Navigating ARNP Billing Issues

2. Navigating ARNP Billing Issues Angela Mann, MS, ARNP, NP-C

3. I have nothing to disclose

4. Objectives The attendee will be able to: • Describe the qualifications needed for Medicare, Medicaid and commercial insurance billing • Explain Medicare rules related to NP-physician collaboration, coverage and restrictions for inpatient and outpatient visits • Explain Medicare and Medicaid billing for ARNPs related to direct billing and billing under a physician

5. The NPI number • HIPPA • Unique health care provider identifier • Required for billing for services using electronic billing • The NPI number is permanent and remains with the provider regardless of job or location changes • NPI numbers are required to bill for Medicare or Medicaid, they are commonly used by commercial insurance companies as well. • NPIs may be required for ARNPs, certified nurse midwives, certified registered nurses, CRNAs, and clinical nurse specialists

6. Medicare rules • Must be a registered professional nurse authorized by the state in which services are furnished. Practices as an in NP in accordance with state law and meet one of the following: • Obtained Medicare billing privileges as an NP for the first time on or after January 1, 2003 • Obtained Medicare billing privileges as an NP for the first time before January 1, 2003 and meet certification requirements • Obtained Medicare billing privileges as an MP for the first time before January 1, 2001

7. Medicare rules • Is certified as an NP by a recognized national certifying body that has established standards for NPs; and • Has a Masters degree in nursing or a Doctorate of nursing practice degree

8. Absolute Medicare rules • Services must be medically reasonable and necessary • Services must have been provided as billed, as supported by the medical record • The clinician providing the service must have a Medicare provider number • The entity seeking payment must submit a Centers for Medicare and Medicaid services CMS 1500 form appropriately completed • The entity seeking payment must accept Medicare’s rates • Providers may not provide kickbacks for referrals • Services must be billed under the provider number of the clinician performing the service, unless ‘incident-to’ or ‘shared visit’ rules are followed • Medicare will pay only certain parties

9. Billing • NPs are expected to submit claims under their own NPI number. • NPs may assign numbers to a group practice for purposes of billing. • There are no limitations on CPT codes, as long as they are recognized by Medicare and have reimbursement codes

10. Incident-to They must be an a integral, although incidental, part of the physicians professional service They must be commonly rendered without charge or included in the physician’s bills They must be of the type that is commonly furnished in physicians offices or clinics They must be furnished by the physician or by auxiliary personnel under the physicians direct supervision

11. Shared visit • NPS with their own billing number providing shared visit with physicians and hospitals may bill 100% as long as the physician has also seen the patient. The same day in a “face-to-face” encounter. Billing will take place under the physicians billing number • It is not required to have a physician counter signature for hospital admission

12. In-Patient Billing • NP salary vs. reimbursement billing

13. Medicaid • Services provided by an ARNP under direct supervision of the physician may be billed by the physician, instead of the ARNP. Direct physician supervision means the physician: • Is on the premises when the services are rendered, and • Reviews, signs and dates the medical record

14. Content and Documentation

15. E/M Documentation and Billing • HPI • Brief 1-3 • Extended-four or more elements or associated comorbidities • OLDCART • ROS • Pertinent-1 • Extended 2-9 • Complete 10 or more • PFSH • Pertinent-1 • Complete-2 or more • Initial visits require at least one item from all three PFSH areas • Past medical • Family history • Social history

16. Reimbursement

17. Review of systems (ROS) • For purposes of ROS, the following systems are recognized: • Constitutional symptoms • Eyes • Ears, nose, mouth, throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary ( skin and/or breast) • Neurological • Psychiatric • Endocrine • Hematologic/lymphatic • Allergic/immunologic

18. ROS • A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI • The patient’s pertinant positive responses and pertinent negatives for the system related to the problem should be documented

19. ROS • An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems. • The patient’s pertinent positive responses and pertinent negatives for 2-9 systems should be documented

20. ROS • A complete ROS inquires about the system(s) directly related to the problem(s) identified in HPI plus all additional body systems • At least 10 organ systems must be reviewed. The assistance with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation at least 10 systems must be individually documented.

21. Measurements of any three of the following seven vital signs: Sitting or standing blood pressure Supine blood pressure Pulse rate and regularity Respiration Temperature Height Weight General appearance of patient (development, nutrition, body habitus, deformities, attention to grooming) Constitutional

22. Inspection of conjunctiva and lives Examination of pupils and irises(PERRL) Ophthalmoscopic examination of optic discs Examination of the neck Examination of thyroid Eyes Neck

23. Ears, nose, mouth and throat • External inspection of ears and nose • Otoscopic examination of external auditory canals and tympanic membranes • Assessment of hearing • Inspection of nasal mucosa, septum and turbinates • Inspection of lips, teeth and gums • Examination of the oropharynx

24. Assessment of respiratory effort Percussion of chest Palpation of chest Auscultation of lungs Palpation of heart Auscultation of heart Examination of Carotid arteries Abdominal aorta Femoral arteries Pedal pulses Extremities for edema and/or varicosities Respiratory Cardiovascular

25. Inspection of breasts Palpation of breast and axilla Examination of abdomen Examination of liver and spleen Examination for presence or absence of hernia Examination of anus, perineum, and rectum Obtain stool sample for occult blood when indicated Chest Gastrointestinal

26. Examination of scrotal contents Examination of penis Digital rectal examination of prostate gland Pelvic examination Examination of external genitalia Examination of urethra Examination of bladder Examination of Cervix Examination of Uterus Examination of Adnexa/parametria Male Female

27. Examination of gait and station Inspection and/or palpation of digits and nails Examination of joints, bones and muscles of one or more of the following six areas: Head and neck Spine, ribs and pelvis Right upper extremity Left upper extremity Right lower extremity Left lower extremity Examination of the area includes: Inspection and/or palpation Assessment of range of motion Assessment of stability Assessment muscle strength and tone Musculoskeletal

28. Palpation of lymph nodes in two or more areas: Neck Axillae Groin other Inspection of skin and subcutaneous tissue Palpation of skin and subcutaneous tissue Lymphatic Skin

29. Test cranial nerves Examination of deep tendon reflexes Examination of sensation Description of patients judgment and insight Recent assessment of mental status including: Orientation to time, place and person Recent and remote memory Mood and affect Neurologic Psychologic

30. Medical decision-making • Review/order of clinical labs and tests • Review/order of tests and radiology • Review/order tests in medicine • Discuss test with performing/interpreting physician • Decision to obtain old records or obtained history from someone other than patient • Review and summary of old records and/or obtaining history from someone other than patient • Discussion of case with another health care provider and documentation of relevant findings • Independent visualization of image, tracing or specimen itself ( not simply reviewing report)

34. Document Document Document • Avoid words such as “maybe”, “perhaps”, “probably”, or “rule out”. • Record specific signs and symptoms • Right legibly • Always clearly document chief complaint, ”follow-up” is insufficient

35. ICD-9

36. Hierchical Condition Catagories (HCC) • Must be captured in documentation every 12 months • Risk adjustment diagnosis must be based on clinical medical record documentation from a face-to-face encounter • Coding according to ICD-9 guidelines • Medical record documentation must support unassigned HCC

37. HCC Hypertension • Hypertensive CKD, w/CKD stage I-IV • Hypertensive CKD, w/CKD stage V • Hypertensive heart & CKD w/HF &CKD Stage 1-IV • Hypertensive heart & CKD w/HF &CKD Stage V • Hypertensive heart, & CKD w/o HF w/CKD Stage 1-IV • Hypertensive heart, & CKD w/o HF w/CKD Stage V • Hypertensive heart disease

38. Risk Adjustment

39. Meaningful Use • Computerized provider order entry • Electronic prescriptions • Record demographicsand vital signs • Record smoking status • Clinical decision support • Patient assess ability to health information • Clinical summaries • Protected EHR • Lab interface • Grouping patients • Reminder systems • Patient education • Medication reconciliation • Or referral summary of care • Immunization • Secure electronic messaging

40. Healthcare Effectiveness Data and Information Set (HEDIS) • Asthma medication use • Persistence of beta blocker treatment after a heart attack • Controlling high blood pressure • Comprehensive diabetes care • Breast cancer screening • Antidepressant medication management • Childhood and adolescent immunization status • Childhood and weight/BMI assessment

41. Healthcare Effectiveness Data and Information Set (HEDIS) • Prevention and screening • Respiratory conditions • Cardiovascular conditions • Musculoskeletal conditions • Diabetes • Behavioral health • Medication management • Access/availability of care • Experience of care • Utilization • Relative resource use • Health plan descriptive information

42. Modifiers

43. Barriers Third-party reimbursement Hospital privileges Inconsistent and restrictive prescriptive authority Statutory limitations to NP scope of practice

44. Medicare fraud Red flags Affordable Care Act Exclusion statute Federal fraud and abuse laws: False Claims Act (FCA) Anti-Kickback Statute Physician Self Referral Law (Stark Law) Social Security Act U.S. criminal code

45. Improper claims • Billing for services that you did not actually render • Billing for services that were not medically necessary • Billing for services that were performed by improperly supervised or unqualified employee • Billing for services that were performed by an employee who is been excluded from participation in the federal health care programs

46. What to do if you think you have a problem • Immediately cease filing the problematic bills • Seek knowledgeable legal counsel • Determine what money you collect it in error from your patients and from the federal health care programs and report and return overpayments • Undo the problematic investment by taking all necessary steps to free yourself from your involvement in the investment • Disentangle yourself from the suspicious relationship

47. What to do if you have information about fraud and abuse • http://www.stopmedicarefraud.gov • 1-800-HHS-TIPS • E-mail HHSTips@oig.hhs.gov

48. Billing home visits

49. Billing nursing home visits • An NP may not perform the initial comprehensive visit, unless the following requirements are met: • The NP is performing the service for patients in a nursing facility ( as compared with the skilled nursing facility) • ENP is not an employee of the nursing facility • State law permits an NP to perform the service • The services within the scope of practice of the NP understate law • A physician has delegated the service to the NP • The NP is working in collaboration with the physician

50. Clinical Nurse Specialists Services or supplies must be medically reasonable and necessary All of the following must be met Services are performed in collaboration with a physicianServices of the type considered physician services if furnished by an M.D. or aD.O. Services are not otherwise precluded due to statutory exclusion He or she is legally authorized and qualified to furnish the services in the state where they are performed