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vnorman

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Hello all,

What services are allowed to be billed when a nurse / MA performs then and a doctor is not in the office? I continue to receive push back from our clinical director on what can be performed and billed. :( Please help!

Thank you,
Valarie, CPC, CPPM
 
Last edited:
vnorman said:
Hello all,

What services are allowed to be billed when a nurse / MA performs then and a doctor is not in the office? I continue to receive push back from our clinical director on what can be performed and billed. :( Please help!

Thank you,
Valarie, CPC, CPPM
Click to expand...

If your practice is licensed as a physician office the there must always a physician or nurse practitioner in the office anytime a patient is being attended to. Your nurse was taught this in nursing school! A nurse or MA should never see a patient without a provider present in a physician office practice. When you submit the claim you must use an NPI in field 25J for rendering or supervising provider. Since the nurse has no NPI and the provider was not there to render nor supervise, then whose NPI are you using?
 
That is what I thought and I have been telling them, however they continue to do some services and wonder why I continue to no charge them. I can NOT bill for them, but somehow this has not gotten through. Thank you!
 
Just so I can clarify it for my clinic staff. This is regardless of what insurance the patient has correct? Medicare, BCBS, UHC, Aetna... it does not matter.
 
Yes check your state laws. I believe you will find that as a physician office and due to malpractice concerns you cannot have patient services at all of a provider is not present. Also check with the malpractice carrier. I had one physician office do this and they discovered that, if it was reported to the malpractice carrier that patient services were conducted without the provider on site they would cancel the insurance. What would happen if one little thing would go wrong and there was no physician on site?
 
Thank you. I guess I am still a little confused as I am finding some conflicting information regarding some services...

Must a supervising physician be physically present when flu shots, EKGs, laboratory tests, or X-rays are performed in an office setting in order to be billed as ‘incident to’ services?
These services have their own statutory benefit categories and are subject to the rules applicable to their specific category. They are not "incident to" services and the "incident to" rules do not apply.


So with SOME services a physician does not have to be present?
 
You cannot bill a physician as rendering or supervising if they are not physically present. Physician office services are vastly different from the exact same service in an ASC or a hospital outpatient or even nursing home health services. Each type of clinic/facility/office has it own separate rules and malpractice standards.
So yes in a physician office when licensed as a physician office must have a provider present when services are rendered and the supervising provider is the NPI in 24J
 
Debra,

Do you happen to know where I can find this information? As some diagnostic testing is listed as 'General Supervision' (the procedure is furnished under the physician’s
overall direction and control, but the physician’s presence is not required.
However, the training of non-physician personnel, maintenance of equipment
and supplies are the continuing responsibility of the physician.) and it does not specify that the physician has to be on-site I am still receiving push back. I am being directed to have "Facts" regarding the billing requirements. I was always under the impression that a physician or a PA needed to be in the office in order to bill for any services performed. You are tell me the same thing, but as stated I am still receiving push back regarding the 'General Supervision' level for some diagnostic testing. Direct Supervision states - originally meant the physician must be present in the same office suite and immediately available. Due to the difference of Direct being on-site or immediately available and General being under overall direction and control but not specifying a need for a physician to be on-site, I need to have documentation to show the billing requirements. I know I am probably being a pest, and I apologize but I have already presented documents on the supervision levels and information on Incident-to rules and it does not appear to be enough. Any help is greatly appreciated!

Thank you!!
 
Stark is a good place to look for this it specifies in Stark that only DHS may be performed in a physician office without the provider in the office suite. Then the definition of DHS is services such as DME and PT.
 
Here is the except from Stark regarding ancillary services in the physician office:
The principal Stark Law exceptions for DHS performed within a physician
organization are the in-office ancillary services exception and the physician services exception, which are described below.
The in-office ancillary services exception has the following four (4) requirements:
• Typically a physician organization with more than one physician must be structured as a "group practice," as defined at 42 CFR ? 411.352, in order to take advantage of the in-office ancillary services exception. It is important to note that diagnostic tests cannot be allocated directly to a physician as "incident to" services when calculating compensation within a group practice, and that employing specialists may affect the physician organization’s ability to satisfy the group practice requirement that its members perform at least 75 percent of their patient care services through the physician organization.
• The DHS must be furnished personally by one of the following persons: (a) the referring physician, (b) a physician who is a "member" of the group (generally an owner or employee physician), or (c) an individual who is supervised by the referring physician or another physician in the group practice in compliance with Medicare payment and coverage rules for the services.
• The DHS must be furnished in either a “centralized building” used by the group for the provision of some or all of its DHS, or in the “same building” in which the group maintains an office satisfying at least one of three alternative tests, each of which requires that parameters relating to hours and physician services be satisfied. The first "same building" test is satisfied if the DHS are furnished in a building in which the group maintains an office which is open at least 35 hours per week and member physicians furnish physician services at least 30 hours per week, including at least some services which are unrelated to DHS. The second and third "same building" tests are more complicated but would allow part-time offices.
• The DHS must be billed by the physician performing or supervising the service, the group practice (either directly or through a billing company) under the group's billing number, or by a wholly-owned subsidiary of the group practice. An entity that is individually owned by multiple group practice physicians will not satisfy this requirement.
The physician services exception applies to physician services (such as the professional component of diagnostic tests) that are furnished either personally by or under the supervision of another physician who is a member of the referring physician’s group practice or is a physician in the group practice. Services personally performed by the referring physician are excepted from the definition of “referral.”
 
So IF I understand this correctly.. we are a 'Group Practice' and we are rendering Designated Health Services (DHS) such as diagnostic imaging within one of our practice locations while our physician is NOT in the office we are okay to bill under our group using the referring provider as the rendering? I am SO confused
 
I understand it as a provider within the group practice must be supervising while the service is being rendered. Check with your state licensing entity to clarify the supervision requirements.
 
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