JustinPA Posted March 14, 2014 Share Posted March 14, 2014 I don't know a lot about billing but I was just curious if it's standard practice to bill patients seen by a PA under the supervising physicians NPI or if they are supposed to be billed under the PAs NPI. I remember learning a little about incident to billing but I thought it required the supervising physician to be on site. Thanks in advance. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 14, 2014 Moderator Share Posted March 14, 2014 most places bill under the pa unless the doc also sees the pt. Link to comment Share on other sites More sharing options...
JustinPA Posted March 14, 2014 Author Share Posted March 14, 2014 Is it wrong if they are billing all the patients I see as a PA under my supervising physicians NPI number despite him rarely being on site? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 14, 2014 Moderator Share Posted March 14, 2014 Is it wrong if they are billing all the patients I see as a PA under my supervising physicians NPI number despite him rarely being on site? yup. Link to comment Share on other sites More sharing options...
JustinPA Posted March 14, 2014 Author Share Posted March 14, 2014 Thanks. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 14, 2014 Moderator Share Posted March 14, 2014 possibly it is okay depends on setting In an out patient office they are allowed to bill under the Doc's NPI if the doc is in the office and immediatly available for consultation - even if they never see the patient - twisted little know fact that allows the PCP's to get paid like a doc saw the patient, but only pay a PA salary.... I am unsure if this applies to the UC or ER setting.... I can say that when I opened my own business (after 10 years of practice in Outpatient, ER, and inpatient setting) I was amazed that I had NEVER been indiviually credentialed with Medicare! Seems that EVERYONE had billed under Doc's NPI (some 5+ jobs!) so it is a common thing..... (and a few of the jobs were even reporting my individual productivity - so they must have loaded me in the billing computer but then billed under the doc.....) Much harder question to answer then a simple yes no -for the pure legality of it..... And is gets even more confusing for private payers The only think I am pretty sure of - if a PA does a house call then it MUST be under their PIN, if a PA does an entire visit in the hospital (inpatient) it must be billed under the PA Link to comment Share on other sites More sharing options...
jmj11 Posted March 14, 2014 Share Posted March 14, 2014 Most of the time you bill under the PAs NPI unless it is truly and incident to situation. However, there are a few insurance companies (and I can't remember which ones but my biller knows) who are so backwards that they see the PA as an "assistant" or extender of the physician and require that you bill under the physicians NPI. However, when they found out they could save 15% by paying according to CMS at 85% of physician, they have been quick to then recognize PAs as a independent biller and most now require billing under the PAs NPI. It is about money. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 15, 2014 Moderator Share Posted March 15, 2014 From: http://www.acponline.org/about_acp/chapters/ca/nhic_march07.pdf For services of a non-physician practitioner to be considered “incident to” a physician’s professional service, they must be performed under the direct supervision of the physician and meet all of the other “incident to” requirements. Direct supervision means the physician is within the office suite and immediately available to provide services. and for a more detailed discussion http://medicaleconomics.modernmedicine.com/medical-economics/news/demystifying-medicares-incident-billing-nurse-practitioners-physician-assista?page=full Demystifying Medicare's 'incident to' billing by nurse practitioners, physician assistants Publish date: SEP 25, 2013 Print By: Renee Stantz Renee Stantz Q: I am one of several specialist physicians who recently joined a large hospital organization.We use our midlevels extensively, both in the hospital and the office. Some are on staff at the hospital and are normally the first to see our patients. Our physicians then see the patients during rounding, document that they agree with the midlevel’s findings, and sign off on the note. We bill these visits under the physician’s Provider Identification Number (PIN). Is this correct? We utilize our PAs in a similar fashion in the office. They initiate the visits for new and established patients, document the visits and write the plans of care. The physician then sees the patient and signs off on the plan of care. We have been told by our new organization’s compliance team that we are not billing these visits appropriately. How should we bill them? A: Let’s delve into incident-to guidelines first. Incident-to billing is a way of billing outpatient services (rendered in a physician’s office located in a separate office or in an institution, or in a patient’s home) provided by a non-physician practitioner (NPP) such as a nurse practitioner (NP), physician assistant (PA), clinical nurse specialist, certified nurse midwife, clinical psychologist, clinical social worker, physical therapist, or occupational therapist. NPPs have their own benefit category and may provide services without direct physician supervision. They can bill directly for services and incident-to a physician’s services, if they are licensed by their state to assist perform the services. Billing under a physician’s PIN According to the Center for Medicare and Medicaid Services (CMS) National Coverage Provision for incident-to services, when NPPs provide services that are incident-to a physician or other practitioner’s service, they may bill under the physician’s PIN when the service or supply is: An integral, although incidental, part of the physician’s professional service; Commonly rendered without charge or included in the physician’s bill; Of the type that is commonly furnished in physician offices or clinics; Furnished by the physician or auxiliary personnel under the physician’s direct supervision. Medicare defines these services as those performed by a NPP or auxiliary staff member who is acting under the supervision of a physician and who is employed by or contracted with the physician or the legal entity that employs or contracts with the physician. There must have been a direct, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the non-physician is an incidental part. This means that the physician must see the patient first, in order to initiate the plan of care for that patient, and the NPP follows that plan of care during subsequent visits. It also means that if a patient mentions a new problem during a follow-up visit for a problem with an established plan of care, the visit cannot be billed incident-to. For example: Dr. A is treating a patient for diabetes. The patient’s evaluation and management (E/M) encounter in the office is with a PA of the same group for an upper respiratory infection. Can the PA bill the service incident-to Dr. A and bill under Dr. A’s PIN? In this situation, the upper-respiratory infection is not part of the treatment for diabetes and, therefore, is not an “integral, although incidental” part of Dr. A’s “professional service.” The PA should not bill incident- to under Dr. A’s provider number, but should bill the appropriate level of new or established E/M service provided under his or her own provider number. The physician must have performed the initial service for the diagnosis or condition, and must remain actively involved in the course of treatment. Finally, the physician must perform subsequent services that reflect his or her continued active management of the patient’s care. Direct physician supervision To understand this billing scenario, we need to explore further what CMS means by “physician’s direct supervision.” According to CMS, “Direct supervision in the office setting means the physician must be present in the office suite and immediately available and able to provide assistance and direction throughout the time the service is performed. Direct supervision does not mean that the physician must be present in the same room with his or her aide.” Additionally, CMS states, “If auxiliary personnel perform services outside the office setting, e.g., in a patient’s home or an institution (other than a hospital or Skilled Nursing Facility,) their services are covered incident to a physician’s service only if there is direct personal supervision by the physician.” Therefore, the only time when a NPP or auxiliary staff member can bill a service under a physician’s PIN is when a physician is in the office suite and directly available to help, if needed. The physician merely being available by phone does not constitute direct supervision. Keep in mind that the physician providing the direct supervision (or who is in the office) does not need to be the physician who established the plan of care for the patient. Check with your Medicare carrier for where the physician name(s) (i.e., the supervising physician and the physician who established the patient’s plan of care) should be placed on the claim form. Exception to direct supervision Services to homebound patients in underserved areas, CMS says, are not subject to direct supervision, but rather general supervision requirements. CMS defines general supervision as “The physician needs to be physically present at the patient’s place of residence when the service is performed. But the service must be ordered by the physician and performed under his overall supervision and control. The physician retains professional liability for the service.” A patient is considered homebound when his ability to leave his home is restricted and requires considerable effort. Closer look at your choices While auxiliary personnel must bill their services incident-to (because insurance carriers do not credential them), NPPs have a choice whether to bill their services incident-to to Medicare. The incentive to bill incident-to services is reimbursement. Medicare allows 100% of the Medicare fee schedule amount for coverable services submitted by a physician. Medicare allows a percentage of the physician fee schedule amount when services are submitted under a NPP provider number. The percentage is 85% for physician assistants, nurse practitioners, and clinical nurse specialists. The drawback to incident-to billing is the administrative burden of coordinating physicians and NPPs schedules in order to have a supervising physician on-site. If your NPP or auxiliary staff is going to bill incident-to a physician’s services, be sure to follow the guidelines because this is an area under scrutiny by payers who recognize this type of billing. For that reason and because of the complexity of the guidelines, some offices have chosen to avoid incident-to billing. The answer to our reader’s question was provided by Renee Stantz, a billing and coding consultant with VEI Consulting Services in Indianapolis, Indiana. Send your practice management questions to medec@advanstar.com. Subscribe to Medical Economics' weekly newsletter. It's free! Login or Register to post comments Tags billing coding Coding Insights Medicare Medicare claim Medicare reimbursement Modern Medicine Feature Articles nurse practitioner nurse practitioners physician assistant physician assistants Health Care Information Technology Practice Management MORE ARTICLES IN THIS ISSUE Is it the right time for you to buy another practice? With all of the changes facing healthcare, including the increased bureaucracy and frustration, buying a medical practice may seem like more trouble than it’s worth. However, many experts agree that now is a good time to consider buying. Bundling data services saves time, money for primary care physicians Very few things will frustrate a medical practice owner or administrator more than the sight of outside vendors blaming each other for a technical problem the practice is experiencing. How physicians can increase employee satisfaction at their medical practice Keeping your staff happy while pushing them to be better takes time and work outside of your busy schedule. By properly training and incentivizing your staff, you will see a return in better performance. Helping your patients kick the smoking habit Primary care physicians (PCPs) often think of themselves as being on the front lines of the battle to keep Americans healthy, and nowhere is that more true than in combatting smoking and other forms of tobacco use. Reimbursements are heading the wrong way, fast A reader complains that the reimbursement process has become overly complex and burdensome for providers. READ MORE - See more at: http://medicaleconomics.modernmedicine.com/medical-economics/news/demystifying-medicares-incident-billing-nurse-practitioners-physician-assista?page=full#sthash.hwEF4gBg.dpuf Link to comment Share on other sites More sharing options...
coloradopa Posted March 15, 2014 Share Posted March 15, 2014 I don't know a lot about billing but I was just curious if it's standard practice to bill patients seen by a PA under the supervising physicians NPI or if they are supposed to be billed under the PAs NPI. I remember learning a little about incident to billing but I thought it required the supervising physician to be on site. Thanks in advance. Urgent care is generally billed similar to outpatient office visits. For Medicare rules are the same. A number of people have mentioned incident to billing for urgent care. In theory this will work, in reality it won't. Incident to requires several steps: 1. The physician must personally see an perform the initial visit for each problem. They must establish a treatment course. 2. On follow up visits the NPP (PA or NP) can see and treat the problem as long as the physician is in the office or suite and immediately available. This is usually restricted to a contiguous set of offices. For example the physician being in the hospital which is connected by a bridge to the office does not count. 3. If the patient presents with a new problem or a new problem is found during the encounter either the physician must see the patient and establish the plan of care or have the NPP see the patient and bill under their NPI. For most urgent care centers, since the problems are new and episodic having a PA bill incident to makes little sense. It would require the physician to see the patient for each new problem leaving little for the PA to do. Most PA billing experts recommend against using incident to. In the case that you mention in the case of Medicare this probably constitutes fraud. In the case of private payors it will depend on the rules of the payor. May payors do not credential PAs and have you bill under the physicians NPI. The specific incident to language: To qualify as “incident to,” services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary. The patient record should document the essential requirements for incident to service. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0441.pdf Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 16, 2014 Moderator Share Posted March 16, 2014 The above is not totally true..... as i have said they can bill under the Doc PIN for out patient visits if the Doc is immediately available. See above posts Dirty little secret that practices use to make the same revenue as a doc seeing the patient, while they pay 50% of a doc rate.... To qualify as “incident to,” services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary. The patient record should document the essential requirements for incident to service. Link to comment Share on other sites More sharing options...
coloradopa Posted March 16, 2014 Share Posted March 16, 2014 The above is not totally true..... as i have said they can bill under the Doc PIN for out patient visits if the Doc is immediately available. See above posts Dirty little secret that practices use to make the same revenue as a doc seeing the patient, while they pay 50% of a doc rate.... To qualify as “incident to,” services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary. The patient record should document the essential requirements for incident to service. You are completely ignoring the first part of the statement. The physician must perform the initial treatment (bolded). Then a qualified NPP can continue treatment for the problem as long as the physician is present in the suite. It's only a dirty little secret if you bill fraudulently. Here is the AAPA statement for those who don't have access: To bill Medicare “incident to” for services provided by a PA, the following criteria must be met: The service performed must be one that is typically performed in a physician's office. The service performed should be within the scope of practice of the PA and in accordance with state law. The physician must have personally treated the patient on the patient's first visit to the practice or treat any established patient who comes to the office with a new medical condition. PAs may provide follow-up care. The physician (or another physician in the group practice) should be in the suite of offices (on site) when the PA is rendering care. The physician must continue providing the patient’s overall care at a frequency that reflects ongoing involvement in the patient's treatment. Here is there example: A Medicare patient has been previously treated by the physician and was diagnosed with hypertension. On a subsequent visit to the office a PA treats the patient and evaluates his or her hypertension within the plan of care established by the physician on the initial visit. The physician or another physician within the group is on site, within the suite of offices at the time the PA treated the patient. The PA may then bill the office visit "incident to" under the physician's name and NPI with reimbursement at 100 percent of the physician fee schedule. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 16, 2014 Moderator Share Posted March 16, 2014 You are completely ignoring the first part of the statement. The physician must perform the initial treatment (bolded). Then a qualified NPP can continue treatment for the problem as long as the physician is present in the suite. It's only a dirty little secret if you bill fraudulently. Here is the AAPA statement for those who don't have access: To bill Medicare “incident to” for services provided by a PA, the following criteria must be met: The service performed must be one that is typically performed in a physician's office. The service performed should be within the scope of practice of the PA and in accordance with state law. The physician must have personally treated the patient on the patient's first visit to the practice or treat any established patient who comes to the office with a new medical condition. PAs may provide follow-up care. The physician (or another physician in the group practice) should be in the suite of offices (on site) when the PA is rendering care. The physician must continue providing the patient’s overall care at a frequency that reflects ongoing involvement in the patient's treatment. Here is there example: A Medicare patient has been previously treated by the physician and was diagnosed with hypertension. On a subsequent visit to the office a PA treats the patient and evaluates his or her hypertension within the plan of care established by the physician on the initial visit. The physician or another physician within the group is on site, within the suite of offices at the time the PA treated the patient. The PA may then bill the office visit "incident to" under the physician's name and NPI with reimbursement at 100 percent of the physician fee schedule. I have to disagree with your interpretation, as does all my previous employers - a few of which are fairly big institutions (with lawyers on payroll) and a few of which hired legal counsel to determine. Yes in theory you are correct, but in execution of the above policy every single prior employer of mine (about 8 in two different states) billed under the doc pin as the doc was in the office and immediately available. In this case with the OP asking rather this is okay - I think it is reasonable to state my experience as well as the fact that this is multiple employers in different states... and even two private practices that retained legal counsel to advise who all said the same thing.... The sentence I have underlined is the 'give-back' to the out patient physician employer that allows this... You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary. The OP was asking.... In fact, I went through a medicare audit at one job and they sided with this interpretation....... But I do agree with you in that I don't like it and I think it undermines what we do..... but it does appear to be legal Link to comment Share on other sites More sharing options...
Guest Paula Posted March 16, 2014 Share Posted March 16, 2014 I've been reading this with interest as my clinic had been billing incident to for some cases, but it got very complicated when the doc was off. No one could figure out how to line up billing with the doc's schedule since billing was sometimes done weeks or months late. (We have only one person in billing....it's a long story). When I started working at the clinic I specifically asked to NOT be billed under the doc's pin and to bill all under my NPI number. We talked about fraud issues and I think we have it straightened out. Plus, often times I was the first person who saw, evaluated, diagnosed, started the treatment plan and prescribed the medications. No doc involvement at all. I agree that the incident to billing is complicated and I think it should be done away with. PAs should be able to bill all under their own numbers with all insurers and CMS. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 16, 2014 Moderator Share Posted March 16, 2014 I've been reading this with interest as my clinic had been billing incident to for some cases, but it got very complicated when the doc was off. No one could figure out how to line up billing with the doc's schedule since billing was sometimes done weeks or months late. (We have only one person in billing....it's a long story). When I started working at the clinic I specifically asked to NOT be billed under the doc's pin and to bill all under my NPI number. We talked about fraud issues and I think we have it straightened out. Plus, often times I was the first person who saw, evaluated, diagnosed, started the treatment plan and prescribed the medications. No doc involvement at all. I agree that the incident to billing is complicated and I think it should be done away with. PAs should be able to bill all under their own numbers with all insurers and CMS. Exactly! Link to comment Share on other sites More sharing options...
coloradopa Posted March 17, 2014 Share Posted March 17, 2014 I have to disagree with your interpretation, as does all my previous employers - a few of which are fairly big institutions (with lawyers on payroll) and a few of which hired legal counsel to determine. Yes in theory you are correct, but in execution of the above policy every single prior employer of mine (about 8 in two different states) billed under the doc pin as the doc was in the office and immediately available. In this case with the OP asking rather this is okay - I think it is reasonable to state my experience as well as the fact that this is multiple employers in different states... and even two private practices that retained legal counsel to advise who all said the same thing.... The sentence I have underlined is the 'give-back' to the out patient physician employer that allows this... You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary. The OP was asking.... In fact, I went through a medicare audit at one job and they sided with this interpretation....... But I do agree with you in that I don't like it and I think it undermines what we do..... but it does appear to be legal You can disagree, but its the opinion of the AAPA and CMS. We recently go hammered on a Medicare audit in our clinic for this exact problem. The part you underlined clearly refers to continued service after the physician performs the initial service for the problem. Yes the physician does not have to be present for subsequent visits but has to personally perform the initial visit. This has been the opinion of every job where I have worked. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted March 17, 2014 Share Posted March 17, 2014 And this friends is the primary problem....ok, one of several....that this stinkin' profession has to put up with. Why do the rules, whether they be billing, state licensure, DEA licensure (oh, it also depends on your employment setting, i.e.-hospital vs. out-patient), obtaining of CME, or even what we call ourselves have to be so dang difficult? And people wonder why there seem to always be so many opportunities in health care.... Caring for others while honest to goodness wanting to do the right thing by others for the right reason shouldn't be so d*** difficult! OK, I feel better now. Do I pay upfront as I leave? Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.