ED Coding and Reimbursement Alert

Review the checklist below to make sure you are on the right path with the right provider.

If non physician practitioners such as physician assistants or nurse practitioners provide ED services, be sure that supervising physicians and ED managers stay current on state and individual payer rules that govern each component of the process. Follow our advice on discerning who to credit for the care provided in an ED using these providers.

Review Signature Rules First

Check out the signature rules before you sign off on who gets credit for the NPP visit. Medicare Transmittal 248 clarifies that only handwritten or electronic signatures would be acceptable for orders or other medical record documentation, says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates in Baton Rouge LA. Stamped signatures will no longer be considered valid. Medicare requires a legible identifier for all services provided and/or ordered.

Where Medicare is concerned, non-physician providers (NPP) may not furnish or be reimbursed for services outside of their scope of practice, licensure and applicable supervision requirements, Edelberg explains.

Follow this order: Your state law and hospital policies may be more restrictive than Medicare’s policies. Medicare reminds us that where state law is more restrictive than Medicare, the Medicare contractor needs to apply the state law standard, says Edelberg. The supervision requirements vary from state to state, but Medicare rules have stayed consistent since the release of Medicare Transmittal 1776 on October 25, 2002, she adds.

Be Sure You Have an NPI For Your NPP

If the NPP will be providing services to Medicare patients, Medicare mandates that all NPPs have their own national Provider Identification (NPI) number.

Great idea: It would be wise to do a compliance audit with your company or billing entity to assure that proper NPI numbers are on the CMS 1500 form for services provided by your NPPs, says Edelberg.

Don’t Be Overly Generous With Shared Services

The combined services of a PA and emergency physician may be billed under the name and Medicare provider identification number (PIN) of the physician and will be paid at 100 percent of the Medicare Part B fee schedule, as long as the physician provides any face-to-face portion of the E/M service.

The policy also requires the physician and PA to work for the same employer, practice, or hospital. According to the American Academy of Physician Assistants (AAPA), “If the PA provides the majority of the service for the patient and the physician provides any face-to-face portion of the E/M encounter, the entire service may be billed under the physician’s name and PIN.”

What to do: If the physician is not present for or does not document face-to-face interaction with the patient for any portion of the E/M encounter, the service is appropriately billed under the PA’s name and Medicare PIN. Medicare reimburses this PA service at 85 percent of the physician Medicare Fee Schedule amount, warns Edelberg.

In order for the emergency physician to bill for services that include the physician assistant, follow these pointers offered by Edelberg:

·         Both the emergency physician and PA see the patient;

·         The PA must be employed by the ED physician group or both work for the same entity (faculty practice plan, etc.);

·         Because Incident-to doesn’t apply in the emergency department, the emergency physician must personally participate in the service and record a face-to-face Evaluation and Management service through personal interaction with the patient;

·         Both the PA and emergency physician must participate in documenting the service;.

·         Both the PA and emergency physician must provide a legible signature that clearly identifies who provided the service for which payment is made.

Challenges and impact: Insufficient documentation greatly restricts how the service is billed and significantly impacts revenue. For handwritten charts, it may be virtually impossible to determine who provided the service and at what level. Often both the PA and emergency physician signature are on the record, but documentation does not differentiate PA from emergency physician service to the patient. In more extreme cases, the nurse’s notes may be the only reference that the emergency physician and PA saw the patient when their documentation does not distinguish what service was provided. In this instance, the service cannot be billed to Medicare by the physician, Edelberg explains.

Apply These Strategies

The medical record must clearly identify both the NPP and the ED physician who shared in rendering the service. Specifically, the ED physician’s documentation should be linked to the NPP documentation of the shared service and affirmatively state one or more elements of the encounter. This element may be an element of history, physical examination, or medical decision-making.

Warning: In a shared E/M situation, both parties must document the work they performed. A generic attestation of “I have seen and evaluated this patient and agree with the PA notes” or a notation of “seen and agreed” or “agree with above” may be viewed by some auditors as not qualifying the situation as a shared visit, says Edelberg.

Do this: ED managers should perform routine audits on records for patients seen by PAs, review copies of billing claims, and assure that the bills accurately identify the provider of the service consistent with payer and state licensure policies, says Edelberg. If there is no physician interaction for Medicare, no physician service can be reported.

With Medicaid audits increasing across the country, it’s also a good idea to review your State Medicaid policies to assure that your documentation and billing is accurate. Be aware that future Medicaid/RAC audits are on the horizon, and if documentation is not complete they could target inappropriate PA and NP billing practices, Edelberg warns.

Proceed With Caution: Shared Services Only Apply to E/M

Procedures and interpretations performed by the NPP must be billed using the NPP’s NPI number. The shared service rules only apply to E/M services and “incident to” does not apply in the ED.

Any physician or non-physician practitioner (NPP) authorized to bill Medicare services will be paid by the carrier at the appropriate physician fee schedule amount based on the rendering NPI. The practitioner who substantially performs the procedure is the one under whose name and number the procedure should be billed, says Edelberg.