Billing Non-physician Provider Services

1. Billing Non-physician Provider Services School of Medicine Compliance Heather Scott May 16, 2007

2. Things to Consider… • Employment • License • Payer • Involvement of physician

3. General Principles • NC law requires payers to reimburse certain non-physician services • How it is paid is based on payer • Scope of practice • No physician co-signature required • No supervision of residents for Medicare and Medicaid

4. Employment criteria • Salary support from physician practice. • Percentage of salary = billable time • Direct or “incident to” billing • Exceptions for some specially designated funding • Not included on Hospitals cost reports

5. Medicare in the Inpatient Setting • Licensed non-physicians that may bill Medicare directly • Nurse Practitioner • Physician Assistant • Clinical Nurse Specialist • Clinical Psychologist • Reimbursed at 85% of the physician allowable • Services of non-physicians ineligible to bill directly are not reimbursable via Part B

6. Medicare Shared Visit Option • NPP and MD make individual evaluations on the same day • Each documents his service • May bill in MD’s name combining notes for level for established patients and problems • May not bill consults • “Shared” initial evaluations billed in NPP’s name • Rules are currently being reconsidered by Medicare • Physician must document detail beyond a resident attestation • NPP collaboration with an MD makes service billable as subsequent daily care, even without an MD note

7. “Incident to” Billing Principles • Option for billing non-physician provider services to Medicare outpatients and Medicaid patients • The billing provider (usually a physician) is the only named provider on the bill • The third party payer does not know who rendered the service • The billing provider and supervising physician retain liability for all “incident to” services

8. “Incident to” - Medicare • “Incident to” services may not be billed in an inpatient setting or hospital-based clinic • The billing provider must perform and document the initial visit • Thereafter, if the NPP is eligible to bill Medicare directly, the billing provider must • become involved when changes occur and • perform subsequent services at a frequency which reflects his continuing involvement in the management of the patient • For NPPs not eligible to bill directly, • E&Ms may not exceed nurse visit level • Billing provider must perform/document every third service

9. “Incident to” - Medicaid • No site limitations for “incident to” services • No difference in reimbursement (excepting mental health professions) • For NPs, PAs and CNMs • No requirement for an initial evaluation • Direct supervision by billing provider • available by telephone or pager • have a preexisting plan for emergencies • For other non-physician providers, the billing provider must • Perform and document the initial visit • Be involved when changes occur • perform subsequent services at a frequency which reflects the billing provider’s continuing involvement in the treatment and management of the patient

10. No “incident to” for commercial • The concept of “incident to” billing does not exist for commercial, managed care and other third party payers • Billing providers may work with NPPs as appropriate to the situation • Must meet the standard of care • Patient satisfaction is always important • Signature always required for PAs

11. Direct Billing - Medicare • Clinical psychologists, clinical nurse specialists, nurse practitioners and physician assistants may obtain a billing number and bill Medicare directly • May bill for anything within the state-determined scope of practice at any site • Generally pays 85% of physician reimbursement • No physician signature requirements for Medicare; however the state requires a physician signature for all PA services

12. Direct Billing - Medicaid • Clinical psychologists, clinical nurse specialists, nurse practitioners, and nurse midwives, and certain other NPPs may obtain a billing number and bill Medicaid directly • May bill for anything within their state-determined scope of practice at any site • Pays 100% of physician reimbursement

13. Direct Billing - Medicaid • Clinical psychologists and other non-psychiatrists cannot treat and bill Medicaid for mental health services to patients over 20 • PAs cannot obtain a Medicaid billing number and cannot bill directly • No physician signature requirements for direct billing by NPPs

14. Direct Billing - Commercial • Most commercial carriers and managed care organizations do not accept direct billings by NPPs

15. Where To Get Help • School of Medicine Compliance Office 843-8638 Heather Scott, CPC, Compliance Auditor Wendy Smith, CPC, Compliance Auditor Charles Foskey, Compliance Officer Chris Agosto, Office Manager • Confidential Help Line 800-362-2921

16. In closing… • Congratulations on recognition and increased independence • NPPs have increased responsibility for knowing state rules governing their respective practices • NPPs have increased responsibility for knowing insurance-specific billing rules • Leadership and communication are critical

17. Proper Teaching Physician Attestation • Document seeing and/or examining patient • Refer to resident’s note • Make a summary comment about the history • Comment on the physical exam • Comment on medical decision making • Only 2 of 3 areas need noting for established patients

18. Teaching Physician Attestation Unacceptable, non-specific note: “The above patient was seen concurrently with Dr. Smith (resident). I obtained a history from the patient, performed a physical exam and participated in the medical decision making.”

19. Teaching Physician Attestation Acceptable, specific-to-patient note: “Patient seen and discussed with Dr. Resident, whose note is available for further detail. Mr. Patient complains of intermittent chest pain. Personal findings on exam: Heart-regular, rate of 68. Chest-clear. BP remains elevated at 180/100. Will increase Inderal and proceed with remainder of treatment plan as noted above.”