Billing for NonPhysician Practitioners
Presented by NYU School of Medicine
Office of Physician Reimbursement
Compliance
Gretchen L. Segado, MS, CPC, Director
316 East 30th Street
New York, NY 10016
(212) 263-2446
(212) 263-6445 fax
Gretchen.Segado@med.nyu.edu
Goals for This Session
Understand the difference between Direct
Billing and Incident-to Billing
Understand need to learn CPT and ICD-9
coding principles
i.e. Understand E&M coding
Be aware of documentation requirements
Understand how services are reimbursed
Be aware of differences between insurance
companies and their coverage
And….it is very important to
remember……
Two Different Billing
Scenarios
Direct Billing
Certain NP Practitioners can be credentialed
and can bill under their own provider number
Nurse Practitioners, Physician’s Assistants, Certified
Nurse Specialists, Clinical Psychologists,
Medicare reimburses on a percentage of the
Physician Fee Schedule
Incident-to Billing
Physician directed team
Service is billed under physician’s provider
number
Direct Billing Criteria for
Medicare
Non-Physician Practitioner bills services
directly to Medicare
Must meet Medicare’s credentialing
requirements
Can bill in any setting allowable under
scope of practice (office, inpatient and
outpatient hospital, etc)
Direct Billing Criteria for Medicare
Can provide any services allowed
under their scope of practice, but will
only be reimbursed for covered
services.
Should have a collaborative
agreement with physician or group of
physicians
Refer to Non-Physician Practitioner
Direct Billing Guide
Please note:
Diagnostic testing rules have a different
set of regulations and supervision
levels……
What Is an Incident-to Service?
When services are provided by auxiliary
personnel under direct physician
supervision, they may be covered as
“incident-to” services
Non-physician practitioner bills for services
“under physician’s name”
Incident-to Requirements
Integral though incidental part of
physician’s professional service
Commonly rendered without charge or
included in the physician's bill
Of a type commonly furnished in
office/clinic
Furnished under direct supervision of the
physician/group
Source: Medicare Carrier’s Manual, Part 3, Chapter
2, 2050.1
Part of Professional Service
Service must be medically necessary
Service must follow initial physician
service
Supervision alone is not a service
Physician incurs overhead expense
for service
Integral though incidental
Services and supplies commonly furnished in
physician’s offices are covered
Where supplies are clearly of a type that a physician is
not expected to have on hand in his/her office setting, or
are of a type no considered medically appropriate to
provide in the office, they are not covered under the
incident-to provision
Supplies, including drugs and biologicals must be an
expense to the physician or legal entity billing.
Example: if patient supplies the drug and physician
administers it, only administration can be billed by physician
Service must be medically necessary
Physician performs subsequent service to show
active management and participation
Commonly furnished in
Physician’s office or clinic
Place of service MUST be office/clinic
Generally no hospital or other settings
For hospital patients and for SNF
patients who are in a Medicare covered
stay, there is no Medicare coverage of
the services of physician-employed
auxiliary personnel as services incident
to physicians' services
Direct Personal Supervision
Not part of same day physician
service
Not in same room
Physician or other member of group
practice must be present in suite
Clinic exception
Direct Personal Supervision
Auxiliary personnel means any individual
who is acting under the supervision of a
physician, regardless of whether the
individual is an employee, leased
employee, or independent contractor of the
physician, or of the legal entity that
employs or contracts with the physician.
Likewise, the supervising physician may be
an employee, leased employee or
independent contractor of the legal entity
billing and receiving payment for the
services or supplies.
Direct Supervision
If auxiliary personnel perform services outside the
office setting, e.g., in a patient's home or in an
institution (other than hospital or SNF), their
services are covered incident to a physician's
service only if there is direct supervision by the
physician.
Example:
nurse accompanied the physician on house calls
and administered an injection, the nurse's services
are covered.
If the same nurse made the calls alone and
administered the injection, the services are not
covered (even when billed by the physician) since
the physician is not providing direct supervision.
Supervising vs. Ordering
Physician
In a group practice, where one physician
orders a treatment/service to be
performed by ancillary personnel under
the supervision of a different physician
who is a member of the group practice,
the service should be billed under the
provider number & name of the
supervising physician who was present
in the office when the service was
provided NOT under the ordering
physician.
Supervising vs Ordering con’t
Example:
Oncologist orders chemo to be given by
a nurse while he/she is not present in
the office, but under supervision of
another physician member of the
same group.
Service should be billed under the
name of the supervising physician
Supervising vs. Ordering con’t
Example #2
Patient with high blood pressure. At
first visit, treatment plan is established
that the patient will come in once per
week for a BP check. Patient sees a
nurse for these weekly visits. This
service is billed under the physician
supervising the day that the patient is
seen in the office.
Per Chapter 14 of Medicare
Carriers Manual
A Nurse Practitioner, Physician
Assistant, Nurse Midwife or Certified
Nurse Specialist can bill any E&M
service (99210-99499) per MCM
15501G
Other employees must bill 99211
Cannot bill based on counseling time
per MCM 15501C
Incident-to vs Direct Billing
Incident To
No New Patients
No New Problems
Physician In Suite
Not at Hospital or
SNF
Physician Directs
Patient Care
Full Payment
Code at Any Level
Direct Billing
Any Patient
Any Problem
Who cares where Dr
is?
Any Place of Service
NPP Directs Patient
Care
85% of Physician
Fee
Code Any Level
Private Insurance and Managed
Care Companies may have
different policies and requirements!!
Some insurance companies do not
allow incident-to or billing under the
doctor.
Know your most common payer
requirements
General Principles Of Medical
Record Documentation
Complete medical records for each
patient
Make all entries in ink
Use drawings, illustrations & pictures
when appropriate
Write legibly
General Principles Of Medical
Record Documentation
For each encounter:
reason for the encounter and relevant
history, exam and prior diagnostic test
results
assessment, clinical impression or
diagnosis
plan of care
date and legible identity of the
observer
General Documentation
(Continued)
Make entries promptly
Do not leave blank spaces in the
patient records
Document relevant conversations
between patient, responsible parties,
physicians and staff
Use standard abbreviations
General Principles Of Medical
Record Documentation
If not documented, the
rationale for ordering and
other ancillary services should
be easily inferred
Past and present diagnoses
should be accessible to the
treating and/or consulting
physician
Appropriate health risk factors
should be identified
General Principles Of Medical
Record Documentation
CPT and ICD-9 codes reported on the
health insurance claim form or billing
statement should be supported by the
documentation in the medical record
Basics Of Medical
Reimbursement
Payers are willing to pay for services provided
they are:
•covered within the patient’s policy
•medically appropriate for the patient's
condition
•medically necessary
•coded correctly
Covered services are those services:
•defined as “covered” within the terms of the
patient's benefit plan
•documented in the medical record
medically necessary
Variables That Affect
Reimbursement Include:
 Individual insurance policies and
regulations
 Patient’s coverage
 Federal regulations
 Contractual agreements
 Accuracy of diagnosis and procedure
coding
 Physician office systems
What Is CPT-4?
Systematic listing of procedures & services
performed by physicians
Five-digit codes for procedures or services
Used to describe the physician’s services to
a patient for diagnosis and treatment of the
medical condition(s)
Codes and descriptive terminology
developed and copyrighted by AMA CPT
Editorial Panel
Organization Of CPT Manual
Text organized in 6 major sections
Evaluation and Management ( 99201 - 99499)
Anesthesiology ( 00100 - 01999,
99100 - 99140)
Surgery ( 10040 - 69990)
Radiology ( 70010 - 79999)
Pathology and Laboratory ( 80049 - 89399)
Medicine ( 90281 - 99199)
Format Of The CPT-4 Manual
Developed as a stand-alone descriptions of the
procedures
To conserve space, some are not printed in their
entirety but refer back to a common portion
listed in a preceding entry
EXAMPLE:
25100 Arthrotomy, wrist joint; for biopsy
25105
for synovectomy
Reads:
25105
Arthrotomy, wrist joint; for
synovectomy
Linkage Between ICD-9 & CPT
(Continued)
ICD-9 represents the “WHY” component
of the procedure
CPT-4 represents the “WHAT”
component of the procedure
How Does It Differ From ICD-9?
ICD-9 represents to the carrier why a
service was billed:
Medical Necessity--------- 786.50
(Chest
Pain)
CPT-4 represents to the carrier what
was billed:
Procedure------------------- 93010
(EKG)
Over 17 different Otitis Media Codes
Acute? Chronic? Supportive? Serous?
Mucoid?
Over 28 different codes for Diabetes
Type I or II? Insulin Dependent? With
complications?
Acute Upper Respiratory Tract Infections
4 codes
Disorders of Lipid Metabolism
11 codes
Establishing The Medical
Necessity For Procedures
Only clinically proven effective
procedures are reimbursable
under the Medicare program
Medicare has a specific list of
ICD-9 codes that support the
medical necessity of each
procedure
Medical Necessity
Diagnostic studies
without established
diagnosis (i.e., rule
out, probable,
suspected)
Example:
Pelvic Ultrasound
for R/O Ectopic
Pregnancy
ICD-9-CM
Report signs &
symptoms
Pelvic Pain (625.9)
Medical Necessity
(continued)
Diagnostic studies with confirmed or
established diagnosis
Report the ICD-9 Code representing the
confirmed diagnosis
Example:
Diagnostic Study:
Pt. for Pelvic Ultrasound
ICD-9 Linkage
uterine fibroid
(218.9)
Documentation Of Technical
Detail Of Procedure
1. Pre-operative
evaluation
2. Medical Necessity
3. Separate note for
the procedure
4. Complete procedure
note itself
5. Signed and Dated
by the MD
Procedure Note
Anesthetized with 2% Lido +
Epi irrigated with NS, and
Explored
Laceration was
subcutaneous, approx 6 cm
w/ skin flap
Wound closed with #8 sutures
(4-0 nylon interrupted
sutures)
Signature
Evaluation And Management
Services
Codes 99201 to 99499
Basic format:
Unique code number is listed
Place/type of service is specified
Content of service is defined
Nature of presenting problem usually
associated with a given level is described
Time typically required to provide the service is
specified
Categories Of E/M Services
Office or other
Outpatient Services
New and Established
Patients
Hospital Observation
Services
Initial Hospital Care
Subsequent Hospital
Care
Hospital Inpatient
Services
Initial Hospital Care
Subsequent Hospital
Care
Categories Of E/M Services
(Continued)
Consultations
Office of Other Outpatient Consultation
Initial Inpatient Consultation
Follow-up inpatient Consultations
Confirmatory Consultations
Emergency Department Services
Critical Care Services
Categories Of E/M Services
(Continued)
Neonatal Intensive Care
Nursing Facility Services
Preventive Medicine
Newborn Care
Special Evaluation and
Management Services
Other Evaluation and
Management Services
Is This A New Patient Visit Or
An Established Patient Visit?
New Patient
Has not received any professional
services from the physician or another
physician of the same specialty, same
group practice, within the past three
years
Established Patient
Has received professional services from
the physician or another physician of the
same specialty, same group practice,
within the past three years
Is This A Problem Oriented Visit
Or A “Well Visit”?
Preventive Medicine Services are a
special category of E&M
Code selection is based on patient’s
age and status with the practice
99381-99387 Initial Comprehensive
Preventive Medicine
99391-99397 Periodic
Comprehensive Preventive Medicine
Keep Your Practice Safe
Learn how to code your services
Attend coding classes as specialty
conferences
Attend seminars given by local Medicare
Contractors
Educate your staff on coding and
compliance
Document, Document, Document
Any questions?????