The top 10 must-do's for billing NP services

Rules on billing are complicated. However, often it is a failure to attend to the basics that causes lost revenues. In order for a nurse practitioner (NP) or physician to receive third-party payment:

The clinician must be enrolled with the payer (Medicare, Medicaid, commercial managed care organization (MCO) or commercial indemnity insurer). The patient's coverage must be current.

The payer's rules and process must be followed.

Often, the approval of the designated Primary Care Provider (PCP) must be obtained.

The service must be one that is medically necessary.

The claim must be "clean;" i.e. appropriate CPT (Current Procedural Terminology) and ICD (International Classification of Diseases) codes and correct patient information.

The top 10 things a clinician must attend to, to get paid fairly, are:

1. Get credentialed and/or admitted to the provider panel of the organization paying the bill. Medicare and Medicaid authorize NPs to bill for physician services. Some health plans are admitting some NPs to provider panels. Some are not, but allow an NP's work to be billed under the name of a physician. To get paid, or for an NP's employer to be paid, an NP needs to either be approved as a provider (have a provider number if the payer is Medicare or Medicaid) or the NP or billing staff must ascertain that the organization will pay the bill if a NP performs the service and it is billed under a physician's name.
2. Ascertain that the patient is covered by a third-party payer, or that the patient agrees to pay the bill himself. Each card from an insurer or health plan has a telephone number for a practice or facility to call to determine whether coverage is current. Each practice should have a system for checking the validity of coverage, and for getting patients to sign a document in which they agree to pay the bill if their coverage is not valid.
3. Ascertain that the service the clinician is providing is covered by the patient's insurance, or that the patient agrees to pay the bill himself. Payers differ, rather significantly, regarding the services they will pay for. For example, virtually all commercial managed care plans pay for preventive visits, but Medicare does not (with a few exceptions). Telephone advice is generally not reimbursed under fee-for-service arrangements. Few, if any, third party payers pay for e-mail advice, but nothing precludes a clinician from charging a patient for e-mail advice, as long as the patient knows he or she must pay the bill and has signed any forms required by the patient's insurer (for example, an Advance Beneficiary Notice, in the case of Medicare).
4. Document a physician service, consistent with the requirements stated in Current Procedural Terminology for the current year and the "Documentation Guidelines for Evaluation and Management," 1995 or 1997 versions, from the Center for Medicare and Medicaid Services, www.cms.hhs.gov. To avoid a demand for repayment of monies already paid (if audited), meet all of the criteria for billing evaluation and management and document what was done, for each visit. Review the first 35 pages of Current Procedural Terminology for the current year, every year. The elements of evaluation and management are history-taking, examination, medical decision-making, coordination of care, and counseling. At minimum, for an established patient, a clinician must document history and examination with enough detail so that the following criteria are met:
   
   

   Visit level	History	Examination	Diagnoses
   Level 1	0	0	1 medical problem
   Level 2	1 descriptor	1 element	1 medical problem
   Level 3	1 descriptor, 1 review of systems element	6 elements	2 minor medical problems, or 1 stable chronic illness, or 1 acute uncomplicated illness or injury
   Level 4	4 descriptors, 2 review of systems elements, 1 element of past, family or social history	12 elements	1 chronic disease with mild exacerbation, or 2 stable chronic illnesses or 1 acute illness with systemic symptoms, or 1 acute complicated injury
   Level 5	4 descriptors, 10 review of systems elements, 2 elements of past, family or social history	18 elements from 9 body systems	1 chronic illness with severe exacerbation, or 1 illness or injury with threat to life

   
   
5. Select and include on the claim form, one or more appropriate CPT codes. If a procedure and a significant, separately identifiable evaluation and management service is performed by the same clinician on the same day as the procedure, bill the CPT code for the procedure and use a modifier -25 with the CPT code for the evaluation and management service on the claim form. For example, if performing a joint injection, and it is necessary to examine the extremity before performing the procedure, bill the CPT code for the injection and the CPT code for the E&M service, with -25 added to the CPT code for the E&M service. If the service performed will qualify as both a preventive service and evaluation and management, the clinician may choose to bill one or the other. In this situation, there is nothing wrong with billing the visit for which the reimbursement is best, as long as the service provided fits the CPT code description and the documentation is appropriate.
6. Select one or more appropriate ICD codes. Payers insist that clinicians submit an ICD-9 code which indicates the medical necessity of the service performed, and that the ICD code include the appropriate number of digits. For example, for the diagnosis diabetes, include 5 digits. For multiple sclerosis, only 3 digits are required.
7. Follow the payer's rules for billing under a physician's name, if that is what the practice is doing. Some payers, such as Medicare, allow a practice to bill a service performed by a NP under a physician's name, and get a higher payment, if certain rules (incident-to rules or shared billing rules) are followed. Some payers will pay for a service performed by a NP but billed under a physician's name as long as the physician and NP have a contractual or employment relationship. For each payer billed, determine what that payers' rules are, and follow them.
8. Read carefully the terms of any contract a managed care company offers the practice and attempt to negotiate better terms. Once the contract is signed, follow its terms and the accompanying policies and insist that the company follow the contract and its own policies. Sometimes payers don't follow their own rules. If the payer is Medicare or Medicaid read the rules related to the clinician performing the service, the service, the setting, and the documentation requirements. If Medicare or Medicaid is not following its own rules, call the Provider Relations Office or the Medicare Carrier's Provider Education Office, explain the situation, and follow the process to appeal or complain.
9. If dealing with commercial payers, negotiate a decent fee schedule. If dealing with Medicare and Medicaid, take the time to learn how those fees are set, and the process by which those fees can be raised. Fee schedules may not be fair, but they are negotiable, if one a) asks for a raise, b) explains why the raise is justified, and c) threatens to withdraw something the company wants if they don't come through with a raise.
10. Bill all medically necessary services, drugs and devices. It is easy to forget to bill a medication, the administration of an injection, a urinalysis, or a separately identifiable service performed on the same day as another service. Don't let money slip through your fingers.

Copyright 2006, Carolyn Buppert
This article is taken from The Green Sheet, published monthly from the Law Office of Carolyn Buppert. To order, click here. For more detail on billing nurse practitioner services, see "Billing Physician Services Provided by Nurse Practitioners is Specialists' Offices, Hospitals, Nursing Facilities, Homes and Hospice." To order, click here.

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