Pitchbook US template

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UCSF Medical Group and Medical Center Nurse
Practitioner as Billing Provider POLICY
3.08.01 Business and Finance Nurse Practitioners
as Billing Providers Issued April 2009
August 10, 2010 CIDP Leadership Meeting
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General Information

• UCSF Medical Center Policy 3.08.01
• Nurse Practitioner (NP) Services Guidelines for
  Professional Billing
• http//manuals.ucsfmedicalcenter.org/AdminManual/I
  ndividualPolicies/NursePractitionersasBillingProvi
  ders.pdf
• Reviewed Every Two Years
• Proposed for next revision
• Inclusion of Physician Assistants under policy

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Definitions

• Types of Clinics
• Hospital-Based Clinics
• Operate under license of the hospital
• Includes all Academic Departments
• Two Billing Components
• Professional Fee
• Technical (Use of Facility)
• NPs employed by the Medical Center must be
  removed from the Medicare Cost Report once they
  start to bill. This has implications in terms of
  AB915 revenue.
• Free-Standing Clinics
• Do not operate under license of the hospital
• Currently none operating at UCSF
• One Global Fee

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Definitions

• Supervising Physician
• Fully Licensed Physician
• MD or DO
• Not participating in an ACGME, GME or ABMS
  Program
• Types of Supervision
• Direct Supervision
• The physician must be present in the room when
  the service is provided
• Indirect Supervision
• The physician must be present in the office or
  clinic suite and immediately available
• General Supervision
• Services are under the physicians overall
  direction and control, but the physicians
  presence is not required during the performance
  of the procedure or service. The physician can
  be available in-person or through electronic
  means to authorize the service
• One of these supervision requirements apply
  whether billing under the name of the NP or
  supervising physician

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Minimum Qualifications

• Providing NP Services
• Registered Professional Nurse
• Masters Degree
• Currently Licensed in the State of California
• Nurse Practitioner (NP)
• Family Nurse Practitioner (FNP)
• Pediatric Nurse Practitioner (PNP)
• Must have active UCSF Medical Center Medical
  Staff Privileges which includes national
  certification (for NPs hired after 1992).
• Supervising NP Services
• All services billed under a NP provider number
  require a minimum of General Supervision
  regardless of payer source
• Services not billed under a NP provider number
  require Indirect Supervision as part of a
  shared visit methodology.
• One supervising physician is not permitted to
  supervise more than the full-time equivalent of
  four NPs at any one time

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Scope of Practice

• General
• Governed by rules of RNs and UCSF credentialing
  requirements
• California Nursing Practice Act
• Allows NP to provide certain medical functions in
  addition to nursing
• In some cases, medical functions must adhere to
  Standardized Procedures that are developed by the
  employer (UCSF), in accordance with the
  California Nursing Practice Act
• Medical Functions Requiring Standardized
  Procedures/Protocols
• Any function that is not commonly recognized as a
  nursing practice and that requires the NP to
• Diagnose Disease
• Furnish Medicine
• Furnish Treatment
• Penetrate or Sever Tissue

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Scope of Practice

• California Nursing Practice Act, cont
• Medical Functions Requiring Standardized
  Procedures, cont
• NP is allowed to furnish Schedule II-V Drugs with
  a Standardized Procedure
• Drugs must be consistent with the NP educational
  preparation
• Clinical competency has been established and
  maintained
• Schedule II or III controlled substances
  furnished or ordered shall be in accordance with
  a patient-specific protocol approved by the
  treating or supervising physician
• In addition to standardized procedures, other
  written protocols and standing orders may be
  developed by the supervising physician(s),
  subject to approval by the UCSF Committee on
  Inter-disciplinary Practice (CIDP).

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Terms

• Billing Terms
• Incident-to
• Medicare term Allows services provided by a NP
  to be billed under the supervising physicians
  provider number.
• Setting must be Freestanding/Stand Alone Setting
• None of which currently exist at UCSF
• Split/Shared Visit
• Another Medicare term Applies to Evaluation
  Management (E/M) Services only
• Rule allows documentation from the physician and
  NP note to be combined
• Setting must be Hospital-Based
• Hospital Inpatient or Outpatient, Emergency Room
  Hospital-Based Clinics
• Requires
• Two separate notes
• NP AND supervising physician face-to-face time
• Consultations, Critical Care and Surgical
  Procedures are Exempt and Cannot use this Rule

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Documentation Guidelines

• All Payers
• EMR and/or Chart
• All services ordered and provided by the NP are
  to be personally documented, signed and dated.
• For billing purposes, it is strongly recommended
  that NPs identify their supervising physician in
  their note.
• When the NPs supervising physician is away or on
  vacation the supervising physician noted would be
  the physician called that day for assistance or
  direction.
• If NP is on the UCSF Cost Report, the NP cannot
  submit a professional fee and must use the
  split/shared visit methodology.

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Payor Specific Billing Guidelines

• Medi-Cal All Locations
• FNP and PNP
• Allowed to bill under their own name for any
  services provided within their scope of practice
• NP
• Must bill under their supervising physician name
• There are specific HCPCS, CPT-4 and Medi-Cal only
  codes (NP only)
• For a list of these codes go to
• http//files.medi-cal.ca.gov/pubsdoco/DocFrame.asp
  ?wURLpublications2Fmasters-mtp2Fpart22Fnonph_m
  00o03o11.doc
• Difference between billable and payable

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Payor Specific Billing Guidelines

• Workers Compensation All Locations
• NP may provide services to workers compensation
  patients
• NP may not
• Initiate new treatment
• Report on an injured workers entitlement to
  benefits
• Change the Primary Treating Physician (PTP)
  treatment plan

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Modifiers

• Modifiers
• Medi-Cal/GMC
• When billing under the name of the FNP or PNP no
  special modifiers are required
• When billing NP services including FNP and PNP,
  under the name of the supervising physician the
  modifier -SA is required
• When there are multiple modifiers selected, the
  Billing System automatically assigns the modifier
  99 to indicate there are multiple modifiers
• Workers Compensation
• When billing NP services for workers
  compensation, the modifier 98 is required

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Considerations

• Additional requirements/considerations under this
  policy include
• A face to face meeting between the Nurse
  Practitioner and the Supervising Physician
  occurring the year between credentialing cycles.
  The purpose of this meeting is to ensure that the
  Nurse Practitioner is continuing to practice
  within the scope of the protocol on file.
• Nurse Practitioners, whether billing
  independently or otherwise, cannot supervise
  Residents. Residents will continue to require a
  physician in attendance to supervise their
  activities.
• Currently many departments receive State of
  California AB-915 reimbursement to for the
  facility costs related to clinic operations.
  Nurse Practitioners who bill independently can no
  longer qualify to be included in these facility
  costs.
• It is up to the department managers discretion
  whether a Nurse Practitioner can bill
  independently as there may be workflow issues
  within the clinic.

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Process For Enrollment As an Independent Biller

• A web page is under construction at the following
  address
• http//www.medschool.ucsf.edu/medgroup/credentiali
  ng/index.aspx
• Contained at this site will be
• Application Form
• Educational presentation
• Link to current UCSF policy
• Link to current Medi-Cal coding guidelines
• List of active NPs credentialed to bill
  independently