Using your NPP as part of a team can bring special billing challenges for hospital visits

Last month we shared some ideas of creative ways to increase productivity, income, and patient satisfaction in your practice by upping the utilization of NPPs. In response to some of your questions, here is a follow-up article of things you need to know on the billing side of those practice-building ideas.

Specifically, let's look at using your NPP to aid with hospital rounds, consults, admissions and discharges, and how you should - and should not - be billing it to Medicare.

But first - three exceptions.

Of course, Medicare rules only apply to Medicare billing. Although many commercial insurers do follow some or all of the Medicare guidelines, some do not. When billing services to your commercial insurers, check into their billing policies. You may be able to be reimbursed for services by commercial insurers that Medicare won't reimburse.

And - you may decide, especially if you are part of a very large group practice with several business lines, that your NPP's time-saving role is worth more to you than Medicare reimbursement for a specific service.

If an NPP doing a job "earns" you more money than billing it to Medicare, then you don't need to apply the Medicare billing rules to that service - just don't bill it to Medicare.

Of course, even if you decide to not bill a service, any clinician doing the service would have to stay within his state scope of practice, always.

Last, you can bill Medicare for the combined E/M work of a physician and an NPP only if you bill the service using 99499 - unspecified service - and send in all the documentation to your carrier along with the claim. This process is very time-consuming and often results in carrier rejections.

That said, one of the most important rules to remember when you want to integrate your physician and NPP services is: You cannot bill Medicare for the combined E/M work of an NPP and a physician to support billing one E/M service (unless you use 99499).

Running a close second is that there is no incident-to billing in a hospital setting. If you are billing a service done in the hospital under the physician's PIN, the physician must do the service - all of it.

Both rules are key to understanding the billing requirements for NPPs and physicians doing hospital rounds, consults, admissions and discharges. For our examples, we'll talk about nurse practitioners, since their scopes of practice are most likely to include all of these services.

Rounds: There are several good, billable ways to integrate your nurse practitioner into doing hospital rounds, says consultant Quin Buechner, Cumberland, Wis.

1. Your NPP can alternate days with the physician doing rounds in the hospital, and you can bill it under the NPP's PIN.

2. You can have your NPP do all the rounds, with the physician doing the orders. You can only bill for the NPP piece based on the extent of the hx, exam and/or decision making, but you may see cost savings in the time the NPP gives to the physician. If you were to bill the physician only, you would have to bill at the level documented. Orders alone would probably not be enough. Writing orders alone do not constitute the elements of history, exam and/or decision making required for a hospital E/M.

3. If the services are being billed under the global fee for a surgery, the surgeon could turn over most of the post-op care to the nurse practitioner, and save time that way. The physician would see the patient for the first post-op visit, then the NPP could do follow-up visits, with the physician returning as needed.

Consults: Some states allow NPPs, especially nurse practitioners or certified nurse midwives, to do consults. If that's the case, an NPP can do a consult and bill under his own PIN, which might be more cost effective than having a physician do it, says Jan Rasmussen, head of Professional Coding Solutions, Eau Claire, Wis.

An NPP could collaborate with a physician on a consult, but you cannot bill that to Medicare. NPPs and physicians can share jobs, but they cannot share bills, Rasmussen stresses.

Admissions: There are several sticking-points on NPPs doing hospital admissions, not the least of which is that many hospitals do not give NPPs admitting privileges, says Rasmussen. They can assist the physician with the required work elements of an admission, but only to a certain extent.

To support the E/M level of an admit (or a consult), there must be documentation that the physician (or qualified NPP) performed all of the history, the exam, and the medical decision making, 3-of-3. If the physician just comes in and makes the decisions after the NPP has done the exam and the history, then you cannot bill that service to Medicare unless you bill 99499. Assuming, of course, that the NPP is allowed to contribute to the admit by State and Hospital rules.

For an admission or consult, an NPP could speed things up by doing the review of systems (ROS) and the past family and social history (PFSH), says Buechner, but those tasks would not really require the skills of an NPP.

Discharges:As with admits, NPs or PAs are able to do discharges at some hospitals, but you need to check. If they are allowed to do discharges by hospital and state rules, then bill it to Medicare under the NPP's PIN.

Another way to have an NPP help with hospital discharges is to have her dictate the discharge summary (hospital administrative requirement) of the patient's stay at the hospital. The physician, however, still needs to put a progress note in the patient's chart indicating that he saw the patient face-to-face on the day of discharge and personally completed the discharge work (other than dictating the formal discharge summary required by the hospital) says Rasmussen. Of course, to use the higher level discharge code the doc would have to document over 30 minutes of his/her personal time.

But be careful with this. One hospital Rasmussen worked with thought it would be a good idea to assign an NPP or PA to do this job. The problem was that the physician seemed to think that this then freed him of any day of discharge documentation. One doctor working at that hospital never documented he saw his patients face-to-face to complete the discharge. The doctor will have to refund Medicare about four years worth discharge billings.

OVERALL: Be careful how your practice defines "collaboration." It's better to look at it as qualified people doing different jobs, rather than different people contributing to the same job - especially if you're billing Medicare.