Billing for Non Physician Visits Enhance Review, Increase Efficiency

1. Billing for Non Physician VisitsEnhance Review, Increase Efficiency E&M Services & Compliance to Medicare Guidelines December 6, 2010 Sponsored by Louisiana Regional PHO Presented by Health Care Consulting Services, Inc.

2. Speaker Disclosure/Disclaimer Joanne Byron, LPN, BS, CHA, CIBS, CMC, COBS,CPC, CPC-1, MCMC, PCS President, CEO Health Care Consulting Service, Inc. has declared no disclosures.

3. Learning Objectives Documentation and supervision requirements for medical assistant, LPN, and RN patient visits when billing 99211. Medicare’s supervision requirements when billing incident-to for nurse practitioner, physician assistant and other non-physician practitioners in the office. Limitations: Medicare Compliance when billing incident-to

4. Evaluation & Management (E&M) - the Focus of the OIG in 2011! Although billing incident-to can make your office more efficient and profitable, there are various compliance issues to consider! Billing "incident to" services has a financial incentive for physicians 100% of the physician’s fee schedule when utilizing non-physician practitioners! However, compliance when billing Medicare or insurances following Medicare guidelines is critical to avoid potential fraud and/or abuse risk.

5. The Office of Inspector General (OIG) has published the 2011 work plan which includes focus of E&M coding and reimbursement. Medicare paid $25 billion for E&M services in 2009 which represents 19% of all Medicare Part B payment.

6. The OIG reminds providers in the 2011 Work Plan responsibility to accurately submit codes which reflects services provided which includes:   Type Setting Complexity Patient status and new versus established

7. In addition to the accuracy of claims, the OIG will review the extent and potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations made by local Medicare contractors. The Medicare Claims Processing Manual instructors providers to select the code for the service based upon the content of the service where documentation supports the level of service reported.

8. The accuracy of claims is extremely important to avoid filing a “false claim”. Appropriately billing “incident to” visits when non-physicians are providing the services can potentially be a compliance nightmare. Let’s review the pros and cons of incident-to billing and how to strengthen compliance when filing claims.

9. Advantages of billing incident-to? Increases efficiency of the physician’s time; Can improve service to our patients by delegating particular functions to non physician staff; Allows 100% reimbursement for NPP services (non-physician providers such as nurse practitioners and physician assistants) in lieu of 85% of the fee schedule when billing Medicare.

10. Disadvantages of billing incident-to? Incident-to is generally restricted to the office setting (non hospital or SNF); The physician must be present in the office suite when a NPP is providing services billed under the physician’s provider number; Medicare restricts or limits the types of services which can be performed and billed as incident to.

11. The following guidelines are for non-institutional settings Guidelines presented address physician office and setting other than hospital or skilled nursing facility. Medicare: Physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, clinical psychologists, clinical social workers, physical therapists and occupational therapists all have their own benefit categories and may provide services without direct physician supervision and bill directly for these services.

12. However, under Medicare guidelines. . . When their services are provided as auxiliary personnel (under direct physician supervision), they may be covered as incident to services, in which case the incident to requirements would apply.

13. What is covered as an incident to service? To be covered incident to the services of a physician or other practitioner, services and supplies must be: An integral, although incidental, part of the physician’s professional service (§60.1); Commonly rendered without charge or included in the physician’s bill (§60.1A); Of a type that are commonly furnished in physician’s offices or clinics (§60.1A); Furnished by the physician or by auxiliary personnel under the physician’s direct supervision (§60.1B).

14. Qualifying Factor To qualify as “incident to,” services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment.

15. Institutional Setting The hospital’s intermediary (or Medicare Administrative contractor) makes payment for these services under Part B to the hospital: Hospital services incident to physician’s or other practitioner’s services rendered to outpatients (including drugs and biologicals which are not usually self-administered by the patient), and Partial hospitalization services incident to such services may also be covered.

16. Institutional Setting These services are only payable to the hospital because of the bundling provisions, but the hospital could, in turn, purchase the services from you when furnished in a hospital setting. You are not eligible for a payment from Medicare because supervision alone does not constitute a reimbursable practitioner service.

17. Institutional Setting You must personally perform the practitioner service for which you bill in order for it to be payable in a hospital setting. If you do not personally perform the service, you are not entitled to any practitioner payment. (We will be discussing “Shared Visits” in the hospital setting and Medicare guidelines later in this presentation) When your staff provides services to hospital patients (such as the services of nurses or therapists, diagnostic tests, etc.), the Medicare payment for those services is included in the Medicare payment to the hospital.

18. Social Security Act You may not seek payment from the patient for such services. You may, however, seek payment from the hospital. Neither you nor the hospital may charge the patient. The Social Security Act authorized civil money penalties for any person who bills for services in violation of the bundling requirement; this provision applies to improper billings of the patient as well as to improper billings to a Medicare contractor.

19. The Social Security Act provides that every service to hospital inpatients and outpatients, except for the professional services of physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists, as well as qualified psychologists services, must be provided by the hospital directly, or by others under arrangements made by the hospital, and only the hospital may bill Medicare for the services. This is the hospital “bundling” provision. Social Security Act

20. Hospital bundling provision This provision is applicable to hospital patients where a Medicare payment can be made to the hospital, including patients in psychiatric hospitals. There are some psychological tests that physicians and clinical psychologists may bill to Medicare Part B that are not considered “bundled” into the Part A payment to the hospital.

21. These tests are:

22. You must personally perform the practitioner service for which you bill in order for it to be payable in a hospital setting. If you do not personally perform the service, you are not entitled to any practitioner payment. This means that services and supplies that would normally be covered “incident to” in an office setting, such as the services of nurses and other clinical assistants that you hire and supervise, are not billable by you in hospital settings. Therefore, if you utilize the services of your own employees in a hospital setting and you merely supervise their services, you are not eligible for a payment from Medicare.

23. Incident To Physician’s Professional Services Direct Personal Supervision - Private Practice Coverage of services and supplies incident to the professional services of a physician in private practice is limited to situations in which there is direct physician supervision of auxiliary personnel.

24. Defining “Auxiliary Personnel” Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician. Likewise, the supervising physician may be an employee, leased employee or independent contractor of the legal entity billing and receiving payment for the services or supplies.

25. Relationship is Required – at the physician’s “expense” The physician personally furnishing the services or supplies or supervising the auxiliary personnel furnishing the services or supplies must have a relationship with the legal entity billing and receiving payment for the services or supplies that satisfies the requirements for valid reassignment.

26. As with the physician’s personal professional services, the patient’s financial liability for the incident to services is to the physician or other legal entity billing and receiving payment for the services or supplies.

27. Where a physician supervises auxiliary personnel to assist him/her in rendering services to patients and includes the charges for their services in his/her own bills, the services of such personnel are considered incident to the physician’s service if there is a physician’s service rendered to which the services of such personnel are an incidental part and there is direct supervision by the physician.

28. The direct supervision requirement must still be met with respect to every non-physician service billed as incident to! Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. It does mean that the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.

29. Outside the Office Setting If auxiliary personnel perform services outside the office setting, e.g., in a patient's home or in an institution (other than hospital or SNF), their services are covered incident to a physician's service only if there is direct supervision by the physician.

30. For hospital patients and for SNF patients who are in a Medicare covered stay, there is no Medicare Part B coverage of the services of physician-employed auxiliary personnel as services incident to physicians? services under §1861(s)(2)(A) of the Act.

31. In the Office Setting– billing 99211 for medical assistant and nurse visits The service rendered should be conducted according to the plan of care set forth by the physician or provider overseeing treatment of the patient. The service must be documented appropriately: date of service, observations made of the patient’s condition, signature/authentication of the note. The physician must be present in the office suite and immediately available if necessary. It should be a service ordinarily rendered by a physician’s office staff person such as taking blood pressures and temperatures, giving injections, and changing dressings

32. In the Clinic Setting – Supervision Rules In highly organized clinics, particularly those that are departmentalized, direct physician supervision may be the responsibility of several physicians as opposed to an individual attending physician. In this situation, medical management of all services provided in the clinic is assured. The physician ordering a particular service need not be the physician who is supervising the service.

33. In the Clinic Setting Therefore, services performed by auxiliary personnel and other aides are covered even though they are performed in another department of the clinic. Supplies provided by the clinic during the course of treatment are also covered.

34. In the Clinic Setting When the auxiliary personnel perform services outside the clinic premises, the services are covered only if performed under the direct supervision of a clinic physician. If the clinic refers a patient for auxiliary services performed by personnel who are not supervised by clinic physicians, such services are not incident to a physician’s service.

35. Coding Incident to Services of Auxiliary Personnel Code 99211 is provided in CPT and worded as follows: Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.

36. 99211 may not always be reimbursed Many insurance plans require the presence of the physician to reimburse a patient encounter. Check with your billing staff regarding reimbursement history for this code. Verify whether the insurance carrier follows Medicare guidelines or has other guidelines.

37. CPT examples - 99211 The American Medical Association (AMA) provides clinical examples of E&M levels of service for various specialty situations in Appendix C of the CPT book. The following slides demonstrate examples taken from CPT 2011.

38. Clinical Example 99211Geriatrics/Internal/Family Medicine Office visit for an 82-year old female, established patient, for a monthly B12 injection with documented Vitamin B12 deficiency.

39. Office visit for an established patient for a dressing change on a skin biopsy. Office visit for an established patient requesting a return-to-work certificate for resolving contact dermatitis. Clinical Example 99211Dermatology

40. Office visit for established patient who is performing glucose monitoring and wants to check accuracy of home machine with lab blood glucose by technician who checks accuracy and function of patient machine. Clinical Example 99211Endocrinology

41. Office visit for a 45 year old female, established patient, for a blood pressure check. Office visit with 12 year old male, established patient, for cursory check of hematoma one day after venipuncture. Clinical Example 99211Internal/Family/Pediatrics Medicine

42. Billing 99211 for Anticoagulation Management  CPT code 99211 is the lowest level evaluation and management (E/M) service and does not require a physician face-to-face encounter with the patient. However, it does require direct physician supervision (i.e. the supervising physician must be present in the office when the service is rendered) of the ancillary staff who are conducting the face-to-face encounter.

43. 99211 & Anticoagulation Management Services billed to Medicare under CPT code 99211 must be reasonable and necessary for the diagnosis and treatment of an illness or injury. This would include appropriately performed and documented anticoagulation management.

44. The following represents the guidelines that would be used in review of these charges as well as the errors that have previously been found on carrier or Comprehensive Error Rate Testing reviews. 99211 & Anticoagulation Management

45. 99211 for Anticoagulation Management “Do’s”  Documenting the patient’s indication for anticoagulant therapy, current dose, protime and INR results Assessing the patient in-person for signs and symptoms of bleeding/adverse effects to anticoagulant therapy Assessing the patient for changes in health status that may impact or account for fluctuations in lab results (for example, new or changed medications that may cause a drug interaction with the anticoagulant therapy)

46. Providing medically necessary education as needed based on the patient’s individual circumstances Documenting the identity of the ancillary staff performing this service “incident to” the supervising physician Documenting the identity of the billing physician who was notified of results, gave orders, and provided direct supervision 99211 for Anticoagulation Management “Do’s” 

47.  99211 for Anticoagulation Management “Don’ts”  Billing for 99211 when the in-person encounter with the patient was only for the diagnostic test Billing for 99211 for telephone care, i.e. instructions on changing dose, assessment, and/or education Billing for 99211 when the only documentation would be vital signs, the patient’s current and future dose of anticoagulant, and when lab work is to be repeated

48. Billing for 99211 when direct physician supervision is not met or is not by the physician treating the patient’s medical problem requiring anticoagulant therapy (i.e. as seen in some “Coumadin ® clinic” scenarios) Billing for 99211 based on the delivery of repetitive education that does not serve the medical needs of the individual patient  99211 for Anticoagulation Management “Don’ts” 

49. Additionally (and not just limited to anticoagulation management), 99211 should not be used for: routine, in-person prescription renewals unless the patient’s condition requires reevaluation prior to the renewal determination routine blood pressure checks that have no impact on patient’s care performing diagnostic or therapeutic procedures

50. 30.6.1 Claims Processing Manual Chapter 12SPLIT/SHARED E&M SERVICE A separate handout “Clarification of Incident-to and Split/Shared Services by Non-Physician Practitioners – Revision published online 11/05/2010 applicable to Louisiana has been provided to you. This document summarizes the information we are about to discuss. Please take this handout back to your office and review carefully with your billing manager.

51. Office/Clinic Setting In the office/clinic setting when the physician performs the E/M service the service must be reported using the physician’s NPI#. When an E/M service is a shared/split encounter between a physician and a NPP (non-physician practitioner such as NP, PA, CNS or CNM), the service is considered to have been performed “incident to” if the requirements for “incident to” are met and the patient is an established patient.

52. New Patient, New Problem or Other Factor Disallowing Incident to If “incident to” requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s NPI# and payment will be made at the appropriate physician fee schedule payment – which is 85% of the normal Medicare reimbursement rate.

53. SPLIT/SHARED E&M SERVICE Hospital Inpatient/Outpatient/Emergency Department Setting When a hospital inpatient/hospital outpatient or emergency department E&M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E&M encounter with the patient, the service may be billed under either the physician's or the NPP's NPI number! Authentication rules and supporting documentation must be evident. We will review this shortly!

54. SPLIT/SHARED E&M SERVICE Hospital Inpatient/Outpatient/Emergency Department Setting If there was face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP's NPI. Payment will be made at the appropriate physician fee schedule rate based on the NPI entered on the claim (85% of the normal Medicare rate).

55. Medicare Example of Inpatient Shared Visit If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.

56. Medicare Example of an Office Shared Visit In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the "incident to" requirements are met, the physician reports the service. If the “incident to” requirements are not met, the service must be reported using the NPP’s NPI.

57. Proof of Face-to-Face Health Care Consulting Services (HCCS) has had the unfortunate opportunity to be retained by physicians where overpayment determinations were made when a NPP was utilized in a shared visit situation, but proof of any face-to-face by the physician was not evident. History – is not proof Exam – yes, you needed to be face-to-face to complete a physical exam Assessment/Plan – is not proof

58. Pinnacle Business Solutions – Policy for Incident To PBS policy is the same as national Medicare policy reviewed above. The PBS policy reiterates national policy. Here is additional information PBS provides to physicians reflecting national policy: Direct Supervision- Direct supervision in the office setting means the physician must be present in the office suite and immediately available and able to provide assistance and direction throughout the time the service is performed.

59. If you are a solo practitioner, you must directly supervise the care. If you are in a group, any physician member of the group may be present in the office to supervise. The requirement for direct supervision of a service incident to a physician or non-physician practitioner is not satisfied unless there is a specific physician or non-physician practitioner responsible for the supervision of the billed service.

60. If more than one person supervises a service, the one who had the responsibility for the major part of the service should be identified on the claim. The claim is paid at the rate appropriate to the supervisor (at 85% if the supervisor is a non-physician practitioner).

61. In some cases the physician or non-physician practitioner who performed an initial service and ordered the service that is subsequently performed by auxiliary personnel is not the same person who is supervising the service. Then the supervising physician must be identified on both the paper and electronic claim forms.

62. When the paper Form CMS 1500 is used, follow the instructions for completing the form, found in Pub 100-04, chapter 26, §10.4. When filing electronic claims with incident to services, supply the ordering physician information for each line of service in the 2420E loop and supply the supervising physician information in loop 2310E. If the supervising physician information differs for a specific detail line, then supply that detail line supervising physician information in loop 2420D. PBS – billing instructions

63. If auxiliary personnel perform services outside the office setting, e.g., in a patient’s home or in an institution (other than hospital or SNF), their services are covered incident to a physician’s service only if there is direct supervision by the physician. For example, if a nurse accompanied the physician on house calls and administered an injection, the nurse’s services are covered. If the same nurse made the calls alone and administered the injection, the services are not covered (even when billed by the physician) since the physician is not providing direct supervision.

64. The availability of the physician by telephone and the presence of the physician somewhere in the institution does not constitute direct supervision. (See §70.3 of the Medicare National Coverage Determinations Manual for instructions used if a physician maintains an office in an institution.)

65. Pinnacle provides additional explanation of incident to for NPPs to clarify the complexity of compliance to the incident-to Medicare rules: A non-physician practitioner such as a physician assistant or a nurse practitioner may be licensed under State law to perform a specific medical procedure and may be able to perform the procedure without physician supervision and have the service separately covered and paid for by Medicare as a physician assistant’s nurse practitioner’s service.

66. However, in order to have that same service covered as incident to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician’s personal in-office service.

67. It also means there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the non-physician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment.

68. Homebound Patients Some physicians and physician-directed clinics call upon nurses and other paramedical personnel to provide these services under general (rather than direct) supervision. The Senate Finance Committee Report accompanying the 1972 Amendments to the Act recommended that the direct supervision requirement of the “incident to” provision be modified to provide coverage for services provided in this manner.

69. Homebound Patients Accordingly, to permit coverage of certain of these services, the direct supervision criterion in §60.2 above is not applicable to individual or intermittent services outlined in this section when they are performed by personnel meeting any pertinent State requirements (e.g., a nurse, technician, or physician extender) and where the criteria listed below also are met:

70. The patient is homebound The service is an integral part of the physician’s service to the patient (the patient must be one the physician is treating) and is performed under general physician supervision by employees of the physician or clinic. General supervision means that the physician need not be physically present at the patient’s place of residence when the service is performed; however, the service must be performed under his or her overall supervision and control.

71. The physician orders the service(s) to be performed, and contact is maintained between the nurse or other employee and the physician, e.g., the employee contacts the physician directly if additional instructions are needed, and the physician must retain professional responsibility for the service. All other “incident to” requirements must be met. The services are included in the physician’s/clinic’s bill, and the physician or clinic has incurred an expense for them.

72. The services of the paramedical are required for the patient’s care, that is, they are reasonable and necessary as defined in the Medicare Benefit Policy Manual, Chapter 16, “General Exclusions from Coverage,” §20; and 5. When the service can be furnished by an HHA (home health agency) in the local area, it cannot be covered when furnished by a physician/clinic to a homebound patient under this provision, except as described in §60.4.C.

73. This coverage should not be considered as an alternative to home health benefits where there is a participating home health agency in the area that could provide the needed services on a timely basis. A copy of the seven (7) page Incident-to Policy is provided to you as a separate handout. Remember – each insurance has different guidelines. It is recommended to implement procedures to be compliant with the most stringent guidelines (such as Medicare) for risk mitigation purposes!