Transcript Introduction to NP/PA Billing

UCSF Medical Group and Medical Center
Nurse Practitioner as Billing Provider
POLICY 3.08.01
Business and Finance
Nurse Practitioners as Billing Providers
Issued: April 2009
August 10, 2010 CIDP Leadership Meeting
General Information
UCSF Medical Center Policy 3.08.01
• Nurse Practitioner (NP) Services:
Guidelines for
Professional Billing
• http://manuals.ucsfmedicalcenter.org/AdminM
anual/IndividualPolicies/NursePractitionersasBil
lingProviders.pdf
• Reviewed Every Two Years
UCSF Medical Group
• Proposed for next revision:
• Inclusion of Physician Assistants under policy
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Definitions
Types of Clinics
• Hospital-Based Clinics
• Operate under license of the hospital
• Includes all Academic Departments
• Two Billing Components
UCSF Medical Group
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— Professional Fee
— Technical (Use of Facility)
NPs employed by the Medical Center must be removed
from the Medicare Cost Report once they start to bill.
This has implications in terms of AB915 revenue.
• Free-Standing Clinics
• Do not operate under license of the hospital
• Currently none operating at UCSF
• One Global Fee
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Definitions
Supervising Physician
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Fully Licensed Physician
MD or DO
Not participating in an ACGME, GME or ABMS Program
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Types of Supervision
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UCSF Medical Group
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Direct Supervision
The physician must be present in the room when the service is
provided
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Indirect Supervision
The physician must be present in the office or clinic suite and
immediately available
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General Supervision
Services are under the physician’s overall direction and control,
but the physician’s presence is not required during the
performance of the procedure or service. The physician can be
available in-person or through electronic means to authorize
the service
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One of these supervision requirements apply whether billing under
the name of the NP or supervising physician
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Minimum Qualifications
Providing NP Services
• Registered Professional Nurse
• Masters Degree
• Currently Licensed in the State of California
• Nurse Practitioner (NP)
• Family Nurse Practitioner (FNP)
• Pediatric Nurse Practitioner (PNP)
• Must have active UCSF Medical Center Medical Staff Privileges which
includes national certification (for NPs hired after 1992).
Supervising NP Services
• All services billed under a NP provider number require a minimum of
“General Supervision” regardless of payer source
• Services not billed under a NP provider number require “Indirect
UCSF Medical Group
Supervision” as part of a shared visit methodology.
• One supervising physician is not permitted to supervise more than the
full-time equivalent of four NPs at any one time
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Scope of Practice
General
• Governed by rules of RN’s and UCSF credentialing requirements
California Nursing Practice Act
• Allows NP to provide certain medical functions in addition to
nursing
• In some cases, medical functions must adhere to Standardized
Procedures that are developed by the employer (UCSF), in
accordance with the California Nursing Practice Act
Medical Functions Requiring Standardized Procedures/Protocols
— Any function that is not commonly recognized as a nursing
practice and that requires the NP to
— Diagnose Disease
— Furnish Medicine
— Furnish Treatment
— Penetrate or Sever Tissue
UCSF Medical Group
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Scope of Practice
California Nursing Practice Act, cont’
Medical Functions Requiring Standardized Procedures,
cont’
— NP is allowed to furnish Schedule II-V Drugs with a
Standardized Procedure
— Drugs must be consistent with the
NP educational preparation
— Clinical competency has been established and
maintained
— Schedule II or III controlled substances furnished or
ordered shall be in accordance with a patient-specific
protocol approved by the treating or supervising
physician
In addition to standardized procedures, other written
protocols and standing orders may be developed by the
supervising physician(s), subject to approval by the UCSF
Committee on Inter-disciplinary Practice (CIDP).
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UCSF Medical Group
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Terms
Billing Terms
• “Incident-to”
• Medicare term ~ Allows services provided by a NP to be billed under the
supervising physician’s provider number.
• Setting must be Freestanding/Stand Alone Setting
— None of which currently exist at UCSF
UCSF Medical Group
• Split/Shared Visit
• Another Medicare term ~ Applies to Evaluation & Management (E/M)
Services only
• Rule allows documentation from the physician and NP note to be
combined
• Setting must be Hospital-Based
— Hospital Inpatient or Outpatient, Emergency Room & Hospital-Based
Clinics
— Requires
— Two separate notes
— NP AND supervising physician face-to-face time
— Consultations, Critical Care and Surgical Procedures are Exempt and
Cannot use this Rule
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Documentation Guidelines
All Payers
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EMR and/or Chart
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All services ordered and provided by the NP are to
be personally documented, signed and dated.
For billing purposes, it is strongly recommended
that NPs identify their supervising physician in
their note.
— When the NPs supervising physician is away or
on vacation the supervising physician noted
would be the physician called that day for
assistance or direction.
If NP is on the UCSF Cost Report, the NP cannot
submit a professional fee and must use the
split/shared visit methodology.
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Payor Specific Billing Guidelines
Medi-Cal – All Locations
• FNP and PNP
• Allowed to bill under their own name for any services provided
within their scope of practice
• NP
• Must bill under their supervising physician name
• There are specific HCPCS, CPT-4 and Medi-Cal only codes (NP
only)
• For a list of these codes go to
UCSF Medical Group
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— http://files.medical.ca.gov/pubsdoco/DocFrame.asp?wURL=publications%2Fm
asters-mtp%2Fpart2%2Fnonph_m00o03o11.doc
Difference between billable and payable
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Payor Specific Billing Guidelines
Workers Compensation – All Locations
• NP may provide services to workers’ compensation patients
• NP may not:
• Initiate new treatment
• Report on an injured workers’ entitlement to benefits
• Change the Primary Treating Physician (PTP) treatment
UCSF Medical Group
plan
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Modifiers
Modifiers
• Medi-Cal/GMC
• When billing under the name of the FNP or PNP no special
modifiers are required
• When billing NP services including FNP and PNP, under the
name of the supervising physician the modifier -SA is required
• When there are multiple modifiers selected, the Billing System
automatically assigns the modifier –99 to indicate there are
multiple modifiers
• Workers Compensation
• When billing NP services for workers compensation, the
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modifier –98 is required
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Considerations
Additional requirements/considerations under this policy include:
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UCSF Medical Group
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A face to face meeting between the Nurse Practitioner and the
Supervising Physician occurring the year between credentialing
cycles. The purpose of this meeting is to ensure that the Nurse
Practitioner is continuing to practice within the scope of the
protocol on file.
Nurse Practitioners, whether billing independently or otherwise,
cannot supervise Residents. Residents will continue to require a
physician in attendance to supervise their activities.
Currently many departments receive State of California AB-915
reimbursement to for the facility costs related to clinic
operations. Nurse Practitioners who bill independently can no
longer qualify to be included in these facility costs.
It is up to the department manager’s discretion whether a Nurse
Practitioner can bill independently as there may be workflow
issues within the clinic.
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Process For Enrollment As an Independent Biller
A web page is under construction at the following address:
http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx
Contained at this site will be:
UCSF Medical Group
• Application Form
• Educational presentation
• Link to current UCSF policy
• Link to current Medi-Cal coding guidelines
• List of active NPs credentialed to bill independently
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