NP billing

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.

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