Wiki NPs referring patients to physicians

[fgreen776]

Circumstances:
- Nurse Practitioner sees patient at a Facility Based clinic for Breast Health (for high risk or benign patients)
- After exam, she determines patient needs a surgical intervention
- She bills new patient visit independently
- She refers the patient that requires surgical intervention to a surgeon employed by the same group under the same TIN.
- Nurse Practitioner has a different Taxonomy code (for specialty and sub specialty) than the surgeon

In this circumstance, can the surgeon bill this visit as a new patient visit as well? Does this constitute a compliance issue or anti Stark issue? Especially if the same NP is assisting the surgeon with dictations and exam on her non practice days?

 

[thomas7331]

Two different issues here. Whether or not the surgeon should bill as a new patient visit is based on coding rules and payer policy. It may depend partly on how the payer credentials and determines the specialty of the NP, but since the Medicare enrollment process always classifies a NP as a different specialty from an MD, and since your NP has a different taxonomy, it is certainly defensible that these are different specialty providers and that a new patient visit billed by the physician is correct. You would be following established coding guidelines and this should not pose a compliance risk.

The other issue, the potential compliance or Stark issue, could involve the referral within the practice. A referral to a surgeon, in and of itself, is not a violation and unlikely to be a problem. But depending on the ownership arrangement of your practice and how the providers are compensated and/or given financial incentives, there can always be potential risks involved in referring patient for services if there is an ownership stake in the entity that stands to benefit from that referral, or any form of 'kickback' or financial reward is given referring a patient. If this is a concern, it's something that should be discussed with your practice attorneys or a professional legal service.