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College of Medicine Office of Compliance, Gainesville, Florida
COMPLIANCE TIPFrequently Asked Questions
About the Services of Nurse Practitioners and Physician Assistants
Original issue May 4, 2001, Updated December 2007
ARNP and PA SERVICES
HOW ARNPs and PAs CAN BILL, AND OBTAIN A BILLING NUMBERQ: Should ARNPs or PAs obtain a billing number?
A: According to COM policy, ALL ARNPs and PAs involved in any patient care activities MUST obtain both Medicare and Medicaid provider numbers.
Q: What if we never intend to submit a bill in the PA or ARNP's name?
A: You must obtain a provider (billing) number for all PAs or ARNPs involved in clinical care as soon as (or before, if possible) the PA or ARNP is hired, even if no bill is ever intended to be submitted under the PA's or ARNP's name.
Q: How do ARNPs and PAs bill for services they perform without any direct physician involvement in the particular service - under their own billing numbers or the physician's billing number?
A: Either is acceptable. In an outpatient or physician office setting, ARNPs and PAs can bill "incident to" a physician's services, under the physician's UPIN number, when the "incident to" rules are met. Alternatively, in either inpatient or outpatient/physician office settings, they may bill under their own billing numbers at a reduced rate.
Q: How do ARNPs and PAs get their own billing number?
A: After obtaining the appropriate credentials, ARNPs and PAs must complete an application package furnished by the Faculty Group Practice. See your Departmental Administrator for an application package.
THE BASICS
Q. Are the rules for combined/split services for inpatient and outpatient services the same? (Services where both the physician and the ARNP/PA see the patient).
A. No. They are different! See sections below describing rules.
Q: What types of services can ARNPs and PAs perform?
A: All services may be performed and billed as long as those services fall within the scope of their practice.
Q: Do ARNPs and PAs billing under their own numbers on the inpatient or outpatient side need a physician co-signature on the chart for services or procedures they have performed?
A: No for ARNPs, but yes for PAs.
Q: What level (E/M) codes (inpatient and outpatient clinic visits) can ARNPs and PAs bill?
A: ARNPs and PAs can bill for all code levels when billing under their own billing numbers It is suggested that the ARNPs and PAs consider carefully whether the required high level of medical decision making necessary to meet the standard for level 4's and 5's are within the scope of their practice.
Q: Which E/M requirements must ARNPs and PAs follow - the 1997 exam requirements, or the 1995 exam requirements?
A: Either/or, which is the same rule for physicians. Please be aware, you may NOT combine the rules - you may not use sections of the 1995 rules with sections of the 1997 rules.
Q: Do ARNPs and PAs need to document their services according to CPT and Medicare guidelines?
A: Yes. The same as any physician would.
Q: When ARNPs or PAs bill under their own numbers, do modifiers need to be attached to the claim?
A: Yes, for example, when an E/M service and a procedure are done on the same day, the modifier -25 would need to be attached to the E/M service. The modifiers should be used the same way a physician would use them.
Q: Are pre-op physicals performed by ARNPs or PAs billable?
A: Yes, as long as (as with the physician) the service does not fall within the Medicare surgical global period. Medicare states that the global period begins within 24 hours of major surgery, the day of for minor surgery.
CAVEAT: If the visit is a scheduled pre-op it is not billable unless there is medical necessity documented for the visit; e.g., the patient's condition has changed and needs to be reevaluated.Q: Can a faculty physician utilize ARNPs' or PAs' documentation and/or services if they do not have an employment contract with that physician or group practice?
A: No, the ARNPs and PAs must be directly employed by the University of Florida or must have some other contractual relationship with the University.
INPATIENT SERVICES
INPATIENT SERVICES/HOSPITAL BASED CLINICS/EMERGENCY DEPARTMENT
The Hospital Based Clinics are:
The Bone Marrow Transplant Unit; the Hematology/Oncology Infusion center; and the Burn Unit For a physician to combine the E&M service with ARNP/PA for new patient or subsequent visits - and bill in the physician's number - the following conditions must be met:
Both the non-physician practitioner and the physician's notes must be SAME date Co-signature is NOT sufficient The Physician must provide a face-to-face portion of the E&M encounter with the patient and write a separate note: "I saw and evaluated the patient today. See today's PA/ARNP note" Physician's Signature & Date Do not use a macro to generate the note A physician MAY NOT COMBINE/SPLIT INPATIENT CONSULTS with an ARNP or PA and bill MEDICARE/GA MEDICAID/CHAMPUS in the physician's billing number. If the ARNP/PA participates in the service in any way, including dictating the note, then the service is considered combined/split.
[THERE IS NO "INCIDENT TO" in inpatient/hospital based clinic/emergency services - the physician must SEE
and provide a portion of the service to bill in the Physician's name and write/dictate a short note.]
OUTPATIENT SERVICES
There are only three hospital-based clinics -
The Burn Unit, the Bone Marrow Transplant Unit and Hematology/Oncology Infusion Center All other UF clinics are outpatient clinics
A Physician MAY NOT COMBINE/SPLIT the following services with an ARNP or PA and bill MEDICARE/GA MEDICAID/CHAMPUS in the physician's billing number for:
NEW PATIENT VISITS OR CONSULTATIONS NEW PROBLEMS in Established Patient Visits (does not meet "incident to") Medicare requires these combined/split E&M services be submitted under ARNP/PA number (85% rate) If ARNP/PA participates in service in any way, including dictating the note then the Service is considered combined If an ARNP or PA participates in the service, they MUST SIGN THE ENCOUNTER FORM Summary: if the non-physician practitioner is involved in same service as a physician in an outpatient clinic, there are two choices on how submit bill to Medicare:
1) bill under the physician's billing number if "incident to" rules are met, OR
2) if "incident to" rules are not met, then the bill must be submitted under the ARNP or PA's billing number.
Bills may be submitted to commercial payors in accordance with their contractual agreements, but Departments
MAY NOT REQUIRE providers to document differently for federal vs commercial payorsEncounter forms are being amended to indicate:
when an ARNP or PA was involved in a service and if a new patient, consultation, or a established patient with an new problem "Incident to" rules:
ESTABLISHED PATIENT and NOT A NEW PROBLEM The physician does NOT need to see patient, but MUST sign chart and MUST be present in clinic at time of service. Bill in the physician's provider number.
Medicare's "INCIDENT TO" rule applies to Outpatient Services Only
Q: Can ARNPs and PAs see new patients without the participation of a physician?
A: Yes, but Medicare rules state the ARNP or PA may ONLY bill under their own number and cannot bill under the physician's number when either 1) performing a service on their own or, 2) for outpatient services only, when combining or splitting an Evaluation and Management Service (E/M) with a physician for: a new patient; a consultation; or an established patient with a new problem; 3) for inpatient services only, when combining or splitting an inpatient consult with a physician. When combining E/M services with a physician that do not fall under the provisions of the "incident to" rules, the bill must be submitted under the name and provider number of the ARNP or PA. It is also important that the ARNP or PA always sign the encounter form when involved in a service.
Please be aware that commercial insurers' rules and, at present, most only pay for services submitted under a physician's billing number. Such distinctions are the function of billing personnel. Please note that we don't vary our DOCUMENTATION, we simply expect that billing is done pursuant to the Medicare standards unless there is a separate mechanism, approved by the Office of Compliance, in place.
Q: What requirements must be met in order to bill "incident to"?
A: The patient must be "established, a physician within the group practice must have established a plan of care or treatment, the ARNP or PA must be following that plan of care on subsequent visits, and the physician must periodically see the patient for the problem being followed.
Q: What is an "established patient"?
A: An established patient is one who has received professional services, within the past three years, from the physician, or another physician of the same specialty who belongs to the same group practice.
Q: What type of supervision requirements must be met in order to bill for ARNP or PA services as "incident to" under the physician's number?
A: The physician in the clinic the day the patient is seen provides direct supervision for the services rendered, and therefore the services are billed using this provider number. It need not be the physician that saw the patient initially. The College follows the Medicare documentation standard to ensure no bill is submitted to Medicare with insufficient documentation. However, please note that Florida Medicaid requires that the physician be on the premises and sign the medical record.
Q: Why is it important to distinguish "incident to"? Are there different rules for what can be billed?
A: Yes. "Incident to" applies ONLY to established patients with previously diagnosed problems seen in OUTPATIENT settings. In other words, only RETURN/ESTABLISHED PATIENT CODES can be billed. The physician is not required to see the patient on the "incident to" visit. Medicare states that documentation must show that the physician actively participated in the treatment and demonstrate management over the course of treatment.
Q: How do supervising physicians document their presence?
A: Generally, there is no requirement to specifically document the physician's presence in the clinic. Important: Several payors (including Medicaid) require the physician not only to be present, but also to sign the chart in order for the service to be billable. However, as stated below, the Physician must always sign the chart for PA services.
Q: When billing "incident to" does the physician need to co-sign the ARNP's or PA's note?
A: Because many (but not all) payors require a physician's signature, it is UF policy that physicians co-sign notes where services are billed in the physician's name. Physician signatures on charts are always required for PA's.
Q: Is "incident to" the only way ARNPs and PAs can bill for outpatient services provided?
A: No, ARNPs and PAs may also bill Medicare and Medicaid under their own billing (UPIN) number.Medicare now prohibits billing for the combined or split services of a physician and an ARNP or PA for outpatient E/M services for new patients, consultations, or established patients presenting with new problems in the physician's provider number.
Q: If you have a large group practice, should the ARNPs and PAs submit an "incident to" bill under the physician supervising for that day or should the bill be submitted under the name of the physician listed as the ARNP's or PA's supervisor?
A: Our physicians are part of a group practice, and therefore, "cover" each other's patients. The ARNPs and PAs should bill under the physician who is available to provide supervision and direction for the services being rendered (i.e., the physician who is present for that day in the clinic).
Q: With "incident to" billing, if the physician who initiated treatment for a patient is not in the office suite that day, can the ARNP or PA see that patient even though the initiating physician is not able to provide direct supervision?
A: The ARNP or PA may still see the patient "incident to" if another physician of the same group practice provides direct supervision for the ARNP or PA. The claim must be billed under the physician supervising the ARNP or PA that day.
ASSISTING AT SURGERY
Q: Can a PA assist at surgery when a qualified resident is involved in a surgical procedure(s) as well?
A: YES, provided the surgical procedure(s) requires an assistant, the PA has direct supervision by the faculty member(s) he or she is employed by, and the PA's services are not being billed by the hospital. The operative report would need to state that the PA's services were required. No modifier would need to be attached to the service, however, the type of service would need to be indicated on the claim form. The type of service is "8". The Medicaid reimbursement rate for a PA assisting at surgery varies.
Q: Can a ARNPs bill for assisting at surgery?
A: NO, Medicare will not reimburse for an ARNP assisting at surgery.
OTHER SERVICES
Q: Can ARNPs and PAs act as scribes for a physician??
A: Scribes only write what another person does. IMPORTANT: The term "scribe" DOES NOT APPLY when the person writing also performs professional services. The use of scribes is strongly discouraged and they may only be used when the term accurately applies.
Q. What provider number do I use for procedures performed in the clinic?
A. The bill is submitted under the provider number of the individual who personally performed the procedure for Federal payers.
DOCUMENTATION REQUIREMENTS FOR RESIDENTS
Q. I am a Teaching Physician and I work with PAs, ARNPs and Residents. Are the documentation requirements the same?
A. No; separate and distinct rules apply. The Teaching Physician documentation requirements apply to services that involve Teaching Physicians and Residents. Both sets of rules are now the focus of government enforcement action, and therefore it is important that the distinctions are clearly understood.
If you have any questions about this tip, or another compliance concern,
the Office of Compliance for the College of Medicine is here for you.
Please call (352) 265-8359 or e-mail Nina Tarnuzzer at nwt@ufl.edu.
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| Webmaster<ahagan@dean.med.ufl.edu>College of Medicine, Office of Compliance This page created February 02, 2004. Updated December 17, 2007 Please read our disclaimer and permitted use statement. |
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