Wiki Billing versus ordering physician

[Girlzsmom66]

Our administrator approached me earlier this week with this scenario:

"We are wanting to go from our assigned provider days to doctor of record". I hope I can explain this well enough.... Currently we have two physicians (three in a few weeks), and they have providing doctor days (i.e. one has T/TH and the other M/F and they alternate W). The administration came to me and said, "WE want to go from providing doctor days to doctor of record" meaning, "our docs want to write orders and be the billing doctor of record for their patients". My dilemma is... administration wants ME to find where a physician can write an order on their patient and have it be standing until their procedure takes place. I work in a facility where patients are monitored several times a week/month before a procedure takes place. Often times the provider/ordering physician is NOT in the office due to illness, performing surgery elsewhere, or vacation. HOW would it be possible for a physician to write an order, have another physician change/update a treatment plan, and the ordering physician STILL get credit for the services billed?

Ethically, I am having a HUGE problem with this scenario! Where can I find information to state that a physician cannot write an ongoing order on a patient if a different physician reads, changes, or alters a care plan? I have looked on CMS and OIG, but perhaps my searches are to vague, because I am not finding what I am looking for.

ANY suggestions would help me and my comfort level!!!!

So.... EXAMPLE: can a provider write an order on their patient, leave for vacation, and have another physician give a treatment plan and it be billed under the ordering physician? Patient X came in for ultrasound and lab work today and it was determined by NOT ordering physician to increase Drug A and add Drug B to their protocol and return to the clinic on day 5? Can ORDERING provider get credit/bill for this case?

Thank you! My ethics are holding firm!

Michelle

 

[thomas7331]

I've read this over a few times but unfortunately don't really understand exactly what you are asking or what your administrator is requesting - there is a lot of confusing information in here, so my answer may or may not be what you are looking for, but I will try.

If the question is: 'Can a physician A who ordered a service bill for the services of another physician B (or the 'incident to' services that were supervised by physician B) who actually personally carried out those services?', then the answer is no (unless it is a locum or reciprocal billing arrangement as defined by CMS) as that would be a false claim.

However, if your practice just wants to credit the work of physician B to physician A for tracking or compensation purposes when that physician initiated the care or wrote the order or otherwise oversees the case, then I don't see any problem with that - many practices do this - but it just needs to be done in a way that does not affect the accurate submission of the claim. I think many practice management/billing systems are able to do this by giving you a field in the system that allows you to enter a different physician that the one billed on the claim, e.g. a 'doctor of record' in this case. Or, alternatively, it may be possible to post a 'dummy code' to the account that does not actually go onto the claim form but which can be used by the practice for reporting purposes. You might consider speaking with your practice management software vendor to see what is available in this respect. But even in cases where it is outside the capabilities of the billing system, practices find a way to do it on the 'back end', so to speak, by generating reports and/or performing manual adjustments so that the provider compensation takes these situations into account.

It sounds to me like maybe your administration has a legitimate need but perhaps does not understand that it just needs to be done in a different way than by changing the billing itself.

Does this help or get to what you are asking at all?

 

[Girlzsmom66]

More information...

I knew this would be confusing.

Let me do this as an example:

Physician A writes a "global order" to include ultrasound be done day one. Ultrasound and labs be done days 5, 7 and possible day 9 ultrasound with lab. Patient will come in for procedure on day 10 or 11. Physician A was NOT in the office on day 7 (in another city seeing other patients), so Physician B reviews the ultrasound and lab and increases medication and adds another medication to the treatment plan. Can Physician A still take billing credit for day 7 when, in fact, Physician B was the doc reviewing/revising the treatment plan?

OR how about this: Physician A writes the "global order" (for above scenario) and is at another clinic (in another city), reviews the results (from the other city), and calls in the new treatment plan. Is this still billable by Physician A?

Perhaps that was a little clearer? I am just not sure the latter scenario is even a possibility. I also don't think the two providers are willing to "give up" their productivity to the other provider.

Thanks again for assisting!

Michelle

 

[thomas7331]

Happy to try to help.

In your first example, I'm still not understanding what you mean by 'take billing credit for day 7'. First of all, what is being billed that day? Are the ultrasound and labs being done at your facility or somewhere else? Is your physician doing the I&R of the ultrasound? Is the patient being seen by the physician that day, or is the physician just reviewing results and changing the plan? Physician A cannot bill for anything done in the office if he or she was not there. Physician B would have bill for any of the services performed that day that are billable, but if the patient was not seen face-to-face, the only billable professional service would be the reading of the ultrasound. Same in the second example - what exactly would Physician A be billing? Writing an order, reviewing results and calling in a new treatment plan are not separately billable services anyway, so it would not matter where the physician is located, or am I not understanding something?

As for whether or not providers are willing to give up their productivity to another provider, or who gets 'credit' for what - that is a human resources matter that would have to be worked out between the providers and the owners of the practice and should not have any bearing on how the services are coded or billed.

 

[mitchellde]

why not just use the NPI of the provider that actually saw the patient and rendered the care in field 24J and use the ordering provider in field 17 with the DK modifier for ordering provider. This would totally correct and admin can search under field 17 for the ordering provider stats.

 

[Girlzsmom66]

Thomas

Happy to try to help.

In your first example, I'm still not understanding what you mean by 'take billing credit for day 7'. First of all, what is being billed that day? Are the ultrasound and labs being done at your facility or somewhere else? Is your physician doing the I&R of the ultrasound? Is the patient being seen by the physician that day, or is the physician just reviewing results and changing the plan? Physician A cannot bill for anything done in the office if he or she was not there. Physician B would have bill for any of the services performed that day that are billable, but if the patient was not seen face-to-face, the only billable professional service would be the reading of the ultrasound. Same in the second example - what exactly would Physician A be billing? Writing an order, reviewing results and calling in a new treatment plan are not separately billable services anyway, so it would not matter where the physician is located, or am I not understanding something?

As for whether or not providers are willing to give up their productivity to another provider, or who gets 'credit' for what - that is a human resources matter that would have to be worked out between the providers and the owners of the practice and should not have any bearing on how the services are coded or billed.

I know, it's hard explaining myself in writing. This is a private practice, so the physicians split days. Each has clinic days and each have operating room days. They each have their own patients, but if their patient needs to come in on either/or of their surgery/OR days, the other reviews the ultrasound and blood work (the billing provider flip-flops). The example I gave of taking credit for day 7 (just an example) was that the patient (Dr. A's) was scheduled to have ultrasound and labs done but the opposite physician (Dr. B) was in clinic day 7. (Golly I hope this is making sense) Currently, we bill under the provider who is in "clinic" on any given day. Now, it's being recommended that the physician initially seeing the patient is the billing physician for ALL treatment (even if it is the physicians surgery/OR day, NON clinic day). I cannot see how this will work. I 100% agree that the order, review, and new treatment plan aren't separately billable. I am being TOLD that whichever physician saw the patient, as a new patient, will be "their" patient and they WILL be the billing provider for ALL services (regardless of whether or not they are in the building, because they wrote a "global order" on "their" patient). I was taught a physician cannot be the billing physician if they are not on site and have reviewed the patient's case.

 

[Girlzsmom66]

Debra

why not just use the NPI of the provider that actually saw the patient and rendered the care in field 24J and use the ordering provider in field 17 with the DK modifier for ordering provider. This would totally correct and admin can search under field 17 for the ordering provider stats.

Forgive me for sounding uneducated, but is the DK modifier used for Medicare?

We are a private practice and do not take Medicare, Medicaid, or Tricare.

 

[mitchellde]

It is not strictly a Medicare Modifier. It is a modifier created for use with the CMS 1500 for provider designation in field 17 as being referring provider, supervising provider or ordering provider. DK is the one for Ordering provider.

 

[thomas7331]

I know, it's hard explaining myself in writing. This is a private practice, so the physicians split days. Each has clinic days and each have operating room days. They each have their own patients, but if their patient needs to come in on either/or of their surgery/OR days, the other reviews the ultrasound and blood work (the billing provider flip-flops). The example I gave of taking credit for day 7 (just an example) was that the patient (Dr. A's) was scheduled to have ultrasound and labs done but the opposite physician (Dr. B) was in clinic day 7. (Golly I hope this is making sense) Currently, we bill under the provider who is in "clinic" on any given day. Now, it's being recommended that the physician initially seeing the patient is the billing physician for ALL treatment (even if it is the physicians surgery/OR day, NON clinic day). I cannot see how this will work. I 100% agree that the order, review, and new treatment plan aren't separately billable. I am being TOLD that whichever physician saw the patient, as a new patient, will be "their" patient and they WILL be the billing provider for ALL services (regardless of whether or not they are in the building, because they wrote a "global order" on "their" patient). I was taught a physician cannot be the billing physician if they are not on site and have reviewed the patient's case.

I think there must be some misunderstanding of what you mean by 'billing physician'. I follow you above until you say we bill under the provider who is in "clinic" on any given day. What are you billing, and to whom? Is it an E&M service?

 

[Girlzsmom66]

Claims

I think there must be some misunderstanding of what you mean by 'billing physician'. I follow you above until you say we bill under the provider who is in "clinic" on any given day. What are you billing, and to whom? Is it an E&M service?

My bad...

clarification is the ultrasounds and labs are being billed, not an E&M. The claim will reflect either Physician A or Physician B as the provider of service. Physician A wants to be on the claim for all services rendered even though Physician A is not on the premises. Physician B reviews/reads the ultrasound and labs therefore, physician B is on the claim form. Clearer or muddier? LOL

 

[Girlzsmom66]

I am uneducated

It is not strictly a Medicare Modifier. It is a modifier created for use with the CMS 1500 for provider designation in field 17 as being referring provider, supervising provider or ordering provider. DK is the one for Ordering provider.

Where will I find these modifiers?

So, Physician A CAN be the primary provider, not be on the premises, and CAN be used as the provider of service for what Physician B reads/reviews? (for claims purposes)

I LOVE learning!!!!

Michelle

 

[thomas7331]

OK, so in case you are talking here primarily about clinical labs and diagnostic radiology which are non-physician services in that they are not personally performed by a physician, and where you would normally bill under the physician supervising the test. CMS guidelines do allow a certain amount of latitude in this, but since you've said that your practice doesn't take Medicare or Medicaid, it probably won't help much to cite those regulation since they don't apply. If your practice really wants to bill these under a different physician than the one in the office, you'll need to review your payers' policies or contact your network representatives to see if this would be acceptable. I don't think that most commercial payers would have a huge problem with doing this as long as the amount that is paid would not be affected because the check is going to the same place regardless of which doctor's name is on the claim. But you never know if this would present a problem down the road, and personally I think it is an approach that is not without risk, so if the practice chooses to do this, I would recommend getting a compliance or legal specialist's services to review the arrangement and verify that it is compliant and also not in conflict with any of your payer contracts.

However, I'd go back to my original point, which is why go to the trouble of doing this? If it is a matter of wanting the income to go a specific provider, this can be done internally. In your place, I would be recommending that no changes be made to the process of submitting claims, and that the practice find an internal method of getting the revenue reported to the provider that they want it reported to instead of manipulating the billing of claims in order to achieve this.

 

[thomas7331]

Where will I find these modifiers?

So, Physician A CAN be the primary provider, not be on the premises, and CAN be used as the provider of service for what Physician B reads/reviews? (for claims purposes)

I LOVE learning!!!!

Michelle

No, the DK is not a CPT modifier, it is actually called a 'qualifier' and is the code entered into box 17 to identify whether the NPI in that same box is of the referring, supervising or ordering provider. It does not allow you to bill one provider's services under a different provider's credentials. Box 17 is not a billing provider field - it is for information purposes, which is why you could put your ordering provider's number in this box as a way to identify which provider's case these charges belong to, but without affecting the rest of the information on the claim.

 

[Girlzsmom66]

Thank you!!!

OK, so in case you are talking here primarily about clinical labs and diagnostic radiology which are non-physician services in that they are not personally performed by a physician, and where you would normally bill under the physician supervising the test. CMS guidelines do allow a certain amount of latitude in this, but since you've said that your practice doesn't take Medicare or Medicaid, it probably won't help much to cite those regulation since they don't apply. If your practice really wants to bill these under a different physician than the one in the office, you'll need to review your payers' policies or contact your network representatives to see if this would be acceptable. I don't think that most commercial payers would have a huge problem with doing this as long as the amount that is paid would not be affected because the check is going to the same place regardless of which doctor's name is on the claim. But you never know if this would present a problem down the road, and personally I think it is an approach that is not without risk, so if the practice chooses to do this, I would recommend getting a compliance or legal specialist's services to review the arrangement and verify that it is compliant and also not in conflict with any of your payer contracts.

However, I'd go back to my original point, which is why go to the trouble of doing this? If it is a matter of wanting the income to go a specific provider, this can be done internally. In your place, I would be recommending that no changes be made to the process of submitting claims, and that the practice find an internal method of getting the revenue reported to the provider that they want it reported to instead of manipulating the billing of claims in order to achieve this.

EXCELLENT!! Thank you so much for all of your input! You were delightful and willing to see me through this!

Michelle

 

[mitchellde]

No, the DK is not a CPT modifier, it is actually called a 'qualifier' and is the code entered into box 17 to identify whether the NPI in that same box is of the referring, supervising or ordering provider. It does not allow you to bill one provider's services under a different provider's credentials. Box 17 is not a billing provider field - it is for information purposes, which is why you could put your ordering provider's number in this box as a way to identify which provider's case these charges belong to, but without affecting the rest of the information on the claim.

Yes Qualifier so sorry I used the wrong term and caused confusion. But it would be an excellent way to track this without affect the claim submission.

 

[Girlzsmom66]

qualifier

Yes Qualifier so sorry I used the wrong term and caused confusion. But it would be an excellent way to track this without affect the claim submission.

Where can I locate these qualifiers? The person working with the CMS 1500 should also know this information, who is the administration, and doesn't know this.

Thank you for your assistance!!!!

Michelle

 

[mitchellde]

go to NUCC.org then about 1/3 of the way down is a menu that goes across, locate the selection for 1500 claim form and a menu will drop down click on 1500 instructions.. you will see the most recent version was just released, open tat and page thru until you get to field 17.