Wiki Infusion services in clinic billed under NP

[brittcalvert]

I noticed a patient for Injectafer infusion service, which is carried out in our clinic setting (POS 11), was ordered by the NP. I have never billed our infusion services under any NP as therapy plans are under the provider. This particular situation was a patient saw the NP in clinic and obtained lab iron studies. Following the results, the NP ordered for Injectafer infusion services to begin. So the charge sheet came across my desk with NP as ordering provider. However, I remember other coders stating they received denials for infusion claims billed under NPs. I am sure the conference leader stated "infusion services should be billed under the physician". I have personally never billed the NP on any infusion service. I informed my staff, NP, etc. that orders for infusion services require a physician to review and approve behind the NP with physician signature so claims can be billed under the physician for payment. I was understanding NP cannot bill infusion services without physician approval. Is this an accurate understanding?

For more understanding of this example, the patient has regularly received Entyvio infusion services which is under therapy plan signed and administered by a physician. The injectafer infusion service was initiated by the NP following iron lab results showing a deficiency. So the request came with her name on it, not a physician name.

 

[thomas7331]

I have never heard that an infusion service cannot be ordered or billed by a NP, or that an NP cannot supervise staff performing infusions. However, the scope of practice of a NP does vary from state to state, so it's possible that in some states it could be outside of the NP license's scope - you may wish to contact your state's board of nursing to confirm whether or not this is the case.

From a purely coding standpoint, an infusion service is a technical service performed by clinical staff under the supervision of a qualified provider, and would be billed under the 'incident to' requirements, so in most cases it would be billed under the credentials of the provider who was on site supervising at the time and not the provider who ordered it (though it really shouldn't matter for payment purposes because it is not a professional service that is personally performed by the provider). There isn't any coding guidance I'm aware of that precludes you from billing this under the NP if they are the one that supervised this service, however it's possible that some payers may have requirements that you bill this under a physician - I think you'd need to contact your payers or review their policies to know for sure.

 

[brittcalvert]

I have never heard that an infusion service cannot be ordered or billed by a NP, or that an NP cannot supervise staff performing infusions. However, the scope of practice of a NP does vary from state to state, so it's possible that in some states it could be outside of the NP license's scope - you may wish to contact your state's board of nursing to confirm whether or not this is the case.

From a purely coding standpoint, an infusion service is a technical service performed by clinical staff under the supervision of a qualified provider, and would be billed under the 'incident to' requirements, so in most cases it would be billed under the credentials of the provider who was on site supervising at the time and not the provider who ordered it (though it really shouldn't matter for payment purposes because it is not a professional service that is personally performed by the provider). There isn't any coding guidance I'm aware of that precludes you from billing this under the NP if they are the one that supervised this service, however it's possible that some payers may have requirements that you bill this under a physician - I think you'd need to contact your payers or review their policies to know for sure.

Thank you for the information. We are in Mississippi where NP require provider relationship for treatment scope. I was trying to find information for the NP scope in regards to infusion services. Any suggestions where I might find this info? Or it will probably be payor specific.

 

[csperoni]

Most likely your state nursing society has guidance about the scope of work for NPs. MOST states allow NPs to act fairly independently, so my educated guess (but still a guess) is that it is within NP scope.
Assuming the carrier follows incident to guidelines, it would be billed as incident to which means the provider on site supervising at the time of the infusion would go on the claim, regardless of who ordered it.
It's been years, but we used to do chemo in the office. We billed under MD if he was onsite, or under PA if they were onsite. But it was all ordered by MD.

 

[brittcalvert]

On this same general subject, there is a new add-on HCPCS code M1145 "MFN, add on code" from Medicare regarding certain medications. Most of our infusion meds are on this list. Per CMS, M1145 is a new code required with these medication for "Most Favored Nation for drug models" that passed when Trump was in office. I have been confused with this code. I was told M1145 was to be included on the claims for MC for these specific medications including: Remicade, Entyvio, Injectafer, etc. When I searched the allowable for M1145 to create the charge, it was a little confusing. I am not sure if I am supposed to be attaching a price to this because it's an "adjustment" or is it strictly supposed to be $0 for strictly reporting purposes. There seems to be conflicting research on M1145 that insinuates the allowance for the medications has been adjusted automatically when M1145 is reported along with it. We have submitted claims since January 1 with the M1145 ($200), but claims denied for "non-allowed". Has anyone heard about M1145 code and how this is actually working? Any clarity on this is appreciated. I am tracking every claim and still unsure as to how M1145 actually plays a role in reimbursements from CMS.