We recently, recorded a new episode of Compliance Conversations, titled “Understanding the Nuance of NPP Coding” with Christopher Chandler, a Technical Manager of Professional Documentation and Coding, and we had a lot to cover. So much so, that we actually recorded two new podcast episodes.
In the first episode, if you couldn’t have guessed by the title, we dove into the world of non-physician practitioner (NPP) coding. NPPs, as Medicare calls them, are made up of a number of different provider types. They include nurse practitioners, physician assistants, certified nurse anesthetists, clinical nurse specialists, amongst others. The world of NPPs is ever-changing as hospitals are, in Chandler’s words, “developing new ways of providing care to patients… and help alleviate the burden that physicians are feeling, with the amount of patient load that they have.”
If your hospital or clinic has a number of NPPs, it could be a signal to payors to keep an eye on your claim submissions. Which makes it all the more critical that your billing department has the tools to correctly code your NPPs. Listen to our newest episode of Compliance Conversations, where Chandler and I discussed everything NPPs, including:
- Identifying the Difference Between Shared Services and Incident-to
- Avoiding Double Billing the Patient and the Payor
- Following the Intense Guidelines of Shared Services
CJ: Welcome everybody to another episode of Compliance Conversations. I'm CJ Wolf, Healthicity's Sr. Compliance Executive, and today's guest is Christopher Chandler from Intermountain Healthcare. Welcome, Christopher.
Christopher: Thank you for having me.
CJ: Yeah, and Christopher's title, he's a Technical Manager of Professional Documentation and Coding. Tell us a little bit about how you ended up where you are Christopher, and what you're doing now.
Christopher: Absolutely. I've been in the coding field for about six years now, and started out as a consultant, where I would meet with physicians of certain specialties that specialize in general surgery and podiatry for a long time. I'd consult with those physicians on a one-on-one level, and I loved it. It's such interesting stuff because you get to learn a lot about the medical field, medical practices, surgeries, all that kind of stuff. Learning and studying, loved it so much that I eventually became a manager of documentation and coding and work a little bit more on a system level now. Maybe I'll work still with physicians, but then I'll meet with executives throughout the system and the company and try to provide consultation to them that will help streamline Intermountain Healthcare in the correct direction per the coding guidelines.
CJ: Great. That's exciting, I agree. We all come to it from different directions, and I found a lot of excitement when I worked there as well. Much as you said, you get to meet with different people and you get to learn what advances are happening in medicine, they are always improving things, and innovating, and you get to try to help them, to make sure that they are compliant and coding, and getting reimbursed correctly, so it can be a lot of fun.
Christopher: It's an incredible field.
CJ: Yeah. Well today I wanted to pick your brain about NPP coding. Great topic, and I know you're an expert in it, but maybe we should just start with what is NPP and how can they be used. Some people might not know what NPP is, so what is it.
Christopher: NPP is a non-physician practitioner. That is what Medicare calls, they lump together a bunch of types of providers, and call them non-physician practitioners. So, a non-physician practitioner is going to be a nurse practitioner, a physician assistant, certified register nurse anesthetist, clinical nurse specialist, and certified nurse midwife. That is how the OIG and Medicare describe non-physician practitioners. They are called all sorts of things though, we have NPP, we have Advanced Practice Clinicians, APC. Advanced Practice Provider, some still call them mid-level providers, but I think the industry is trying to go away from that name, but they are called a little bit of everything right now.
CJ: Yeah, but for Medicare purposes, NPP is probably the right term. Is that true for Medicare?
Christopher: For Medicare, NPP is the correct term, yes.
CJ: So, now we've kind of defined it, tell us a little bit, how can they be used? How are they utilized tin the flow of clinical operations?
Christopher: As we mentioned earlier, this field is always changing, they are developing new ways of providing care to patients. And a big way that they are doing that is really pushing NPPs in the clinics and the hospitals to help alleviate the burden that a lot of these physicians are feeling with the amount of patient load that they have. APPs will be in the clinic, and a big way that we see them used in the clinic is going to be in a very collaborative manner with a physician. There are, and I think we'll talk about this a little bit later, incident-to services, but then there are just services where the APP will go in and see the patient, collect the entire history from the patient, maybe do a little bit of a physical exam, go and provide that information to the physician, and then the physician will go in and provide the medical decision making for the patient and then working with the NPP in that collaborative manner. Another big way, especially in urgent care specialty, is to have the NPP independently practicing under the supervision of a physician.
Christopher: So they will have their own patient schedule, they will see a lot of the established patients, or the acute problems, like laceration repairs and things like that that don't necessarily require the expertise of a physician, and can be treated by a well trained NPP.
Christopher: That is a way we see it in the outpatient setting. And then in the inpatient setting, they are used even more in a collaborative manner, with they are doing shared services with a physician and working in a collaborative manner that help provide more care for the patient and spend more time with the patient. And yet the physician needs to spend less time with the patient and can see more patients that way.
Christopher: So, using these NPPs is a really great way to provide more access to care for patients.
CJ: Yeah, you know, and on a personal note, you know, though this may not always be a billable service, I have family members that are seeing a physician for kind of a semi serious chronic condition and we often, when we have issues that come up, that don't necessarily require us to go into the office, we often are consulting with the NPP, who then will run things by the physician if he or she thinks that's necessary. Even from a telephonic type of experience, we're starting to see more. Do you see that as well?
Christopher: Absolutely, Intermountain Healthcare right now is really pushing this product called Connect Care, where it's almost like Skyping with a provider, but all the service provided through Connect Care are provided through NPPs.
CJ: Yeah, you know, one thing that I've noticed is that physicians get very comfortable and develop a trust level with NPPs, you know. They have been trained in that specialty as well as the physician has, and they get very comfortable, and they are almost an extension, I don't mean any disrespect in any way, but it can really help the physician, because he or she can trust that NPPs decision making and can really save time.
Christopher: Absolutely, I mean they are Physician Assistants, like their title says. They can learn the way the physician likes to run his or her clinic and help provide the physicians type of care to all, to more patients, than the physician would on his or her own.
CJ: That's a great background and foundation for some of these next questions. Maybe we could talk about the difference between shared services in incident-to, and maybe we start with shared services about, you know, what is that, and what are some pros and cons about shared services.
Christopher: Absolutely. The first difference you would want to think of is, shared services is an inpatient services and incident-to is going to be outpatient services.
Christopher: Shared services are specifically for evaluation of management services. So shared services is when NPP see's the patient, and the physician also sees the patient, at the same time, or separately, usually it's separately, and the physician can bill for all of his or her own work, in addition to all the work done by the NPP. They would combine it all together and bill it under one level of service, and the physician could use the NPPs documentation to help support his or her own level of service as well. It's a great way for the physician and the hospital to get reimbursed at the physician rate, and it's a great opportunity to provide more patient access, like we were mentioning earlier. It gets tricky, though, because there are a lot of regulations and guidelines associated with shared services. And the way I usually talk to my providers about it is, first I ask them, "Are you allowed to do shared services, per the guidelines?" So, these are E/M services in the hospital, inpatient or outpatient setting. But it's hospitals, so these are going to be your hospital inpatient, hospital outpatient, hospital observation, ER, and hospital discharge codes, and the first thing you want to k now is, are the physicians and the NPP employed by the same group? Now, in a smaller hospital, or a standalone hospital, it's a pretty easy answer, it's usually yes, but when you get into these bigger healthcare systems, and you have medical groups, it gets a little bit trickier, because if the NPP is employed by the hospital, then the hospital is probably billing for the work the NPP is doing.
Christopher: So, the medical group provider should not bill for the work that the hospitals already billing for, and that's where a lot of these gets dicey, they want to avoid double billing the patient and the insurance company. So, the first thing is, are they employed by the same group? Another thing you want to focus on, do they both provide a substantive face to face portion of the E/M? And the way Medicare describes a substantive portion of the E/M is, "all or some of the portion of history of exam or medical decision making."
Christopher: The example I gave earlier, where the NPP goes in and gets the history and performs an exam, goes and talks to the physician, the physician comes in and provides medical decision making. That would work. As long as they both see the patient face to face, and they both document the portion that they did as well.
CJ: Okay. Now, just to back up a little bit, is shared services, is that a Medicare term? Or, is it, first of all, and if it is, are we only talking about Medicare patients, or can these shared services occur maybe with a commercial payor?
Christopher: It is a Medicare term that a lot of commercial payors have adopted. I wouldn't go as far as to say all of them, because I don't know that for sure, but many commercial payors have adopted the policy of shared services> But they watch it pretty closely and they have these intense guidelines to make sure they are doing it correctly because, if you do not meet the shared services guidelines, then the service must be billed under the NPP. The reason the payors are watching this so closely is that they don't want to pay a physician rate for work that was done by an NPP unless they meet the shared services guidelines.
CJ: And just so that some people are clear listening, the reimbursement rate for the exact same CPT code performed by an NPP is probably less than what, if that same CPT code is reported by a physician, is that, am I saying that right?
Christopher: Correct. Yes, Medicare pays an NPP at 85% at what they would pay for a physician services. So same code, but it's just reduced by 15%.
CJ: Okay. What are some other pros and cons then of shared services?
Christopher: Some of the pros are, like I mentioned earlier, the greater patient access. The patient is able to have more patient care as well, because these NPPs are able to spend a little more time with the patient, it's much cheaper to employ NPPs than it is to employ physicians. You could have three NPPs working with one doctor, and splitting the one doctors patient load, so that NPP is able to give a little more time and treatment to that patient, and then that physician is able to see more patients, and bill all of those at the physician rate, when normally he or she would have to cut that in half because they just don't have enough time in the day to see those patients that they need to.
Christopher: So that's a pro. A con is that it's very difficult to get correct, and because it's difficult to get correct, if you get it incorrect, then you are payed at a physician rate when you should have been payed at an NPP rate. And if you're audited, you'll end up owing that 15% back.
CJ: Yeah, and you know, on that point, I've given some recent webinars about the 60-day overpayment rule, that the final rule there suggests that you need to be proactively looking for overpayments. This might be an example that you can't just assume that it's being done right. You have to be actively monitoring to make sure that it's being done right so you're not overpaid.
Christopher: Correct. If you are a clinic or hospital who employs a number of NPPs, then that might be a signal to payors that hey, maybe we should watch this, or maybe we should look for this.
CJ: Yeah, great point. Now, if you feel like we're done with shared services, do you want to transition to incident-to and compare and contrast that?
Christopher: Absolutely. incident-to, as I mentioned before, is more of an outpatient setting. Shared services on the inpatient side. incident-to is outpatient E/M services, and these are when services or supplies are furnished incident-to, a physician's professional services. So, the way that's "incidental" in this situation, means that it's a necessary part of the treatment, but not a major part. An example I like to give that is so easy, because everybody has had this happen, is a physician comes in and he or she is providing you your physician for the year, and they say, "Let's take your blood." The physician is not going to take the patients blood, their nurse or NA will do that. That is an incident-to services, and that is not a problem, because the nurse or the NA can't bill for their own work, it becomes a problem when you start doing incident-to services with NPPs, because NPPs technically could be billing for that work.
Christopher: So, the way it looks. The way incident-to is set up, is, a new patient comes into the clinic, the physician sees that patient and establishes a plan of care for that patient. So, these are going to be your chronic condition patients a lot of the time. In that plan of care, they will say you come back and we will provide these services for you and evaluate you for this each time you come back. Every time the patient comes back, on that established patient visit, the NPP would be providing that service that was detailed in the plan of care, and then it would be billed under the physician, because it's the physicians plan of care. The physician does not have to see the patient every visit, they can bill for it if the NPP is following that physicians plan of care.
CJ: So, what do you do, let's say, you have this chronic patient and they are following it, let's say four visits in a row they are following the plan of care that was established on the first visit just fine. On the fourth visit, the patient comes in, see's the NPP, and they are there for their chronic condition that they have been treated for, but there is a new problem now, what do you do there?
Christopher: Right, so if there is a new problem, if you want to bill that under the physician, then the physician needs to see the patient. One of the requirements of incident-to is that when the NPP is providing the services dictated in the plan of care, the physician must be supervising, have direct revision, which means they are physically in the clinic.
Christopher: They don't have to be in the same room, but they have to be physically in the clinic so that they can come in and see the patient if necessary, like having new problems, or if there is a change in the patients condition and the plan of care needs to change. The problem that happens with NPPs, is that NPPs are licensed to provide a lot of the services that could be done without the physician. They could change the patient's medication if needed, they could order a stress test, they could evaluate a new problem. All of a sudden, if they are doing that without the involvement of the physician, it now becomes the NPPs plan of care.
Christopher: So, the physician can't bill for it anymore. It's important to keep the physician involved, in fact, Medicare talks about how there needs to be continued physician involvement throughout the course of the treatment. There are no guidelines out there that specifically say how often the physician should be seeing the patient. I know a lot of healthcare systems kind of have this general "every third visit" rule.
Christopher: There is a lot of grey area with incident-to, and that is one of them. Another is, what is changing the care? That is a big one I've come across as well. I mean, what is considered changing the plan of care? Is it just considered decreasing the amount of medication? I've found one local Medicare carrier that stated if the physician states in his initial plan of care that the NPP can adjust medication dosage, then the NPP can do that and it's not changing the plan of care.
CJ: Yeah, and where I suspect, or in my experience where it becomes frustrating, is making sure that, like as a coding educator, you're separating for the providers the difference between their scope of practice and licensure and billing. So, yes NPP, you have the legal right to do all those things. The state has licensed you; you can do these things medically within your scope of practice, but when you do it you could now have to bill in your name, at 85%, not the physicians. It's trying to help them understand that those are two separate worlds so to speak.
Christopher: Right, and sometimes it's hard for healthcare providers to separate the two.
CJ: It is, absolutely, they think. "Look, I can do it, I'm licensed, so why won't everyone pay me that way?" It just doesn't work that way.
Christopher: Yep, it can be a difficult conversation.
CJ: Yep, exactly. Kind of as we're running towards the end of our time here, can we talk a little bit about independent practitioners? You mentioned that a little bit, that some of these NPPs, you know, they have the authority to be practicing on their own. What is the best way to use NPPs in that way?
Christopher: Honestly, this, in my opinion, is the best way to use NPPs, especially in the outpatient setting, because it allows the NPPs to practice to their full licensure and see patients that would allow them to do that, and there is a lot less risk involved when they are practicing independently than if you're trying and failing to do shared services and incident-to.
Christopher: So, what it would look like is they have their own schedule. As I mentioned earlier, this is very popular in urgent care, where they see the patients that are coming in last minute, or maybe you have, you have trained up your NPP to see all of your established patients, or all of your follow up post op patients, and they manage that kind of stuff. They end up having their own schedule, and people who are scheduled to meet with the NPP, rather than the physician. Sometimes they will, also, for those last minute patients that call and say they need to see the doctor today, they can say the doctor is booked, but we have a spot open for the NPP, do you want to come in and see the NPP? It allows better care.
Christopher: I think it's the way, it gives more patient satisfaction. You are getting less money as a practice, because everything is being billed out at 85% to Medicare, and some private payors, but you are also not spending as much money and payroll as a physician, you're spending significant amount less.
CJ: Exactly, and when you're talking about less money, it might be less when you're comparing this E/M code to this E/M code, but if you don't have to interrupt the doctors, if the NPP can just see their own patients and see their own schedule, they may increase their efficiency to make up for that.
CJ: There's a difference between kind of that service to service comparison, versus let's look at their whole day, or whole week, or whole month, and now let's compare revenue to revenue.
Christopher: Yeah, let your NPPs see all the lower level E/M patients, and then that allows your physicians to see more of the new patients, which normally pay higher, or the higher level patients, the 99214's and 215's that will probably require the expertise of a physician anyway.
Christopher: You're allowing the physician to see more higher reimbursable patients anyway.
CJ: Yeah, and you're absolutely right. If I'm just speaking for a compliance standpoint, that's the option I like best, because it takes away some of the risk of doing, of not following the rules with precision.
CJ: Well Christopher this has been wonderful, you're obviously an expert in all of this, and really appreciate your insights.
Christopher: Thank you so much for having me, it's been a pleasure.
CJ: Yes and thank you to all of our listeners for listening into another episode, until next time take care.