Billing Medicare for Non-Physician Providers

1. Billing Medicare for Non-Physician Providers AOA-26 Educational Conference Chicago Sept 19, 2008

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3. Non-physician Practitioners�Who are they? Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Nurse Midwives, Physical Therapists, Occupational Therapists, CRNAs, Clinical Psychologists, Clinical Social Workers Audiologists In 2008, CPT added term: nonphysician qualified healthcare personnel My least favorite term: mid-level providers 3 Betsy Nicoletti �2008

4. Medicare Allows notes �within state scope of practice� and other license or test criteria Subject to incident to versus direct billing rules in the office Shared services allowed for hospital work (not consults or critical care) Diagnostic test supervision rules Private payer rules may and do vary! 4 Betsy Nicoletti �2008

5. Direct bill or incident to Direct: Bill under NPP # Incident to: Bill under MD provider number New problem, consults Not part of a physician initiated plan of care Physician not in the office that day Be paid at 85% of the MD fee schedule Report (that means bill under) the NPP�s own provider number Established patient services, in office�POS 11 ONLY Part of plan of care previously established by the physician No new problems No consults Physician in office Be paid at 100% of the MD fee schedule Report (bill) under MD # 5 Betsy Nicoletti �2008

6. Incident to Basics All services must be medically necessary NP�s and PA�s must practice within their state�s scope of practice to be reimbursed by Medicare PA�s and NP�s should have their own provider number for Medicare 6 Betsy Nicoletti �2008

7. What are they? From the MCM: Incident to a physician�s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician�s professional services in the course of diagnosis or treatment of an illness or injury. 7 Betsy Nicoletti �2008

8. Incident to Requirements: Under the direct supervision of the physician Employee providing the service must be employed by MD, or be a leased employee, or be an independent contractor, or be an employee of the group that employees the MD 8 Betsy Nicoletti �2008

9. Direct supervision. For I-2, this means Physician is in the suite of offices (not separated by stairs or elevators) when service is provided Available to provide assistance if needed Not if the physician is not in the office 9 Betsy Nicoletti �2008

10. Incident to Requirements, cont. Service is an integral part of the MD plan of care Requires on going MD involvement Must take place while physician is in office, immediately available ONLY FOR PLACE OF SERVICE OFFICE If provided by anyone but NP/PA, CNM, or Clinical Nurse Specialist, only 99211 as an office visit can be billed 10 Betsy Nicoletti �2008

11. Incident to services Are paid at 100% of the physician fee schedule Services billed under the PA/NP provider number are paid at 85% of the physician fee schedule 11 Betsy Nicoletti �2008

12. Incident to rules No new problems, new patients, consults Bill under the supervising physician, not the ordering physician Allowed only in the office, not the hospital, ED, nursing home Place of service 11 (not 22 for clinic) 12 Betsy Nicoletti �2008

13. What if? New consult schedule to see PA at 10:00 a.m. PA does comprehensive history, comprehensive exam, makes a diagnosis and plan that requires surgery Steps out of the room for the MD to come in and see the patient at 10:45 a.m. MD meets patient, confirms key points of hx, exam, MDM Can you bill under MD? Should you bill under PA? 13 Betsy Nicoletti �2008

14. Are incident to guidelines met? Is the service part of a previously established plan of care that the MD has developed? No, bill under PA not MD Can�t we bill a shared service between PA/MD No, shared services in the office must meet incident to rules, and this one doesn�t Bill under PA provider number�PA will have the more extensive documentation 14 Betsy Nicoletti �2008

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16. Joint MD/NPP consults May not be billed under the MD�s provider number, adding together the work each has done and documented Bill under the provider number of the clinician who does and documents the work�typically the NPP, even if the MD adds to the note 16 Betsy Nicoletti �2008

17. Shared Visits Just when you thought you understood it all, CMS gave us shared visits! 17 Betsy Nicoletti �2008

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20. Shared Visits�hospital services MD must have face to face service with patient MD can see patient before, during or later than the visit by NP/PA If no face to face service with MD, bill under NP/ PA # Combine MD and PA/NP notes to select level of service 20 Betsy Nicoletti �2008

21. Shared visits Can be billed in the hospital, inpatient or outpatient, or ED, but not consults or critical care Can be billed in the physician office only IF incident to requirements met Are shared visits between MD and NP/PA in the same group Can be billed using MD provider number and paid at 100% of fee schedule 21 Betsy Nicoletti �2008

22. NPP documents for shared services Typically, most of the history, exam and MDM 22 Betsy Nicoletti �2008

23. MD documents for shared services That he/she had a face to face service with the patient Some clinically relevant portion of the key components (hx, exam, MDM) Ties note to NPP�s note �I saw Ms. Betsy today, and she reports�.. Her exam shows�. I agree with Mr. NPP�s plan to�..� 23 Betsy Nicoletti �2008

24. PA/NP as part of the global package Can bill Medicare for PA/NP assistant at surgery, use modifier AS (modifier 80 for commercial insurances) Services provided by PA/NP during global period within your practice are not paid separately Insurers see those services the same as if your surgeon had provided them No special requirements for those post op visits 24 Betsy Nicoletti �2008

25. Audiology Review of covered services Qualifications Spring transmittals (old news by now) Documentation of services Incident to tests performed by tech or nurse Supervision requirements of tests performed by nurse or tech 25 Betsy Nicoletti �2008

26. Audiologists and PQRI MIPPA law (Why?? Why another acronym?) includes audiologists as eligible to report PQRI indicators for 2008 Look for indicators in 2009 PQRI list related to audiology (MIPPA: Medicare Improvements for Patients and Providers Act) 26 Betsy Nicoletti �2008

27. Qualified Audiologist Masters or doctorate in Audiology Licensed by state If no state license, successfully completed 350 hours supervised Performed not less than 9 months supervised audiology services after obtaining degree Successfully completed national exam approved by Secretary 27 Betsy Nicoletti �2008

28. Spring transmittals from CMS Clarified CMS policy that Audiologists must bill under their own NPI numbers, not under MD�s provider number Do not bill for Audiologists services incident to (under MD�s provider number) after Oct 1 2008 Audiologist must have NPI number Audiologist must be signed up with Medicare (enrolled, credentialed) and attached to the group 28 Betsy Nicoletti �2008

29. Audiology testing Require a physician/NPP order When sent to audiologist for testing, audiologist may select appropriate battery of tests Payment allowable by reason the test was done, not by diagnosis or patient condition 29 Betsy Nicoletti �2008

30. Testing Covered, if reason is covered, even if the only outcome is the prescription of a hearing aid Not covered if ordered solely for the purpose of fitting or modifying a hearing aid Document reason for test on the order, on the evaluation report in the medical record Identify the name of the referring MD/NPP 30 Betsy Nicoletti �2008

31. Computer assisted screening tests Do not require skilled services of audiologist Examples include �otograms� and pure tone or immitance screening devices 31 Betsy Nicoletti �2008

32. Tests performed by a tech or nurse Must have a referral from MD/NPP May still be performed incident to (billed/reported under the MD provider number) MD must delineate what tests need to be done to a tech or nurse, while an audiologist may select appropriate tests Performed under �general supervision of MD� 32 Betsy Nicoletti �2008

33. What is general supervision for diagnostic tests? First, check the Medicare Fee Schedule. Each diagnostic test has a supervision indicator. Audiology tests have indicator 5 Second, go the IOM manual http://www.cms.hhs.gov/Manuals/IOM/list.asp and look at Pub 100-02, Chapter 15, Section 80 33 Betsy Nicoletti �2008

34. Description for indicator 5 Physician supervision policy does not apply when procedure is performed by a qualified audiologist; otherwise must be performed under the general supervision of the physician General: MD does not need to be in office Direct: MD needs to be in office Personal: MD needs to be in room 34 Betsy Nicoletti �2008

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36. Some non-covered audiology services Routine hearing aid evaluations or services performed only to determine need for hearing aid Fitting of hearing aids Chronic tinnitus Chronic vertigo Screening audiometry Therapeutic services performed by an audiologist 36 Betsy Nicoletti �2008

37. Speech-language pathologists Must meet education and experience requirements for a Certificate of Clinical Competence granted by American speech-Language Hearing Association; or Meets educational requirements for certification and is in the process of accumulating the supervised experience required for certification 37 Betsy Nicoletti �2008

38. For SLP services incident to, in MD office: Requirements for SLP licensure does not apply; all other personnel qualifications do apply But, the requirements in the previous slide do apply! Services of SLP assistants not recognized or covered by Medicare 38 Betsy Nicoletti �2008

39. SLP services Must be part of a physician developed plan of care Direct MD supervision Must be of a complexity that require MD intervention and care 39 Betsy Nicoletti �2008

40. Plan of care should contain Patient�s significant past history Diagnoses requiring therapy Related MD orders Therapy goals/potential Any contraindications Patient�s awareness of diagnosis, prognosis, goals When appropriate, summary of treatment provided and results achieved in other tx 40 Betsy Nicoletti �2008

41. SLP covered services Evaluations and re-evaluations (not screening, not routine) Therapeutic services for medical disorders such as CVA, neurological diseases Disorders of the auditory system Dysphagia 41 Betsy Nicoletti �2008

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43. Search government web sites only http://www.google.com/ig/usgov (Help from the geniuses at Google�.) 43 Betsy Nicoletti �2008

44. The CMS website Filled with great info, hard to find it Use Google: in a Google search box type site:www.cms.hhs.gov incident to Returns incident to info from only CMS (site:www.patio.com umbrella returns only umbrellas from patio.com) 44 Betsy Nicoletti �2008

45. Audiology sources for Medicare http://www.cms.hhs.gov/Manuals/IOM/list.asp Publication 100-02, Chapter 15, Section 80.3.1 Publication 100-04, Chapter 12, Section 30-3 One carrier�s LCD for Audiology testing http://www.ngsmedicare.com/NGSMedicare/ngslcd/policy/L28190_active_lcd.htm Transmittals 1470 and 84 45 Betsy Nicoletti �2008