Non-Physician PractitionersNon-Physician Practitioners

Who, What, When, Where, HowWho, What, When, Where, How & But & But

Terry L. ReevesTerry L. ReevesExec. Director of Institutional ComplianceExec. Director of Institutional Compliance

Who are they?Who are they?

• Nurse PractitionerNurse Practitioner

• Advanced Practice NurseAdvanced Practice Nurse

• Certified Nurse Midwife Certified Nurse Midwife (CNM)(CNM)

• Certified Registered Certified Registered Nurse Anesthetist Nurse Anesthetist (CRNA)(CRNA)

• Clinical Nurse Specialist Clinical Nurse Specialist (CNS)(CNS)

• Physician AssistantPhysician Assistant• Surgery AssistantSurgery Assistant• Clinical Social WorkerClinical Social Worker• Clinical Psychologist Clinical Psychologist

(Ph.D.)(Ph.D.)• Non-clinical Non-clinical

PsychologistPsychologist• PT, OT, Speech PT, OT, Speech

PathologistPathologist

What is the difference between a What is the difference between a NP and a PANP and a PA

• Nurse PractitionerNurse Practitioner• All NPs are Registered All NPs are Registered

Nurses (RN) Nurses (RN)

• Masters degree trained Masters degree trained in Nursingin Nursing

• Certified by a nursing Certified by a nursing specialty organizationspecialty organization

• Not possible for a non-Not possible for a non-RN to be a NPRN to be a NP

• Physician AssistantPhysician Assistant• Undergraduate degree Undergraduate degree

from an approved PA from an approved PA program. program.

• It is possible for an It is possible for an LVN, or RN to be a PA LVN, or RN to be a PA

What can they do?What can they do?

• Services as outlined by state law. The Services as outlined by state law. The scope of practice and the reimbursement scope of practice and the reimbursement methodologies are all established by state methodologies are all established by state law.law.

• Normally outlined in the Texas Normally outlined in the Texas Occupation Code and in the Rules and Occupation Code and in the Rules and Regulations of the Board Governing that Regulations of the Board Governing that profession.profession.

What can they do?What can they do?

• Nurse PractitionerNurse Practitioner• Physician ServicesPhysician Services

• Defined by their Scope Defined by their Scope of Practice as stated in of Practice as stated in state law BNE Rules state law BNE Rules 221.12221.12

• Limited prescriptive Limited prescriptive authorityauthority

• Physician AssistantPhysician Assistant• Physician ServicesPhysician Services

• Defined by their Scope Defined by their Scope of Practice as stated in of Practice as stated in state law TSBME state law TSBME Board Rules 185.11Board Rules 185.11

• Limited prescriptive Limited prescriptive authorityauthority

Who licenses and governs Who licenses and governs them?them?

• Nurse PractitionerNurse Practitioner• Board of Nurse Board of Nurse

Examiners for the Examiners for the State of Texas (BNE)State of Texas (BNE)

• Some references to the Some references to the TSBME for prescriptive TSBME for prescriptive authorityauthority

• Various specialty Various specialty organizationsorganizations

• UTMB Nursing ServiceUTMB Nursing Service

• Physician AssistantPhysician Assistant• Texas State Board of Texas State Board of

Medical Examiners Medical Examiners (TSBME)(TSBME)

• Texas State Board of Texas State Board of Physician Assistant Physician Assistant ExaminersExaminers

• UTMB Medical Staff UTMB Medical Staff OfficeOffice

Where can a non-physician Where can a non-physician practitioner perform services?practitioner perform services?

• Nurse PractitionerNurse Practitioner• In all settingsIn all settings

• InpatientInpatient

• OutpatientOutpatient

• SNFSNF

• HomeHome

• Nursing HomeNursing Home

• Physician AssistantPhysician Assistant• In all settingsIn all settings

• InpatientInpatient

• OutpatientOutpatient

• SNFSNF

• HomeHome

• Nursing HomeNursing Home

Are protocols required?Are protocols required?

• Nurse PractitionerNurse Practitioner• YesYes

• Section 221 .1 (12) Section 221 .1 (12) Rules and Regulations Rules and Regulations of BNEof BNE

• NHIC Texas Medicaid NHIC Texas Medicaid Provider Procedures Provider Procedures Manual 34.3Manual 34.3

• Physician AssistantPhysician Assistant• YesYes

• Texas State Board of Texas State Board of Medical Examiners Medical Examiners (TSBME)(TSBME)

• NHIC Texas Medicaid NHIC Texas Medicaid Provider Procedures Provider Procedures Manual 34.3Manual 34.3

What are Protocols?What are Protocols?

Nurse PractitionersNurse PractitionersWritten authorization to provide medical aspects Written authorization to provide medical aspects of patient care which are agreed upon and of patient care which are agreed upon and signed by the advanced practice nurse and the signed by the advanced practice nurse and the physician, reviewed and signed at least physician, reviewed and signed at least annually, and maintained in the practice setting annually, and maintained in the practice setting of the advanced practice nurse. Protocols or of the advanced practice nurse. Protocols or other written authorization shall be defined to other written authorization shall be defined to promote the exercise of professional judgment promote the exercise of professional judgment by the advanced practice nurse commensurate by the advanced practice nurse commensurate with his/her education and experience. with his/her education and experience.

What are Protocols? (continued)What are Protocols? (continued)

Nurse Practitioners (continued)Nurse Practitioners (continued)

Such protocols or other written authorization Such protocols or other written authorization need not describe the exact steps that the need not describe the exact steps that the advanced practice nurse must take with respect advanced practice nurse must take with respect to each specific condition, disease, or symptom to each specific condition, disease, or symptom and may state types or categories of drugs and may state types or categories of drugs which may be prescribed rather than just life which may be prescribed rather than just life specific drugs.specific drugs.

What are Protocols? (continued)What are Protocols? (continued)

Physicians AssistantsPhysicians Assistants

• NHIC 2001 Texas Medicaid Provider NHIC 2001 Texas Medicaid Provider Procedures Manual 34.3Procedures Manual 34.3• requires protocols.requires protocols.

What are Protocols? (continued)What are Protocols? (continued)

Physicians AssistantsPhysicians Assistants

It is the obligation of each team of physician(s) It is the obligation of each team of physician(s) and PAs to ensure that:and PAs to ensure that:• The PA’s scope of practice is identified;The PA’s scope of practice is identified;

• delegation of medical tasks is appropriate to the PA’s delegation of medical tasks is appropriate to the PA’s level of competence;level of competence;

• the relationship between the members of the team is the relationship between the members of the team is defined; that the relationship of, and access to, the defined; that the relationship of, and access to, the supervising physician is defined;supervising physician is defined;

What are Protocols? (continued)What are Protocols? (continued)

Physicians Assistants (continued)Physicians Assistants (continued)• a process for evaluation of the PA’s a process for evaluation of the PA’s

performance is established; andperformance is established; and

• The PA’s annual registration is current.The PA’s annual registration is current.

Provider-based facility vs.Provider-based facility vs.Office-based facilityOffice-based facilityProvider-Based facilityProvider-Based facility

• Designation is determined by CMSDesignation is determined by CMS

• Patient receives two bills: hospital and a Patient receives two bills: hospital and a professional fee billprofessional fee bill

• Hospitals bill DRGs for inpatient services Hospitals bill DRGs for inpatient services and APCs for outpatient services.and APCs for outpatient services.

• Certain clinics are designated as provider-Certain clinics are designated as provider-basedbased

Provider-based facility vs.Provider-based facility vs.Office-based facilityOffice-based facilityOffice-based facilityOffice-based facility

• Designation if not provider based then you are Designation if not provider based then you are office-based. office-based.

• Patient one bill: a professional fee billPatient one bill: a professional fee bill

• Office-based clinic bills the RBRVU associated Office-based clinic bills the RBRVU associated with the CPT code for a “non-facility”.with the CPT code for a “non-facility”.

• Global or both TC and CPT code are billed. Global or both TC and CPT code are billed.

Medicare ReimbursementMedicare ReimbursementProvider-based facilityProvider-based facilityNurse Practitioner and Physician AssistantsNurse Practitioner and Physician Assistants

• Both receive Medicare Provider numbersBoth receive Medicare Provider numbers

• Billed in the PA or NP name and provider Billed in the PA or NP name and provider numbernumber

• Reimbursed at 85% of the fee scheduleReimbursed at 85% of the fee schedule

• Supervision requirements are as stated in state Supervision requirements are as stated in state lawlaw

• Documentation requirements are same as a Documentation requirements are same as a “stand alone” note for an attending“stand alone” note for an attending

Medicare ReimbursementMedicare ReimbursementProvider-based facilityProvider-based facility““Incident to” billingIncident to” billing

• ““Incident to” billing is expressly Incident to” billing is expressly prohibited in any provider-based setting.prohibited in any provider-based setting.

Medicare ReimbursementMedicare ReimbursementOffice-based facilityOffice-based facilityNurse Practitioner and Physician AssistantsNurse Practitioner and Physician Assistants• May bill either in the name of the PA or NP using May bill either in the name of the PA or NP using

their provider number their provider number oror

• Bill “incident to” i.e., in the name of the Bill “incident to” i.e., in the name of the physician. physician.

• ““incident to” billing is reimbursed at 100% of the incident to” billing is reimbursed at 100% of the fee schedule. fee schedule.

Medicare ReimbursementMedicare Reimbursement“Incident to” Billing“Incident to” BillingWhat is “incident to” billing?What is “incident to” billing?

• ““Incident to” refers to services or perhaps Incident to” refers to services or perhaps items provided after or in relation to a items provided after or in relation to a professional service that has already been professional service that has already been provided by a physician. provided by a physician.

• Services of other healthcare professionals Services of other healthcare professionals provided to a most commonly in an provided to a most commonly in an outpatient setting. outpatient setting.

Medicare ReimbursementMedicare Reimbursement“Incident to” Billing (continued)“Incident to” Billing (continued)Requirements for “incident to” billingRequirements for “incident to” billing• PA or NP must be an employee of the physician PA or NP must be an employee of the physician

(for UTMB paid by MSRDP)(for UTMB paid by MSRDP)• Initial visit must be performed by the physician.Initial visit must be performed by the physician.• Direct supervision: Physician must be in the Direct supervision: Physician must be in the

office and immediately available to assist.office and immediately available to assist.• Physician has an active part in the ongoing care Physician has an active part in the ongoing care

of the patient. Subsequent services by the of the patient. Subsequent services by the physician must be of a frequency that reflects physician must be of a frequency that reflects continuing active participation in, and continuing active participation in, and management of the course of treatment. management of the course of treatment.

Medicare ReimbursementMedicare Reimbursement“Incident to” Billing (continued)“Incident to” Billing (continued)Requirements for “incident to” billing.Requirements for “incident to” billing.

• Service is typically performed in a Service is typically performed in a physician’s officephysician’s office

• Billed on the claim as if the billing Billed on the claim as if the billing physician had provided the services. physician had provided the services.

• Cannot bill “incident to” for inpatient Cannot bill “incident to” for inpatient services.services.

Medicare ReimbursementMedicare ReimbursementProvider # vs. “Incident to”Provider # vs. “Incident to”

Medicare has stated that once a PA or NP Medicare has stated that once a PA or NP has billed in their own number they has billed in their own number they cannot switch back to billing “incident cannot switch back to billing “incident to”.to”.

Medicaid ReimbursementMedicaid Reimbursement

Legal ReferencesLegal References

Texas Administrative CodeTexas Administrative Code

25 TAC Section 29.50225 TAC Section 29.502

NHIC Texas Medicaid Provider Procedures NHIC Texas Medicaid Provider Procedures Manual (2001)Manual (2001)

Section 34.3 Benefits and LimitationsSection 34.3 Benefits and Limitations

Medicaid ReimbursementMedicaid Reimbursement

Nurse Practitioner Nurse Practitioner • Option #1 Direct Billing 85% of fee scheduleOption #1 Direct Billing 85% of fee schedule

NPs may apply for individual provider numbers for NPs may apply for individual provider numbers for direct billing purposes. All covered services direct billing purposes. All covered services rendered may be billed using the NP’s direct provider rendered may be billed using the NP’s direct provider number.number.

• Option #2 As a physician service Option #2 As a physician service A NP may provide services as a physician’s A NP may provide services as a physician’s services using the physician’s provider services using the physician’s provider

number. This is similar to “incident to” number. This is similar to “incident to” billing. billing.

Medicaid ReimbursementMedicaid Reimbursement

Physician Assistant Physician Assistant

• Option #2 As a physician service Option #2 As a physician service

A PA may provide services as a A PA may provide services as a physician’s services using the physician’s services using the physician’s provider number. This physician’s provider number. This is is similar to “incident to” billing. similar to “incident to” billing.

• This is the only option for a PA under This is the only option for a PA under MedicaidMedicaid

Medicaid ReimbursementMedicaid Reimbursement

Supervision Requirements Supervision Requirements

• Medicaid does not require supervision of Medicaid does not require supervision of the NP or PA in the clinic.the NP or PA in the clinic.

SettingsSettings

• No limitationsNo limitations

• Can’t double bill or “double dip”Can’t double bill or “double dip”

Other third party ReimbursementOther third party Reimbursement

• Private insurers generally cover medical Private insurers generally cover medical services provided by PAs or NPs when services provided by PAs or NPs when they are included as part of the they are included as part of the physician’s bill or as part of a global fee physician’s bill or as part of a global fee for surgery, i.e. “Incident to”.for surgery, i.e. “Incident to”.

• Other third party insurers normally Other third party insurers normally require that the providers be credentialed require that the providers be credentialed and enrolled as a provider with that and enrolled as a provider with that insurer. insurer.

Medicare and MedicaidMedicare and MedicaidDocumentation RequirementsDocumentation Requirements• Same as a “stand alone” note for teaching Same as a “stand alone” note for teaching

physician or attendingphysician or attending• Meet key component requirementsMeet key component requirements• Medical necessityMedical necessity• Chief complaintChief complaint• History, physical exam, decision-makingHistory, physical exam, decision-making• 3 out of 3 for new patient3 out of 3 for new patient• 2 out of 3 for established patient 2 out of 3 for established patient • Personal involvement should be obviousPersonal involvement should be obvious• Sign, date, and time the noteSign, date, and time the note

Medicare and MedicaidMedicare and MedicaidDocumentation RequirementsDocumentation Requirements• A NP or PA may not supervise a residentA NP or PA may not supervise a resident• Same as a “stand alone” note for teaching Same as a “stand alone” note for teaching

physician or attendingphysician or attending• Meet key component requirementsMeet key component requirements

• Medical necessityMedical necessity• Chief complaintChief complaint• History, physical exam, decision-makingHistory, physical exam, decision-making• 3 out of 3 for new patient3 out of 3 for new patient• 2 out of 3 for established patient 2 out of 3 for established patient • Personal involvement should be obviousPersonal involvement should be obvious• Sign, date, and time the noteSign, date, and time the note

Frequently asked QuestionsFrequently asked Questions

Q.Q. Can a non-physician practitioner order Can a non-physician practitioner order ancillary services?ancillary services?

A.A. Yes, if it is in their scope of practice. Yes, if it is in their scope of practice. For a PA or NP, yes it is allowed.For a PA or NP, yes it is allowed.

Frequently asked QuestionsFrequently asked Questions

Q.Q. Can a teaching physician supervise a Can a teaching physician supervise a PA or NP in the same way as a PA or NP in the same way as a

resident?resident?

A.A. No. The teaching physician guidelines No. The teaching physician guidelines apply to medical residents only. apply to medical residents only.

Frequently asked QuestionsFrequently asked Questions

Q.Q. What does a teaching physician need What does a teaching physician need to write to link to a NP or PA note?to write to link to a NP or PA note?

A.A. Nothing. You may only bill for the Nothing. You may only bill for the service provided by the NP or PA or the service provided by the NP or PA or the physician, but not both. physician, but not both.

Frequently asked QuestionsFrequently asked Questions

Q.Q. Can a PA or NP bill upper level E&M Can a PA or NP bill upper level E&M codes codes for example, 99215?for example, 99215?

A.A. Yes. A PA or NP can bill any physician Yes. A PA or NP can bill any physician service that is within their scope of practice. service that is within their scope of practice.

However, since 99214 or 99215 usually However, since 99214 or 99215 usually require complex medical decision making, it require complex medical decision making, it might be hard to argue that a PA or NP might be hard to argue that a PA or NP should should be doing this activity.be doing this activity.

Frequently asked QuestionsFrequently asked Questions

Q.Q. Can a NP or PA bill new patient codes?Can a NP or PA bill new patient codes?

A.A. Yes. But not in an office-based setting. The Yes. But not in an office-based setting. The office-based setting requires a service office-based setting requires a service provided by a physician to which a NP or PA provided by a physician to which a NP or PA can provide a service that is “incident to” that can provide a service that is “incident to” that service. If a patient has never been seen service. If a patient has never been seen before, there is no service that a PA or NP can before, there is no service that a PA or NP can provide that is “incident to” another service. provide that is “incident to” another service.

Web SitesWeb Sites

Nurse PractitionersNurse PractitionersBoard of Nurse ExaminersBoard of Nurse Examinerswww.bne.state.tx.us/Default.htmwww.bne.state.tx.us/Default.htm

Texas Nurses AssociationTexas Nurses Associationwww.texasnurses.orgwww.texasnurses.org

Coalition of Nurses in Advance PracticeCoalition of Nurses in Advance Practicewww.cnaptexas.orgwww.cnaptexas.org

Web SitesWeb Sites

Physician AssistantsPhysician Assistants

Texas State Board of Medical ExaminersTexas State Board of Medical Examinerswww.tsbme.state.tx.us/www.tsbme.state.tx.us/

American Academy of Physician Assistants American Academy of Physician Assistants www.aapa.orgwww.aapa.org

Texas Academy of Physician AssistantsTexas Academy of Physician Assistantswww.tapa.orgwww.tapa.org

Web SitesWeb Sites

Physician AssistantsPhysician Assistants

Texas State Board of Medical ExaminersTexas State Board of Medical Examinerswww.tsbme.state.tx.us/www.tsbme.state.tx.us/

American Academy of Physician Assistants American Academy of Physician Assistants www.aapa.orgwww.aapa.org

Texas Academy of Physician AssistantsTexas Academy of Physician Assistantswww.tapa.orgwww.tapa.org