Medical Management Associates, Inc.
Ask-A-Consultant: Nurse Practitioner Billing and Reimbursement
Question: I am a solo practitioner and am considering hiring a nurse practitioner to oversee procedures in my office so that I may spend more time in the hospital performing more complicated procedures. The in-office procedures include tilt table tests, echos, stress echos, dobutamine stress echos and TWave Alternans. Will my reimbursements from Medicare and other insurance companies be adversely affected if the nurse practitioner is the only supervisor on the premises? Would these procedures be billed under my name or his/her name?
East Islip, New York
In order to provide the services you have outlined, the nurse practitioner (NP) must be qualified and licensed to perform such services in your state. It is also important to verify whether the tests outlined above can be supervised by a non-physician provider.
For echocardiography services, Medicare requires the General Supervision requirement be met which means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel that actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician. Medicare also requires these services be performed by the physician or someone credentialed by Cardiovascular Credentialing International CCI in the relevant area, ARDMS (American Registry of Diagnostic Medical Sonographers) or NCUDT – National Certification of Ultrasound Diagnostic Technologists).
If these requirements are met, Medicare will reimburse these services at 85% of the physician fee schedule. You must bill the services under the NP's own Medicare PIN, since they do not fall under the incident-to billing guidelines. Even though the reimbursement is less, the addition of the NP will allow you to provide more services which should increase your efficiency and overall revenue.
Unfortunately, private insurer reimbursement and billing requirements are not so clear cut. Since not all private insurers credential NPs, it is important that you contact your largest payors and obtain their policies and instructions for billing. Make sure you have this information in writing in case the reimbursement varies or services are denied because they are provided by the NP. When entering into new contracts, be sure to include this issue in your negotiations.
Other issues that you should consider are: 1) for risk management purposes, you should consult with your professional liability insurance carrier and obtain its advice/approval before hiring the NP; 2) have a collaborative agreement with the NP outlining the NP's scope of practice; 3) make sure a physician is always available by telephone for General Supervision requirements to be met, to consult on abnormal reports and to review findings; 4) it must be clear to patients that the testing is being supervised by an NP, not a physician; and 5) policies/protocols should be established to address emergency situations.
Mary Beth Black, CPC
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