Healthcare Coding: Billing for NPP services



You run across lots of times where you've got a note that says, “Dictated by nurse practitioner” and then this physician code signs. And they're trying to tell me that that physician is just a scribe. Maybe it's in the office setting where we haven’t met incident-to. Maybe it's not clear in the hospital that the physician had a face-to-face encounter. But what they want to say is when the nurse practitioner dictates that means she was a scribe. Read this expert information provided by our expert in a coding and compliance conference.

Well, CMS is silent on scribes. Medicare does not have a specific policy on scribes. Again, check with your local carrier. A lot of them do have policies on scribes. But remember what a scribe is. A scribe is a human dictaphone. It's somebody that’s just writing down what the doctor said, not what the doctor did, what the doctor said.

And this person can't add any observations of their own into that record other than review of systems and past family social history. Remember the documentation healthcare guidelines that allow anybody to add that. The recommendation is that they sounded as, “Scribed by” this person for the physician. And the physician review it and sign off on it.

Now, how are you going to bill these in the medical coding and billing scenarios we see? In some practices, they choose to always bill under the non-physician practitioner’s number and that's cleaner, that’s easier. You don't have to worry about is it an incident-to or is it shared? You just have to audit those notes to the level of service, history, exam, decision-making.

Your revenue is a little bit lower in this case because you are going to be paid at 85% under the Medicare program. So, you're not fulfilling the potential, so to speak, of having 100% reimbursement but it's cleaner, it's easier to deal with.

The other extreme would be to always bill under the physician’s number. But in that case, you have to make sure that there is always a physician in that suite providing that supervision, that that non-physician practitioner never sees a new patient, never sees a new problem. And that limits them and takes away from the fact that they are highly skilled and very highly trained.

But if you are going to bill everything in the physician’s number, you have to make sure that you’ve always met those incident-to medical billing guidelines or you’ve always met those shared guidelines. The other way is being handled is that the documentation for that visit determines how we’re going to bill that service.

And that can vary from patient to patient. It can vary from visit to visit. In order for this to work and to be compliant, we have to make sure that that nurse practitioner, that PA, that CNS, that nurse midwife fully understands the medical billing rules and requirements. They don’t all fully understand that.

Many of them, when they come out of training, they may have learned a little bit about medical coding, coding levels of service and that kind of thing but most of them do not understand incident-to versus shared billing, they don’t understand those.

In order for this to work, we have to make sure that that practitioner understands that because they're the ones who's in the room with that patient that day and they're the one who decides yes, this visit’s incident-to, no, this visit’s independent.

And the last that work is the practitioner would have two numbers, two billing numbers in the practice management system. And they would write whichever one was applicable on that patient’s encounter form that day.

So if they're in the room with that patient and this visit, yes, it did make incident-to healthcare guidelines, they'd bill in that way. And when that – under that billing number in the practice management system, the claim would go out under the physician.

Well, if we knew the incident-to guidelines were not met, they would enter the billing number for their independent billing and that claim would go out the door with their own that non-physician practitioner should provide a number on it.

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