We had a client to come into clinic for quick f/u for her meds. It was then determined that she needed to speak with our MD regarding issues, so he met with her for a 99214. The nurse ended up writing her regular note and went on about her day.
The M.D./nurse did not make me aware of this until 3 days after the fact (before billings have gone out), so my question is:
A. Does the M.D. add an addendum to the Nurse note and we bill for only the M.D. time (as i know we cannot bill 2 e/m on same day)
~OR~
B. Does M.D. write his own note and reference the nurse note for further documentation?
I am concerned because this was not documented by the M.D. immediately that we "may" be in trouble with it. In the nurse note, it is documented that our M.D. did come in and meet with client on urgent basis, she noted all medication changes per M.D. etc, however, M.D. did not make any of the note himself on the day client was seen.
Help?
Whoa...Okay - a few things:
1. If it's just a nurse, and not an FNP taking the notes, they can't be used for E/M. The provider (eg, physician or non-physician practitioner) must document the HPI, exam, and MDM personally (or by use of a scribe) - they can't just piggyback off of someone else's work. The services must be within the nurse's scope of practice; if they're not licensed to provide E/M services, then they can't provide E/M services
2. If this does qualify for 'incident-to' billing, you'd only submit one claim for the doctor, not one for each of them.
See page 12:
http://www.trailblazerhealth.com/Publications/Training Manual/incident_to.pdf
"Requirements for “incident to” are:
The services are commonly furnished in a physician's office.
The physician must have initially seen the patient.
There is direct personal supervision by the physician of auxiliary personnel, regardless of whether the individual is an employee, leased employee or independent contractor of the physician.
The physician has an active part in the ongoing care of the patient.
Direct supervision in the office setting does not mean that the physician/non-physician must be present in the same room with his aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction while the aide is performing services....
The only NPPs who may bill E/M services (above the level of 99211) under the “incident to” criteria are NPs, CNSs, PAs and nurse midwives.
To ensure proper reimbursement according to the fee schedule, Medicare requires that documentation submitted to support billing “incident to” services must clearly link the services of the NPP to the services of the supervising physician."
3. A follow-up for chronic conditions/medication refills may not be billable as a level 4 E/M; you should check with your MAC over what they considered medically reasonable and necessary. Trailblazer, for example, requires that at least 3 distinct chronic conditions be evaluated (mentioned in the HPI), and treated (Mentioned in the MDM), in order to report a 99214 or 99215, and they have restrictions on the frequency of which follow-up visits are allowed. (Usually once every 3 months at most).
You may want to discuss changing the billing practice in your office, to one where you code off of the chart, as opposed to a superbill, to avoid these situations in the future. Something that's incorrectly marked on the superbill, or wasn't documented properly, could cause a sticky compliance issue, if the right hand doesn't know what the left hand's doing. You may find that it cuts down on claim denials, and that you catch charges that the physician might have forgotten to bill, so the benefits definitely outweigh the slight drawback of having to wait a little bit longer to enter the day's charges. Hope that helps!
