What’s In Your Wallet?

Houston Area Nurse Practitioners

November 7, 2015

Elizabeth Ellis DNP, RN, FNP-BC, FAANP Pam Conrad, CMOM

Elizabeth Knight, CPC, CCS-P, CMOM, CMIS

Disclosures

• Dr. Ellis has no affiliations to disclose • Pam Conrad has no affiliations to disclose • Elizabeth Knight has no affiliations to

disclose

Objectives

• Define and discuss the key components of basic coding, documentation, compliance, terminology and compliance audits for the new NP graduate

• Discuss the components and definitions of Direct NP billing and Incident-To Billing per CMS Rules and Regulations

Objectives Cont.

• Discuss the basic components and “how to” for properly documenting a Level IV office visit.

• Discuss the basic components and “how to” for documenting Welcome to Medicare Visits

• Discuss the basic components of monthly productivity reports and how the NP provider can improve their performance

What Is In your Wallet?

• As a new and/or experienced NP there are several key areas that will increase your financial productivity – Proper Coding-Know your Coding Team – Proper Charting-Know your trainers – Compliance-Know your representative

• Federal, State and Corporate – Welcome to Medicare Visits/Annual visits – Level IV Patient Visits

Billing

• Important to document NP productivity – Independent and Incident To Billing

• Know your employers practice • Be knowledgeable

– Implications – components – risk

• Outpatient vs Inpatient

Independent Billing

• Billed directly under NP National Provider Identification(NPI)

• Pt scheduled for the NP • NP bills for:

– Level of Care – Time – Diagnosis – Preventative Care – Counseling http://www.napnapcareerguide.com/np-billing-coding-reimbursement

Independent Billing cont.

• Know regulations • Work with coding team to be informed • Documentation is key • Obtain Coding/Compliance Review/Audits • Know your resources • Paid at 85% of MD reimbursement

Incident- To Billing

• Billed under the physicians NPI number but performed by nonphysicians

• To obtain full reimbursement • Many regulatory components

1. MD must see Pt 2. Diagnose PT 3. Establish plan of care prior to NP visit 4. Be in suite 5. NPP must be employee 6. F/U with MD

Incident-to Billing cont.

• Hides/negates NP Productivity • OIG has “incident-to-billing” top 5 audit

tasks….on their radar! – http://oig.hhs.gov – may not meet standard of care – Know state/federal law

• Many OIG Fines with NPs and PAs being primary target

• Ultimately reduces access to care

Hospital Based

• Employed vs non-employed • Hospital Cost Report

– Must be removed for hospital to bill • Shared Visits

– NPP must be employee of MD or same entity MD is an employee of

• Independent Billing

wRVU

• Work Relative Value Unit – Development eliminates old “usual, customary

and reasonable” payment system – Budget Reconciliation act of 1989 devised

new Medicare payment schedule – Each service, procedure, act you perform for

the patient is provided a relative value unit – Each service contains three values

• Work, practice expense and malpractice expense

wRVU Cont.

• CMS supplies value units for each CPT/HCPCS(Healthcare common procedure coding system) code and represents the cost for providing the service. – Three components make up an RVU

• Provider work • Practice expense • Malpractice overhead

AAPC Advancing The Business of healthcare : https//www.aapc.com/practice-management/rvu-calculator.aspx

wRVU Cont.

• Medicare payments are comprised of these values multiplied by factors of conversion and geographical adjustment

• MGMA has also determined how many RVU’s each NP (per specialty/field) should be producing to break even at 50%

wRVU Threshold rounded to nearest

• Primary Care- 3,067 wRVU • Non primary Care Non Surgical- 2,054

wRVU • Surgical (this is dependent on 25% or

50%; 25% is 700 wRVU) • Additional considerations are:

– Credit for panel size – Ramping period/pro-rated – ACO Payments to Institution

Productivity

• Salaried- Non-Productivity Based • Productivity- wRVU Based • Salary + Bonus

– How is your bonus structured – Is your bonus wRVU related? – Know Qualifying factors

• Quality Performance Indicators

Productivity Based Plans

• Quality Performance Incentive Based Plans – Minimum wRVU Threshold – Then $ assigned to each RVU above creates

bonus – Maximum Threshold – Payment dependent on QPI

• QPI may be tied to meaningful use measures or determined by entity or combination

Welcome to Medicare-IPPE-G0402

• Initial Provider Performed Exam – Once in a lifetime – Performed in first 12 months of enrollment – No hands on exam

• G0403 IPPE with EKG optional – Once in a lifetime – Performed in first 12 months of enrollment

IPPE cont

• Pt must bring screening form completed • Risk Factor Assessment

– What screenings have occurred – History/Family History – What screenings/preventative svc. need to be

performed – Factors that may affect pt health – Document Referrals for better health

IPPE cont

A. Required components at min. 1. Medical and Social History 2. Functional Ability and level of Safety 3. Review of Risk Factors for Depression 4. Document: vitals, visual acuity, height,

weight, BMI and other routine vitals 5. Provide end-of-life counseling 6. Provide education/counseling based on

components of exam: written plan for preventative svcs.

IPPE Billing

• G0402 : 4.81wRVU • $150 reimbursement?? • G0403 IPPE + EKG: 0.54 wRVU • G0438 Annual Wellness Visit (AWV): 4.98

wRVU • G0439 Subsequent Annual Wellness:3.29

wRVU

IPPE Plus New Pt Visit

• If during an IPPE it is determined pt wants/needs exam/RX refilled may also charge a New Patient Visit

Level IV Patient Visit

• New Patient 99204 – wRVU 2.43

• Established Patient 99214 – wRVU 1.5

• NOTE: do not record unnecessary information just to solely achieve the higher level

Level IV New Patient

1. Comprehensive History 2. Comprehensive Exam 3. Medical Decision Making of Moderate

Complexity or 45 min spent face-face with the patient or patient & family if coding based on time

Level IV New cont

1. Comprehensive History Chief Complaint HPI-4 descriptors ROS –at least 10 systems PFSH-3 areas documented

2. Comprehensive Exam At least 8 organ systems

Level IV New cont.

3. Medical Decision Making of Moderate Complexity # of Problems: one new problem Amount/complexity: 3 points Data to be reviewed (see handout)

Complexity: Pt must be Moderate Risk See Risk Complications Table Anytime you give a pt a RX they

are Moderate!

Level IV Established Visit

Must meet 2/3 Key Components 1. Detailed History 2. Detailed Exam 3. Medical Decision Making of Moderate

Complexity 1.Detailed History Chief Complaint HPI: 4 descriptors ROS: at least 2 systems PFSH: Document 1 pertinent history area

Level IV Est. Visit cont

2. Detailed Exam: 12 Bullets 3. Medical Decision Making of Moderate Complexity: Number of problems: one new with/without a

plan OR two established problems One worsening AND 1 stable

OR three stable est. problems to examiner

Level IV Est. Visit cont

3. Medical Decision Making of Moderate Complexity Cont. Data: 3 points Complexity: Complexity is Moderate Put status of chronic problems

Resources

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MPS_QRI_IPPE001a.pdf – This is the link to the 2015 IPPE CMS Quick

Reference Guide • https://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN905706.pdf

Resources Cont.

• https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-QuickReferenceChart-1TextOnly.pdf

This is the link to the 2015 CMS Preventive Service Quick Reference Guide • https://www.cms.gov/Medicare/Prevention/Prevn

tionGenInfo/Health-Observance-Mesages-New-Items/2015-01-08-AWV-IPPE.html – This is a link to CMS 2015 Preventive

Service On-Line information, other links can be located and launched from this site

Resources Cont.

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7079.pdf – Link to a MedLearns Matters Article

• Buppert, C. (2014). 8 Things About Billing NP Hospital Services. Journal for Nurse Practitioners, 10.(3)207-208.

.

Resources Cont.

• Hull-Grommesh,L., Ellis, E.,Mackey.,(2010). Implications for Nurse Practitioner Billing: A Comparison of Hospital Versus Office Practice. Journal of The American Academy of Nurse Practitioners 22(2010) 288-291.

Happy Nurse Practitioner Week November 8–14, 2015

Questions