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Billing Non-physician Provider Services. School of Medicine Compliance Heather Scott May 16, 2007. Things to Consider…. Employment License Payer Involvement of physician. General Principles. NC law requires payers to reimburse certain non-physician services

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billing non physician provider services

Billing Non-physician Provider Services

School of Medicine Compliance

Heather Scott

May 16, 2007

things to consider
Things to Consider…
  • Employment
  • License
  • Payer
  • Involvement of physician
general principles
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
employment criteria
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
medicare in the inpatient setting
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
medicare shared visit option
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
incident to billing principles
“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
incident to medicare
“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
incident to medicaid
“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
no incident to for commercial
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
direct billing medicare
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
direct billing medicaid
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
direct billing medicaid13
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
direct billing commercial
Direct Billing - Commercial
  • Most commercial carriers and managed care organizations do not accept direct billings by NPPs
where to get help
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
in closing
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
proper teaching physician attestation
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
teaching physician attestation
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.”

teaching physician attestation19
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.”