistants (PTA) services Only allowed under direct supervision of a PT or OT June

17 Physician Assistant (PA) Even though a Physician Assistant (PA) can work independently with a PTAN and bill with their own NPI If they work incident to May only work under a physician (MD/DO) Not under another PA Other NPPs may work incident to a PA IOM , Chapter 15, Section 60.1 June

18 Not Applicable In Facilities Incident to requirements not met in hospital Not the same as split//shared hospital visits NPP/MLP reports service with their own NPI Hospital inpatient or outpatient Skilled Nursing Facility (SNF) Nursing Home (NH) Comprehensive Outpatient Rehabilitation Facility (CORF) Rehabilitation Agencies June

19 Auxiliary Staff Auxiliary personnel (licensed/certified) considered under physician s direct supervision Nurses, technicians, etc. May provide services usually performed by physician Therapeutic injections, breathing treatments, chemotherapy administration, diagnostic, etc. No additional Medicare benefit for employing special service staff Staff not licensed to perform medical services Considered to be employment cost incurred by provider and part of Medicare payment Students/residents not eligible under incident to physicians June

20 Licensed Professional Counselor (LPC) LPCs can not be incident to CSWs CSWs can be incident to these providers Physicians, CPs, CNSs, NPs, PAs, or CNMs Services furnished as incident to CSW s professional services are not covered Physicians, CPs, CNSs, NPs, PAs, or CNMs May have outpatient psychiatric services Furnished incident to his/her professional service June

21 Patient Exception Example Q) If two providers designated as supervising at various points in the patient s infusion, who bills the service? Providers split supervision duties during a patient s infusion. NP supervises patient from 7 a.m. to 8 a.m. and MD supervises from 8 a.m. to Noon. A) Chemotherapy administration is one of the split/shared service exceptions where drugs can be billed incident to a physician. Since the MD was there for 80% of the visit, the NP would bill incident to under the MD. Do not bill under both providers (NP/MD). Shared services only apply to inpatient, outpatient, and ER visits. Read IOM Publication , Chapter 12, Section and Medicare B News Issue 270 dated May 25, 2011 June

22 BILLING June

23 Billing Incident To or Direct Mid level NPPs CNM, CNS, CP, CRNA, CSW, NP and PA Bill under on site physician s NPI If different than physician who initiated visit and monitors patient care No separate payment for bundled services or procedures Advance Beneficiary Notice of Noncoverage (ABN) does NOT apply Patient not financially responsible June

24 NPP Direct Billing and Payment NPP may bill direct with own NPI number Not considered incident to, but direct payment Enrolled with Medicare and valid PTAN Must accept assignment Pays 85% of fee schedule Less any deductible/coinsurance applicable Scenario includes Urgent Care Clinic NPP orders tests; physician has no face-toface with patient or plan of care June

25 CMS-1500 Claim Paper Billers! Use new CMS-1500 Dated (02/12) - mandated April 2014 Item 17/17B If applicable, ordering/referring physician Who performed initial service and/or Referring patient to current practitioner Physician s Name/NPI Item 19 Narrative/Comment May use for auxiliary/reciprocal provider name June

26 CMS 1500 Claim 2 Item 24J NPI of rendering/supervising physician Item 31 Signature of rendering physician/npp providing direct supervision Item 32 Complete address where service performed Item 33 NPI of rendering individual or group (if applicable) June

27 99211 Incident To Established patient with minimal problem Typically five minutes/less spent on services Medical necessity for visit Documentation of clinical history, exam, decision level and physician supervision Blood pressure monitoring Anticoagulation monitoring visits Immunization/administering injection/medications June

28 99211 Payable Examples Established office visit on regular immunotherapy; developed wheeze/rash/swollen arm after last injection Possible dose adjustments discussed/injection continued Established patient s office visit for blood pressure check and medication monitoring/advice Established office visit with new/concerning bruise Checked by nurse, if patient taking anticoagulants If on anticoagulants, continuing current dosage advised Patient advised on care, what to be concerned about Deciding factor if an E/M service may be billed is documentation of medically necessary services, clinical history, clinical exam and/or clinical decision and physician supervision.

29 99211 Non Payable Examples Established office visit with long standing allergic rhinitis receiving monthly maintenance allergy injection Bill only allergic vaccine and administration Est. patient with previous stroke to coagulation clinic staffed by a lab technician/pharmacist; no MD/DO in facility when blood is drawn flow sheet sent to patient s doctor Bill only blood draw Established patient s visit only to draw blood/receive an injection, then do not bill Bill appropriate drug/administration or blood drawing In each of the above examples, criteria for not met. There is no medical necessity for the visit, no documentation of clinical history, no clinical exam, no clinical decision and/or no physician supervision.

30 SUPERVISION June

31 Supervising Physician Recommended that physician informs patient that NPP taking over care Under physician s direction and monitoring Supervising physician (MD/DO) must: See patient first and initiate plan of care Remain actively involved in care with periodic visits with patient for ongoing disease or illness Not to supervise outside own scope of practice Psychiatrist hire CSW? Yes Psychiatrist hire CNM? No Employment arrangement between parties June

32 Direct Supervision Direct supervision is within office suite and immediately available to provide direction and assistance E.g. cardiac or respiratory arrest, anaphylactic shock or other emergencies Without delay to assist same floor Not a few floors up/down or across building Take over care as necessary Is not otherwise occupied, preventing immediate hands-on intervention June

33 Physician s Direction Recommended that physician informs patient that an NPP taking over care Under physician s direction and monitoring Office services provided by NPP Part of physician s documented treatment plan Physician reviews NPP s chart notes and monitors treatment progress NPP must be employee of physician or same employer June

34 Compliance Responsibility of physician to be compliant with state regulations Governing licensing requirements of employees providing specific services Title 18, Section 1861 of SSA Services provided by personnel with direct financial expense to physician/npp Leased employee, W2 employee or independent contractor June

35 Mid-Level Providers (MLP) Reminder MD sees patient first for any/every new problem IOM , Chapter 15, Sections 60/60.1 Direct, personal and professional service by physician to initiate course of treatment Performed by NPP/MLP as incidental part Attending MD not on site, other MD colleague supervises NPP may bill with other colleague s physician NPI Must be subsequent services by physician continuing active participation and management of treatment course Physician must be physically present in same office suite and immediately available if necessary June

36 Nurse Assessment No separate payment for nurse assessment preceding a service Nurses not paid separately to diagnose, evaluate patients, review lab results or prescribe Telephone calls never covered Incident to can apply where trained nurses do interrogation and physician does analysis for Pacemaker device checks (93279/93280) Documentation must support all aspects billed June

37 Counselors Non Covered Counselors non-covered to bill Medicare Can be covered incident to physician Non-eligible practitioner unable to bill Medicare, assist beneficiary to bill direct Not meeting provider-required credentials To complete CMS-1490S claim form to Medicare Include provider s itemized bill and statement s1490s-english.pdf June

38 OIG Audit Review 2014 Office of Inspector General (OIG) reviews physician s services incident to May be vulnerable to overutilization Will examine non physician qualifications Assess whether qualifications are consistent with professionally recognized standards of care June

39 LOCUM TENENS COVERAGE June

40 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 direct per diem Typically no practice of their own As needed, Locums travel/move to areas long term June

41 Overview 2 Within authorized scope of practice Medical necessity must be met Appending modifier Q6 Services furnished by a locum tenens Documentation must clarify provider of service was locum tenen Along with billing provider documentation June

42 Eligible/Non Eligible Locums Eligible Physicians Medicine Osteopathy Podiatric Optometry Chiropractic Dental Surgery Non Eligible NPPs Clinical Nurse Specialist Nurse Anesthetist Nurse Midwife Therapists OT, PT, SLP Psychologist Social Worker June

43 Locum Tenens Coverage Locums may provide services for deceased provider up to 60 days from date of death education_center/locum_tenens_and_recipro cal_billing.html Applies to both assigned/non-assigned June

44 Provider Leaving Practice 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 auto-deactivated Without activity after 12 months June

45 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 June

46 Locum Tenens Billing Regular physician bills with their own NPI Locum s name/npi must be in medical record May reflect locum name/npi in Item 19 Not necessary to be enrolled with Medicare Append modifier Q6 to all CPT codes Services furnished by locum tenens physician Locum covering for hospice patient s attending physician Append modifier Q6 with GV modifier All arrangements must be in writing June

47 RECIPROCAL/SUBSTITUTE June

48 Reciprocal/Substitute Physician Arrangement between two physicians to substitute for one another Regular physician not available E.g. emergency visits/weekend calls Reciprocal arrangements need not be in writing Identify name in records/item 19 narrative Append modifier Q5 Services furnished by substitute physician; reciprocal billing arrangement June

49 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 Cannot be billed with Q5, since regular physician paid global fee, so not needed to be identified substitution May have reciprocal arrangements with more than one physician June

50 NOTEWORTHY INFORMATION June

51 Medicare Learning Network (MLN) Official CMS Information for Medicare FFS Providers Products available: Web-based Training Brochures Fact Sheets Quick Reference Charts Most products come in downloadable/hardcopy formats MLN products FREE of charge/shipping MLN dedicated web pages: MLN General Information -- MLN Matters Articles -- MLN Products -- MLN Web Guides -- MLN Connects Provider enews - Education/Outreach/FFSProvPartProg/index.html?redirect=/FFSProvP artprog June

52 CMS Compliance Table of Contents Information includes CERT Preventive CT Scans Psychiatry Recovery Auditor DME CT Scans Multiple Surgery Reductions June

53 Receive CERT Request Letter? Need assistance? or Follow these steps: Subject line enter CERT Claim Identification (CID#) (seven-digit number starting with 1 ) Body of , provider office contact information (name, phone and fax number, CID#, city and state) Do NOT include beneficiary/phi information in (e.g. beneficiary s name, HIC#, address, phone) If no error because provider documentation supports, then no provider notification June

54 Sign Up For Medicare News! Receive most recent Noridian/CMS news Tuesday/Friday Regulation/policy updates Payment/reimbursement Workshop/educational event notices Noridian hours of availability/related notifications JF JE June

55 Endeavor Sign Up Today! Free, online eligibility Claim and check status View/print Remittances EDI registration required Information, tutorials and user manual JE eavor;jsessionid=47398db81b877707cd2b21a1d23 14C38 JF avor/index.php June

56 CMS Resources Guidance/Guidance/Manuals/Internet- Only-Manuals-IOMs.html Internet Only Manual (IOM), Publication , Chapter 15, Section IOM , Chapter 1, Section Physician Payment Under Locum Tenens IOM , Chapter 5, Section 70 Physician Defined June

57 Noridian Resources Medicare B News Issue 267 January 12, 2011 Incident To Terminology and Billing by Qualified Practitioners Revised Medicare B News Issue 283 January 23, 2013 Wound Care and Debridement Provided by Physician, NPP or as Incident-to Services Use of Q6 Modifier for Locum Tenens June

58 CEU Process Reminder When registering, add additional attendees First and last names Attend entire workshop Take short polling survey After closing out of webinar CEU ed 3 days after presentation Earn between.5 and 1.5 CEUs No password or index number needed All providers may use CEU certificate Certificate of Attendance no longer available June

59 Questions? Thank you!