Ob-Gyn Coding Alert

Editors Note: Many ob/gyn practices are extending their services through the use of certified nurse midwives (CNM) who provide care for ob patients. CNMs are also providing Medicare-reimbursable services to elderly and disabled gyn patients. OCA asked Senior Policy Analyst for the American College of Nurse Midwives, Karen S. Fennel, RN, MS, to explain CNM reimbursement.

The laws and regulations governing billing for nurse-midwifery services under federal programs such as Medicare are separate and different from billing for nurse practitioners and physician assistants services.

In 1987, a federal law was passed that provided for coverage of nurse-midwifery services under the Medicare program. Payments for covered services were to be made on the basis of a fee schedule established by the Secretary of Health and Human Services. The effective date for coverage was July 1, 1988. At that time, coverage of paid services was limited to the maternity cycle. The law provided the Secretary with little guidance as to how the fee schedule should be established, except to stipulate that payment for the nurse-midwife services cannot be greater than 65 percent of the applicable prevailing charge for the same service when performed by a physician. The law further specified that payments must be made on an assignment-only basis. This means that both coinsurance by the beneficiary and the Medicare deductibles are applicable to payment for the CNM services and the CNM may not charge additional fees. In 1993, the law was amended to include payment of all covered services that a CNM is legally authorized to perform under state law.

Definitions

Under Medicare, a Certified Nurse-Midwife (CNM) is defined as a registered nurse who has successfully completed a program of study and clinical experience meeting guidelines prescribed by the Secretary, or who has been certified by an organization recognized by the Secretary. 42 U.S.C. 1395x (gg)(2).

Certified Nurse-Midwife (CNM) services are such services furnished by a CNM, as defined above, and such services and supplies furnished as an incident to CNM services which the CNM is legally authorized to perform under State law (or as would otherwise be covered if furnished by a physician or as an incident to a physicians services). 42 U.S.C. 1395x(gg)(1).

Billing Under Medicare

When billing for Medicare services, the Health Care Financing Administration (HCFA) 1500 form should be used. The form requests that the provider use his or her unique provider identification number (UPIN). The form also requires that the provider identify who performed the services. Billing can be performed by a corporate entity or employer. This means the check for the payment of the service will be paid out to that entity. The midwife must have a legal relationship with that group. For example, the CNM can be part of a group practice that does her billing. However, failure to identify the actual provider of the services on the HCFA form constitutes fraud. For example, the CNM may not bill under her collaborating physicians name if she is not employed by that physician (refer to billing incident to a physicians services in this section).

Even when billing under the corporation, the CNMs service will only be reimbursed at 65 percent of the physician fee schedule. CNMs should obtain a copy of the Medicare Carriers Manual from the local Medicare carrier and follow the procedures as outlined. There are also regional offices of HCFA with Medicare officials who can help CNMs identify the local Medicare carriers and obtain information about billing under the Medicare program.

HCFA recognizes that CNMs may be paid for primary care services if two conditions are met:

the services provided are within the legal scope of practice of the CNM; and

if those services are also covered under the Medicare program.

Congress recognizes CNM services as separate and distinct from hospital inpatient and outpatient services. Specifically, 4157 of OBRA 1990 (P.L. 101-508) amended 1861 (b)(4) of the Medicare statute to exclude CNMs from inpatient hospital services. In addition, the statute exempts CNM services from outpatient services. This means that CNMs are authorized to bill separately for the services they furnish to hospital patients (both inpatient and outpatient).

CNMs and Physicians

There are multiple ways to bill for services that are not addressed in law or opinion, and business and employment relationships can affect billing methods. State requirements regarding physician involvement in the practice of a nurse-midwife create a host of potential problems regarding billing for the services provided by both the physician and the CNM. Federal law does not mandate physician involvement in the practices of CNMs unless such involvement is required by the state. HCFA policy provides that when a CNM is providing primary care to a Medicare beneficiary and the collaborating physician provides a portion of the services, the fee paid to the CNM must be part of the global fee that the physician would have received for the services provided by the CNM. To illustrate the payment process in such an arrangement, HCFA provides the following example:

1. A CNM has a collaborative practice with a physician.

2. Per that agreement, the CNM requests the physician to examine the beneficiary prior to delivery.

3. The CNM has provided the antepartum care and plans to perform the delivery and postpartum care.

4. The physicians global fee for the physicians total care is $1,000, and the fee schedule amount for the office visit is $30.

5. The fee schedule amount for the CNM would be: $1,000 minus $30 = $970 x 65%= $630.50.

6. The CNM, therefore, would be paid by Medicare no more than $504.40 (80% of 630.50) for the care to the beneficiary.

The above calculation would also apply when a physician provides most of the services and calls in a CNM to provide a portion of the care. Physicians and CNMs would use reduced service modifiers to report that they have not provided all the services covered by the global allowance.

Physician Consultation

Under Medicare, a physician who bills with an Evaluation and Management (E/M) code may bill for CNM services regardless of whether the physician actually saw the patient, as long as an initial physician consultation has already been performed (MCM 15501G & 2050.1 B). E/M codes are based upon the complexity of care, with five levels delineated for billing purposes.1 The complexity is reported with the use of three components, depending on the code reported: (1) history consisting of an a review of systems, history of present illness and patient, personal, family and social history; (2) a physical examination; and (3) the providers medical decision-making. Billing codes and amounts differ according to the setting, the services, and the relevant state law. Federal law does not clarify the responsibilities of a physician who is not billing with an E/M code. The CNM, when seeking physician consultation, should write a consultation note in the progress notes that indicates the purpose of the consultation.

Billing Incident to a Physicians Services
Under Medicare

According to HCFAs Medicare Carriers Manual, the services of certain non-physician practitioners may be covered as services incident to a physicians professional services. These non-physician practitioners, who are being licensed by the States under various programs to assist or act in the place of the physician, include, for example, certified nurse midwives.... Medicare Carriers Manual (MCM) 2050.2 (Trans. 1463, Aug. 1993).

Incident to a physicians professional services means that the services must be furnished by an employee of the physician as an incidental, although integral, part of the physicians professional services and must be furnished under the physicians direct supervision. Also, the services must be of the type commonly furnished in a physicians office or a physician-directed clinic and either furnished without charge or included in the physicians bill. 42 CFR 410.26 and MCM 2050.1.

In allowing for physician billing of incident to services performed by non-physician practitioners, HCFA policy states as follows with regard to the issue of personal supervision:

A non-physician practitioner...may be licensed under state law to perform a specific medical procedure without physician supervision and have the service separately covered and paid for by Medicare... However, in order to have that same service covered as incident to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physicians personal in-office service. This does not mean that each occasion of an incidental service performed by a non-physician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the non-physician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects his or her continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary. MCM 2050.2 (Trans. 1463, Aug. 1993)

In summary, the above MCM appears to allow a physician to bill certain CNM services as incident to the physicians services. However, the requirements relating to incident to must be scrupulously adhered to by the physicianor example, the CNM must be an employee of the physician. Given the various federal statutes prohibiting fraudulent billing, false claims, upcoding, etc., any doubt on the part of the physician or CNM as to whether the CNM service would qualify as incident to should be resolved in favor of CNM billing the service directly and avoiding potential false claims and related challenges.

Therefore, under Medicare, the following criteria must be met in order for CNM services to be billed incident to a physicians:

the CNM must be employed by a physicians office, group practice, a physician-directed clinic or a physician practice; a physician must be providing personal pervision;...personal supervision does not require that the physician be consulted for each time on each patient for which you are billing; and

the physician must be physically present in the office suite/facility and immediately available for consultation.