Cardiology Coding Alert

More and more cardiology practices are hiring non-physician practitioners (NPPs) such as physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists (CNS), to provide services that traditionally have been performed by physicians. For example, depending on a states scope of practice law, a physician assistant could take history and physicals, render an independent evaluation or treatment of the patients condition, perform consultations, and assist in cardiac catheterizations, explains Ron Nelson, PA-C, president, HSA Consulting Group in Fremont, MI and president of the "American Academy of Physician Assistants".

However, unless you learn the intricacies of correct billing for these services provided by NPPs, your cardiology practice could be subject to a post-payment review and reduced reimbursement, experts warn.

Here are the five most common misconceptions cardiologists and their coders have about billing the use of NPPs, and how to correctly code them:

1. Bill incident to without non-physician provider ID number. Many practices believe that they dont need a billing number for their PAs, Nelson says. Because theyre getting paid, they assume their continued use of incident to is okay. However, using this option in every circumstance without meeting all the requirements can open your practice up to fraud and abuse accusations, Nelson warns.

Alice Gosfield, attorney with Alice G. Gosfield and Associates in Philadelphia, PA, agrees. Gosfield goes on to say that while Medicare carriers wont evaluate incident to on the basis of a claims submission, they may indeed ask you to prove it in a post payment audit, she explains.

Tip: Medicares incident to rule is defined as - services or supplies that are furnished as an integral, although incidental part of the physicians personal, professional services in the course of diagnosis or treatment of an injury or illness.

To be covered as incident to the services must be:

a. an integral, although incidental, part of the physicians professional service;

b. commonly rendered without charge or included in the physicians bill;

c. of a type that are commonly furnished in physicians offices or clinics;

d. furnished under the physicians direct personal supervision; and

e. furnished by the physician or by an individual who qualifies as an employee of the physician.

2. Bill incident to for NPPs who make hospital rounds. The incident to provision can only be used for services and procedures done by the NPP in the physicians office, not in a hospital or nursing facility, the experts stress.

If you use NPPs to make rounds in the hospital, fine, explains Gosfield. But this can only be reimbursed at 85% of the fee schedule using the NPPs number.

Your practice should not bill incident to and expect to receive 100% of the physician fee schedule. Otherwise, you will open your practice up to a post-payment review because you have been overpaid, she says.

Ive seen similar cases where an NPP performs hospital visits, but then the physician bills as if he or she had provided the service. The practice is then eligible to receive 100% of the fee schedule allowance, says Cynthia Swanson, coding specialist with Seim, Johnson, Sestak & Quist, LLP, a healthcare consulting firm in Omaha, NE.

You simply cant bill for incident to in a hospital, she states. Swanson, who was formerly with a Medicare carrier, warns that having the cardiologist countersign NPP notes from hospital rounds wont save your practice from possible accusations of Medicare abuse.

The correct method is to bill the hospital service under the NPPs billing number and take the 85% of the physician fee schedule, the experts point out. There are no two ways about it stresses Gosfield, If an NPP makes rounds, you must bill it as such and get the lower reimbursement at 85%. A countersignature is not enough to bill as incident to.

Tip: File a claim for services provided by an NPP using the same fee schedule that you would for the physician, recommends Nelson. A common mistake is that billers calculate the 85% off the fee schedule before they submit the claim. he says. If you pre-discount your fee, Medicare is likely to discount it again.

Also, you no longer need a modifier to distinguish services performed in various settings. Under the new requirements, the only instance in which a modifier is used is when PAs first assist at surgery, he says. In that case, use modifier AS.

3. Physician supervision, off-site. Under the incident to provision, the physician must be on site when a service is rendered by a PA.

It does not qualify as direct supervision, for example, when a cardiology PA is performing stress tests in the office while the cardiologist is across the street at the clinic -- even though the physician can be reached by phone.

Unless the state law requires it, the cardiologist need not be physically present in the room when the PA is performing the services. However, as the supervising physician, he or she must be immediately available to the PA for consultation, Nelson explains. The cardiologist should at least be in the office suite.

Swanson agrees, adding that the availability by telephone, or the mere presence of the physician somewhere in a large institution does not constitute direct supervision.

4. Billing incident to when the NPP is the only provider of care. This is completely incorrect. And Nelson points out that simply having the physician co-sign the chart or medical record or briefly meet the patient does not constitute the physicians personal treatment of the patient.

The physician must perform the first evaluation and establish a diagnosis, and the NPP then does the subsequent visits, says Nelson. In fact, this is one of the criteria for billing incident to.

The cardiologist must also first see established Medicare patients who have new medical problems. PAs may then provide the subsequent care, he explains.

Swanson adds that the cardiologist should not only perform the initial service, but also enough subsequent services to reflect his or her participation in and management of the patients course of treatment.

5. Billing higher than a Level I for lipid nurse. Unfortunately, HCFA does not recognize providers other than NPs, PAs, CNSs and certified nurse midwives. You may have the best lipid nurse around who spends a great deal of time with the patient, but if he or she is not one of the non-physician providers outlined above, you cant bill more than a 99211 if the physician is not involved with the patient on that service date, Gosfield says. (If the lipid nurse meets the definition of a CNS, such as a masters degree in nursing, then he or she may qualify, adds Gosfield.)

6. Only billing Level I for non-physician providers. Here are the documented facts that show there is no restriction on the levels of CPT codes that can be utilized for NPP services:

A. The HCFA carrier manual says that, under the incident to provision, the physician may bill the CPT code that describes the evaluation and management service furnished by NPs, PAs and CNSs.

B. Medicare only gives two billing criteria for using an NPPs identification number.

1) It has to be a physician service.

2) Services must be within the scope of the state licensure law.

Tip: The PA must be licensed by state law or regulation in the state in which the services are to be performed in order for Medicare to cover them.

Note: Audit alert - Why in the world is Medicare now auditing for 99211 usage with NPP services- the lowest level of established patient office visit?

In this case, its not an issue of overcoding, explains Susan Stradley CPC, CCS-P, senior consultant for Medical Group of Elliott Davis and Co., LLP, headquartered in Greenville, SC. They are determining whether or not an appropriate service was performed by a valid non-physician practitioner and whether or not the physician knew it was performed, she explains.

So it pays to adhere to the requirements of incident to billing.

Editors note: The American Academy of Physician Assistants has a free fax-on-demand service that contains valuable coding and reimbursement information. Call 800-286-2272.

Billing NPP Services Clarified A major change in reimbursement rules under Medicare has caused a lot of confusion about how to bill for NPP services, says Alice Gosfield, attorney with Alice G. Gosfield and Associates in Philadelphia, PA. For example, the Balanced Budget Act of 1997, which went into affect January 1, 1998, says that Medicare must reimburse for non-physician provider services in ALL settings at 85% of the physician fee schedule. This includes inpatient, outpatient, and emergency departments, nursing facilities, offices and clinics and first assisting at surgery. (Previously, regulations restricted reimbursement according to site of service.) State law determines supervision and scope of practice. Under the new rule, you can file for reimbursement for NPP services with the following methods: 1. Use the NPPs own identification number. Medicare calculates reimbursement at 85% of the physician fee schedule, says Ron Nelson, PA-C, president, HSA Consulting Group in Fremont, MI and president of American Academy of Physician Assistants. Nelson urges cardiology practices to obtain billing identification numbers for their PAs. Medicare now requires that PAs who treat Medicare patients have provider identification numbers. Contact your carriers provider relations office and request a HCFA 855 Provider/Supplier Application to apply for a number, he instructs. He adds that a PA may be either a W-2 employee or an independent contractor. The practice should be the one billing Medicare for the services provided by the PA. Thus, the PA does not receive direct reimbursement. (However, nurse practitioners can receive direct reimbursement from Medicare.) 2. Using the incident to provision. If you bill as incident to, Medicare considers the NPP invisible, explains Gosfield. Its as if the service or procedure was performed by the cardiologist; therefore, Medicare reimburses at 100% of the physician fee schedule. The claim form is filled out using the cardiologists name and provider number. But, you must adhere to incident to provisions.