A lot of practices are using non-physician practitioners to ease the busy load and enhance capacity. But the challenges that come with reporting these physician extender services aren’t easy to face. Read these few answers to real life NPP scenarios provided by our expert in a billing conference.
Question: Your physician urges or uses a nurse or a nurse practitioner to help him in the hospital. He calls it teeing up the patient for him to see. What portions of the documentation can she complete for him?
Answer: You got two situations. You got a nurse and you’ve got a nurse practitioner. If it's a nurse, she can only do the review of systems and the past, family, social history for the to count towards the level of service no matter what type of service we're billing or it’s an admit, a consult, subsequent visit discharge. That's the only thing that that nurse can do.
If it's the nurse practitioner however, and it is anything except the consult, the nurse practitioner could do the bulk of the visit according to the recent E and M coding guidelines. And then the physician will just have to complete the face to face. Even it's a consult, you cannot combine that documentation. If it's a consult, the only thing the nurse practitioner can do is again, the review of systems and the past, family, social history.
So what you really have to decide is do you really want to use somebody with that level of expertise to tee that patient up for you, so to speak? If you want them to do the consult, that's fine. They can do that consult and perhaps bill it under their own number. But they can't just tee them up and getting them ready for you to see and use their expertise towards your level of service if it's a consult as per the medical billing rules.
Question: Does the physician have to be present when the nurse practitioner sees the patient in the hospital?
Answer: No. The physician can provide the face to face service at some other time during the day. Now, remember when we talk about billing days, it's calendar day. So it's midnight. It's 12:01 to 11:59. It's midnight to midnight.
So as long as they both see the patient face to face that same calendar day, they don’t have to be there at the same time. And in fact, that's what a lot of clients are doing. They're having the nurse practitioner make rounds in the morning and the doctor send them in the afternoon or vice versa so the patient is getting seen twice a day and we, combining the documentation to bill in the physician. But no, they don’t have to be there at the same time as per the medical coding and billing guidelines.
Question: If the doctor who set up the plan of care is not in the office on the date the PA sees the patient and another physician serves as the supervising physician, which physician needs to sign off on the note?
Answer: Well, from a Medicare billing perspective, nobody has to sign off on the note. Now, for, you know, you may have state regulations that require certain number of notes co-sign or if you're dealing with another payer that requires the notes to be co-sign, then you may have to deal with those issues. But Medicare doesn’t require co-signature at all. And think about it, all that made is the doctor had chart and he had a chart, he had a pen. It doesn’t mean he actually was there.
So again, from Medicare, you don’t have to have a co-signature. What they'll look for to determine who was the supervising physician is who was in the office at the time. They'll look at appointment schedules to help determine that as far as who set up the plan of care. Co-signing doesn’t set up the plan of care. Setting up the plan of care is a previous office visit, making the diagnosis and setting up that protocol for that patient. So you don’t even have to have a co-signature just for Medicare billing purposes as per the healthcare rules.
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