# Teaching physicians & hospital employed nurse practitioners



## jpace8266@yahoo.com (Feb 28, 2012)

Good morning everyone! I have a question that I hope someone may be able to help me with. We have teaching physicians that cover the medical ICU and bill for those visits or procedures done while there. There is a nurse practitioner that is employed by the hospital that sees these patients as well and does a full documentation into the patients chart. However, the hospital does not bill for any visits or procedures done by the NP. The teaching physician sees the patient and then reviews the notes written previously that day by the NP and writes a couple lines of notes themselves (just as they do with the residents) and bill for the visit. Can a teaching physician use the notes of the hospital employed NP as part of their documentation or should they be doing a full documentation themselves? I contacted our compliance department and presented this question to them and their answer was the doctors cannot bill for anything done by a hospital employed NP, even if they supervised it, wrote a note behind it, etc. My physicians say this is incorrect information and all of the physician in the different ICU's document this same way in order to bill. I certainly don't want to be doing anything illegal but have been unable to find a definite answer to this situation. Any help will be greatly appreciated!


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## LLovett (Feb 28, 2012)

There is no incident to on the inpatient side and this is not a teaching situation when you are talking about a mid level provider, like a NP. NPPs are not the same as residents and can not be treated the same.

The only way the physician can bill for a mid levels services, that do not qualify as incident to, is in a split/shared situation. For either incident to or split/shared there has to be an employment relationship between the mid level and the physician.

If the NP has no employment relationship with the physician, then there is no compliant way for that physician to bill for anything that NP did. 

http://www.wpsmedicare.com/part_b/departments/medical_review/2009_1116_em.shtml

http://www.cms.gov/manuals/downloads/clm104c12.pdf

Hope this helps. I hear that all the time "This is how everyone does it", drives me up the wall. It makes me think back to the old parental favorite "If everyone jumped off a bridge would you?". I cringe when I think that but hey its valid!

Laura, CPC, CPMA, CEMC


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## cheermom68 (Feb 29, 2012)

Amen, Laura!

I agree with you entirely, especially about the "this is how everyone does it"   I also like "they do it and get paid, why can't I"

LeeAnn


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## jpace8266@yahoo.com (Feb 29, 2012)

Thank you so much for this valuable information Laura!  The websites you provided are exactly what I was looking for to show the physicians.  Hopefully, this will clear up any confusion they have once and for all.  I agree fully about hearing how everyone else does it and gets paid .  Like I tell my physicians...there are probably plenty of physicians sitting in jail cells now because they thought the same way!!!


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## leeannatk (May 21, 2012)

Thought I'd tailgate onto this thread - all of this discussion makes sense to me, my dilemma is I deal with pediatric subspecialists/hospitalist so the majority of our payers are medicaid. To my knowledge FL Medicaid is silent on this issue of whether or not the MLP is employed by or with the physician. Anyone have experience on arguing for or against co-signing and appending the note of a MLP employed by the hospital and being able to bill for it? 
The example would be the MD and the MLP see all the patients together on multi-disciplinary round and discuss assessment and plan together. The MLP writes her notes on some of the patients then the physician attests to the fact that he saw and discussed the patient with the MLP and signs the note. Can he base his billing on that note? In your opinion? - NOT for CMS or those following CMS rules but for Medicaid.

Thanks
Lee Ann (Orlando)


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## kml1764 (Jul 3, 2012)

Medicaid is under CMS, isn't it?


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## mcandia (Jul 3, 2012)

There still has to be an employment relationship and the mid level has to be credentialed with the practice regardless of whether the payer is Medicare or Medicaid.

If these requirements are not met than the MD cannot utilize the mid levels notes for billing purposes.

Maria CPC, CPC-H, CPCO, CPMA, CEMC


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