# Consult/New Patients



## mmagness (Feb 10, 2009)

If both a physician and an NP/PA see a "new patient" or "consult" a Medicare patient (together on the same visit/day) is it appropriate to bill under the Physician's NPI #? This could not be billed incident to because Medicare states that you can't bill "incident to" for patient's with a new problem. Since the physician was involved he should get credit right?

Since the doctor is establishing the care and diagnosing the patient is it okay to bill under the NPI of the physician even though the NP/PA was involved? Would the physician or PA (whoever dictates) just need to document the doctor's envolvement and to what extent? 

Thanks,

MollyM


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## RebeccaWoodward* (Feb 11, 2009)

-An NPP may request and/or perform a consultation service within the scope of practice and licensure requirements for the NPP in the State where he/she practices and the requirements for physician collaboration and physician supervision are met;

-*A consultation will not be performed as a split/shared E/M visit*

http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm4215.pdf

http://www.cms.hhs.gov/transmittals/downloads/r788cp.pdf


Also---

*"Shared/Split" Visits*

According to CMS, current payment policy precludes a consultation from being a "shared/split" service. It is felt that a consultation is a unique E/M service not performed jointly or as a team. It may be decided by an NPP and physician to share or split a consultation service; however, this service must then be billed using the NPP's UPIN/PIN, not the physician's UPIN/PIN (NPI now). The physician may bill the consultation under his or her UPIN (NPI now) only when all components have been performed by the physician.

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_032259.hcsp?dDocName=bok1_032259


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## mmagness (Feb 11, 2009)

When you say that the physician should satisfy all components does that mean that the NP can't assist at all (example ROS and PFSH)? What all would be needed in dictataton as the doctor's part of the service for it to be acceptable to bill under the physician? 

I am just trying to make sure that the office that I currently work for is billing appropriately for with the documentation supplied to me. NP/PA billing is a challenge to me because they seem to think they can do everything that the doctor does...  They don't seem to understand the concept of "supervision" and appropriate documentation.

Thanks,

Michelle


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## RebeccaWoodward* (Feb 12, 2009)

Use of NonphysicianPractitioners (NPPs) for Consultations 

Q: Can a nurse practitioner or physician assistant do any part of a consultation and still bill under the physician's billing number?

A: The Evaluation and Management guidelines established by CMS would allow a physician's ancillary staff (which may include NPPs) to document a *limited* portion of the patient's history (specifically, a patient's review of systems and/or past, family, social history**). No other parts of an initial visit or consultation (i.e. the other key components—exam, medical decision-making or the chief complaint of the patient's history) could be done by these practitioners and the service still be billed under the physician's billing number. CMS guidelines stipulate that consults, whether office or inpatient, cannot be split/shared.


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## mmagness (Feb 12, 2009)

Rebecca,
In the instance that the NP performed the ROS and the PFSH and the doctor provided the rest of the service (exam etc)...  Should the dictated report show individually what was done by each provider?  Please see the instance below:

I am not at the office where the services are provided and don't actually know what part of the services are performed by whom (all I have is a report).  The report has the NP's name on the heading of the report as a consultation service and at the bottom it reads  (Mr NP for Mr Doctor).  In your opinion would you bill this under the NP or the doctor?  I know that if an auditor comes in they want proof of billing.  What are your suggestions/thoughts?

Thank you for all of your help...  You really seem to know alot about NP/PA billing.

Michelle


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## FTessaBartels (Feb 12, 2009)

*Clarify phrasing*

Our dictation system only allows the doctors to sign off, so we had to develop a very specific set of guidelines for phrasing the documentation so we'd know what the actual situation was. 

We ask our PAs and NPs to dictate as follows in order to clearly communicate to us what is happening:

If the NP/PA provided the service s/he dictates: I performed this service on behalf of Dr Supervising, who was available for consultation. Bill then goes out under NP/PA name.

If the NP/PA only assisted (whether in surgery or did the ROS & PFMSH) then we ask that the PHYSICIAN do the dictation, and indicate the NP/PA's level of assistance:  e.g. ROS and PFMSH as per PA XXX documentation in chart dated mm/dd/yy. *-or-* NP xxx assisted in this procedure in the absence of a qualified resident. 

This let's us know that the documentation is the PHYSICIAN's and should be billed under his/her name. (If an assist is allowed on the surgical procedure, we bill the assist to the NP/PA.)

In the example you gave with the NP's name at the top and the "signature" of Mr NP for Mr Doctor ... I'd bill under the NP's name. (Assuming scope of practice allows him/her to perform this service.)

Hope that helped.

F Tessa Bartels, CPC, CEMC


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## RebeccaWoodward* (Feb 12, 2009)

I completely agree with Tessa's post.

_"The report has the NP's name on the heading of the report as a consultation service and at the bottom it reads (Mr NP for Mr Doctor)."_

With this type of documentation, I would submit the bill under the NPP.  As for the documentation, our verbiage is very close to Tessa's examples.  By documenting the role of the NPP, this can avoid scrutiny by CMS.


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## mmagness (Feb 13, 2009)

Thank you both for all of your help.


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