Antother billing question, but different

ANPFNPGNP · Dec 1, 2008

I am relatively new and have some questions re: to billing under my # and the doctors. I am sure some one out there has the answers.
1.) Can an NP see a new patient on her/his own or does the dr. have to see new patients ( in the office).
2.) Currently I am seeing the patients in the office and then, at a later time (either that day or even the next morning) I talk with the dr. and review every patient I saw and explain what I ordered etc and if he wants something additional or different, I would contact the pt. This goes for new and existing patients. Sometimes, if he is in the office, I will discuss it with him at that moment, and he may even come in to the exam room and see the patient if I need him to look at or listen to something. We are billing under my number and of course getting 85% but can we bill at a higher level since he is being consulted on just about every case?
3.) When I discuss the case with him or he comes in and examines the patient, how should I document that? Is it enough to say in my note that this was discussed with dr. and WE have decided to ......?
Thank you.

It depends on the insurance and most will reimburse at 100% if the doctor is on site (they don't even have to see the patient!). However, Medicare requires that the doctor see new patients and they will only let the midlevel bill at 100% if the midlevel is treating the patient for an illness/disease for which the patient has already seen the doctor.

For instance, Mrs. Jones is a new patient and the doctor sees her and diagnoses her with HTN. She is seen by the midlevel for a followup on her HTN in 6 weeks and the doctor is in the building, so Medicare can be billed for the full 100%. The next month Mrs. Jones comes for a visit because she has a sore throat. If the midlevel sees this patient, then they can only bill at 85%, since the patient is being seen for an episodic illness. If they want to bill at the full rate, then the doctor would also have to assess the patient, which is a waste of time.

I know a PA whose boss was billing Medicare at 100% for every patient he saw and they ended up getting audited and they paid a HUGE fine!

core0 · Dec 1, 2008

i am relatively new and have some questions re: to billing under my # and the doctors. i am sure some one out there has the answers.
1.) can an np see a new patient on her/his own or does the dr. have to see new patients ( in the office).
you can see patients on you own. there is no requirement that a physician see new patients.
2.) currently i am seeing the patients in the office and then, at a later time (either that day or even the next morning) i talk with the dr. and review every patient i saw and explain what i ordered etc and if he wants something additional or different, i would contact the pt. this goes for new and existing patients. sometimes, if he is in the office, i will discuss it with him at that moment, and he may even come in to the exam room and see the patient if i need him to look at or listen to something. we are billing under my number and of course getting 85% but can we bill at a higher level since he is being consulted on just about every case?
for most insurances you bill under the physician number at 100%. if they credential npps then you bill under your number at whatever the agreed amount is.
for medicare/caid you have two choices. if the phyisician sees the patient and preforms all the elements of the visit he can bill for the visit. if you follow for the problems that the physician has specifically indicated a plan for you can bill at 100% under incident to. otherwise you can bill at 85% of the physician fee.
whether you discuss the patient or not is irrelevant to the billing. what matters is who preforms and documents the required elements of the visit. if they only do one element then they can't bill. if they never see the patient (ie the patient was discussed) then they can't bill. the consulting is considered part of the care of the patient by the practice. no different than if the physician had asked another physician about some element of the care.
3.) when i discuss the case with him or he comes in and examines the patient, how should i document that? is it enough to say in my note that this was discussed with dr. and we have decided to ......?
thank you.

what i usually write is pt discussed with dr. x who agreed with the plan of care. or if done after the fact "pt discussed with dr. x who wanted ------ done". if the physician examined the patient "dr x examined the patient and agreed with the physical findings". if the physician changes the plan then let them take responsibility (good or bad).

david carpenter, pa-c

JEKA · Dec 2, 2008

"however, medicare requires that the doctor see new patients and they will only let the midlevel bill at 100% if the midlevel is treating the patient for an illness/disease for which the patient has already seen the doctor."

i'm confused. what about nps that have their own practice, or when we see patients in the hospital for consults and/or h&ps?

"if the phyisician sees the patient and preforms all the elements of the visit he can bill for the visit. if you follow for the problems that the physician has specifically indicated a plan for you can bill at 100% under incident to. otherwise you can bill at 85% of the physician fee."

so, if i see cardiology patients for follow-up and nothing cardiac wise developed, i can bill for 100% under the dr.'s # as incident to? even if he isn't in office? what about when i see new patients and the physician is in the next room? do i bill under my number for 85% or his for 100%

"it depends on the insurance and most will reimburse at 100% if the doctor is on site (they don't even have to see the patient!)."

how can this be? is this only for private insurances or medicare too?

thank you all very much for the great information.

core0 · Dec 2, 2008

"however, medicare requires that the doctor see new patients and they will only let the midlevel bill at 100% if the midlevel is treating the patient for an illness/disease for which the patient has already seen the doctor."
i'm confused. what about nps that have their own practice, or when we see patients in the hospital for consults and/or h&ps?
nps that have their own practice bill at 85% of the physician fee for medicare. hospital consults and h&ps (if they are reimbursed are the same). there is another method of billing called shared billing that is used in the hospital. this is used only for follow ups however. inpatient or outpatient consults are billed under the npps number.
"if the phyisician sees the patient and preforms all the elements of the visit he can bill for the visit. if you follow for the problems that the physician has specifically indicated a plan for you can bill at 100% under incident to. otherwise you can bill at 85% of the physician fee."
so, if i see cardiology patients for follow-up and nothing cardiac wise developed, i can bill for 100% under the dr.'s # as incident to? even if he isn't in office? what about when i see new patients and the physician is in the next room? do i bill under my number for 85% or his for 100%
sorry i forgot one of the requirements for incident to is that the physician has to be present in the office to bill incident to. incident to is one of the most confusing parts of billing. however, if used properly it can add to the bottom line.
lets say that you are in cardiology and you are seeing a patient post mi in a cardiology office. the physician has seen the patient, developed a plan that covers bp, lipids, and anticoagulation (just making this up since i don't do cardiology). pt comes in with a bp of 180/110 hdl of 20 and inr of 1.0. you can adjust or start new meds and order any additional testing for those conditions. now lets say the patient also has new onset a-fib which has never been treated by the physician. at that point you have two choices. you can have the physician come in and see the patient and work them up. the physician will then bill for the e&m. or you can do it yourself and bill the entire encounter (with a higher service level than for the previous three problems) under your number at 85%. most practices with fairly autonomous npps find it easier to have the npp provide the service and bill rather than interrupt the physicians schedule.
in answer to the second part, you cannot bill consults under incident to and new patients by definition are never incident to. so even if the physician is in the next office you bill under your number at 85% for all new patients.
"it depends on the insurance and most will reimburse at 100% if the doctor is on site (they don't even have to see the patient!)."
how can this be? is this only for private insurances or medicare too?
thank you all very much for the great information.

for the most part private insurance does not credential non-physicians. since you are not credentialled you bill under the physicians number and get 100% reimbursement (assuming the contract language allows npp services). as above medicare is different. this article by carolyn buppert is very good (medscape registration required).

http://www.medscape.com/viewarticle/422935_1

david carpenter, pa-c

jer_sd · Dec 3, 2008

I am a huge fan of billing under my # for 85% rather than incident to. This allows tracking of productivity and helps in contract discussions at the end of the year.

Also By billing under the physician number you are essentialy invisable health care provider. You do not get credit for the work you do or provide a true representation of the health care work force and what nonphysicians provide.

Jeremy

ANPFNPGNP · Dec 5, 2008

[quote=jeka;3284621

so, if i see cardiology patients for follow-up and nothing cardiac wise developed, i can bill for 100% under the dr.'s # as incident to? even if he isn't in office? what about when i see new patients and the physician is in the next room? do i bill under my number for 85% or his for 100%

as far as medicare goes, you could not bill the 100% (incident to) rate

if the doctor wasn't on site. i'm pretty sure medicare requires that the physician sees new patients.

how can this be? is this only for private insurances or medicare too?

i believe there are some other insurance carriers that have strict rules like this. it will be great when np's are recognized by more insurance companies as primary care providers. i know some np's who are listed as pcp's with insurances. it took a long time for them to get credentialed though.

core0 · Dec 6, 2008

[quote=jeka;3284621
so, if i see cardiology patients for follow-up and nothing cardiac wise developed, i can bill for 100% under the dr.'s # as incident to? even if he isn't in office? what about when i see new patients and the physician is in the next room? do i bill under my number for 85% or his for 100%
as far as medicare goes, you could not bill the 100% (incident to) rate
if the doctor wasn't on site. i'm pretty sure medicare requires that the physician sees new patients.
how can this be? is this only for private insurances or medicare too?
i believe there are some other insurance carriers that have strict rules like this. it will be great when np's are recognized by more insurance companies as primary care providers. i know some np's who are listed as pcp's with insurances. it took a long time for them to get credentialed though.

this is kind of confusing. not sure who is answering who.

to clarify. medicare does not require new patients to be seen by a physician. any eligible provider can see any patient.

to bill at 100% you must follow incident to rules (from the aafp article):

the nonphysician providers must be w-2 or leased employees of the physician, and the physician must be able to terminate the employee and direct how the medicare services are provided by that employee.
the physician must perform the initial patient visit and ongoing services of a frequency that demonstrate active involvement of the physician in the patient's care, thereby creating a physician service to which the nonphysician providers' services relate.
a physician must be on the premises, but not necessarily in the room, when incident-to services are performed.
diagnostic tests must be done under the testing supervision requirements: general, direct and personal, which are designated by cpt code.
incident-to services cannot be performed in the hospital.

some insurance companies do credential npps. some of those that do credential reimburse npps at a reduced rate. some do not pay for services provided by npps even if billed under the physicians npi. most insurance companies do not credential npps and reimburse npps 100% for services billed under the physicians npi.

david carpenter, pa-c

Ally48 · Dec 9, 2008

Hi Everyone

Perhaps taking an insurance and payor reimbursement course, and a diagnosis and procedural coding course would be helpful. It really helped me out tremendously!!!!