Coding and Billing
Determining Who Has the Authority to Bill
September 2004
Q: Our office performs laser treatments for psoriasis. We actually have a relatively large practice since we are one of the few dermatology practices in the area that is willing to treat psoriatic patients. We are a practice that employs two physician assistants with one owner M.D. We also have several LPNs and RNs who have been specially trained and have certification to perform psoriasis phototherapy. Since we have such a variety of healthcare providers treating our psoriasis patient population, we have several questions related to how we should bill for services:
1. If the physician is not on-site, but we have our certified nurses (for example, LPNs, RNs) render the care to our patients, can we can bill under one of the two PAs who is on-site at the time the patients are treated? (We bill CPT codes 99211 and 96920.)
2. If neither the physician nor either of the two PAs is on-site, do we bill under the RN's name and our group number? (We have several satellite offices, and the three providers rotate through the satellite locations. However, our light boxes and lasers for all of our psoriasis treatments are at our main office.)
3. If neither the physician, the PAs or the RN is onsite, do we bill under the LPN's name and our group number?
Since this is a large portion of our practice income, we want to optimize our revenues with the carriers.
A: There are so many issues to address in these questions that it’s hard to make a reasonable guess about where to start. However, I’ll start with the billing of the E/M visit 99211.
When to Bill the 99211
You can’t automatically assume that just because an ancillary staff member is seeing a patient that a 99211 is warranted. It is, after all, an “evaluation and management” service. What that means is that the staffer must evaluate something and manage something.
Many physicians are confused and believe that the involvement of the nurse in the procedure is what justifies the visit — and that is incorrect. For example, if a patient is receiving PUVA therapy and the nurse helps the patient to get undressed and put on the protective goggles, assists the patient into the light box, and then turns on the machine, this does not justify an E/M visit (for example, 99211). It’s why in cases like these that the physician gets paid 96912.
Below, I’ve included a summary of what justifies the billing of an E/M visit by a nurse in conjunction with a procedure.
If a medical assistant or nurse is responsible for “prepping” a patient for the light box or for photodynamic therapy, it’s not uncommon for the nurse to ask a few questions such as the following:
1. Mrs. Jones, have you noticed any improvement since your last treatment?
2. Do you feel the areas of involvement are getting smaller?
3. Did you experience any discomfort after the last treatment?
4. Are you using your topical medications as prescribed by the physician?
5. Are you getting any natural sunlight exposure?
Notating issues such as these helps to support a portion of the 99211 visit.
It’s equally as common for a nurse to perform a post-treatment evaluation. The more experienced nurse can evaluate a patient’s skin immediately after exposure to make sure that no adverse effects are evident and to assess the patient’s response to the therapy.
Finally, the nurse can reiterate site care instructions and assess compliance with adjunctive therapies and note these in the chart.
All of these things work together to justify billing of an E/M visit by a nurse in conjunction with a procedure.
Billing a Nurse Visit to Insurance When There’s No Physician On-site
In a practice with only physicians (no physician assistants [PAs] or non-physician providers [NPPs]), one of the physicians must be on-site if a nurse or medical assistant administers treatment such as laser or photodynamic therapy, as examples of some of the procedures in question. If none of the physicians is present in the office, these nurse services cannot be billed to third-party payers.
Medicare has new filing instructions that now require staff members who perform billing to identify both the physician who orders the service for the patient as well as the physician who is actually on-site during the patient encounter and supervises the procedure performed by ancillary staff.
The New Regulations
1. When the ordering and the supervising physician or provider are different individuals, the ordering provider’s name goes in box 17 of the CMS-1500 form.
2. When the ordering and the supervising physician or provider are different individuals, the ordering provider’s UPIN, not his/her PIN, goes in 17A.
3. Ordering and supervising providers can also be PAs, nurse practitioners (NPs) or certified nurse specialists (CNSs). Of course, the scope of what these three types of non-physician providers (NPPs) can do depends on the scope of practice laws for each U.S. state.
In those instances where the PA, NP or CNS is the supervising provider, the rules of incident-to billing must be followed. Most importantly, all physicians and non-physician providers must be in the same group practice.
4. When the person who ordered the service is not supervising, enter the PIN of the supervisor in 24K.
Important to Remember: If no physician is on-site (and the practice has no PAs or NPs), the visit can’t be billed to any third-party payer.
Can PAs and NPs Supervise Staff When No Physician Is On-site?
As stated above in point number four, yes, PAs and NPs can supervise ancillary staff as long as the incident-to rules are strictly adhered to. Each state regulates what PAs and NPs can and can’t do, so carefully investigate and understand the scope of practice laws for your state before you engage in any billing.
After you’re comfortable with state laws, you then need to verify in writing the rules and restrictions of your contracted carriers. Each carrier has different views regarding non-physician providers.
If you have a green light from your state, Medicare carriers allow PAs and NPs to supervise ancillary staff. However, the PA or NP must be billed under his or her own Medicare PIN number, and, of course, the practice’s group name and number must appear in block 33.
LPN and RN Billing to Third-Party Payers
If your practice provides medical services to patients (regardless of the location), and no supervising physician or non-physician provider (PA or NP) is present, those services can not (I repeat, can not) be billed to any insurance carrier. This is considered a false claim and has serious ramifications under the Federal False Claims Act. If you have problems getting adequate coverage from your providers at all the locations in which you provide care, you have several choices:
1. Stop providing the services.
2. Send the patients to the location(s) where there is appropriate physician/ provider supervision.
3. Don’t bill for the services. (You still assume the medical legal risks if something goes wrong. Also, some states have laws that absolutely prohibit such scenarios.)
4. Keep doing it, and be prepared to face the consequences (fines, sanctions, loss of medical license, prison).
Q: Our office performs laser treatments for psoriasis. We actually have a relatively large practice since we are one of the few dermatology practices in the area that is willing to treat psoriatic patients. We are a practice that employs two physician assistants with one owner M.D. We also have several LPNs and RNs who have been specially trained and have certification to perform psoriasis phototherapy. Since we have such a variety of healthcare providers treating our psoriasis patient population, we have several questions related to how we should bill for services:
1. If the physician is not on-site, but we have our certified nurses (for example, LPNs, RNs) render the care to our patients, can we can bill under one of the two PAs who is on-site at the time the patients are treated? (We bill CPT codes 99211 and 96920.)
2. If neither the physician nor either of the two PAs is on-site, do we bill under the RN's name and our group number? (We have several satellite offices, and the three providers rotate through the satellite locations. However, our light boxes and lasers for all of our psoriasis treatments are at our main office.)
3. If neither the physician, the PAs or the RN is onsite, do we bill under the LPN's name and our group number?
Since this is a large portion of our practice income, we want to optimize our revenues with the carriers.
A: There are so many issues to address in these questions that it’s hard to make a reasonable guess about where to start. However, I’ll start with the billing of the E/M visit 99211.
When to Bill the 99211
You can’t automatically assume that just because an ancillary staff member is seeing a patient that a 99211 is warranted. It is, after all, an “evaluation and management” service. What that means is that the staffer must evaluate something and manage something.
Many physicians are confused and believe that the involvement of the nurse in the procedure is what justifies the visit — and that is incorrect. For example, if a patient is receiving PUVA therapy and the nurse helps the patient to get undressed and put on the protective goggles, assists the patient into the light box, and then turns on the machine, this does not justify an E/M visit (for example, 99211). It’s why in cases like these that the physician gets paid 96912.
Below, I’ve included a summary of what justifies the billing of an E/M visit by a nurse in conjunction with a procedure.
If a medical assistant or nurse is responsible for “prepping” a patient for the light box or for photodynamic therapy, it’s not uncommon for the nurse to ask a few questions such as the following:
1. Mrs. Jones, have you noticed any improvement since your last treatment?
2. Do you feel the areas of involvement are getting smaller?
3. Did you experience any discomfort after the last treatment?
4. Are you using your topical medications as prescribed by the physician?
5. Are you getting any natural sunlight exposure?
Notating issues such as these helps to support a portion of the 99211 visit.
It’s equally as common for a nurse to perform a post-treatment evaluation. The more experienced nurse can evaluate a patient’s skin immediately after exposure to make sure that no adverse effects are evident and to assess the patient’s response to the therapy.
Finally, the nurse can reiterate site care instructions and assess compliance with adjunctive therapies and note these in the chart.
All of these things work together to justify billing of an E/M visit by a nurse in conjunction with a procedure.
Billing a Nurse Visit to Insurance When There’s No Physician On-site
In a practice with only physicians (no physician assistants [PAs] or non-physician providers [NPPs]), one of the physicians must be on-site if a nurse or medical assistant administers treatment such as laser or photodynamic therapy, as examples of some of the procedures in question. If none of the physicians is present in the office, these nurse services cannot be billed to third-party payers.
Medicare has new filing instructions that now require staff members who perform billing to identify both the physician who orders the service for the patient as well as the physician who is actually on-site during the patient encounter and supervises the procedure performed by ancillary staff.
The New Regulations
1. When the ordering and the supervising physician or provider are different individuals, the ordering provider’s name goes in box 17 of the CMS-1500 form.
2. When the ordering and the supervising physician or provider are different individuals, the ordering provider’s UPIN, not his/her PIN, goes in 17A.
3. Ordering and supervising providers can also be PAs, nurse practitioners (NPs) or certified nurse specialists (CNSs). Of course, the scope of what these three types of non-physician providers (NPPs) can do depends on the scope of practice laws for each U.S. state.
In those instances where the PA, NP or CNS is the supervising provider, the rules of incident-to billing must be followed. Most importantly, all physicians and non-physician providers must be in the same group practice.
4. When the person who ordered the service is not supervising, enter the PIN of the supervisor in 24K.
Important to Remember: If no physician is on-site (and the practice has no PAs or NPs), the visit can’t be billed to any third-party payer.
Can PAs and NPs Supervise Staff When No Physician Is On-site?
As stated above in point number four, yes, PAs and NPs can supervise ancillary staff as long as the incident-to rules are strictly adhered to. Each state regulates what PAs and NPs can and can’t do, so carefully investigate and understand the scope of practice laws for your state before you engage in any billing.
After you’re comfortable with state laws, you then need to verify in writing the rules and restrictions of your contracted carriers. Each carrier has different views regarding non-physician providers.
If you have a green light from your state, Medicare carriers allow PAs and NPs to supervise ancillary staff. However, the PA or NP must be billed under his or her own Medicare PIN number, and, of course, the practice’s group name and number must appear in block 33.
LPN and RN Billing to Third-Party Payers
If your practice provides medical services to patients (regardless of the location), and no supervising physician or non-physician provider (PA or NP) is present, those services can not (I repeat, can not) be billed to any insurance carrier. This is considered a false claim and has serious ramifications under the Federal False Claims Act. If you have problems getting adequate coverage from your providers at all the locations in which you provide care, you have several choices:
1. Stop providing the services.
2. Send the patients to the location(s) where there is appropriate physician/ provider supervision.
3. Don’t bill for the services. (You still assume the medical legal risks if something goes wrong. Also, some states have laws that absolutely prohibit such scenarios.)
4. Keep doing it, and be prepared to face the consequences (fines, sanctions, loss of medical license, prison).
Q: Our office performs laser treatments for psoriasis. We actually have a relatively large practice since we are one of the few dermatology practices in the area that is willing to treat psoriatic patients. We are a practice that employs two physician assistants with one owner M.D. We also have several LPNs and RNs who have been specially trained and have certification to perform psoriasis phototherapy. Since we have such a variety of healthcare providers treating our psoriasis patient population, we have several questions related to how we should bill for services:
1. If the physician is not on-site, but we have our certified nurses (for example, LPNs, RNs) render the care to our patients, can we can bill under one of the two PAs who is on-site at the time the patients are treated? (We bill CPT codes 99211 and 96920.)
2. If neither the physician nor either of the two PAs is on-site, do we bill under the RN's name and our group number? (We have several satellite offices, and the three providers rotate through the satellite locations. However, our light boxes and lasers for all of our psoriasis treatments are at our main office.)
3. If neither the physician, the PAs or the RN is onsite, do we bill under the LPN's name and our group number?
Since this is a large portion of our practice income, we want to optimize our revenues with the carriers.
A: There are so many issues to address in these questions that it’s hard to make a reasonable guess about where to start. However, I’ll start with the billing of the E/M visit 99211.
When to Bill the 99211
You can’t automatically assume that just because an ancillary staff member is seeing a patient that a 99211 is warranted. It is, after all, an “evaluation and management” service. What that means is that the staffer must evaluate something and manage something.
Many physicians are confused and believe that the involvement of the nurse in the procedure is what justifies the visit — and that is incorrect. For example, if a patient is receiving PUVA therapy and the nurse helps the patient to get undressed and put on the protective goggles, assists the patient into the light box, and then turns on the machine, this does not justify an E/M visit (for example, 99211). It’s why in cases like these that the physician gets paid 96912.
Below, I’ve included a summary of what justifies the billing of an E/M visit by a nurse in conjunction with a procedure.
If a medical assistant or nurse is responsible for “prepping” a patient for the light box or for photodynamic therapy, it’s not uncommon for the nurse to ask a few questions such as the following:
1. Mrs. Jones, have you noticed any improvement since your last treatment?
2. Do you feel the areas of involvement are getting smaller?
3. Did you experience any discomfort after the last treatment?
4. Are you using your topical medications as prescribed by the physician?
5. Are you getting any natural sunlight exposure?
Notating issues such as these helps to support a portion of the 99211 visit.
It’s equally as common for a nurse to perform a post-treatment evaluation. The more experienced nurse can evaluate a patient’s skin immediately after exposure to make sure that no adverse effects are evident and to assess the patient’s response to the therapy.
Finally, the nurse can reiterate site care instructions and assess compliance with adjunctive therapies and note these in the chart.
All of these things work together to justify billing of an E/M visit by a nurse in conjunction with a procedure.
Billing a Nurse Visit to Insurance When There’s No Physician On-site
In a practice with only physicians (no physician assistants [PAs] or non-physician providers [NPPs]), one of the physicians must be on-site if a nurse or medical assistant administers treatment such as laser or photodynamic therapy, as examples of some of the procedures in question. If none of the physicians is present in the office, these nurse services cannot be billed to third-party payers.
Medicare has new filing instructions that now require staff members who perform billing to identify both the physician who orders the service for the patient as well as the physician who is actually on-site during the patient encounter and supervises the procedure performed by ancillary staff.
The New Regulations
1. When the ordering and the supervising physician or provider are different individuals, the ordering provider’s name goes in box 17 of the CMS-1500 form.
2. When the ordering and the supervising physician or provider are different individuals, the ordering provider’s UPIN, not his/her PIN, goes in 17A.
3. Ordering and supervising providers can also be PAs, nurse practitioners (NPs) or certified nurse specialists (CNSs). Of course, the scope of what these three types of non-physician providers (NPPs) can do depends on the scope of practice laws for each U.S. state.
In those instances where the PA, NP or CNS is the supervising provider, the rules of incident-to billing must be followed. Most importantly, all physicians and non-physician providers must be in the same group practice.
4. When the person who ordered the service is not supervising, enter the PIN of the supervisor in 24K.
Important to Remember: If no physician is on-site (and the practice has no PAs or NPs), the visit can’t be billed to any third-party payer.
Can PAs and NPs Supervise Staff When No Physician Is On-site?
As stated above in point number four, yes, PAs and NPs can supervise ancillary staff as long as the incident-to rules are strictly adhered to. Each state regulates what PAs and NPs can and can’t do, so carefully investigate and understand the scope of practice laws for your state before you engage in any billing.
After you’re comfortable with state laws, you then need to verify in writing the rules and restrictions of your contracted carriers. Each carrier has different views regarding non-physician providers.
If you have a green light from your state, Medicare carriers allow PAs and NPs to supervise ancillary staff. However, the PA or NP must be billed under his or her own Medicare PIN number, and, of course, the practice’s group name and number must appear in block 33.
LPN and RN Billing to Third-Party Payers
If your practice provides medical services to patients (regardless of the location), and no supervising physician or non-physician provider (PA or NP) is present, those services can not (I repeat, can not) be billed to any insurance carrier. This is considered a false claim and has serious ramifications under the Federal False Claims Act. If you have problems getting adequate coverage from your providers at all the locations in which you provide care, you have several choices:
1. Stop providing the services.
2. Send the patients to the location(s) where there is appropriate physician/ provider supervision.
3. Don’t bill for the services. (You still assume the medical legal risks if something goes wrong. Also, some states have laws that absolutely prohibit such scenarios.)
4. Keep doing it, and be prepared to face the consequences (fines, sanctions, loss of medical license, prison).
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