Effective Utilization of Nonphysician Providers– Billing & Scope of Practice Restrictions

1. Effective Utilization of Nonphysician Providers– Billing & Scope of Practice Restrictions John F. Bishop, PA, CPC, CPMA, CGSC, CPRCPresident John Bishop and Associates, LLCPhysician, Provider Coding, Auditing Compliance andReimbursement ConsultingTampa, FL

2. Reimbursement for Non-Physician Providers Real Life Practice 2014 John F. Bishop, PA, CPC, CPMA, CGSC, CPRC AAPA National Chair Reimbursement Work Group Principle, John Bishop and Associates, LLC Private Consultant Tampa, Florida

3. Objectives • Get managed care and private carrier companies to recognize and pay for NPPs services • Bill properly for a shared visit • Supervision requirements • Identify what physician supervision rules apply to NPPs performing diagnostic tests • List the modifiers to use for NPPs • Discover whether NPPs can perform consults • “Incident to” – one more time! • Skilled Nursing Facility billing for NPP’s

6. Coding-Caveats • If you didn’t write it down-you didn’t do it • If you did write it down but incorrectly-you didn’t do it • If you can’t produce a dictated copy of whatever you said you did (OR, ER,ASC)-you didn’t do it • If you didn’t do it, don’t bill it. That’s called FRAUD!! • If you can’t justify the medical necessity of what you dictated or wrote down-you didn’t do it • If you code it incorrectly-you still didn’t do it • If you did code it correctly-justmaybe you’ll get paid! • If you did get paid, doesn’t mean you get to keep it!! • If you did get paid, be prepared to give it back!!

7. OIG

8. FRAUD and ABUSE • http://oig.hhs.gov/fraud/fugitives/index.asp

10. New: OIG WORK PLAN FOR 2013 • Physician-owned distributors of spinal implants • Physicians: Place of service errors in ASC and outpatient locations • Evaluation and Management Services: Trends in Coding of Claims • We will review E&M claims to identify trends in coding of E&M services from 2000-2009 • E&M services during Global Surgery periods • E&M services: Use of modifiers during global surgical periods*****

11. New: OIG Work Plan 2013 • E&M services: • We will review multiple E&M services for the same providers and beneficiaries to identify EHR documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across all services, Medicare requires providers to select the code for the service based upon the content of the services and have documentation to support the level of service reported.

12. 2013 New: Incident-To services • “Incident to” Services-medical necessity, documentation, quality of care. Determine whether payment for such services had a higher error rate than that for non-incident to services. We will also assess CMS’s ability to monitor services billed as “incident to.” Medicare Part B pays for certain services billed by physicians that are performed by nonphysicians incident-to a physician office visit. They found that over half of services in 24 hours were being performed by nonphysicians. Also found unqualified nonphysicians performed 21% of the services that physician did not perform personally. Incident-to services represent a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record.

13. OIG WORK PLAN FOR 2013 • Excessive dosages…monitoring high volume, high cost drugs for acceptable therapeutic levels for patient condition • Wound Care Services • “Incident to” Services-medical necessity, documentation, quality of care • Physical Therapy and OT providers • Place of Service Errors-services provided in ASC and outpatient locations • E/M during global surgery periods • Consults • Home Calls

14. OIG WORK PLAN FOR 2013 • Services by Social Workers • Medicare payments for Interventional Pain Management procedures • Geographic areas with high utilization of Ultrasound services • Geographic areas with high density of Independent Diagnostic Testing Facilities • Psychiatric Services – inpatient setting • Polysomnography reimbursement – • Medical necessity • Violation of assignment rules-improper balance billing • Business relationships with Advance Imaging Service in Physician office

15. Below are the top ten errors RAC has identified: 10. Debridement Coding - Errors in coding surgical debridement versus active wound care management.9. Duplicate Billing - Filing claims more than once for the same service.8. Stark Violations - Physicians referring patient to services in which they have a financial interest or in which a family member has a financial interest.7. Pharmaceutical Coding in Physician Offices - Incorrect use of codes or units in billing of injections.6. Social Work Services in Facilities - Some clinical social worker services provided to inpatients in hospitals or skilled nursing facilities cannot be billed under Part B.

16. Below are the top ten errors RAC has identified: • 5. Psychiatric Services - Over utilization of psychiatric services provided in outpatient setting.4. Medical Necessity - Documentation not supporting the level of service provided in the outpatient setting.3. E/M Billed During Global Periods - Use of modifier -24 in billing services that should have been included in the global package.2. Place of Service Errors - Physicians performing services in ASCs or outpatient facilities but when billing applying a place of service code indicating the service was performed in the physician office.1. Incident-to Errors - Physician assistants and nurse practitioners performing services for a physician but not following billing-specific guidelines related to the physician's relationship to the patient and the physician's presence in the office.

17. Incident-To Services

18. Non-Physician Providers? • Allowed by state and federal laws to provide physician services and procedures and direct bill (Medicare/Medicaid/Tricare) • Physician Assistants-PA’s • Nurse Practitioners-NP’s • Clinical Nurse Specialists-CNS’s • CRNA’s

19. Non-Physician Providers? • The “other” group • RNFA’s • Physical Therapists-PT • Occupational Therapists-OT • Speech/Audiology Therapists • Surgical Techs-CST • Psychologists • LCSW

20. Billing for Non-physician Professionals • Medicare usually defers to state laws Scope of Practice • Hospitals CANNOT bill for those considered auxilliary personnel services (on payroll) • Require UPIN/PIN • File CMS form # 855-Medicare Part B • Services must be considered Physician Services • Hospital based NPP’s charges may be billed IF NOT INCLUDED ON THE COST REPORT

21. Non-Physician Providers? • Must have national certification/license • Must have state license/registration • Must have hospital (s) privileges • If employed by hospital, must still have a supervising physician of record (most states) • PA’s tied to physicians by law • NP’s may be independent in some states • Reimbursement is totally dependent upon carrier discretion and interpretation!! • Must be considered Revenue generators****

22. Medicare “Incident To” Rule-100% Reimbursed • NPP’s can get reimbursed for seeing patients in the office • Physician must be in Office suite • MD must maintain direct supervision • MD does not have to see patient • NPP can see established, (not new patient or new problem) for “incident to” • Bill in MD’s PIN number-100% reimbursed • If No MD—NPP bills 85% with NPP PIN • NPP can see new patient or new problem-just bill under NPP NPI number

23. “Incident To” • Only Medicare Part B • Not commercial carriers or Medicaid • Bill at 100% of physician fee schedule in physician’s provider number • Must be established patient • Service must be within Physician’s plan of care-(not a new problem) • Physician must be in office suite • ARNP/PA must be employee/leased back to practice

24. Billing Under Incident-To indicates: • The physician was directly involved in the patients care • Services were provided in an office setting • The patient was not new, nor had new conditions • You expect 100% of the allowed fee schedule

25. Billing Under the NPP’S Number indicates that: • There was general supervision (physician NOT in office) • The patient had a new or exacerbated condition (NPP deviated from plan of care) • Expect to receive 85% of the allowed fee schedule • Think of NPPs as Revenue Generators!!

26. Billing for Non-physician Professionals • Medicare usually defers to state laws Scope of Practice • Hospitals CANNOT bill for those considered auxilliary personnel services (on payroll) • Require UPIN/PIN/NPI • File CMS form # 855-Medicare Part B • Services must be considered Physician Services • Hospital based NPP’s charges may be billed IF NOT INCLUDED ON THE COST REPORT

27. Physician Supervision Requirements • CMS defines 3 levels • General (level 1) – procedure is furnished under physician’s overall direction and control (ie, is available by telephone or beeper)-does NOT need to be present • Direct** (level 2) – physician must be physically present in office suite (laboratory suite) and immediately available to furnish assistance and direction throughout the performance of the procedure • Personal supervision** (level 3) - physician must be in attendance in the room during procedure ** Apply equally to all places of service (office/clinic and hospital facility)

28. Physician Supervision Requirements • Level 1 - Most diagnostic pulmonary function tests require general supervision • Level 2 – Direct supervision involves • administering an inhaled medication • 94060, 94070, 94664 • Breathing unusual gas mixture-carbon dioxide • 94400 • Low percentage oxygen-94450, 94452, 94453 • And exercise 94621, 94680, 94681 • Pulmonary stress testing 94620 only requires level 1 supervision

29. Setting Supervision  Requirements For Reimbursement Rates and Services for PA’s and NP’s • Office/Clinic when physician is not on site-85% of physician’s fee schedule • All services PA is legally authorized to provide that would have been covered if provided personally by a physician in Office/Clinic when physician is on site • Physician must be in the suite of offices for 100% of physician’s fee schedule • Home visit/  House Call- 85% of physician’s fee schedule • Skilled Nursing Facility & Nursing Facility • 85% of physician’s fee schedule • Hospital-85% of physician’s fee schedule • First assisting at surgery in all settings- 85% of physician’s first assist fee schedule • Federally Certified Rural Health Clinics- Cost-based reimbursement. • HMO-  Reimbursement is on capitation basis. All services contracted for as part of an HMO contract Using carrier guidelines for "incident to" services.

30. “Incident To”NPP’s Provider # • “General” Supervision • Doctor doesn’t have to see new patients or exacerbated or new conditions • 85% of physician fee schedule • Not required • Not required • “Direct” Supervision • Doctor must see all new Medicare patients and established patients with exacerbations or new conditions • 100% of physician fee schedule • Must indicate point of doctor’s involvement • Doctor should sign all notes

31. Obvious Advantages • Indirectly-MD time is freed up for other uses-office, surgery, hospital rounds, golf course, home, family/children, exercise, reading • MD efficiency, accuracy and skills  • MD bill all carriers for NPP services • MD can set a base salary plus give performance bonus based on either productivity, percentage of their monthly A/R or overall practice A/R • Prescription writing (DEA) • Work for your practice (not Hospital) • NPPs are Revenue Generators

32. Salaries by Specialty-2013 NPs • Oncology $98,327 - $90,574 • ED - $104,549 • Hospital - $93,943 • Surg. Specialties - $91,511 • Women’s Health- $76,483 • Gerontology-$93,668 • Cardiology-$100,881 • Int. Med-$88,287 • Family Practice- $86,518 • Academia- $80,400 PAs • Cardiology $109,030 • Dermatology $107,727 • ED $103,489 • Surgery $102,760 • Hospital based $97,680 • House Calls $94,383 • Orthopaedics $91,491 • Family Practice $90,528 • Pediatrics $86,894 • Oncology $85,851 • Academia $95,215

33. Reimbursable Burn Services and Procedures for NPP’s • Burn Wound Dressing changes under anesthesia • 1st Assist in the OR • VAC changes • Compartment measurements-Wick catheter • ALL Central lines, Triple lumens, A-line, Hickman’s, Ports, Use of US and Fluoro w/interp • I&D’s, NG tubes under guidance, Intubation, Trach’s • Consults • Admission H&P • Daily subsequent visits (not related to Burn injury) • Counseling and Coordination of care • Joint injections/aspirations • Discharge summaries $$$

34. Smoking Cessation • 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes • 99407 intensive , greater than 10 minutes • INCLUDES: Administration and analysis of a health risk assessment (99420)Face-to-face services for new and established patients based on time increments of 15 to 60 minutesIssues such as a healthy diet, exercise, alcohol and drug abuseServices provided by a physician or other qualified healthcare professional for the purpose of promoting health and reducing illness and injury

35. Smoking Cessation 99406-99407 • EXCLUDES: Counseling and risk factor reduction interventions included in preventive medicine services (99381-99397)Counseling services provided to patient groups with existing symptoms or illness (99078)Code also distinct evaluation and management services when performed in additionDo not report with heath and behavioral services provided on the same day (96150-96155)

36. RVU Examples-Ortho • Surgery Day-Surgical Assisting • THR (27130) x 3=37.70 x 36.07=$4271.07 • 4271.07 x 13.6% = $580.87**** • TKR (27447) x 2=40.38 x36.07=$3051.62 • 3051.62 x 13.6% = $415.02**** • Arthroscopy, knee • Menisectomy 29881x3:16.38 x 36.07=$1834.50 • 1834.50 x 13.6% = $249.49**** • TOTAL generated $ 9157.19 • TOTAL paid $1,244.88

37. RVU Examples • Office Day-Dr. in office (“Incident To”) • PA schedule 40 patients • 30 follow-up = 99213=1.70 x 36.07=$1813.50 • 10 new pt/new problems=99204=3.93 x 36.07=$1203.18 (85%) • 5 Trigger points injected= 20550=1.49 x 36.07=$273.30 • 3 Large joint injections=20610=1.94 x 36.07=$211.65 • 2 Med. Joints injected=20605=1.50 x 36.07=$109.12 • TOTAL $3610.75 • ALL charges go under supervising physician’s billing number except new patients. Then they go under PA’s NPI number (expect 85% return)

38. Billing for Time • If more than 50% of visit is spent in counseling the patient • Document total visit and counseling time • Document what was discussed • Can use time as overriding factor on those categories where time is a factor • Must make sense for the diagnosis/reason for visit

39. Visit Codes Do Not Use Alone – Add-on Code** • Prolonged Services • Office • 99354 • 30 minutes to 1 hour additional time (above the time designated for the “base” visit code) • 99355 • each additional 30 minutes additional time (above the time designated for the “base” visit code and after the first hour of additional time (99354)

40. Visit Codes Do Not Use Alone – Add-on Code** • Prolonged Services • Hospital • 99356 • 30 minutes to 1 hour additional time (above the time designated for the “base” visit code) • 99357 • each additional 30 minutes additional time (above the time designated for the “base” visit code and after the first hour of additional time (99356)

41. Scribing • NPPs are highly educated licensed health care providers • Federal and State agencies do not find it credible that an NPP would refrain from providing health care services or making their own observations to solely report the work of a physician • NPPs can (and should) be better utilized!! • They are revenue generators!!!

42. Medical Necessity Issues • Medicare only allows coverage for services and items which are “medically reasonable and necessary” for treatment/diagnosis of a patient. • Medical necessity may be determined according to several factors including the following: • Items or services provided to the patient must be appropriate for that patient’s treatment/diagnosis • Documentation (When identified as required or when requested) supports the medical need. • The frequency of service or dispensing of an item is within the accepted standards of medical practice.

43. ICD-9 CM • Working diagnosis must match the ICD-9 description • Close doesn’t count • Do not up-codeFraud • Do not down-codeFraud • Do not not code-???? • Don’t code from the index • Always verify and check the book! • Then run it through your CCI and NCCI edits • 60-70% of first denials come from wrong/not specific/ ICD-9

44. Fracture Classification in ICD-10-CM • Fracture coding in ICD-10-CM requires: • documentation of site, • laterality, • type of fracture, • whether it is displaced or nondisplaced, • and the stage of healing (or encounter), which includes open fracture classification. • This resource is to assist in the understanding of the classification system utilized in ICD-10-CM for open fractures.

45. Open fractures • The procedure for evaluation and management of open fractures is basically a set of principles that involve initial management and subsequent surgical interventions. The purpose of any fracture classification system in the clinical setting is to allow communication that infers fracture morphology and treatment parameters.

46. Gustilo Classification for Open Fractures • Grade I: • • wound less than 1 cm with minimal soft tissue injury; • • wound bed is clean; • • bone injury is simple with minimal comminution; • • with intramedullary nailing, average time to union is 21–28 weeks • Grade II: • • wound is greater than 1 cm with moderate soft tissue injury; • • wound bed is moderately contaminated; • • fracture contains moderate comminution; • • with intramedullary nailing, average time to union is 26–28 weeks • Grade III: • The following fracture types automatically results in classification as type III: • • segmental fracture with displacement • • fracture with diaphyseal segmental loss; • • fracture with associated vascular injury requiring repair; • • farmyard injuries or highly contaminated wounds; • • high velocity gun shot wound; • • fracture caused by crushing force from fast moving vehicle;

47. Gustilo Classification for Open Fractures • Grade IIIA fracture: • • wound less than 10 cm with crushed tissue and contamination; • • soft tissue coverage of bone is usually possible; • • with intramedullary nailing, average time to union is 30–35 weeks; • Grade IIIB fracture: • • wound greater than 10 cm with crushed tissue and contamination; • • soft tissue is inadequate and requires regional or free flap; • • with intramedullary nailing, average time to union is 30–35 weeks; • It is important to educate providers on the use of this scale for the specific documentation necessary in ICD-10-CM. • This will ensure that proper code assignment can be made without multiple queries to the provider.

48. “Arthritis” • 715.16 Primary localized osteoarthrosis, lower leg • 715.00 Generalized osteoarthrosis, unspecified site • M17.0 Bilateral primary osteoarthritis of knee • M17.10 Unilateral primary osteoarthritis, unspecified knee • M17.11 Unilateral primary osteoarthritis, right knee • M17.12Unilateral primary osteoarthritis, left knee • M15.0 arthritis of multiple sitesbilateral involvement of single joint (M16-M19)

49. Ortho/Sports Medicine • ICD-9-CM • 719.47 - Pain in joint; ankle and foot, Ankle joint, Digits [toes], Metatarsus, Phalanges, foot, Tarsus, Other joints in foot • ICD-10-CM • M25.571 Painin right ankle • M25.572 Painin left ankle • M25.579 Painin unspecified ankle • M79.671 Painin right foot • M79.672 Painin left foot • M79.673 Painin unspecified foot • M79.674 Painin right toe(s) • M79.675 Painin left toe(s) • M79.676 Painin unspecified toe(s)

50. Ortho/Sports Medicine • ICD-9-CM • 726.12- Bicipital tenosynovitis • ICD-10-CM • M65.811Other synovitis andtenosynovitis, right shoulder • M65.812Other synovitis andtenosynovitis, left shoulder • M65.819 Other synovitis andtenosynovitis, unspecified shoulder • ICD-9-CM • 729.5 - Pain in limb • ICD-10-CM • M79.601Paininright arm • M79.602Paininleft arm • M79.603Paininarm, unspecified • M79.604Paininright leg • M79.605Paininleft leg • M79.606Paininleg, unspecified • M79.609Paininunspecifiedlimb