Transcript Document

1
Navigating ARNP Billing Issues
Angela Mann, MS, ARNP, NP-C
I have nothing to disclose
Objectives
The attendee will be able to:
 Describe the qualifications needed for Medicare,
Medicaid and commercial insurance billing
 Explain Medicare rules related to NP-physician
collaboration, coverage and restrictions for
inpatient and outpatient visits
 Explain Medicare and Medicaid billing for ARNPs
related to direct billing and billing under a
physician
4
The NPI number
 HIPPA
 Unique health care provider identifier
 Required for billing for services using electronic billing
 The NPI number is permanent and remains with the
provider regardless of job or location changes
 NPI numbers are required to bill for Medicare or
Medicaid, they are commonly used by commercial
insurance companies as well.
 NPIs may be required for ARNPs, certified nurse
midwives, certified registered nurses, CRNAs, and
clinical nurse specialists
5
Medicare rules
 Must be a registered professional nurse
authorized by the state in which services are
furnished. Practices as an in NP in accordance
with state law and meet one of the following:
Obtained Medicare billing privileges as an NP for the
first time on or after January 1, 2003
Obtained Medicare billing privileges as an NP for the
first time before January 1, 2003 and meet
certification requirements
Obtained Medicare billing privileges as an MP for the
first time before January 1, 2001
6
Medicare rules
Is certified as an NP by a recognized
national certifying body that has
established standards for NPs; and
Has a Masters degree in nursing or a
Doctorate of nursing practice degree
7
Absolute Medicare rules
1.Services must be medically reasonable and necessary
2.Services must have been provided as billed, as supported by the
medical record
3.The clinician providing the service must have a Medicare provider
number
4.The entity seeking payment must submit a Centers for Medicare
and Medicaid services CMS 1500 form appropriately completed
5.The entity seeking payment must accept Medicare’s rates
6.Providers may not provide kickbacks for referrals
7.Services must be billed under the provider number of the
clinician performing the service, unless ‘incident-to’ or ‘shared
visit’ rules are followed
8.Medicare will pay only certain parties
8
Billing
• NPs are expected to
submit claims under
their own NPI number.
• NPs may assign
numbers to a group
practice for purposes of
billing.
• There are no limitations
on CPT codes, as long as
they are recognized by
Medicare and have
reimbursement codes
9
Incident-to
1.They must be an a integral, although
incidental, part of the physicians professional
service
2.They must be commonly rendered without
charge or included in the physician’s bills
3.They must be of the type that is commonly
furnished in physicians offices or clinics
4.They must be furnished by the physician or by
auxiliary personnel under the physicians direct
supervision
10
Shared visit
• NPS with their own billing
number providing shared
visit with physicians and
hospitals may bill 100% as
long as the physician has
also seen the patient. The
same day in a “face-to-face”
encounter. Billing will take
place under the physicians
billing number
• It is not required to
have a physician
counter signature for
hospital admission
11
In-Patient Billing
• NP salary vs. reimbursement billing
12
Medicaid
• Services provided by an ARNP under direct
supervision of the physician may be billed by
the physician, instead of the ARNP. Direct
physician supervision means the physician:
– Is on the premises when the services are
rendered, and
– Reviews, signs and dates the medical record
13
Content and Documentation
Level of exam Perform and document
99212
1-5 elements
99213
At least six elements
99214
At least 12 elements
99215
Perform all elements
14
E/M Documentation and Billing
• HPI
– Brief 1-3
– Extended-four or more
elements or associated
comorbidities
– OLDCART
• ROS
– Pertinent-1
– Extended 2-9
– Complete 10 or more
• PFSH
– Pertinent-1
– Complete-2 or more
– Initial visits require at
least one item from all
three PFSH areas
• Past medical
• Family history
• Social history
15
Reimbursement
99212 99213
99214
Medicare $42.50 $70.65 $104.45
Medicaid $21.84 $26.61
$41.46
Est. patient
Average time
99211
5 min.
99212 10 min.
99213 15 min.
99214 25 min.
99215 40 min.
New patient
99201 10 min.
99202 20 min.
99203 30 min.
99204 45 min.
99205 60 min.
Subsequent hospital care
99231 15 min.
99232 25 min.
99233 35 min.
16
Review of systems (ROS)
• For purposes of ROS, the following systems are recognized:
– Constitutional symptoms
– Eyes
– Ears, nose, mouth, throat
– Cardiovascular
– Respiratory
– Gastrointestinal
– Genitourinary
– Musculoskeletal
– Integumentary ( skin and/or breast)
– Neurological
– Psychiatric
– Endocrine
– Hematologic/lymphatic
– Allergic/immunologic
17
ROS
• A problem pertinent ROS inquires about the
system directly related to the problem(s)
identified in the HPI
– The patient’s pertinant positive responses and
pertinent negatives for the system related to the
problem should be documented
18
ROS
• An extended ROS inquires about the system
directly related to the problem(s) identified in
the HPI and a limited number of additional
systems.
– The patient’s pertinent positive responses and
pertinent negatives for 2-9 systems should be
documented
19
ROS
• A complete ROS inquires about the system(s)
directly related to the problem(s) identified in
HPI plus all additional body systems
– At least 10 organ systems must be reviewed. The
assistance with positive or pertinent negative
responses must be individually documented. For
the remaining systems, a notation indicating all
other systems are negative is permissible. In the
absence of such a notation at least 10 systems
must be individually documented.
20
Constitutional
Measurements of any
three of the following
seven vital signs:
1. Sitting or standing
blood pressure
2. Supine blood pressure
3. Pulse rate and
regularity
4. Respiration
5.
6.
7.
8.
Temperature
Height
Weight
General appearance of
patient (development,
nutrition, body
habitus, deformities,
attention to grooming)
21
Eyes
• Inspection of
conjunctiva and lives
• Examination of pupils
and irises(PERRL)
• Ophthalmoscopic
examination of optic
discs
Neck
• Examination of the neck
• Examination of thyroid
22
Ears, nose, mouth and throat
• External inspection of ears and nose
• Otoscopic examination of external auditory
canals and tympanic membranes
• Assessment of hearing
• Inspection of nasal mucosa, septum and
turbinates
• Inspection of lips, teeth and gums
• Examination of the oropharynx
23
Respiratory
• Assessment of
respiratory effort
• Percussion of chest
• Palpation of chest
• Auscultation of lungs
Cardiovascular
• Palpation of heart
• Auscultation of heart
• Examination of
–
–
–
–
–
Carotid arteries
Abdominal aorta
Femoral arteries
Pedal pulses
Extremities for edema
and/or varicosities
24
Chest
• Inspection of breasts
• Palpation of breast and
axilla
Gastrointestinal
• Examination of abdomen
• Examination of liver and
spleen
• Examination for presence or
absence of hernia
• Examination of anus,
perineum, and rectum
• Obtain stool sample for
occult blood when indicated
25
Male
• Examination of scrotal
contents
• Examination of penis
• Digital rectal
examination of prostate
gland
Female
• Pelvic examination
– Examination of external
genitalia
– Examination of urethra
– Examination of bladder
– Examination of Cervix
– Examination of Uterus
– Examination of
Adnexa/parametria
26of
Musculoskeletal
• Examination of gait and
station
• Inspection and/or palpation
of digits and nails
• Examination of joints, bones
and muscles of one or more
of the following six areas:
– Head and neck
– Spine, ribs and pelvis
– Right upper extremity
– Left upper extremity
– Right lower extremity
– Left lower extremity
• Examination of the area
includes:
– Inspection and/or
palpation
– Assessment of range of
motion
– Assessment of stability
– Assessment muscle
strength and tone
27
Lymphatic
• Palpation of lymph
nodes in two or more
areas:
–
–
–
–
Neck
Axillae
Groin
other
Skin
• Inspection of skin and
subcutaneous tissue
• Palpation of skin and
subcutaneous tissue
28
Neurologic
• Test cranial nerves
• Examination of deep
tendon reflexes
• Examination of
sensation
Psychologic
• Description of patients
judgment and insight
• Recent assessment of
mental status including:
– Orientation to time,
place and person
– Recent and remote
memory
– Mood and affect
29
Medical decision-making
•
•
•
•
•
Review/order of clinical labs and tests
Review/order of tests and radiology
Review/order tests in medicine
Discuss test with performing/interpreting physician
Decision to obtain old records or obtained history
from someone other than patient
• Review and summary of old records and/or obtaining
history from someone other than patient
• Discussion of case with another health care provider
and documentation of relevant findings
• Independent visualization of image, tracing or
specimen itself ( not simply reviewing report)
30
Established
patient
99211
Minimal
99212
99213
99214
99215
Prob Focused
Exp Prob Focused
Detailed
Comprehensive
Brief 1-3
Brief 1-3
Extended 4 or more
Extended 4 or more
HPI
N/A
ROS
N/A
N/A
Pertinent problem -1
Extended 2-9 systems
Complete 10 systems
PSSH
N/A
N/A
N/A
Problem pertinent 1 of 3 areas
Complete
Straightforward: optionsMedical
decision-making minimal; complexity-
Straightforward:
Low complexity: options- Moderate complexity: optionsoptions-minimal;
limited; complexitymultiple; complexity-moderate risk
complexity-minimal;
limited; risk of
of complications-moderate;risk of complicationscomplications-low;
minimal,
General
multisystem exam
Perform and
document 1-5
elements in one or
more systems or
body areas
Perform all elements from at least nine
Perform and document at Perform and document at least two
least six elements in one elements from at least six systems or body systems/body areas and document at least
areas, or at least 12 elements from two or two elements from each selected area
or more systems or body more body systems or body areas
areas
Single organ system
exam
Perform and
document 1-5
elements
Perform and document at Perform and document at least 12 Perform all elements; document
least six elements
systems (except for eye and psych every element in each.
exam, which should be at least
nine bulleted elements)
minimal; risk of
complications- minimal,
Hi complexity: options-extensive;
complexity-extensive; risk of
complications-high
31
New patient
99201
Problem focused
99202
99203
99204
99205
Expanded problem
Detailed
Comprehensive moderate
Comprehensive high
Brief 1-3
Extended 4 or more
Extended 4 or more
Extended 4 or more
Extended 2-9 systems
Complete 10 systems
Complete 10 systems
Problem pertinent
Complete all 3 areas
Complete all 3 areas
Brief 1-3
HPI
ROS
N/A
Problem pertinent
PSSH
N/A
N/A
Straightforward: options- Low complexity: optionsModerate complexity: optionsMedical decision- Straightforward: optionsminimal;
complexity-minimal;
minimal;
complexitylimited;
complexity-limited;
multiple; complexity-moderate
making
Hi complexity: optionsextensive; complexityextensive; risk of
complications-high
risk of complications- minimal, minimal; risk of
complications- minimal,
risk of complications-low;
risk of complications-moderate;-
General multisystem
exam
Perform and document
1-5 elements in one or
more systems or
body areas
Perform and document at
least six elements in one or
more systems or body areas
Perform and document at least two
elements from at least six systems or
body areas, or at least 12 elements from
two or more body systems or body areas
Single organ system
exam
Perform and document
1-5 elements, whether
in shaded or unshaded
box
Perform and document at
Perform and document at least Perform all elements
least six elements, whether 12 systems (except for IE and
document every element in
initiated her unshaded box psych exam, which should be at each.
least nine elements)
Perform all elements from at least
nine systems/body areas (unless
specific directions limit content)
and document at least two
elements from each selected area
32
Consultation
99241
99242
99243
Problem focused
Expanded
problem
Detailed
Brief 1-3
Brief 1-3
Extended 4 or
more
Extended 4 or
more
Extended 4 or
more
Extended 2-9
systems
Complete 10
systems
Complete 10
systems
Problem
pertinent
Complete all 3
areas
Complete all 3
areas
HPI
ROS
N/A
Problem
pertinent
PSSH
N/A
N/A
99244
99245
Comprehensive Comprehensive
moderate
high
Medical Straightforward: Straightforward:
Low
Moderate
Hi complexity:
decision- options-minimal; options-minimal; complexity:
complexity:
optionscomplexitymaking complexityoptionsoptions-multiple;
extensive;
minimal; risk of
minimal; risk of
limited;
complexitycomplexitycomplicationscomplicationscomplexity- moderate risk of extensive; risk
minimal,
minimal,
limited; risk of complicationsof
complicationsmoderate;complicationslow;
high
33
Document Document Document
• Avoid words such as “maybe”, “perhaps”,
“probably”, or “rule out”.
• Record specific signs and symptoms
• Right legibly
• Always clearly document chief complaint,
”follow-up” is insufficient
34
ICD-9
35
Hierchical Condition Catagories (HCC)
• Must be captured in documentation every 12
months
• Risk adjustment diagnosis must be based on
clinical medical record documentation from a
face-to-face encounter
• Coding according to ICD-9 guidelines
• Medical record documentation must support
unassigned HCC
36
HCC Hypertension
• Hypertensive CKD,
w/CKD stage I-IV
• Hypertensive CKD,
w/CKD stage V
• Hypertensive heart &
CKD w/HF &CKD Stage
1-IV
• Hypertensive heart &
CKD w/HF &CKD Stage
V
• Hypertensive heart, &
CKD w/o HF w/CKD
Stage 1-IV
• Hypertensive heart, &
CKD w/o HF w/CKD
Stage V
• Hypertensive heart
disease
37
Risk Adjustment
38
Meaningful Use
• Computerized provider
order entry
• Electronic prescriptions
• Record demographicsand
vital signs
• Record smoking status
• Clinical decision support
• Patient assess ability to
health information
• Clinical summaries
• Protected EHR
•
•
•
•
•
•
•
•
Lab interface
Grouping patients
Reminder systems
Patient education
Medication reconciliation
Or referral summary of care
Immunization
Secure electronic messaging
39
Healthcare Effectiveness Data and
Information Set (HEDIS)
• Asthma medication use
• Persistence of beta
blocker treatment after
a heart attack
• Controlling high blood
pressure
• Comprehensive
diabetes care
• Breast cancer screening
• Antidepressant
medication
management
• Childhood and
adolescent
immunization status
• Childhood and
weight/BMI assessment
40
Healthcare Effectiveness Data and
Information Set (HEDIS)
• Prevention and
screening
• Respiratory conditions
• Cardiovascular
conditions
• Musculoskeletal
conditions
• Diabetes
• Behavioral health
• Medication
management
• Access/availability of
care
• Experience of care
• Utilization
• Relative resource use
• Health plan descriptive
information
41
Modifiers
42
Barriers
• Third-party reimbursement
• Hospital privileges
• Inconsistent and restrictive prescriptive
authority
• Statutory limitations to NP scope of practice
43
Medicare fraud
•
•
•
•
Red flags
Affordable Care Act
Exclusion statute
Federal fraud and abuse laws:
– False Claims Act (FCA)
– Anti-Kickback Statute
– Physician Self Referral Law (Stark Law)
– Social Security Act
– U.S. criminal code
44
Improper claims
• Billing for services that you did not actually
render
• Billing for services that were not medically
necessary
• Billing for services that were performed by
improperly supervised or unqualified
employee
• Billing for services that were performed by an
employee who is been excluded from
participation in the federal health care
programs
45
What to do if you think you have a
problem
• Immediately cease filing the problematic bills
• Seek knowledgeable legal counsel
• Determine what money you collect it in error from
your patients and from the federal health care
programs and report and return overpayments
• Undo the problematic investment by taking all
necessary steps to free yourself from your
involvement in the investment
• Disentangle yourself from the suspicious relationship
46
What to do if you have information
about fraud and abuse
• http://www.stopmedicarefraud.gov
• 1-800-HHS-TIPS
• E-mail [email protected]
47
Billing home visits
48
Billing nursing home visits
• An NP may not perform the initial comprehensive
visit, unless the following requirements are met:
– The NP is performing the service for patients in a nursing
facility ( as compared with the skilled nursing facility)
– ENP is not an employee of the nursing facility
– State law permits an NP to perform the service
– The services within the scope of practice of the NP
understate law
– A physician has delegated the service to the NP
– The NP is working in collaboration with the physician
49
Clinical Nurse Specialists
• Services or supplies must be medically reasonable
and necessary
• All of the following must be met
– Services are performed in collaboration with a
physicianServices of the type considered physician services
if furnished by an M.D. or aD.O.
– Services are not otherwise precluded due to statutory
exclusion
– He or she is legally authorized and qualified to furnish the
services in the state where they are performed
50
Clinical Nurse Specialists
• Clinical nurse specialist may bill the Medicare
program directly for services using his or her NPI
number or under an employer or contractor’s NPI.
Incident to services. Claims must be submitted under
the supervising physician’s NPI and identified on
provider filed by specialty code 89. Payment is made
only on assignment basis, the outpatient mental
health transition limitation applies, services repeated
85% of the PFS amount and when services furnished
the hospital inpatients and outpatients are billed
directly, payment is unbundled and make the CNS
51
Certified Nurse-Midwives
• Services or supplies must be medically reasonable
and necessary
• Here she must be legally authorized qualified first
services in the state in which they were acquired
• Services are covered in all settings, including:
– Offices
– Clinics
– Birthing centers
– Patient’s homes
– Hospitals
Incident to services and supplies may be covered
52
Certified Nurse-Midwives
• Build the Medicare program directly for services using his or
her NPI number
• Or
• Under an employer or contractor’s NPI number Incident to
service claims must be submitted under the supervising
physician’s NPI
• Use billing modifier 52 to report that all services covered by
the global allowance were not provided by the billing
provider( should not be used when billing for split/shared
evaluation and management visits)
• Identified on provider filed by specialty code 42
53
ICD-10
• Everyone covered by HIPPA must transition to
ICD 10
• Change in format
• ICD 10-CM & ICD 10-PCS
• ICD 10 will not affect CPT coding for
outpatient procedures
54
Thank you
Questions?
55
• NPI number application process can be done
online or with paper application,
https://www.cms.gov/nationalprovidentstand
/
• http://medicare.fcso.com/EM/175804.pdf
56