Incident-to Billing As It Relates to NPPs
Questions
Answers
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can you go back and forth between incident to and not?
It is about the documentation. So in an afternoon of patients it would be possible for a NPP to have one pt that is an incident to visit and the next billed as direct care
We have a question regarding our OB/GYN practice. For specific questions about procedures and care need to #1 go nurse practitioners, is it within their scope of practice to fit to your state's scope's definitions #2 what is the training of for pessaries? Thank you. the supervising physician? (this is from Michigan and several other states but CHECK YOURS) If they have the skills to do the procedure then it would be possible. You have to check state first and see if they have restrictions other than this and then meet any conditions #3 will the carrier pay for the NPP to bill directly for the service sometimes there are procedures that the payer will not pay an NPP for. I hope this long answer helps Is "General Supervision" a billing methodology or a scope of practice. Example: If a NPP is practicing in an office suite alone and no Physician is around. Can we bill under the Physician?
If you are asking about incident to billing the requirement is a level of supervision must be in place (physician in the office suite) This is a medicare requirement. State scope may have other restrictions or not If you have a medicare patient being seen by the NPP there MUST be a physician in the office to bill "incident to" If there is none the service is billed directly
In California, PA's can bill Medicare directly, correct?
I am sorry, I would have to check to be sure State Scope in CA does not present a precluding reason that they could not. If the scope is OK then Medicare would allow a PA to be credentialed and bill directly
How frequently does the physician overseeing a NPP need See language slide 33B. Sorry but nothing more specific. to physically see the patient? Can the physician bill for the time he spends going over the as stated in the other Critical Care question this type of care NP's notes in critical care? is only allowed to be billed directly by ONE PROVIDER. ALL the work of the time spent on visit must be that of one provider. Except for a slight difference in Teaching Rules. Unless the notes are that of another provider/group/specialty When physician is collabrating and bills incident to, what Please see slide 46 &47 sort of documentation is required to bill under the physician, when history physical plan of car ei sdone by NP Are Federally Qualified Health Centers required to follow the "Incident Too" rules?
They can but I would suggest checking with your carrier to see what their FQHC info says. IE Trailblazers has a policy sheet Can you explain "grandfathering" of NPPs who had billing They did not have to have a masters for credentialing privileges prior to 1/1/2003? Does the supervising physician need to sign off on the Check your state scope first (ie Michigan says no) Next medical record along with the NP? what type of situation and service -Inpatient or outpatient
A: No physician in the office suite No physician billing Bill directly FOR MEDICARE and payers who follow their policies
Regarding the "General Supervision" question I mentioned a few mins ago. The question wasn't in regards to "Incident to". The example I gave was referring to the NPP being alone, but a Physician reachable by phone. Can we bill under the Physician who is "available by phone" OR should it only be billed under that NPP who performed the service herself? Thanks
Please explain the required employment relationship between MD and NPP for "incident to"
The NPP MUST BE EMPLOYED by the physician/group. So if the NPP works for another group or works for say the hospial, those services cannot be billed because the NPP does not work for the person supervising/ giving them instructions (Medicare Rules)
Slide 32 says physcian must be in the office suite for NPP. This is for incident to billing which is NOT ALLOWED in What are the rules for the hospital setting? the hospital setting. If you are talking split shared see slide 44 So those NPPs without masters but nationally certified are If they had their UPIN number issued prior to the 2003 OK? deadline then they were grandfathered in . and should now have an NPI As related to Plan of Care can a PA see a 'new' patient in Under Medicare rules YES and it is billed directly the office ( one who has net been seen by the Physician)? So would an NP be unable to bill a NEW patient visit as "incident to"? But bill under their own number instead depending or their state scope?
See previous answer
Can PA's see new patients within a practice that does include M.D.s? Can you restate the verbage you mentioned on slide 34 in reference to the "link" between the visit and the physician's plan of care?
See prior answer
For a Rural Health Clinic, are the rules for "incident-to" services the same as nonrural?
See MBPM Policy Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services Section 50 and others
If you have an established patient who is seeing the NPP and has a new problem, the physician sees the patient and establishes the plan of care at that visit and the NPP dictates that Dr. XX was consulted, examined patient, and established the above plan of care and physician cosigns the record would this be incident to or does the physician have to have his own documentation.
Unless the NPP was acting as a scribe the physician needs to document the work done in support of the code billed
Slide 34 - could you re-state the suggestion made for the NPP to document the initial visit performed by the physician?
see answer above but remember . The physician has to see the patient at intervals to show they are involved in the care of the patient. I know some have been told as long as the patient sees the physician first then the NPP can see the patient after that (forever) that is not correct See slide 33B
just make your own statement that allows the auditor to know where to look for a visit's note that the provider had face to face with the patient in which the plan of care was indicated. It should have the date but after that what would YOU put to make the auditor see that the physician had seen the patient and was directing care
Upcoming on Slide 56, we have a correction: On CMS' If the requirements of state scope are not an issue YES for FAQ Answer ID#10795 clarifies that the IPPE and AWV Medicare rules have their own benefit category and therefore does not fall under the incident to benefit category under section 1861(s)(2)(A) of the Act can the PA or NP bill directly if there is no physician in the yes suite? Can a NP or PA perform an initial and skilled nursing The simple answer is yes. The complicated answer is facility (not incident to)? depends. CFR Section 483.40(c)(4) offers guidance with specific information based on federally mandated rules found in Section 483.40(c) Can a PA or NP student act as a scribe and what are the WPS , Michigan's carrier, has statements but no policy documentation guidelines? check you carrier SEARCH Scribe and documentation on their website How do you document or prove which MD was supervising Sorry I tihink I missed this one. The office schedule is on a given day? (slide 39) what they tell us they check. THere is no documentation, per Medicare , needed in the chart record for that day On slides 35-38, is the entire slide rescinded or just the bullet stamped "Rescinded".? Can PA's and NP's provide services for a new patient?
Unfortunately the entire policy
Medicare policy states yes and they are directly billed No Incident to for NEW Can a NP bill both ways, direct bill when she is alone in the If there is a plan of care on the patient and other preoffice and incident to when the physician is in? cluding conditions (state scope etc) are met yes
Our supervising physician reviews and signs all patient charts, np dictates and states they provided service. Should the np sign chart and then physicians state "chart reviewed" and sign? What is correct signature policy for incident to billing?
Medicare does not have a specific signature policy that I am aware of on individual charts. The policy does state that "subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment." Ch 15: Sec 60
Does Slide 58 Bullet #3 include throat cultures and urine dips done in the office as diagnostic testing? So does this mean that you would bill the E/M visit incident to the physician but you would bill associated diagnostic tests (lab, xray, ekg, etc) directly under the NPP number? Does the MD portion of the shared visit need to be a separate and distinct note or can the doctor add his notes to the NP notes? must the doctor who originated the plan of care be the one who stays involved in patient care or can any doctor in the group periodically see the patient? For shared/split visits in an inpatient setting, can the shared services be billed by the physician when the NPP is employed by the hospital?
My slide 58 does not have a bullet #3
Referring to slides both 47 and 50 can you elaborate... on the incident to E/M visits where hospitals as facilities are concerned What does the acronym EMTALA stand for? Did I miss that slide?
You would bill the tests based on the level of supervision for that type of service
I would "suggest" they are separate notes so there is no confusion. There is no requirement in the policy of a format Another physician could see the patient and start a NEW plan of care or extend the old one, I would guess. No #1) the NPP would not be working under their supervising physician so they would be in violation of their scope #2) the physician is billing for services he nor his staff performed. This is not appropriate MCM Ch 12 Sec 30.6.1(B) states Incident to is Office only In the hospital, NPP care is billed as documented directly or split shared Emergency Medical Treatment and Active Labor Act
Would you bill the following scenario incident to: New Under the NPP billing directly. patient visit in the office when the NPP sees the first. does history, exam and documents MDM, then the physician comes in and makes a few notes regarding treatment plan?? What does EMTALA stand for again? What is the best way to contact the various payers to find out what their Incident To guidelines are? Just call customer service, or would it be contracting? Can a Nurse Practioner or PA perform and bill for an initial level in a Nursing Facility? If so Can you provide a resource. Can a PA or NP see a new patient incident to ??? We heard you just say that it needs to be an established patient. So we need clarification please.
Emergency Medical Treatment and Active Labor Act Either
http://www.cms.hhs.gov/Medicare/MedicareContracting/ContractorLearningResources/Downloads/JA4 246.pdf Incident to billing is where the NPP is following the plan of care set by the physician. How could you have a plan of care if the physician has never see the patient? For Medicare patients and those folowing their policy, Incident to is only on established patients.
Can you tell us if slide 47 is referring to the NP billing The slide states "Office/Clinic Setting" incident 2 the physician they collaborate with in the facility setting? Can you elaborate on this? to meet incident to, the physician who established the plan Correct of care has to be in the office, correct? to clarify, it can not be a physician the patient has never seen? Can a NPP direct bill for new problems?
yes (Medicare rules)
Can you direct me to guidelines for billing a NP/PA in an Chapter 12 and Chapter 15. In an urgent care setting urgent care setting? would a supervising physician need to problems are generally new so there is no "incident to " be in the office suite in order for the NP/PA to see patients? billing. It would all be direct If NP or PA does the stress test at the hospital or office, is the performance of the stress test billed under the NP/PA or the doctor? Is there a diifference iwhether in the office or hospital? In an OB/GYN office, we often have patients come in for suspected yeast infection. If the patient has been seen by the doctor within the last 3 years and the doctor's note says return PRN, can the NPP see the patient?
See OPPS 2010 and 2011 for information on supervision of diagnostic tests which are in their own category
What is the benefit of billing incident to vs direct billing for an NP?
85% vs 100% reimbursement of physician fee schedule
Yes but in that it is a new problem it must be billed directly under there NPP's own number
Can you tell me where i can find more detail info on Inpatient Shared/split billing. My physicians saying they never knew they had to document an addition statement
Local carriers have the most info see: http://www.wpsmedicare.com/part_b/departments/medical_ review/2009_1116_em.shtml " Both the physician and the NPP must each personally perform part of the visit, and both the physician and the NPP must document the part(s) that he or she personally performed. When the supporting documentation does not demonstrate that the physician "performed a substantive portion of the E/M visit face-toface with the same patient on the same date of service" as the portion of service performed by the NPP, a service billed under the physician's Provider Transaction Access Number (PTAN) will be denied." This is from Medicare carrier WPS Check yours
We have NP in our surgery dept that perform Consults, IPD to bill under the physician per slide #46 document "any progress notes. Does the Attending staff have to document portion of the E&M service" And the NP MUST work an additional statement in thier attestation to bill at 100%. for the physician doing the billing (meaning billing using the physician upin) This is a inpatient facility If a NP or PA does the stress test at the hospital, is the performance of the stress test billed under the NP/PA or the doctor? The doctor will reviewe the EKG before signing off on the reort
Who did the work? Sounds like the NPP - the physician cannot sign off on the NPP's opinion and call it their own just as if a procedure was done by the NPP, the physician could not sign off and say the work was theirs
In the inpatient hospital setting, when a NPP and physician I would not be comfortable with it. both see the patient, if the NPP documents the majority of the encounter and the physician documents the following: •I have personally seen, evaluated, and participated in the services rendered to this patient. The history I obtained and the physical examination I conducted are consistent with that documented by the Nurse Practitioner without modification. I participated in determining and agree with the patient's management, the final impression, and the disposition as documented. Is this sufficient documentation to bill under the physician?
Hi must they document more than i saw and evaluated the If you are talking about hospital services, local carriers pt with NPP- Susan and i agree with the findings and plan. have the most info see: (does this qualify as proof) http://www.wpsmedicare.com/part_b/departments/medical_ review/2009_1116_em.shtml " Both the physician and the NPP must each personally perform part of the visit, and both the physician and the NPP must document the part(s) that he or she personally performed. When the supporting documentation does not demonstrate that the physician "performed a substantive portion of the E/M visit face-toface with the same patient on the same date of service" as the portion of service performed by the NPP, a service billed under the physician's Provider Transaction Access Number (PTAN) will be denied." This is from Medicare carrier WPS Check yours
in an urgent care setting just about every patient is a new problem. How does a NP bill for this? Decision Health has stated per Medicare that you can do "shared visits" on consults, but now that Medicare does not accept consults is this still valid? Can NP do shared visits on consults for those payers that still accepts them?
No plan of care No Incident to billing Must be billed directly to those payers who follow Medicare policy You COULD NOT do consults as split shared visits see MCM CH 12 Sec 30. I am not sure what referenc you would have that says otherwise, sorry
What if carriers don't recognize NP's....is it appropriate to bill under the MD in a hospital setting?
Not arbitrarily
Will Jill Young be at the National Conference? If yes, can YES check registration area or my lectures she be contacted? If a Physician leaves the practice who has written the care And bill directly, yes. plan can the NP take over the care for the patient
