NP billing

  1. My background, I understand mid-level billing and lecture on PA building. I understand that there are some areas that are slightly different for NP billing. Here is my problem:

    I have a friend who has been hired by a hospital to be their "Congestive Heart Failure NP". She is running an inpatient consultant service and outpatient clinic focusing solely on congestive heart failure. The crux is that she is consulted, gives education on CHF to the patients, makes recommendations and then follows up in the clinic. The thought is to decrease length of stay and avoid repeat hospitilizations in this group.

    The issue is billing. She is billing for the outpatients, but she was told by the hospital that she cannot bill for the inpatients. She was given a variety of reasons including that if she didn't write any orders it wasn't a consult and that since she was doing primarily education for inpatients that she couldn't bill for that. I told her there was no need to write orders for a consult and that by strict definition it might be prohibited. As far as education, as long as she is in an advance practice role, there should be no problem billing and it may actually be more lucrative. I am unsure of the reasoning behind this ban on billing, but several reasons occur to me:
    1. They may be charging part of her salary under medicare part A. I know that that they cannot do this for PA's. Is this still legal for NP's?
    2. They may not be credentialled to charge for providers with the various insurance companies.
    3. They have no idea how to bill for mid-levels (most likely)

    The real question is that under the above scenario, is there any reason not to bill for inpatients. The other question is that if you do a consult and then see the patient in follow up do you bill it as a consult or follow up since you didn't bill for the consult?

    Finally does anyone know of any good billing courses for NP's?

    David Carpenter, PA-C
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  2. 3 Comments

  3. by   juan de la cruz
    OK, I asked the coders at work on how this is done at our hospital and here's what they said.

    If she is doing H&P's and follow-up notes for patients in the hospital, she needs the following:

    1. She needs to be credentialed by the hospital as a mid-level provider with a code for billing as an NP.

    2. If she is working under a collaborating physician, the physician needs to sign her H&P's and notes with "I saw and examined this patient and agree with the history, exam, and assessment plan as written". However, even without that notation, being that she is an NP, it can still be billed under her name. There is no requirement that she needs to be able to write orders. As a consult service, she should just give recommendations and it is up to the primary service to carry out her recommendations if they agree with them.

    3. An order should be written by the primary service to consult the CHF service where she falls under. In our hospital, this department is called Heart Failure and Transplant Cardiology, so it would read: "consult CHF/transplant for HF teaching and home management".

    You probably are well aware of the above so that's nothing new to you. As far as charging her salary under Medicare A in the in-patient setting and then billing for services in the out-pt setting, I don't know if this is possible. Chances are her department is not aware that she can charge for her services in the in-patient setting.

    I don't know of any current billing classes for NP's but I would check Fitzgerald Health Education Associates. They have a good website and they usually have these kinds of classes for NP's.
    Last edit by juan de la cruz on Jan 9, '07
  4. by   core0
    Quote from pinoynp
    ok, i asked the coders at work on how this is done at our hospital and here's what they said.

    if she is doing h&p's and follow-up notes for patients in the hospital, she needs the following:

    1. she needs to be credentialed by the hospital as a mid-level provider with a code for billing as an np.

    2. if she is working under a collaborating physician, the physician needs to sign her h&p's and notes with "i saw and examined this patient and agree with the history, exam, and assessment plan as written". however, even without that notation, being that she is an np, it can still be billed under her name. there is no requirement that she needs to be able to write orders. as a consult service, she should just give recommendations and it is up to the primary service to carry out her recommendations if they agree with them.

    3. an order should be written by the primary service to consult the chf service where she falls under. in our hospital, this department is called heart failure and transplant cardiology, so it would read: "consult chf/transplant for hf teaching and home management".

    you probably are well aware of the above so that's nothing new to you. as far as charging her salary under medicare a in the in-patient setting and then billing for services in the out-pt setting, i don't know if this is possible. chances are her department is not aware that she can charge for her services in the in-patient setting.

    i don't know of any current billing classes for np's but i would check fitzgerald health education associates. they have a good website and they usually have these kinds of classes for np's.
    i'll ask about the billing, but she was working for a cardiology group. they were co-billing, but i would assume she has a provider number. she is working on her npi.

    as far as charting, there is a hospital regulation that the chart be co-signed. there is no state law that requires this. medicare also does not require co-signature. it is possible that a physician is co-billing for this, but then they need to participate in the care. i am not sure exactly where they are coming from.

    as far as the "i saw and examined this patient and agree with the history, exam, and assessment plan as written" that is language from the residency programs. there is no need to use this in the setting of a npp. a practice has two options. they can simply sign the note - if required by the hospital or they can participate in the care and document it. for example our physicians usually write "i discussed the plan of care with the patient and discussed the following xxx. the patient is satisfied with the care plan." other groups repeat the the pe or document any changes in condition or new labs that have come in in the interim. this is the most common mistake when billing for npp's. if you document like you do for residents then you will be out of compliance when billing (my teaching point) . also as of 2006 you are not allowed to co-bill for a consult (another misunderstood recent change in billing).

    you assessment of the consult is the same as mine. i did ask michael powe who is a billing expert in the pa field. he stated that " nps who are providing clinical services (as opposed to administrative services) can’t have their salaries included in medicare part a cost reports. this is still not very well known in many parts of the country."

    i knew this applied to pa's but apparently this also applies to np's. he also stated that

    "there may be some lack of understanding. prior to 1998, nps were not covered for services provided in non-rural hospitals. after 1998 they were covered. i assume that the hospital knows this."

    i think the most likely scenario is that they just don't know how to bill for npp's. as far as i know they only have two np's and one doesn't bill. the other possibility is that they are allowing a physician to bill for the services, which would be stupid (and illegal). the impression that i get from talking to several billing services is that if she does a consult in the hospital, she can't bill a consult in the outpatient setting even if you don't charge for the initial consult. i think this will dramatically reduce her earning power. the other possibility is they don't care about the billing since they hope to save enough money by reducing los so that every thing else is gravy.



    david carpenter, pa-c
  5. by   gauge14iv
    David - this is VERY useful info - thanks!

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