What is the difference between a New Patient and Consultation?
Consultation services are distinguished from a New Patient because they are performed at the formal request of a physician, qualified non-physician practitioner, or appropriate source and the consultant physician provides a report of his/her findings and recommendations to the requesting physician for his/her use in management of the patient's condition. The purpose of the physician's, qualified NPP's, or appropriate source's request must be to obtain an opinion or advice regarding the evaluation and/or management of a specific problem or problems. Note: A consulting physician may initiate diagnostic and/or therapeutic services.
Medicare will pay for a consultation if the requesting physician does not transfer the responsibility for the patient's care to the receiving physician until after the consultation is completed. However, if the referring physician transfers the responsibility for treating the patient at the outset, the receiving physician must bill using visit service codes, not consultation service codes.
The consulting physician's documentation must include the 3 R's:
- The name of the Requesting physician, qualified NPP, or appropriate source (Residents cannot request billable consults);
- His/her opinion and or Recommendations; and
- Evidence that a written Report was submitted to the requesting physician. Note: In a large group practice, e.g., an academic department or a large multli-specialty group, in which there is often a shared medical record (i.e. CareFlow/Horizon), it is acceptable to include the consultant's report in the medical record documentation and not require a separate letter from the consulting physician or qualified NPP. The written request and the consultation evaluation, findings and recommendations shall be available in the consultation report.
Lastly, physicians of the same specialty and group may request and perform consultations. For example, if a hematologist/oncologist sees a patient, he/she may request a consultation from a bone marrow transplant specialist. The bone marrow transplant specialist may bill for a consult, provided the he/she documents the 3 R's as noted above.
What is the difference between a new and established patient?
AMA's definition of a new patient is one who has not received any profesional services (i.e., face-to-face) from the physician, or another physician of the same specialty who belongs to the same group within the past three years. On the flip side, an established patient is one who has received professional services from the physician, or another physician who belongs to the same group practice within the past three years.
CMS Transmittal 1690, released on January 5, 2001, added further clarification that if no evaluation and management service is rendered prior to the visit, the patient may continue to be treated as a new patient. This clarification is important because problems have occurred when billing new patient visits if the providers have rendered a non-face-to-face service for that patient within the pat three years. An example is when a physician bills for an x-ray interpretation and sees the same patient two months later (within 3 years) for an office visit. This visit can still be billed as a new patient office visit.
When is it appropriate to use time-based billing codes?
Time is considered the key or controlling factor in determining a level of service if counseling and/or coordination of care dominates the total encounter with the patient and/or family. The billing (CPT) code is based n the amount of face-to-face time the physician spends with the patient and/or family.
In the outpatient setting, the physician must be in the same room/office with the patient. The patient must be present during a family conference.
In the inpatient setting, the physician must be on the same unit or floor with the patient.
Documentation by the physician must reflect the total encounter time with the patient, the extent of the counseling, and what was discussed.
Common areas for discussions include one or more of the following:
- Patient and family education
- Instructions for management and/or follow-up
- Diagnostic results, impressions, and/or recommended diagnostic studies
- Risks and benefits of management treatment options
- Prognosis
- Risk factor reductions
- Importance of compliance with treatment options
Documentation example:
"Of the 30 minutes I spent with the patient, 20 minutes were spent discussing the patient's lab results and treatment options..."
Note that the total encounter time is documented along with the counseling time, which must be more than 50% of the total encounter time. It is also important todocument what was discussed.
If a specific diagnosis has not been determined, how do I select the appropriate ICD-9-CM code to use?
While the CPT code or service is the driving force behind reimbursement, the ICD-9 diagnosis code must support the CPT code in order to reflect medical necessity. "Suspected" or "Rule Out" diagnoses cannot be coded. The primary diagnosis must support or justify the physician's service. If you are working only with phenomena and have not yet formed a diagnosis, then the sign, symptom, or laboratory abnormality should be selected.
Can a patient checklist/intake form be used to contribute to the Review of Systems and/or Past, Family, and Social History (ROS/PFSH) for a visit?
Yes, anyone can document the ROS and PFSH. A provider may use the ROS/PFSH form, a patient checklist, or other means of obtaining the information. The information (ROS/PFSH only) must either be signed or dated by the provider or the provider must reference the date of the checklist in his/her own documentation. Note: when referring back to a previous ROS/PFSH information, it should be a reasonable date to still be considered current (within one year).
When auditing Evaluation and Management (E/M) services, what area or areas do you find that the physicians overlook the most?
When auditing charats for E/M services, many errors occur in the documentation of Review of Systems and Past, Family and Social Histories. This is especially true when our physician is thinking of reporting a higher level of service (levels 4 and 5) for Consultations and New Patients. This particular problem is not limited to certain specialties, it occurs across the board. Savvy physicians are able to understand the requirements and have utilized patient intake sheets, questionnaires filled out by ancillary staff, or even a simple checklist in their template to meet the documentation requirements. However, it must be evident that the physician acknowledges the intake sheets or questionnaires completed by the patient or ancillary staff. This can be done by referring to it and or by signing and dating it.
In the physician has indeed reviewed 10 or more systems, Medicare allows the physician to mention the pertinent positives and negatives and using the phrase "all others are negative" instead of enumerating that each and every one of the systems are essentially negative.
What types of services can CRNPs and PAs perform?
All services may be performed as long as those services fall within the scope of their practice.
What level (E/M) codes (inpatient and outpatient clinic clinic visits) can CRNPs and PAs bill?
CRNPs and PAs can bill for all code levels when billing under their own provider number. It is suggested that the CRNPs and PAs consider carefully whether the required high level of medical decision making necessary to meet the standard for level 4's and 5's are within the scope of their practice.
Can an attending physician utilize CRNPs' or PAs' documentation and/or services if they do not have an employment contract with that physician or group practice?
No, the CRNPs and PAs must be directly employed by the UAHSF or must have some other contractual relationship with the employing entity (i.e., University Hospital).
Can CRNPs and PAs see new patients without the participation of a physician?
Yes, but Medicare rules state that the CRNP or PA may ONLY bill under their own provider number and cannot bill under the physician's number when either 1) performing a service on their own; or, 2) for outpatient services only, when combining or splitting an E/M service with a physician for: a new patient; a consultation; or an established patient with a new problem. When combining E/M services with a physician that do not fall under the provisions of the "incident to" rules, the bill must be submitted under the name and provider number of the CRNP or PA. It is also important that the CRNP or PA always sign the encounter form when involved in a service.
How do CRNPs and PAs bill for services they perform without any direct physician involvement in the particular service - under their own provider number or the physician's provider number?
Either is acceptable. In an outpatient or physician office setting, CRNPs and PAs can bill "incident to" a physician's services, under the Physician's UPIN number, when the "incident to" rules are met. Alternatively, in either inpatient or outpatient/physician office settings, they may bill under their own provider numbers at a reduced rate.
What requirements must be met in order to bill "incident to"?
The patient must be "established", a physician within the group practice must have established a plan of care or treatment, the CRNP or PA must be following that plan of care on subsequent visits, and the physician must periodically see the patient for the problem being followed.
What type of supervision requirements must be met in order to bill for CRNP or PA services as "incident to" under the physician's number?
The physician in the clinic the day the patient is seen provides direct supervision (i.e., need not be in the exam room but is on the premises and immediately available if needed) for the services rendered, and therefore the services are billed using this provider number. It need not be the physician that saw the patient initially.
Why is it important to distinguish "incident to"? Are there different rules for what can be billed?
Yes. "Incident to" applies ONLY to establsihed patients with previously diagnosed problems seen in OUTPATIENT settings. In other words, only RETURN/ESTABLISHED PATIENT CODES can be billed. The physician is not required to see the patient on the "incident to" visit. Medicare states that documentation must show that the physician actively participated in the treatment and demonstrate management over the course of the treatment.
If you have a large group practice, should the CRNPs and PAs submit an "incident to" bill under the physician supervising for that day or should the bill be submitted under the name of the physician listed as the CRNP's or PA's supervisor?
Our physicians are part of a group practice, and therefore, "cover" each other's patients. The CRNPs and PAs should bill under the physician who is available to provide supervision and direction for the services being rendered (i.e., the physician who is present for that day in the clinic).