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Reimbursement Primer for Compliance, Ethics and Legal Officers: Reimbursement Primer for Compliance, Ethics and Legal Officers: “Everything You Have Always Wanted to Know About“Everything You Have Always Wanted to Know About

Reimbursement but Were Afraid to Ask.”Reimbursement but Were Afraid to Ask.”

Physician and Other Part B Physician and Other Part B Practitioner ReimbursementPractitioner Reimbursement

April 10, 2007April 10, 2007►► John BelknapJohn BelknapBilling Compliance Director, Massachusetts General Hospital,Billing Compliance Director, Massachusetts General Hospital,Massachusetts General Physicians OrganizationMassachusetts General Physicians Organization

►► Jennie Campbell Jennie Campbell Senior Manager, Pershing Senior Manager, Pershing YoakleyYoakley and Associatesand Associates

►► Judith WaltzJudith WaltzPartner, Foley & Lardner LLPPartner, Foley & Lardner LLP

►► Moderated by Lawrence W. Vernaglia, JD, MPHModerated by Lawrence W. Vernaglia, JD, MPH

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Topics We Will CoverTopics We Will Cover

►► General Overview of Coverage and Categories of General Overview of Coverage and Categories of PractitionersPractitioners

►► Physician Billing Physician Billing ►► Non Physician Practitioner BillingNon Physician Practitioner Billing►► “Incident to” Billing“Incident to” Billing►► Shared/Split Encounter BillingShared/Split Encounter Billing►► Physician Supervision of Diagnostic TestsPhysician Supervision of Diagnostic Tests►► Physician Quality Reporting (Incentive Payments)Physician Quality Reporting (Incentive Payments)

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Physicians and NonPhysicians and Non--Physicians Physicians ►► Anesthesiology AssistantAnesthesiology Assistant►► AudiologistAudiologist►► Certified Nurse MidwifeCertified Nurse Midwife►► Certified Registered Nurse AnesthetistCertified Registered Nurse Anesthetist►► Clinical Nurse SpecialistClinical Nurse Specialist►► Clinical Social WorkerClinical Social Worker►► Nurse PractitionerNurse Practitioner►► Occupational Therapist in Private PracticeOccupational Therapist in Private Practice►► Physical Therapist in Private PracticePhysical Therapist in Private Practice►► Physician AssistantPhysician Assistant►► PhysicianPhysician►► Psychologist, ClinicalPsychologist, Clinical►► Psychologist billing independentlyPsychologist billing independently►► Registered Dietitian or Nutrition ProfessionalRegistered Dietitian or Nutrition Professional

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Medical NecessityMedical Necessity

““[N]o payment may be made…for items or [N]o payment may be made…for items or services services –– which, except for items and which, except for items and services described in a succeeding services described in a succeeding subparagraph, are not reasonable and subparagraph, are not reasonable and necessary for the diagnosis or treatment of necessary for the diagnosis or treatment of illness or injury or to improve the illness or injury or to improve the functioning of a malformed body member.”functioning of a malformed body member.”

Soc. Sec. Act 1862(a)(1)(A).Soc. Sec. Act 1862(a)(1)(A).

NOTE: “reasonable and necessary” is still not a defined term!NOTE: “reasonable and necessary” is still not a defined term!

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““Reasonable and Necessary” Reasonable and Necessary” -- CMS CMS Program Integrity Manual GuidanceProgram Integrity Manual Guidance

►► Safe and effective;Safe and effective;►► Not experimental or investigational (exception: routine costs ofNot experimental or investigational (exception: routine costs of qualifying qualifying

clinical trial services with dates of service on or after Septemclinical trial services with dates of service on or after September 19, 2000 which ber 19, 2000 which meet the requirements of the Clinical Trials NCD are considered meet the requirements of the Clinical Trials NCD are considered reasonable and reasonable and necessary); andnecessary); and

►► Appropriate, including the duration and frequency that is considAppropriate, including the duration and frequency that is considered ered appropriate for the service, in terms of whether it is:appropriate for the service, in terms of whether it is:

►► Furnished in accordance with Furnished in accordance with accepted standards of medical practiceaccepted standards of medical practice for for the diagnosis or treatment of the patient's condition or to imprthe diagnosis or treatment of the patient's condition or to improve the function ove the function of a malformed body member;of a malformed body member;

►► Furnished in a Furnished in a setting appropriate to the patient's medical needs and setting appropriate to the patient's medical needs and conditioncondition;;

►► Ordered and furnished by qualified personnel;Ordered and furnished by qualified personnel;►► One that meets, but does not exceed, the patient's medical need;One that meets, but does not exceed, the patient's medical need; andand►► At least as beneficial as an existing and available medically apAt least as beneficial as an existing and available medically appropriate propriate

alternative.alternative.

Program Integrity Manual, Chapter 13, Section 13.5.1 (“Content oProgram Integrity Manual, Chapter 13, Section 13.5.1 (“Content of an LCD”)f an LCD”)

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Preventive ServicesPreventive Services(Non(Non--exclusive list)exclusive list)

►► Abdominal Aortic Aneurysm ScreeningAbdominal Aortic Aneurysm Screening►► Adult ImmunizationsAdult Immunizations►► Bone Mass MeasurementsBone Mass Measurements►► Cancer ScreeningsCancer Screenings►► Cardiovascular ScreeningCardiovascular Screening►► Diabetes ScreeningDiabetes Screening►► Diabetes SuppliesDiabetes Supplies►► Diabetes SelfDiabetes Self--Management TrainingManagement Training►► Medical Nutrition Therapy (for Medicare beneficiaries with diabeMedical Nutrition Therapy (for Medicare beneficiaries with diabetes or tes or

renal disease)renal disease)►► Glaucoma ScreeningGlaucoma Screening►► Initial Preventive Physical Exam ("Welcome to Medicare" PhysicalInitial Preventive Physical Exam ("Welcome to Medicare" Physical

Exam)Exam)►► Prostate Cancer ScreeningProstate Cancer Screening►► Smoking and TobaccoSmoking and Tobacco--Use Cessation CounselingUse Cessation Counseling

http://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asphttp://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asp

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Physician Payment Laying the FoundationPhysician Payment Laying the Foundation

►► Physicians are usually paid a fee for each Physicians are usually paid a fee for each service providedservice provided- there are 3 general exceptions:1. Payers will only reimburse for covered services2. Some services are paid as a packaged price3. Payment for some other services is “bundled”

into payment for the primary service

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FeeFee--ForFor--Service PaymentsService Payments►► The Resource Based Relative Value System The Resource Based Relative Value System

(RBRVS) has been adopted by most payers to (RBRVS) has been adopted by most payers to determine how much each physician service will determine how much each physician service will be paid.be paid.

►► The RVS Update Committee assigns relative The RVS Update Committee assigns relative value units to each service which, when value units to each service which, when multiplied by the dollar conversion factor, results multiplied by the dollar conversion factor, results in the fee schedule amount.in the fee schedule amount.

►► Medicare typically reimburses 80 percent of the Medicare typically reimburses 80 percent of the fee schedule amount, and the patient or fee schedule amount, and the patient or secondary insurance is responsible for the secondary insurance is responsible for the additional 20 percent.additional 20 percent.

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FeeFee--ForFor--Service PaymentsService Payments

►► Physician billing compliance professionals Physician billing compliance professionals assess whether insurance and patient assess whether insurance and patient payments received are accurate based on the payments received are accurate based on the actual services provided.actual services provided.

►► In order to receive the correct payments, In order to receive the correct payments, physicians must accurately communicate the physicians must accurately communicate the services provided with payers. services provided with payers.

►► Therefore, our focus is on the medical record Therefore, our focus is on the medical record documentation, and whether the billing codes documentation, and whether the billing codes selected are accurate and fully supported by selected are accurate and fully supported by the documentation.the documentation.

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The Claim FormThe Claim Form

►► The CMS 1500 form is used to communicate The CMS 1500 form is used to communicate the physician services performed with payers.the physician services performed with payers.

Paper claim forms are not often used. The large Paper claim forms are not often used. The large majority of claims are submitted using an majority of claims are submitted using an electronic equivalent.electronic equivalent.

• A basic understanding of the claim form is necessary for compliance professionals

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Claim Form Attestation

Signature of Physician

(or Supplier)

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SIGNATURE OF PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the health of this patient and were personally furnished by me or myemployee under my personal direction.

NOTICE: This is to certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State Laws.

Claim Form Attestation

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CMS Claim Form 1500Approved 08/05

We will focus on four fields in block 24:

24. A. Date(s) of Service24. B. Place of Service24. D. Procedures, Services

or Supplies24. G. Days or Units

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24. 24. A. Date(s) of ServiceA. Date(s) of Service

04 10 2007

04 09 2007 04 10 2007

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24.24. B. Place of ServiceB. Place of Service

POS

• Doctor’s Office 11

• Inpatient Hospital 21

• Outpatient Hospital 22

• Home 12

• Emergency Room 23

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Place of ServicePlace of Service

►►Medicare makes higher payments for Medicare makes higher payments for services performed in a doctor’s office than services performed in a doctor’s office than in an outpatient hospital setting.in an outpatient hospital setting.

►►Compliance officers in hospital settings Compliance officers in hospital settings should carefully review the accuracy of their should carefully review the accuracy of their physician place of service coding.physician place of service coding.

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2424. . D. Procedures, Services, or D. Procedures, Services, or SuppliesSupplies

99213

11400

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2424. . G. Days or UnitsG. Days or Units

1

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Office Visit ScenarioOffice Visit Scenario

04 10 2007 11 99213

A level 3 established patient office visit, on April 10th, performed in a doctor’s office.

1

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Billing CodesBilling CodesCurrent Procedural Current Procedural

TerminologyTerminology►► CPT codes describe physician servicesCPT codes describe physician services

Evaluation and management (99201 Evaluation and management (99201 –– 99499)99499)Anesthesiology (00100 Anesthesiology (00100 –– 01999, 99100 01999, 99100 –– 99140)99140)Surgery (10021 Surgery (10021 –– 69990)69990)Radiology (70010 Radiology (70010 –– 79999)79999)Pathology/Lab (80048 Pathology/Lab (80048 –– 89356)89356)Medicine (90281 Medicine (90281 –– 99199, 99500 99199, 99500 –– 99602)99602)

CPT is a registered trademark of the American Medical Association

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HCPCS CodesHCPCS Codes

►► HCPCS codes are developed by CMS to be used HCPCS codes are developed by CMS to be used when an accurate CPT code does not existwhen an accurate CPT code does not exist

A4206 A4206 -- A8999: medical and surgical suppliesA8999: medical and surgical suppliesD0120 D0120 -- D9999: dental proceduresD9999: dental proceduresE0100 E0100 -- E9999: durable medical equipmentE9999: durable medical equipmentG0008 G0008 -- G9139: procedural/professional servicesG9139: procedural/professional servicesJ0120 J0120 -- J9999: drugsJ9999: drugsP2028 P2028 -- P9615: pathology/lab servicesP9615: pathology/lab services

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CPT/HCPCS Code SelectionCPT/HCPCS Code Selection

►►Selection of the accurate CPT/HCPCS Selection of the accurate CPT/HCPCS code is the most important step to code is the most important step to ensure physician billing compliance.ensure physician billing compliance.

►►Compliance professionals must Compliance professionals must understand how the coding is done in understand how the coding is done in their practices.their practices.

Coder abstractionCoder abstractionPhysician or other clinician selectionPhysician or other clinician selectionCoding software Coding software

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Evaluation and Management Evaluation and Management CodingCoding

►►Physician visit services are typically coded at Physician visit services are typically coded at an E/M level based on their complexity.an E/M level based on their complexity.

►►The AMA/CMS E/M Documentation The AMA/CMS E/M Documentation Guidelines define the details necessary to Guidelines define the details necessary to support the level of visit coded.support the level of visit coded.

►►Payers closely scrutinize E/M coding Payers closely scrutinize E/M coding patterns and will audit highpatterns and will audit high--end coding end coding outliers. outliers.

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Evaluation & Management Services Coding Pattern Evaluation & Management Services Coding Pattern ABC Medical Practice ABC Medical Practice -- Established Patient Office VisitsEstablished Patient Office Visits

Physician Level 1 99211

Level 2 99212

Level 3 99213

Level 4 99214

Level 5 99215 Average

Physician A 2 149 544 316 4 3.2

Physician B 3 81 28 10 3 2.4

Physician C 0 0 0 164 25 4.1

Physician D 32 158 213 365 184 3.5

Totals 37 388 785 855 216 3.3

State Percent 2.6 10.4 43.1 35.9 7.9 3.4

National Percent 2.5 15.8 54.1 24.0 3.5 3.1

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ModifiersModifiers

►►Modifiers are 2 digit alpha or numeric Modifiers are 2 digit alpha or numeric codes that add additional detail to the codes that add additional detail to the CPT/HCPCS codeCPT/HCPCS code

►►Some modifiers affect payment; others Some modifiers affect payment; others are informational and do not change are informational and do not change payment.payment.

►►Two modifiers deserve special mention:Two modifiers deserve special mention:Modifier 25: significant, separately Modifier 25: significant, separately identifiable E/M serviceidentifiable E/M serviceModifier 59: distinct procedural serviceModifier 59: distinct procedural service

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Modifier 25 Modifier 25

►►Modifier 25 is appropriately used when Modifier 25 is appropriately used when an E/M service is performed on the an E/M service is performed on the same day as a procedure.same day as a procedure.

►►The E/M service must be significant and The E/M service must be significant and separate from the usual evaluation separate from the usual evaluation services done prior to the procedure.services done prior to the procedure.

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Modifier 59 Modifier 59

►►Modifier 59 is appropriately used when Modifier 59 is appropriately used when a procedural service is separate and a procedural service is separate and distinct from another procedure done distinct from another procedure done on the same day.on the same day.

►►Modifier 59 can be used when a second Modifier 59 can be used when a second procedure is done at a different time, or procedure is done at a different time, or through a separate incision.through a separate incision.

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Correct Coding InitiativeCorrect Coding Initiative

►► CCI defines what codes cannot be billed CCI defines what codes cannot be billed together for the same patient on the same together for the same patient on the same day.day.

• CCI lists comprehensive codes and component codes. Component codes are considered part of the comprehensive code.

• Indicators are used in CCI to tell you if you can bill separately for comprehensive and component codes in special circumstances. Modifiers are used when certain circumstances will permit separate payment.

http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage

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Diagnostic CodingDiagnostic Coding

►►The type and number of diagnosis codes The type and number of diagnosis codes submitted on a physician claim form do submitted on a physician claim form do not affect the amount of reimbursementnot affect the amount of reimbursement

• However, for services subject to national or local coverage policies, if a diagnosis code that supports coverage is not listed then the claim will be denied.

• Diagnosis codes support the medical necessity of the physician services billed

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Medicare’s Teaching Physician RuleMedicare’s Teaching Physician Rule

►►The basic rule:The basic rule:

Source: Medicare Claims Processing (PUB. 100-04) Chapter 12-100 Teaching Physician Services

-services furnished in teaching settings are paid under the physician fee schedule if the services are:

•personally furnished by a physician who is not a resident

•furnished by a resident where a teaching physician was physically present during the critical or key portions of the service

•an exception is made for low level E/M services under certain conditions (i.e. primary care exception)

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Teaching Physician RuleTeaching Physician Rule

►► Evaluation and Management services: Evaluation and Management services: the TP must be present during the critical portions the TP must be present during the critical portions of the service of the service andand write a note describing their write a note describing their presence and involvementpresence and involvement

“I saw and evaluated the patient. Discussed with “I saw and evaluated the patient. Discussed with the resident and agree with the resident’s findings the resident and agree with the resident’s findings and plan as documented in the resident’s note”.and plan as documented in the resident’s note”.

-“Agree with above” or co-signed resident notes do not support professional fee billing

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Teaching Physician RuleTeaching Physician Rule

►► Surgical procedures: the teaching surgeon Surgical procedures: the teaching surgeon must be present during the critical portion(s) must be present during the critical portion(s) and remain immediately available throughout and remain immediately available throughout the entire procedure.the entire procedure.

• If the teaching surgeon is present for less than the entire procedure the surgeon must personally document their presence during the critical portion(s) and state their immediate availability throughout the procedure.

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Teaching Physician RuleTeaching Physician Rule►► Anesthesia: similar to surgery; presence during the Anesthesia: similar to surgery; presence during the

critical portions and immediately availablecritical portions and immediately available

►► Radiology and Pathology and other interpretive Radiology and Pathology and other interpretive services: the teaching physician must personally services: the teaching physician must personally review the images or slidesreview the images or slides

►► Time based services (e.g. critical care, prolonged Time based services (e.g. critical care, prolonged services): the teaching physician must be present for services): the teaching physician must be present for the entire time period being billedthe entire time period being billed

►► Three quarters of teaching hospitals apply the Three quarters of teaching hospitals apply the Medicare standard to all patients*Medicare standard to all patients*

* Association of American Medical Colleges annual survey 2006

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Billing for NonBilling for Non--Physician Practitioner ServicesPhysician Practitioner Services

►► A NPP is a person that has attended a specialized A NPP is a person that has attended a specialized graduate program in a designated field. graduate program in a designated field.

►► Depending on the specialty, the candidate may Depending on the specialty, the candidate may have worked in a specified field for a certain have worked in a specified field for a certain period of time.period of time.

►► CMS uses the term Limited License Practitioners CMS uses the term Limited License Practitioners (“LLP”).(“LLP”).

►► Most commonly nurse practitioners and physician Most commonly nurse practitioners and physician assistants in the physician setting.assistants in the physician setting.

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Each State Regulates NPP PracticeEach State Regulates NPP Practice

►► Each state’s licensing body determines the scope of Each state’s licensing body determines the scope of practice for the NPP.practice for the NPP.

►► The scope of practice outlines the requirements for The scope of practice outlines the requirements for the NPP to legally practice in the state and state the NPP to legally practice in the state and state regulations vary.regulations vary.

►► §1861(s)(2)(K) of the Social Security Act allows for §1861(s)(2)(K) of the Social Security Act allows for specified NPPs to bill Medicare provided the NPP is specified NPPs to bill Medicare provided the NPP is supervised by a physician and legally authorized to supervised by a physician and legally authorized to perform the services in the state.perform the services in the state.

►► A common mistake is to confuse what NPPs are A common mistake is to confuse what NPPs are legally allowed to provide as a clinical practice with legally allowed to provide as a clinical practice with what can be billed to Medicare “incident to”.what can be billed to Medicare “incident to”.

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Example: Tennessee RegulationsExample: Tennessee Regulations

a)a) When medically indicated;When medically indicated;

b)b) When requested by the patient;When requested by the patient;

c)c) When prescriptions written by the certified nurse practitioner fWhen prescriptions written by the certified nurse practitioner fall all outside the protocols;outside the protocols;

d)d) When prescriptions are written by a nurse practitioner who posseWhen prescriptions are written by a nurse practitioner who possesses sses a temporary certificate of fitness; anda temporary certificate of fitness; and

e)e) When a controlled drug has been prescribed.When a controlled drug has been prescribed.

Once every ten (10) business days the (Nurse Practitioner's) supervising physician shall make a personal review of the historical, physical and therapeutic data and shall so certify by signature on any patient within thirty (30) days:

Source: Tennessee State Board of Medical Examiners Rule 0880-6-.02

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Example: Maryland RegulationsExample: Maryland Regulations

A nurse practitioner may perform A nurse practitioner may perform independently the following functions independently the following functions under the terms and conditions set forth under the terms and conditions set forth in the in the written agreementwritten agreement: :

Comprehensive physical assessment of patients; Comprehensive physical assessment of patients; Establishing medical diagnosis for common shortEstablishing medical diagnosis for common short--term or term or chronic stable health problems; chronic stable health problems; Ordering, performing, and interpreting laboratory tests; Ordering, performing, and interpreting laboratory tests; Prescribing drugs; Prescribing drugs; Performing therapeutic or corrective measures; Performing therapeutic or corrective measures; Referring patients to appropriate licensed physicians or Referring patients to appropriate licensed physicians or other health care providers; other health care providers; Providing emergency care.Providing emergency care.

Source: Title 10, Subtitle 27, Chapter 07, Article, § 8-205, Annotated Code of Maryland

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““Incident To” BillingIncident To” Billing

►► Outlined in Section 2050 of the Medicare Carriers Manual Outlined in Section 2050 of the Medicare Carriers Manual and applies to the and applies to the Medicare Medicare program only.program only.See: http://www.cms.hhs.gov/Manuals/PBM/list.aspSee: http://www.cms.hhs.gov/Manuals/PBM/list.asp

►► Certain basic requirements must be met to bill “incident to” Certain basic requirements must be met to bill “incident to” the physician and it applies to the office practice (place of the physician and it applies to the office practice (place of service 11).service 11).

►► Services of NPP (or other auxiliary personnel) meeting the Services of NPP (or other auxiliary personnel) meeting the “incident to” requirements are billed under the physician’s “incident to” requirements are billed under the physician’s Medicare provider number and paid at 100% of the Medicare provider number and paid at 100% of the physician fee schedule.physician fee schedule.

►► If “incident to” requirements are not met for services If “incident to” requirements are not met for services provided by an NPP, the services may be billed under the provided by an NPP, the services may be billed under the NPP’s own provider number and paid at 85% of the NPP’s own provider number and paid at 85% of the physician fee schedule.physician fee schedule.

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Basic Requirements for Billing Basic Requirements for Billing Services “Incident To”Services “Incident To”

1.1. An integral, although incidental, part of An integral, although incidental, part of the physician's professional service;the physician's professional service;

2.2. Commonly rendered without charge or Commonly rendered without charge or included in the physician's bill;included in the physician's bill;

3.3. Of a type that are commonly furnished in Of a type that are commonly furnished in physician's offices or clinics;physician's offices or clinics;

4.4. Furnished under the direct personal Furnished under the direct personal supervision of a physician; andsupervision of a physician; and

5.5. Furnished by an individual who qualifies Furnished by an individual who qualifies as an employee, leased employee or as an employee, leased employee or independent contractor of the physician independent contractor of the physician or organization employing the physician or organization employing the physician (“auxiliary personnel”).(“auxiliary personnel”).

The services must be…

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““Incident to” a Physician’s Incident to” a Physician’s Professional ServiceProfessional Service

►► MCM 2050.1: MCM 2050.1: Incident to Physician's Professional Incident to Physician's Professional ServicesServices..----Incident to a physician's professional Incident to a physician's professional services means that the services or supplies are services means that the services or supplies are furnished as an furnished as an integral, although incidentalintegral, although incidental, , part of the physician's personal professional part of the physician's personal professional services in the course of diagnosis or treatment of services in the course of diagnosis or treatment of an injury or illness.an injury or illness.

►► What does this mean?What does this mean?The service is an adjunct to a service of the physician.The service is an adjunct to a service of the physician.The service is not a stand alone service provided by the The service is not a stand alone service provided by the NPP.NPP.

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Commonly Rendered Without Charge Commonly Rendered Without Charge or Included in the Physician's Billor Included in the Physician's Bill

►► MCM 2050.1.A: MCM 2050.1.A: Commonly Furnished in Commonly Furnished in Physicians' OfficesPhysicians' Offices..----Services and supplies Services and supplies commonly furnished in physicians' offices are commonly furnished in physicians' offices are covered under the incident to provision. Where covered under the incident to provision. Where supplies are clearly of a type a physician is not supplies are clearly of a type a physician is not expected to have on hand in his/her office or expected to have on hand in his/her office or where services are of a type not considered where services are of a type not considered medically appropriate to provide in the office medically appropriate to provide in the office setting, they would not be covered under the setting, they would not be covered under the incident to provision.incident to provision.

►► What does this mean? What does this mean? Must be “business as usual” for a physician’s office to be Must be “business as usual” for a physician’s office to be billed “incident to.”billed “incident to.”

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Direct Personal SupervisionDirect Personal SupervisionSee MCM 2050.1.BSee MCM 2050.1.B

What does this mean?What does this mean?Does NOT mean physician must render the service.Does NOT mean physician must render the service.►►Treatment plan must be established by the physician (part Treatment plan must be established by the physician (part

of the essence of “incidental service”).of the essence of “incidental service”).►►Requires “active physician participation” in followRequires “active physician participation” in follow--up care.up care.

Does NOT mean present in same room.Does NOT mean present in same room.►►Must be present in the office suite and available to assist.Must be present in the office suite and available to assist.►►The presence of the physician in the office suite is a The presence of the physician in the office suite is a

prudent documentation practice.prudent documentation practice.

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►► Previously defined by some carriers as the Previously defined by some carriers as the “one“one--inin--three” rule.three” rule.

►► Currently Currently notnot specifically defined in the specifically defined in the Medical Carriers Manual.Medical Carriers Manual.

►► Each practice should adopt a consistent Each practice should adopt a consistent standard for compliance review.standard for compliance review.

What is the Definition of “Active Physician Participation?”

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Auxiliary PersonnelAuxiliary Personnel

►►2050.1.B: What does this mean?2050.1.B: What does this mean?Acting under the supervision of the physician.Acting under the supervision of the physician.Employee, leased employee or independent Employee, leased employee or independent contractor of the physician or the legal entity contractor of the physician or the legal entity that employs the physician.that employs the physician.The “incident to” services or supplies must The “incident to” services or supplies must represent an expense incurred by the physician represent an expense incurred by the physician or legal entity billing for the services or or legal entity billing for the services or supplies.supplies.

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““Incident to” Services Outside the Incident to” Services Outside the Physician OfficePhysician Office

►► What about services outside of the office setting?What about services outside of the office setting?If auxiliary personnel perform services outside the office settiIf auxiliary personnel perform services outside the office setting, ng, e.g., in a patient's home or in an institution (other than hospie.g., in a patient's home or in an institution (other than hospital or tal or SNF), their services are covered “incident to” a physician's serSNF), their services are covered “incident to” a physician's service vice only if there is personal supervision (i.e. overonly if there is personal supervision (i.e. over--thethe--shoulder) by the shoulder) by the physician. physician. Exception: Homebound patients in a medically underserved area Exception: Homebound patients in a medically underserved area (see MCM 2051).(see MCM 2051).For hospital patients and for SNF patients who are in a MedicareFor hospital patients and for SNF patients who are in a Medicarecovered stay, there is no Medicare coverage of the services of covered stay, there is no Medicare coverage of the services of physicianphysician--employed auxiliary personnel as services “incident to” employed auxiliary personnel as services “incident to” physicians' services under physicians' services under §1861(s )(2)(A) of the Social Security Act.§1861(s )(2)(A) of the Social Security Act.

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““Incident to” Compliance RisksIncident to” Compliance Risks

►► Failure to ensure that NPP meets state scope of practice Failure to ensure that NPP meets state scope of practice requirementsrequirements

►► Lack of physician presence in the office suiteLack of physician presence in the office suite►► NPP carries out a treatment plan that they established NPP carries out a treatment plan that they established

themselves and/or revises that treatment planthemselves and/or revises that treatment plan►► Physician does not maintain active participation in patient’s Physician does not maintain active participation in patient’s

carecare►► See example case:See example case:

http://caselaw.lp.findlaw.com/data2/circs/11th/0415283p.phttp://caselaw.lp.findlaw.com/data2/circs/11th/0415283p.pdfdf

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““Shared/Split” EncounterShared/Split” Encounter

►►Occurs when an employed NPP and a Occurs when an employed NPP and a physician share or split the work for a physician share or split the work for a patient encounter.patient encounter.

►►Applies in inpatient and outpatient hospital Applies in inpatient and outpatient hospital setting for evaluation and management setting for evaluation and management services, excluding consultations.services, excluding consultations.

►►Must include a faceMust include a face--toto--face encounter face encounter between the physician and the patient.between the physician and the patient.

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Shared/Split EncounterShared/Split Encounter

►► Documentation must clearly demonstrate:Documentation must clearly demonstrate:The physician had a faceThe physician had a face--toto--face encounter with the face encounter with the patient; andpatient; andThe physician performed some part of the history or the The physician performed some part of the history or the examination or the medical decisionexamination or the medical decision--making during the making during the encounter.encounter.

►► If requirements are met, the encounter may be billed under the If requirements are met, the encounter may be billed under the physician’s Medicare provider number and paid at 100% of the physician’s Medicare provider number and paid at 100% of the physician fee schedule.physician fee schedule.

►► If requirements are not met, the services may be billed under thIf requirements are not met, the services may be billed under the e NPP’s own provider number and paid at 85% of the physician fee NPP’s own provider number and paid at 85% of the physician fee schedule.schedule.

►► See : See : http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdfhttp://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

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““Shared/Split” Compliance RisksShared/Split” Compliance Risks

►►Documentation by physician such as “seen Documentation by physician such as “seen and agree”and agree”

►►No clear documentation of face to face No clear documentation of face to face encounterencounter

►►Dictated notes which don’t clearly Dictated notes which don’t clearly demonstrate the parts of the visit performed demonstrate the parts of the visit performed by the NPP and the part performed by the by the NPP and the part performed by the physician.physician.

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Supervision of Diagnostic TestsSupervision of Diagnostic Tests

►► Section 2070 of the MCM sets forth the Section 2070 of the MCM sets forth the levels of physician supervision required for levels of physician supervision required for furnishing the technical component of furnishing the technical component of diagnostic tests for a Medicare beneficiary diagnostic tests for a Medicare beneficiary who is who is not a hospital inpatient or not a hospital inpatient or outpatient. outpatient.

►► Diagnostic test supervision rules apply in:Diagnostic test supervision rules apply in:Physician’s Office (place of service 11)Physician’s Office (place of service 11)Urgent Care Facility (place of service 20)Urgent Care Facility (place of service 20)Emergency Department (place of service 23)Emergency Department (place of service 23)Many Others Many Others –– see Place of Service listsee Place of Service list

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Supervision Levels for Diagnostic Supervision Levels for Diagnostic TestsTests

►► GeneralGeneralDesignated with a “1” in the Medicare Fee Designated with a “1” in the Medicare Fee Schedule DatabaseSchedule Database

►► DirectDirectDesignated with a “2” in the Medicare Fee Designated with a “2” in the Medicare Fee Schedule DatabaseSchedule DatabaseSometimes called “direct personal”Sometimes called “direct personal”

►► PersonalPersonalDesignated with a “3” in the Medicare Fee Designated with a “3” in the Medicare Fee Schedule DatabaseSchedule Database

►► See http://www.cms.hhs.gov/PhysicianFeeSched/See http://www.cms.hhs.gov/PhysicianFeeSched/

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Tests Requiring General SupervisionTests Requiring General Supervision

►►Over 480 codes in 2004 MFSDB require only Over 480 codes in 2004 MFSDB require only general supervision, for example:general supervision, for example:

Most simple xMost simple x--rays, such as: rays, such as: 7102071020--TC, Chest TC, Chest XX--rayrayImaging studies without dye, such as: Imaging studies without dye, such as: 71550, 71550, MRI, Chest, without DyeMRI, Chest, without DyeBasic pulmonary function tests such as: Basic pulmonary function tests such as: 9420094200--TC, Maximum Breathing CapacityTC, Maximum Breathing CapacityNonNon--invasive vascular studies such as: invasive vascular studies such as: 93922, 93922, Doppler Study of Lower ExtremityDoppler Study of Lower Extremity

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Tests Requiring Direct SupervisionTests Requiring Direct Supervision

►► Over 150 codes in the 2004 MFSDB require Over 150 codes in the 2004 MFSDB require direct supervision, for example:direct supervision, for example:

Cardiovascular stress testing, such as: Cardiovascular stress testing, such as: 93015, 93015, 93016, 9301793016, 93017►►CMS has advised Decision Health that the presence of CMS has advised Decision Health that the presence of

the NPP in the room for cardiovascular stress testing the NPP in the room for cardiovascular stress testing constitutes performance of the test.constitutes performance of the test.

Urodynamic studies such as: Urodynamic studies such as: 5172651726--TC, Simple TC, Simple CystometrogramCystometrogramImaging studies requiring dye, such as: Imaging studies requiring dye, such as: 71551, 71551, MRI of Chest, with dyeMRI of Chest, with dye

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Examples of Tests Requiring Examples of Tests Requiring Personal SupervisionPersonal Supervision

►►Over 260 codes in the 2004 MFSDB require Over 260 codes in the 2004 MFSDB require personal supervision, for example:personal supervision, for example:

Invasive coronary studies, such as: Invasive coronary studies, such as: 9353093530--TC, TC, Right Heart CatheterizationRight Heart CatheterizationOB Ultrasound, such as: OB Ultrasound, such as: 76801, Ultrasound, 76801, Ultrasound, pregnant uterus, real time with image pregnant uterus, real time with image documentation, fetal and maternal evaluation, documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), first trimester (<14 weeks 0 days), transabdominal approachtransabdominal approachRadiological Supervision/Interpretation, such as: Radiological Supervision/Interpretation, such as: 7575675756--TC, Angiography, Internal MammaryTC, Angiography, Internal Mammary

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Test Supervision Compliance RisksTest Supervision Compliance Risks

►►Confusing the diagnostic test supervision Confusing the diagnostic test supervision rules and “incident to” rules and “incident to” –– tests must be tests must be supervised by a physician and supervision supervised by a physician and supervision by a NPP doesn’t meet the requirements.by a NPP doesn’t meet the requirements.

►►Complete unawareness that the supervision Complete unawareness that the supervision rules exist.rules exist.

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Quality Reporting in theQuality Reporting in thePhysician PracticePhysician Practice

►► The Centers for Medicare & Medicaid Services (“CMS”) has The Centers for Medicare & Medicaid Services (“CMS”) has launched quality improvement efforts focused on physicians. launched quality improvement efforts focused on physicians.

New exceptions and Safe Harbors supporting the donation of New exceptions and Safe Harbors supporting the donation of Electronic Prescribing and Electronic Health Record (“EHR”) Electronic Prescribing and Electronic Health Record (“EHR”) information technology and servicesinformation technology and servicesThe Physician Focused Quality InitiativeThe Physician Focused Quality Initiativesee: see: http://http://www.cms.hhs.gov/PhysicianFocusedQualInitswww.cms.hhs.gov/PhysicianFocusedQualInits//The Physician Quality Reporting Initiative (“PQRI”)The Physician Quality Reporting Initiative (“PQRI”)

►► Aims to financially reward physicians for adherence to Aims to financially reward physicians for adherence to accepted quality standards, not quantity of services rendered.accepted quality standards, not quantity of services rendered.

►► Reimbursement based on Reimbursement based on performanceperformance and and outcomesoutcomesquality measures.quality measures.

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What is PQRI?What is PQRI?

►► The President signed the Tax Relief and Health Care The President signed the Tax Relief and Health Care Act of 2006 (“TRHCA”), mandating establishment of a Act of 2006 (“TRHCA”), mandating establishment of a physician quality reporting system and authorizing a physician quality reporting system and authorizing a payment incentive. The payment incentive will be payment incentive. The payment incentive will be based on quality measures reported for care delivered based on quality measures reported for care delivered to Medicare beneficiaries July 1 through December 31, to Medicare beneficiaries July 1 through December 31, 2007. 2007.

►► For the period of July 1, 2007 through December 31, For the period of July 1, 2007 through December 31, 2007 a potential 1.5% incentive payment will be tied to 2007 a potential 1.5% incentive payment will be tied to reporting on these 74 quality measures.reporting on these 74 quality measures.

►► See See http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asphttp://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp

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PQRI FactsPQRI Facts

►► Through 2008 the incentive payment is based on Through 2008 the incentive payment is based on quality quality reportingreporting, not the actual results of the data , not the actual results of the data reportedreported

►► No incentive bonus will be paid to providers who No incentive bonus will be paid to providers who do not report on at least 80% of three applicable do not report on at least 80% of three applicable measures beginning July 1, 2007.measures beginning July 1, 2007.

Exception: Practices with only one or two applicable Exception: Practices with only one or two applicable quality measures need only report on the measures quality measures need only report on the measures that apply.that apply.

►► Sufficiency of reporting will be assessed based on Sufficiency of reporting will be assessed based on CPT and ICDCPT and ICD--9 coding. Certain combinations of 9 coding. Certain combinations of CPT/ICDCPT/ICD--9 Coding will constitute a 9 Coding will constitute a denominatordenominator for PQRI reporting purposes.for PQRI reporting purposes.

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PQRI ExamplePQRI Example

MeasureMeasure: Beta blocker at time of arrival for acute : Beta blocker at time of arrival for acute myocardial infarction.myocardial infarction.

NumeratorNumerator::G8009: Acute myocardial infarction: patient documented G8009: Acute myocardial infarction: patient documented

to to havehave received betareceived beta--blocker at arrival.blocker at arrival.G8010: Acute myocardial infarction: patient G8010: Acute myocardial infarction: patient notnot

documented to have received betadocumented to have received beta--blocker at blocker at arrival.arrival.

G8011: Clinician documented that acute myocardial G8011: Clinician documented that acute myocardial infarction patient was infarction patient was notnot an eligible candidate an eligible candidate for betafor beta--blocker at arrival measure.blocker at arrival measure.

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PQRI ExamplePQRI Example

DenominatorDenominator::Patients with acute myocardial infarction who Patients with acute myocardial infarction who present to hospital emergency department or present to hospital emergency department or are hospitalized as listed:are hospitalized as listed:Patients with acute myocardial infarction:Patients with acute myocardial infarction:ICDICD--9: 410.01, 410.11, 410.21, 410.31, 410.41, 9: 410.01, 410.11, 410.21, 410.31, 410.41, 410.51, 410.61, 410.71, 410.81, 410.91410.51, 410.61, 410.71, 410.81, 410.91AndAndED E&M: 99281ED E&M: 99281--99285; initial hospital care E&M: 99285; initial hospital care E&M: 9922199221--99223; observation: 9921899223; observation: 99218--99220, 99220, 9923499234--99236; critical care services: 9929199236; critical care services: 99291--9929299292

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PQRI ExamplePQRI Example

►► If the appropriate ICDIf the appropriate ICD--9 code is listed 9 code is listed andand the appropriate the appropriate E&M code is listed:E&M code is listed:

►► Three possible scenarios exist:Three possible scenarios exist:

(1) The patient receives beta(1) The patient receives beta--blocker at arrival blocker at arrival –– G8009 G8009

(2) The patient does (2) The patient does notnot receive betareceive beta--blocker at arrival blocker at arrival ––G8010G8010

(3) The patient is not an eligible candidate to receive beta(3) The patient is not an eligible candidate to receive beta--blocker at arrival blocker at arrival -- G8011G8011

Indicate the reason for G8011 using a modifier Indicate the reason for G8011 using a modifier

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Sample PQRI Feedback ReportSample PQRI Feedback Report

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PQRI Compliance RisksPQRI Compliance Risks

►►Lack of documentation in medical record to Lack of documentation in medical record to support quality measure reporting.support quality measure reporting.

Implementation of this concept is completely Implementation of this concept is completely foreign to most practices.foreign to most practices.

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Question and Answer Question and Answer SessionSession

►► John Belknap John Belknap -- JBELKNAP@PARTNERS.ORGJBELKNAP@PARTNERS.ORG

►► Jennie Campbell Jennie Campbell -- JCampbell@pyapc.comJCampbell@pyapc.com

►► Judith Waltz Judith Waltz -- jwaltz@foley.comjwaltz@foley.com

►► Lawrence W. Vernaglia Lawrence W. Vernaglia -- LVernaglia@foley.comLVernaglia@foley.com