Gastroenterology Coding Alert

Presented by Trish Bukauskas-Vollmer, CMM, CPC, CMSCS

The following supplement to Gastroenterology Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and download the current issue, and the slides will be contained therein. If you're not sure how to use the Online Subscription System or need help downloading the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Trish Bukauskas-Vollmer, CMM, CPC, CMSCS, has over 19 years in the medical field.  She currently is the president and CEO of T.B. Consulting, a firm specializing in education, consulting, auditing, compliance and initial start-up of medical offices and clinics. She is a certified medical manager through the Professional Association of Health Care Office Managers (PAHCOM) and a certified professional coder (CPC) with the American Academy of Professional Coders (AAPC) and American Health Information Management Association (AHIMA). She is also an active member of the American Society of Interventional Pain Physicians (ASIPP). She presents seminars and coding workshops across the country.

Hi everybody. Today's topic, we are going to talk about incident-to non-physician providers.  Everyone in a medical practice needs to know how to bill and be reimbursed for non-physician practitioners and incident-to services.

Medicare can reimburse for non-physician practitioner services that are incident-to.  In addition to just nurses, there are also nurse practitioners, physician assistants, clinical nurse specialists, biofeedback techs, respiratory therapists, physical and occupational therapists, psychologists, midwives, x-ray techs, lab techs.  These non-physician providers do not just assist physicians.  They often see patients in the physician's absence.  Due to managed care and capitation, this development creates incentives to save costs by using the least expensive best-trained personnel to meet the patient's needs.

With managed care and malpractice insurance and everything, physicians are often losing revenue.  The only way that they can capture additional revenue is to hire additional help, whether it would be another partner, another physician or to double their volume.  They only way they can double the volume of the number of patients they are seeing without adding another physician and becoming a partner or a large cooperation is to hire either a PA or a non-physician practitioner or a nurse practitioner, midwife, CRNAs, things like that, and there are a lot of different guidelines to do that.  Orthopedics is growing leaps and bounds in the amount of PAs and nurse practitioners that they are hiring now.

The reimbursement of incident-to, failing to bill for services, even if they occur only four times a day, can cost your practice as much as $20,000 a year.  I have done a number of audits at various different specialties that have nurse practitioners.  Some of the times I found that they were using those nurse practitioners solely as a medical assistant or as a nurse.  I had one up in Pennsylvania, their nurse practitioner was calling in lab results, calling and ordering scripts, they were pulling charts, faxing lab work, that is all something that a clerical staff member could do.  They were not utilizing their nurse practitioner in the full scope that they could have in order to achieve additional reimbursement.  Incident-to claims are paid at a 100% of the physician fee schedule.

Requirement to bill incident-to, there must be a physician service to which the non-physician providers' services relate.  If the physician is not present, then the nurse practitioner or non-physician can bill using their own provider number as relevant by their specific license.  One thing you have to remember, there are nurse practitioners, there are PAs, there are midwives and in different states and in different geographical areas, each non-physician practitioner has to practice within the scope of their own license.  So you have to have their license in front of you to know if they are eligible to write prescriptions and do things like that.

Some local carriers also require the physician to see established patients each time they are present with a new symptom; however, BY national Medicare Policy, CMS does not require this.  Non-physician providers may bill incident-to for their services during and after that visit.  Even those who bill Medicare directly using their own provider numbers must meet the requirement if they want to bill incident-to.  So in other words, the physician must be directly supervising, must be available.  After the initial visit, the physician does not need to be involved in each patient encounter.  The Carrier's Manual states that such a service without physician involvement could be considered to be incident-to when furnished during a course of treatment where the physician performed an initial service and subsequent services of frequency which reflects active participation in management of the course of treatment.  Local Medicare carriers have interpreted this to mean that the physician see the patient every third visit, but National Medicare Policy does not specify the frequency of the course of treatment.  There are some carriers that do want the physicians to come in every third time, but CMS' rule is that as long as the physician is aware of the patient's condition and personally active in the treatment of that patient, then the obligations are met.

Some sources you can find in the Medicare Carrier's Manual Section 2050, it can be accessed online.  I have given you the Web site and the handout.  It states that incidental services must be part of the physician's personal services in the course of diagnosis or treatment of an injury or illness.  Therefore, the physicians have to perform the initial visit.  So, if you are billing incident-to, you have to have the physician see the initial patient.  They do not allow nurse practitioners or PAs to bill incident-to under the physician provider number if they are doing the initial evaluation.  If your physician is not available and your PA or your nurse practitioner has to do that initial visit, then you have to bill under their provider number.

During subsequent visits in which a physician is not involved, most non-physician providers' incident-to services can never be billed higher than a 99211.  This refers to a nurse or non-physician practitioner that does not have their own provider number.  So if there is a not a physician available and somebody comes in and gets a blood pressure check or if somebody sees the patient, even if it is a PA or an NPP, if it is a Medicare or a commercial and they are not credentialed with them, they can only bill a 99211.  Medicare states that the services of certain non-physician practitioners can be billed incident-to a physician's services using the highest level of evaluation and management that they are licensed to render under their state law.  So they can bill level-IVs and level-Vs if it is pertinent and if their own particular license allows them to do so.  I have a lot of nurse practitioners who especially like to stay around the 99203s, 99213s because somewhere they were told that they can only bill midlevel evaluation and management.  One thing they need to consider is when they are billing under their own provider number, it is as if they are the physician, they are the medical treating person.  When they are billing under their own provider number, they are only receiving 85% of the reimbursement. 

When billing incident-to, non-physician providers cannot be reimbursed for consultations or time based when more than 50% of the service is counseling or coordination of time.  So if your nurse practitioner or PA is billing incident-to, then you know how the E/M guidelines do state that you need to have a history, a physical exam and a medical decision making - three out of three or two out of the three for an established - but time can become the controlling factor if and when 50-50% of the time is greater spent doing counseling or coordination of care.  This does not pertain to incident-to.  So if you are going to do an E/M and the physician is there and you are going to bill under them and the nurse practitioner is spending most of the time counseling, then they have to bill under their own provider number.  Incident-to billing is strictly prohibited in the hospital.  In the hospital, depending on the scope of the license of the non-physician practitioner, they must bill under their own provider number.

Some scope of services.  In New Jersey, nurse practitioners have prescriptive privileges.  They can diagnose, treat and prescribe similar to a physician.  They can renew narcotics, but they cannot initiate or change the prescription for narcotics.  However, there is current legislation due to a shortage of physicians that will allow them to write for narcotics too.  So there are a lot of steps being taken to open the scope of services allowed for non-physician practitioners.  It is important to always check with the state licensing allowances for all non-physician practitioner services to see what they are allowed and not allowed to do.

Once the initial physician relationship is established, incident-to services can be billed even when there is not a physician in the room.  He or she must only be on the premises immediately available to assist the non-physician provider rendering the services.  The supervising physician does not need to be the physician who performed the initial patient visit.  There has been a lot of controversy; say the nurse practitioner, Sally, goes in to see a patient and on the second visit Dr. Jones was the initial physician and Sally is his nurse practitioner, but two weeks from now Sally is seeing the patient, but Dr. Jones is on vacation and his partner is now supervising - you can still do incident-to.  And I will explain a little bit how we do set up the billing for that and whose UPIN numbers and things have to go where. 

Any physician in the group that is in the clinic or the office is seeing other patients does qualify to provide the supervision, even if he or she is not the patient's primary physician or even if he or she is not of the same specialty as the primary physician.  In a lot of multispecialty practices, you might have an orthopod and maybe a family practitioner or neurologist or something there and if the PA is under direct supervision of the orthopedic specialist, but the orthopedist is not there but the neurologist is, you can still bill incident-to.

Direct billing by non-physician providers.  When you are billing under the non-physician provider's own provider number, Medicare will pay for any service that it would pay a physician to perform as long as that service is within their scope of the license and again the claims are paid at 85% of the physician fee schedule directly to the physician or physician group employing the non-physician provider.  Services that may be billed on the non-physician provider's number include in-office services without the physician supervision, in-hospital services without physician involvement, nursing-home visits, house calls, consultations, and the ordering and provision of diagnostic tests.  Time-based E/M services where more than 50%, if you are not billing incident-to, you can also bill E/M based on time involvement

Third party carriers.  More and more third party carriers are starting to reimburse.  Blue Cross was notorious, it was always my downfall trying to get Blue Cross to credential PAs and nurse practitioners.  Anytime I called them they always would say that they followed Medicare guidelines, but in this instance it was hard to get them credentialed.  They are now, in various states, starting to open up credentialing for PAs and nurse practitioners.  You just have to try to get them credentialed.  What I usually do and this is very tricky when you are doing the billing and the scheduling, you have to remember, you have to keep it clear and your scheduling people need to be in the loop. If you are going to schedule 40 patients or 50 patients today, but your physician might not get back from the OR, you really have to have your office staff really savvy on which carriers that your nurse practitioner or PA is contracted with and which ones they are not, because if there is not a physician on-site and that nurse practitioner or the PA does not have that credentialing with Cigna or United Healthcare, you cannot bill any higher than a 99211.  So you would be losing revenue.  Even though the OIG primarily goes after Medicare and Medicaid, I have seen third party carriers now monitoring, going back and auditing and recouping money civilly from the physician practices and things.  So that is a big challenge, trying to get your whole staff working uniformly and communicating which carriers you can see, which ones you cannot when you schedule.  What I did on my database, when you go to put in the new patient or you bring the patient up, we kind of flagged the carriers with stars, so we know if that patient calls in and we know our physician is not going to be back from the OR until like 2 in the afternoon, we know that we cannot put them until after that because we would not get paid.  And if it is Medicare or something you can and then just bill under that non-physician practitioner's number.

Documentation guidelines.  The documentation guidelines for E/M services state that the patient, family member or non-physician provider can record the past, family and social history and a review of systems, provided the physician reviews the information and documents that he or she has done so.  That does not even have to be a PA or a nurse practitioner.  In a physician's office, a lot of times a medical assistant or a nurse will come in and triage the patient, they will do their history.  I have a lot of pain management specialties that I work with and we do very thorough patient histories, patient assessments, they are like 3-4 pages.  And some of them they will send to the patients in the mail and have them fill out.  I have a medical assistant that has been trained that goes in, reviews all that, takes a very adequate history, documents, we make sure we have the history of present illness, they do the vitals, things like that, and then she goes in and gets the physician or non-physician practitioner.  In another practice, I saw that that is what they were using their nurse practitioner for, just to take the history.  Again, a lot of revenue was being lost in that they could have hired somebody at a fraction of the salary and had them doing that and they could have freed up the nurse practitioner and the physician to see more patients.  The history takes the most time when you are doing an evaluation or consult - and you do need to have a very thorough history because that is the driving force to the rest of the evaluation and your medical decision making, and that tells you how extensive an exam needs to be performed.  But anybody can do the questions and the history taking and the fact gathering. 

If the claim does not meet all the incident-to standards, you bill only for that portion of the service that has been completely documented and could stand alone if submitted by either the physician or the non-physician provider.  So if you are lacking in one area, you would just look at it, then audit and see what level you would be able to bill.  As far as other documentation, even on some list serves that I was looking at just this past week, there were a lot of questions about incident-to. 

A lot of people are asking what are the required documentation guidelines, does the physician need to sign the OP notes?  If your physician is not participating in the care and you are billing incident-to and the physician is seeing his own patient and the physician did not put his head in or see the patient on that visit at all, the physician does not need to document or sign that medical record or that E/M service.  But if he does go in that is another controversial area.  What I do, we go back and forth.  If our physician is present from 9 a.m. to 2 p.m., we will bill every service that the nurse practitioner or PA sees during that time as incident-to.  If the physician leaves at 2 o'clock or steps out or gets called away, then we will bill those under the nurse practitioner or PA's direct number.  What I require my nurse practitioners and PAs to do, which has really helped, because we, the nurse practitioner or the PA, know what we did and I kind of put the accountability back in their lap.  It is up to them to know, "hey, is the physician here?" Again, communication, have the physician say "hey, I'm leaving, I'm going to make rounds, etc."  So then in that instance, all of the rest of the visits that the nurse practitioners or PA sees, all they have to do is document, 'this was performed solely by me.'  Or, on the days that they are doing incident-to from that 9 a.m. to 2 p.m., put, 'these were performed under direct supervision of doctor so and so.'  It is really streamlined and our billers from the back end have a clear understanding of how to bill appropriately, so we are not even running a gamut of possibly billing incident-to when the physician was not there.  Also, on our Superbills, I do have a place for all of the providers and I have made it the responsibility of that nurse practitioner or that PA to circle his or her name if they know that they are billing under their own provider number; and if they are billing under the supervising physician, then they would put the physician that they are supervising, they would circle that.  And that is a good communication follow-through with the billing staff, with the rest of the staff.  So, it is a lot more involved than just the nurse practitioner and the physician knowing what they are doing and when they are doing it - we also have to include the whole element of the registration and the billing and the back people because that is what goes to the claim.

There are various modifiers, 81 for minimal assistant at surgery, AS for physician assistant, SA for nurse practitioner rendering services in conjunction with a physician, and SB for nurse midwife.  A complete listing of all of the modifiers can be located in the CPT or in the HCPCS book right on the front flap or in the appendix of the HCPCS book with a clear description of all the modifiers.  Plus you also have to check with each carrier to make sure that you are aware of what modifiers they want.  Sometimes, they want different modifiers; they will have specific internal ones that they want you to use.

The bottom line, when you are billing incident-to: the only way the services of some of the non-physician providers can be billed in a physician practice, it is an option for others.  There are some small single practitioners that they cannot make ends meet without having a PA or a nurse practitioner.  Some other larger groups, it is just an option and if you are choosing that option, you want to make sure that you are getting the best reimbursement, as well as staying as compliant as possible.  Submitted incident-to claims that do not meet the rules are considered to be potentially false, therefore fraudulent, and are punishable by the OIG for up to $11,500 per claim, plus triple the charges if the OIG determines that the physician should have known the rules.  Criminal punishment is also possible, although it is unlikely.  The OIG has again for 2005 targeted incident-to claims in their work plan.  This is the third consecutive year in a row that the OIG is using incident-to billing guidelines and looking at that.  With that, that is even for anesthesia, the CRNA, the concurrency, all of that - they are looking to see if the physicians are billing incident-to and if they are present.  That is the biggest.  There were a lot of practices that were billing with a wrong provider number on their 1500s and it was easily targeted and tracked through Medicare because it was an orthopedic practice and the orthopedic surgeon was in the OR, and yet the PA saw like 35 patients in that day.  Plus the orthopedic surgeon did about eight huge cases that day.  And they billed incident-to and Medicare looked and said "hey, how can Dr. Smith (that's an alias) see 35 patients and do nine procedures, four of which were total hips and yata yata yata."  So then they went in and audited the practice and found that even though there was a physician there, they were billing under the wrong physician and it raised a flag.

In summary, the non-physician providers must be a W-2 or leased employees of the physician and the physician must be able to terminate the employee and direct how the Medicare services are provided by the employee.  The physician must perform the initial patient visit, ongoing services of a frequency that demonstrate active involvement in the patient's care, creating a physician service to which the non-physician providers relate.  The physician must be on the premises, but not necessarily in the room when incident-to services are performed.  Diagnostic tests must be done under the testing supervision requirements, such as general, direct and personal, which are designated by the CPT.  And incident-to services cannot be performed in the hospital.

Now I would like to extrapolate on some of those bullets.  The direct supervision, a physician must be on the premises, I get this question a thousand and five times a day.  Does that mean if I have a surgery suite, I have an ASC right across the parking lot;  if I am at the ASC and I can be there in 4 minutes, am I considered to be under direct supervision?  I had anesthesiologist that asked one time that, 'if I get called down to the ER, two floors below, can I still be considered directly supervising, medically directing?'  In Medicare guidelines, this is a very gray area, but CMS reports that to the extent that there is confusion about where the office suite ends, it is at the carrier's discretion to review the situation.  But for CMS, their guidelines say that the office suite means within shouting distance, which is on the same floor.  However, there was an Arkansas physician and Dr. Gilson - the Arkansas Medical Director, he is a little more lenient, and he feels that it is ok as long as the physicians are available, qualified to assist in emergencies and can be present within 5 minutes.  So my recommendation is that if you have a gray area, if you do have that surgery suite right across the parking lot and it is less than, you know, 20 feet away or if you are at the other end of the hall and you are not sure if what constitutes, just contact you local carrier and verify their policy and preferably get it in writing if you can. 

Consults cannot be shared because when somebody is requesting a consultation of your physician, they are wanting your physician's medical opinion, they do not want that to be a shared visit, that cannot be incident-to.  However, if you do a consult if the physician is unavailable, then you can bill under the non-physician practitioner's number and not bill incident-to.

Another thing to remember when you are using non-physician practitioners and PAs or midwives or nurse practitioners is how you are going to introduce them to your staff.  I have heard a lot of times that the patients think of the nurse practitioner as doctor so and so.  I had a nurse practitioner at the emergency room many years ago, and I think I worked there for 3-4 months before I realized she was not a physician, but a nurse practitioner.  Make them wear name badges. If you have a physician who is going to use incident-to on a lot of instances, have your physician see the patient, do the initial evaluation and the consult, towards the end of it, bring the nurse practitioner or PA in, introduce that nurse practitioner to the patient as your associate: "so and so is going to be following up, we work very closely together.  I do review the records.  If there is anything you ever need, she can contact me, I can see you the next time.  I just want your care to be handled in the best method possible.  Even though Sally Jones, the nurse practitioner, is going to be here, I am always aware of what is going on with you."  If you do that the patients a lot of times do not have any problems with that, but you telling them up front alleviates a lot of the confusion.

When you are documenting four nurse practitioners or PAs the correct way, there are different scenarios.  A lot of people think that you have to have the same original physician that needs to be the supervising physician at all times, that is not the case.  So what do you do in the instances where Dr. A is the referring physician, he is the one that is the medically directing physician; Sally Jones, the nurse practitioner, works for Dr. A and Dr. A starts the patient, he sets up the plan of care and then Sally Jones, the nurse practitioner, is going to come and do the subsequent visits.  But a couple of months down the line, Dr. A is not available, but Dr. B is now the supervising physician.  The correct way to bill: you have to put the name of the referring physician which would be Dr. A, the medically directing, the one that is setting up care plan, in block 17 of the 1500 with his UPIN in 17A.  This is very important.  The medically directing physician, the one whose patient it is, goes in block 17.  And then in 24K, you would put the supervising - Dr. B.  If on this visit, it is Dr. B that is in there, whether he is a neurologist or whomever, you would put that in block 24K.  And then the signature or the signature stamp needs to go in block 31, that is the supervising physician which would be the same one that is in 24K.  And then 33 would be the groups you have been in, if it is a multiple specialty or whatever the group ID or UPIN number is or provider number.  That is where most of the errors that have seen, occur.  If you are going electronic, you have to make sure that your database, the utility file does match these, that it sets up properly, so it is pulling the right numbers all the time.  It is almost like anesthesiology, where you are tracking the concurrency and you have the right person that is supervising that you are doing that.

As far as the documentation, does the physician have to sign the E/M service or the medical record if the nurse practitioner or if the PA is seeing the patient solely?  No, I have not seen anywhere in writing that it is mandated that the physician sign off on the PA.  I personally like my physicians to review the Superbill and at the end of the day the notes, and if they are reviewing it sign off.  But they do not have to do that.  Another scenario is if the PA goes in to see a patient and the patient develops a new sign or symptom, the PA calls the physician in and the physician ends up doing 90% of the exam and sees a major portion of that service, what would you bill in that instance, would you bill for the PA incident-to or would you bill under the physician's number?  If you are billing incident-to, you are billing for the physician anyway; but at anytime the physician goes in and does any part of an outpatient visit, then you should bill for the physician's number, even if it is a consult, you should not bill for the incident-to, you do not want to take that reimbursement decrease.

So some things in summary, remember when you are billing incident-to, you get 100% of the fee schedule.  When you are billing under the direct provider number, you get 85%; you have to use the modifiers that are appropriate at each instance and you also have to make sure with the third party payers that they are credentialed and that you are within their scope of the practice.  Depending on what the scope of practice is, your a nurse practitioner or PA or midwife or whomever can do anything that is allowed within their scope that a physician can perform.  In a hospital setting, you cannot bill any initial inpatient consultations, initial inpatient evaluations, history and physicals, anything incident-to.  If it is within their scope, then they can bill under their own provider number.  You also have to pay very special attention when you are doing your billing to make sure that you do have the proper physicians' names in each block for the 1500 if it is paper, or on your transmittals and in your database and utilities if it is electronic.

You also have to make sure that you are capturing the adequate reimbursement that your office and your facility can when you are utilizing your nurse practitioners or PAs.  You do not want to use them just as glorified secretaries or medical assistants or a clerical person.  You do have clerical staff that can answer the phones and fax lab work and do things like that.  Use them in the capacity of the physician, as another paid provider because that is what they are, and you do want to follow the guidelines.  If you need any information, you can always download from your local Medicare review policy, what your state's particular criteria is.  Some states do require that every third visit that the physician must go in and see the patient.  That is not CMS' guidelines nor is that Allstate's guidelines.  Many states just state that the physician must have adequate care coverage and be part of the loop that provides subsequent care visits.  Operator we are ready to open up the lines for questions.

Thank you Ms. Vollmer. Ladies and Gentlemen, I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time, please press *1 on your touchtone telephone.  If your question has been answered or you wish to remove yourself from the queue, please press #.  Please limit yourself to one question at a time, so that everyone may have a chance to participate.  If you have another question, you may reenter the queue by pressing the *1. 

Q & A Session:

Question:  Yes, good morning.  I just want a clarity please, regarding incident-to services in the hospital.  There are no such services in a hospital.  Is your hospital considered which place of service and what about outpatient facilities?

Answer:  It is inpatient hospital.  Inpatient hospital there is not incident-to, outpatient hospital facilities like hospital-based clinics and things like that, you can have incident-to.  It is just hospital inpatient, inpatient observation and inpatient consults, evaluations, H&P and things like that.

Question:  Okay, so in other words place of service 21, but if it is considered 22, there is....?

Answer:  Incident-to does apply to outpatient surgery and things like that, yes.

Question:  Okay, and that is for billing incident-to?

Answer:  Right.

Comment:  Okay, I will reenter the queue because I have two more questions.

Question: Yes, if an established patient comes in for a preoperative clearance consultation and the PA sees the patient for preoperative clearance, you cannot bill incident-to?

Answer:  No.

Question:  Even though they are established?

Comment:  Right.

Comment: Okay.

Answer:  Because it is still considered a consultation and they have to bill under their own provider number.

Comment:  Thank you.

Question:  Yes, when a new patient comes in, can a PA bill for if it is a consultation under their own provider number?

Answer:  Yes, as long as it is under their own provider number and they are credentialed, they can bill for a new patient or a consultation.  If they are billing incident-to, then they cannot.  The physician must see the patient for a new evaluation or consultation because the insurance say, because you are rendering, you are setting up the treatment plan, the insurances feel that if they are going to pay 100%, they want the physician to set the roadmap so to speak.

Question:  Our question is in regards to our understanding of incident-to when there is a new diagnosis, how specific when you refer to new diagnosis - can it be in the range of sequence on ICD-9 numbers, the first three digits, the same sequence, but maybe a little variation off, does that qualify as" new" diagnosis or something that can be followed as incident-to?

Answer:  That is a very gray area.  There are no set guidelines.  It would be very easy if it is related to the back or the shoulder or anything like that.  And it depends on if you are going to start a new treatment, and it does not even have to be that the physician comes in at that time.  You can finish your visit now, but in the notes, like your PA can visit that and say that they have a new symptom this and that. But if you are going to treat that symptom on that day, they do like you to notify the physician at that time, and then you would bill under the physician's number.  But no there is no specific CPT.  I would just use good judgment that if it is relevant, if you are talking OB/GYN, if it is relevant to that problem that they are being treated for, or if it is in neurology or spine, if it is in the low back, but now they have shoulder pain or upper back pain, you know those kinds of things, then I would just get my physician involved.  Because you want to remember what they are looking at, when you are billing incident-to, you are telling the industry that, "hey, that physician is readily available.  I am an extension of that physician.  He is right here should I need him, and in the real word if I have another problem that I need treated, I would expect my physician to come in and look at that."  So just use really good judgment and, you know, if it is in that same anatomic area, then I would get my physician involved.

Question:  Yes, our question is related to how this incident-to billing affects physical therapists and physical therapy assistants, are their separate guidelines, or would it follow the same guidelines?

Answer:  Okay, you have a physical therapist and then the assistant to the physical therapist?

Comment:  Correct.

Answer:  Yeah, that follows the same guidelines.  There is a lot of controversy now about physical therapists that they cannot have their own, they do not want incident-to in a physician's office, things like that about the Stark law.  Keep heads up if you do employ a physical therapist in the near future about that, but as of now, your physical therapist guidelines pertain to the same incident-to rules, he is incident-to that physical therapist assistant.

Question:  Hi, my question is, how do you actually prove if you get audited that your physician was there?

Answer:  He would have seen other patients on that day.

Question:  What if they are not seeing patients, they are just in the office doing paperwork?

Answer:  Do you keep a schedule of the physicians, where they are, if they are in the OR, if they are there?  Because if mine is doing paperwork or a narrative report, I will usually in the schedule put 'administrative day' down and that really helps.  I mean there is no way to really... if you do not have any of that now, there is no way - I could ask all the other people get a copy of their phone logs.  I mean there are ways that you could prove it, and I have not heard of the OIG or anybody like calling offices 'liars' that no, he was not there.  As long as they cannot prove, the burden of the proof is always on them.  So before they come in and audit you, they are going to be armed with ammunition, that "hey, we have record that he did 15 surgical cases here or this or that."  You know what I mean?  So they have the burden of proof and I have not ever heard of them coming in like that.  So as long as he personally is there and, I am sure he was on the phone, but go in and put admin day or narrative report or whatever, and that would really protect you.

Question:  Yes, I want a clarity regarding slit billing for consult.  You alluded to that and it was just a little confusing for in hospital.

Answer:  Split billing, shared billing for consults for in hospital, you cannot share bill or split bill at all for consults.  If you are billing a consult, you must bill under the physician's number.  Anytime my physician is there for a part of the visit and he does perform the exam, I bill under the physician's number.

Question:  Okay, so if the nurse practitioner is doing a component of this consult, then it must always be billed under incident-to and that is accepted in the hospital.

Answer:  No.  If your nurse practitioner or physician assistant is billing a component of the consult, but the physician is there and is doing the exam or the other component, then you bill under the physician, because they are going to communicate and it would be as if the physician is doing that.

Question:  Okay, so it is billed under the physician?

Answer:  Under the physician, yeah.  Because you cannot bill consults or inpatient hospital incident-to.

Question:  Okay, but if the nurse practitioner, under her own provider number and given that scope of practice, nurse practitioners can bill for consults?

Answer:  Yes.

Question:  ...that is a new exam, new encounter?

Answer:  Yes, under their own provider number.

Question:  Yes, I just want some clarification, if the PA is seeing a new patient consult and the physician comes in and sees the patient.  If they do the exam or and/or the decision making process, can that then be billed under the physician, and how much does the physician have to do to be billed under the physician?

Answer:  As long as the physician goes into the examining room and evaluates and has any hands on with the patient and finds the documentation, you can bill under the physician's number.  The only thing you want to remember is that when the physician is billing under his number, he then has to sign the note and he then is now taking liability for that service.  Usually they do not have a problem with that because if the physician goes in and does the medical decision-making or just orders the tests, this or that, they are going to communicate and follow up with the PA or nurse practitioner on that specific visit and they are going to review the note anyway, so get them to sign that.  They do not have to dictate the whole note, but that PA or the nurse practitioner would also have to dictate their portion.

Question:  I have a similar question.  Nurse practitioner who bills under her own numbers saw the patient and it was not a consult, but dictated time of 30 minutes, and then the physician later that day also saw that same patient for another 30 minutes.  Can they both bill even though we have the same tax ID number?

Answer:  No, you can only bill one E/M service per tax ID per facility on a given date.  That is not even with just nurse practitioners, that is even partners.  If I do an office visit today and at 2 o'clock I see you in the office, but you know I think you are fine, and then later today this evening you get hurt and you are admitted to the hospital, we have to bill only one E&M.  And say my partner see you, we have to bill one E&M, it would be an inpatient H&P, but it would be the higher - we would incorporate today's billing.  So what you would do in that situation, the nurse practitioner saw the patient for 30 minutes then later in the day the physician did, you would bill under the physician, but you would include both notes.  So say that nurse practitioner was a 99212 and the physician was 99213.  If there is enough elements you can combine both of those and possibly do a 99214, 99215 under the physician's number.

Question:  I just needed some clarification on slide 14 because I was not too clear. Regarding nurse practitioners, PAs if they are billing under their own number, then do some third party carriers still require physicians?  Because I think you said check with carrier guidelines - then what will we be checking for because the physician does not need to be present in the office, or does he/she if we are billing under their own provider's number.|

Answer:  If they are billing under their own provider number, the physician does not have to be present, but there are still a number of third party carriers, commercial carriers that do not credential the non-physician practitioner the PA or nurse practitioner.  So if I am from CIGNA and you do not have the doctor there and yet you saw four patients without a physician then you can only bill a 99211 because I do not accept your nurse practitioner as a provider.

Question:  I am a little confused about the consultations in the hospital.  We all understand that you cannot bill a consult as a shared visit, but to me how you have been explaining that there can be some involvement from our non-physician practitioner and some involvement from the physician.  To me, that is a classic example of what shared billing is and I am not understanding how that would be appropriate to bill under the physician's number then?

Answer:  You would have to look at how much of the work the physician did.  Are you talking about seeing them on the same time or on different times of the day?

Question:  I will say the same part of the day, may be the non-physician practitioner did some of it and then the MD did some of it, but my understanding is that that would be a shared service, like an H&P can be billed as a shared service, an admission service in the hospital can be billed as shared, but we know that consults cannot, but to me you are saying is that they can be and just bill it under the physician's number?

Answer:  Well I meant if the physician and the nurse practitioner are in there and the nurse practitioner does the history and the physician does the exam and the medical decision making and orders the visit then you can bill under the physician.  You can only bill one visit that day.  Now, say he only had low medical decision making as an inpatient, but she came and did a lot more.  We can't combine hers to his, we would bill under his number for the scope that he performed.  But you would want to bill his number if he was involved because you would get more than under her provider number, that is what I meant.  So you are not doing the shared visits, we are not doing shared visits.

Question:  Well, either the doctor performed the entire service or he did not?

Answer:  Well why is he going in if he is not going to perform a service?  He is going into the room, the service that he does while he is in there, is what you are going to bill for?

Question:  But if he only did the exam and then the decision making then that would only be two out of three components?

Answer:  Is it on a new patient history and physical?

Question:  I am talking inpatient consultation.

Answer:  He is not doing any of the history at all.

Comment:  No

Answer:  Then you would not be able to bill for that.  Did the nurse practitioner do anything or the PA?

Question:  In my example I'll just say that he was the one who did all the history.

Answer:  The PA did the history and the physician then went in and did the exam and the medical decision-making.  You cannot combine all of this to get one initial inpatient, that would be shared.

Comment:  That was my understanding

Answer:  You do not have anything that is billable, you cannot even bill the incident-to, because she does not or he does not have the three criteria either.

Comment:  Well that was my understanding before we started, I just got a little confused

Comment:  Yes, there is no shared billing.

Question:  Thanks, I need a quick clarification on hospital rounds for physician assistants and nurse practitioners; after their initial consult, if the PA or nurse practitioner is rounding on a patient as a follow-up, how should that be billed?

Answer:  On inpatient status, if they have their own provider number it will be billed under their own provider number because you cannot do any incident-to for inpatient services.  That is where it gets tricky because you are not going to know all of those insurances a lot of times, and you are not going to know if they are credentialed with all of the them.

Question:  We had a request from our local Medicare carrier PGBA of Columbia, I know you are familiar with them, for records for prepay on an incident-to service that we billed under the supervising physician and upon Medicare's review of those records, after only seeing the PA's signature, Medicare denied it saying it did not match the provider it was billed under for that service.  Can you help explain that, when we go back and talk about whether the physician needs to sign or not,  or is this just possibly related to the pin numbers in those boxes on the HCFA that you referred earlier?

Answer:  I think it was related - you can e-mail me or call me directly - I think it was the numbers on the HCFA you have to have and in Palmetto in particular Palmetto GBA plus they have been trying to come up with any reason not to pay now until you appeal it, but you do need to have the original ordering physician, the physician that initiated the care plan in block 17, his UPIN, and then the supervising physician has to be in 24K and 31, and if you have even one of those things out of the realm, Palmetto I know especially will deny it.  So go back and check that first, and if not, e-mail me but they do not have to sign.

Question:  They do not have to for PGBA, because we go back and forth on that.

Answer:  No and I will pull their LMRP again, but that is mine and we do not have to

Question:  So for Medicare tracking, if that was billed under incident-to, it was billed under the supervising   physician number, how would they know whether the physician saw the patient before that it is not...

Answer:  They should not, they should not, that is why I am saying, I would just look at to make sure you have the blocks filled out correctly and then appeal it.

Comment:  Okay thank you.

Comment:  You are welcome.

At this time, there are no further questions.  I would like to turn the program back to Ms. Vollmer for any closing comments she may have.

All right, thank all of you and please if you have any questions feel free to e-mail me, check your local Medicare review policy, and also for those of you, I know Michigan Pain Specialists they do have physical therapy, it is a big controversial issue, keep your heads up with that, make sure that you are following because usually they will put something in play and then they will come and tell us after the fact when we have had a lot of denials, but thank all of you very much.

To view slides, see the pdf.