Volume 2, Issue 9 September 2004
“Welcome to Medicare” AAPC Seminar
Lisa Oswald Shelli Martin
At one time Medicare never paid for a routine The Show-Me Chapter AAPC Seminar
physical exam. Now with the proposed 2005 Committee is proud to announce our upcoming
physician fee schedule, Medicare will allow annual seminar.
reimbursement for a preventive exam for all When: September 17, 2004 - Lenoir Community
new Medicare patients if performed within six Center 8:30 am - 4:00 pm.
months of the date the patient enters the Lunch provided.
program. The ‚Welcome to Medicare‛ exam
will be reported using a temporary ‚G‛ code Where: Lenoir Community Center
that is due to come online January 1, 2005 and Theme: Change is Inevitable
will include a new patient office visit (99203)
Motivational Speaker: Dr. Daniel Kopp
and an EKG (93000). Other provisions of the
proposed rule would pay for cardiovascular Keynote Speaker: Elizabeth Jordan from
and diabetes screenings. CMS says the PricewaterhouseCoopers LLP.
Medicare Modernization Act (MMA) does not Topics:
allow for the waiver of co-pays and deductibles,
so those will need to be collected from the Review and Revise Documentation and
beneficiary. ¤ Reporting Tools
Prepare for the 2005 Physician Fee
Gear up for FY2005 ICD-9-CM
Identify and Correct Aberrant Billing
I5 SIDE THIS ISSUE
We plan to host a panel of experts in the
2 Director’s Column afternoon session that will include the above
named speakers, as well as, a Medicaid
2 Coding Q&A representative and an Attorney. 6.5 CEU's will
be awarded to each attendee.
3 Resident Consults
If you are interested, please call Gere Harmon,
CPC, CCP at 884-3703 or Shelli Martin, CPC,
3 NPP’s and the Collaborative Practice Agreement
CCP 882-6442 for a registration form.
Also, if you would like to submit questions to
6 Modifier 59
the panel prior to the seminar, please send
those to Gere or Shelli.¤
Compliance Corner 1
I often get questions about using a disclaimer on e-mail or faxes, etc. The General Counsel's
Office advises that these disclaimers have little value from a liability or legal standpoint, but
they not object to our use of one. The State of Missouri has offered a standard disclaimer for
all agencies to use, and I recommend it for your use, as you see fit.
"This electronic communication is from (department or individual) and is confidential,
privileged and intended only for the use of the recipient named above. If you are not the
intended recipient or the employee or agent responsible for delivering this information to
the intended recipient, unauthorized disclosure, copying, distribution or use of the contents
of this transmission is strictly prohibited. If you have received this message in error, please
return the material received to the sender and delete all copies from your system.¤
Coding Q & A
Question: If the physician has to leave the room for a few minutes during an office visit
performed in a teaching physician (TP) setting, does that mean that we cannot bill under the
Answer: The teaching physician, who sees the patient separately from the resident, can tie
into the resident note. He need not redocument those key components that he agrees;
however, he/she is encouraged to add any additional information needed for the continuing
care of the patient.
Example: In the scenario, a resident is performing a level four evaluation and
management (E/M) service on an established 5-year-old patient under TP supervision. The
TP gets an urgent call from his daughter and leaves the room for a brief time while the
resident is monitoring the patient’s vital signs, then returns for the rest of the visit. In this
scenario, the TP may document for joint service with the resident.
You should: Report 99214 (office or other outpatient visit for the evaluation and
management of an established patient, which requires at least two of these three key
components: a detailed history; a detailed exam; medical decision making of moderate
complexity) Attach modifier –GC (this service has been performed in part by a resident
under the direction of a teaching physician) to show that the service was rendered under TP
guidelines. The teaching physician must document that he was present and that he/she was
directly involved in the management of the patient. The TP note should reference the
resident's note by name and date (if not connected to the resident's note). Along with the
GC modifier, for payment the composite of the TP's entry and the resident's entry must
support the medical necessity and the level of service billed by the TP. ¤
Compliance Corner 2
Reimbursement for a Resident Consult
It’s the weekend. A patient presents to the ED and is referred to a resident physician for a consult.
Can we bill for that? CMS says a resident may perform some or all of the required elements of the
service in the absence of the teaching physician. However, the teaching physician must then
personally see the patient, independently perform the critical or key portions of the service, and
participate in the management of the patient.
If, in the scenario above, the patient is admitted then the teaching physician may satisfy these
requirements the following day, for example. However, if the patient is not admitted, then the
teaching physician would not be able to satisfy the requirements necessary to bill for the consult
service unless he or she actually comes in to the emergency department and personally performs the
required services before the patient leaves. ¤
NPP’s and the Collaborative Practice Arrangement
Many of our readers attended an educational session presented by Quinten Buechner, president of
ProActive Consultants, LLP. The topic of this session was billing and documentation for Non
Physician Practitioners, commonly referred to as NPP.
In this presentation, we were introduced to the complexity of NPP compliance and reimbursement
issues associated with regulatory guidance by Centers for Medicare and Medicaid Services (CMS) and
Missouri State Regulations.
In CMS Transmittal 1776, published October 25, 2002 state that Medicare will pay for Evaluation and
Management (E/M) services for specific non-physician practitioners to include nurse practitioners
(NP), clinical nurse specialist (CNS), certified nurse midwife (CNM) and physician assistant (PA).
CMS also states that the services must be medically necessary and the service must be within the
scope of practice for the NPP in the State in which he/she practices.
Missouri State Regulations 4 CSR 200-4:
A NP is required under Missouri State regulations to have a collaborative agreement with a physician.
A collaborative agreement refers to a written agreement, jointly agreed upon protocols or standing
orders, of which will be in writing for the delivery of health care services. The physician will consider
the level of skill, education, training and competence of the collaborating NPP to ensure that the
delegated responsibilities contained in the collaborative practice arrangement are consistent with that
level. The collaborating physician is required to supervise or review the NP’s work, records and
practice of the health care delivered at least every 2 weeks. This review will be documented by the
collaborating physician. The State regulation is not specific on how to document these reviews. Our
office has recommended documenting reviews one of the three ways below:
Compliance Corner 3
A simple co-signature of the collaborating physician on the NP’s note. (Co-signature indicates
agreement with the note).
Within a week or 2-week period, a list of patients seen by the NP would be discussed by both
the collaborating physician and the NP. The collaborating physician would then make notes
and sign this document. This list would be kept for reference.
The NP and the collaborating physician have a regularly scheduled meeting weekly or bi-
monthly to discuss patients seen by the NP. The discussion would be documented and signed
by the collaborating physician. These minutes would be retained for reference.
The physician may not supervise more than three NPPs at any one time.
Services Furnished in the Clinic Setting:
In a provider-based clinic, the NP may submit claims to Medicare and most other parties using
their NP billing number (UPIN/PIN). Medicare will reimburse at 85% of the allowed fee
schedule for physicians.
In Transmittal 1776, CMS describe shared visits. In hospital outpatient setting, an E/M is
shared between the NP and collaborating physician from the same group practice, the
physician must render a portion of face-to-face time (service) with the patient, the service may
be billed under either the physician’s or the NP’s UPIN/PIN number. However is there is no
face-to-face encounter between the patient and the physician then the service may only be
billed under the NP’s number. Review of the medical record is not sufficient to bill share/split
services under the physician’s number. Note: CMS does not indicate the amount of face-to-
face time by the physician, only that they are required to document their face-to-face service.
In a free-standing clinic*, the NP may submit claims incident to the collaborating physician.
Requirements for submitting claims under ‚incident to‛ at 100% reimbursement of the allowed
physician fee schedule include: free-standing clinic location, plan of care established, physician
must be present in facility, the physician is required to treat the patient at intervals, service
must be medically necessary and be normally furnished in a clinic setting. An example: a
patient returns to see the NP for follow up for high blood pressure and renewal of medication.
Patient is doing well under the current plan of care. The physician does not see the patient;
however, is in the clinic complex and immediately available should he be needed. In this
situation, submit the claim under the ‚incident to‛ rules with the physician’s UPIN/PIN for
100% of the allowed physician fee schedule.
*Free-standing clinics are community practice clinics.
NPs in the Teaching Setting:
Non-physician practitioners do not supervise medical students or residents. The only
documentation that a NP may use from medical students or residents note are: the review of
systems (ROS) and the past family and social history (PFSH). The NP must make the
appropriate reference to that documentation.
Limited Services for NPs:
CMS does not place any limitations on the level of service a NP may bill. CMS indicates that
NPs using their UPIN/PIN may provide new patient services, consultations and various other
services within their State scope.
Compliance Corner 4
State regulation states: ‘when a collaborative practice arrangement is utilized to provide health care
services for conditions other than acute self-limited or well defined problems, the collaborating
physician shall see the patient for evaluation and approve or formulate the plan of treatment for a
new or significantly changed condition(s) as soon as is practical, but in no case more than two
weeks after the patient has been seen by the collaborating APN.’ Therefore should the service
rendered be of comprehensive or possibly moderate level of medical decision making, the
collaborating physician is required to see that patient within two weeks.
Can the NP admit patients to a hospital and bill for an admit service? The NP must have privileges
at the hospital and the service must be medically necessary. In this case, perhaps the patient would
require a physician to see them given the Missouri regulation for acute self-limited or well defined
problems with worsening condition that would cause admission to the hospital.
Split Funding of NPs:
Split funding of NP between the hospital and the department offices could cause a situation of
double billing if the hospital reports the NPs on their cost reports. This could still be possible but
would require a great deal of record keeping ensuring their time was not being billed twice.
Currently the University hospital does not report APNs on their cost report and therefore there
would not be the situation where NPs service would be double billed (part of the facility fees and
billing professional fees).
Collaborating Physicians Responsibilities under the Collaborative Practice:
State regulations indicate:
There must be a written agreement signifying that both the NP and the collaborating physician are
aware of its content and agree to follow the terms of the collaborative practice arrangement.
Jointly agreed upon protocols or standing orders by both the NP and the collaborating physician.
The collaborating physician will consider the level of skill, education, training and competence of
the collaborating NP.
Provide guidance for consultation and referral for services or emergency care that is beyond the
education, training, competence or scope of practice of the NP.
When collaborative practice arrangement is utilized to provide health care services for conditions
other than acute self-limited or well defined problems, the collaborating physician shall see the
patient for evaluation and approve or formulate the plan of treatment for new, or significantly
changed conditions as soon as is practical but within 2 weeks after the patient has been seen by the
The collaborating physician or other physician designated must be immediately available for
consultation at all times either in person or via telecommunications.
Collaborating physician must review the NPs work, records and practice of the health care
delivered pursuant to the collaborative practice arrangement at least once every 2 weeks. This
review is to be documented by the collaborating physician.
If you still have questions or situations that concern you, please call the Office of Corporate
Compliance at 884-0632.¤
Compliance Corner 5
Under certain circumstances, a physician may need to indicate that a procedure or service is
separate from other services performed for the same patient on the same day. When certain
services are reported together on a patient by the same physician on the same date of service,
there may be the perception of ‚unbundling‛. Modifier 59 is used to identify procedures or
services that are not normally reported together, but are appropriate under the circumstances
A different session or encounter
A different procedure
A different site or organ system
A separate incision or excision
A separate lesion
A separate injury
Patient presents to ER with lacerations to the left leg and left forearm as result of a motorcycle
accident. Physician does exploration at most severe site for possibility of foreign matter and
removes gravel from deep wound to forearm. Physician also performs simple removal of gravel
from superficial wound to leg.
- 25248, 20520-59
The 59 is appropriate to report multiple service submissions by a clinical laboratory for the same
beneficiary on the same day. These situations usually involve microbiology where samples or
cultures are taken from a patient from different anatomical sites or different wounds, use the
same CPT code, and then are tested the same day. (MCM Transmittal AB-02-030)
Here’s an example:
In the same scenario above, the lab tech obtains independent specimens from the proximal and
distal wound sites of the forearm for aerobic and anaerobic cultures of the drainage material.
-87071, 87071-59, 87073, 87073-59
Remember, policies vary from carrier to carrier so when submitting the documentation
supporting the service, be sure you are clear about the separate distinct procedure.¤
Compliance Corner 6
Compliance Corner 7
ANNOUNCEMENTS AND UPCOMING EVENTS
Thursday, October 7, 2004
2 – 3 p.m. UPMB 3003
Thursday, November 4, 2004
2-3 p.m. UPMB 3003
Presentation by Dr. Boyd Terry on grafting proceudres
Bi-Annual Mid-Missouri Health Information Management Association
Attendance Prizes to Be Given Away!!!!
DATE: October 1, 2004
TIME: 8:30 a.m. – 4:30 p.m. (Registration begins at 8 a.m.)
PLACE: Columbia Regional Hospital, 400 Keene Street, Columbia, MO
PROGRAM (Proposed and subject to change)
8:00 – 8:30 Registration
8:30 –10:30 Stacy Skiles from Jefferson City, Missouri - ‚Violence in the Workplace‛
10:45–11:45 Jill Williams, Registered Dietitician, Boone Hospital, Columbia, Mo. -
‚Battling the Diet Revolution‛
11:45 – 12:30 LUNCHEON (provided)
12:30 – 1:00 Business Meeting
1:00 – 2:00 Christopher Case, M.D.- Update on Diabetes
2:00 – 2:15 Break
2:15 – 3:15 Jerry Sill, Missouri Hospital Association - ‚Legal Update‛
3:15 – 4:15 Judy Bielby - Coding (Please bring a sample of a physician query form)
4:15 – 4:30 Distribution of CE Certificates
Six (6) CEUs will be awarded for attendance at all sessions
‚Partners in Education for Allied Health Career Fields‛ We would like to invite area high
school seniors and technical school students to join us for our meeting to learn more about our
profession. Do you know anyone possibly interested in a career in health information? If so,
please pass a copy of the attached registration form. If you know of a school we could contact,
please notify Diane Swift at 660-831-3008.**********Registration form on page 10
Compliance Corner 8
AAPC EXAM DATES FOR 2004
Times are from 7:30 am until 1 pm
November 13, 2004 QuarterDeck Building QD224
CPC TEST REVIEWS
Saturday, November 6, 2004
These test reviews are from 8:30 am to 4:30 pm and will be held at QuarterDeck Building in Columbia,
Mo Room QD224. There is no break for lunch, so the instructor encourages attendees to bring snacks or
lunch. There is a charge of 39.00 per person and attendee will receive 6 CEU'S.
For any questions or comments, please send me an email at email@example.com
AAPC SHOW ME CHAPTER MEETING DATES/TOPICS.
September 2004 - The seminar on September 17th will take the place of the regular monthly meeting.
October 14, 2004 - Room QD224 Time 11:00 am - 1:30 pm
November 11, 2004 - Room QD118 Time 8:30 am - 11:00 am
Dr. Sara Crowder Assistant Professor Of Clinical Obstetrics & Gynecology - Topic Gynecologic
Oncology with coding scenarios to follow - 2 CEU's
December 9, 2004 - Room QD118 Time 8:30 am - 11:00 am - Christmas Party¤
Compliance Corner 9
2004 MMHIMA Bi-Annual Meeting
(one form per registrant)
___ $35.00 MMHIMA members* (Includes lunch)
___ Free for students (Lunch $ 15.00)
___ $45.00 Non-MMHIMA members*(Includes lunch)
Complete registration form and send along with a reservation check for
$15.00** payable to MMHIMA to:
Judith Mark, Treasurer
991 S. English, Marshall, MO 65340
Phone: 660-886-7431 (Medical Records)
Please pre-register by Sept. 15, 2004. For your convenience, payment will
be accepted at the time of registration for the balance of the registration fee
or feel free to pay entire amount at the time of reservation.
PLEASE USE A SEPARATE REGISTRATION FOR EACH INDIVIDUAL
Name: __________________________Referred by: ____________________
Credentials: ____ RHIA ____ RHIT ____ CCS ____ Student
Preferred Address: ______________________________________________
Preferred Phone: ________________________________________________
Preferred E-mail: ________________________________________________
* Refunds will be issued until one week prior to the meeting date
(Sept 24) minus a $15.00 handling fee.
* Please note the $15.00 (nonrefundable) fee must accompany your registration
Compliance Corner 10