Frequently Asked Questions

What is the reimbursement compliance program?

Why do we need a reimbursement compliance program for payers other than Medicare and Medicaid?

Why shouldn’t I undercode all my services just to be safe?

Why do I need to update my encounter forms annually?

What is the difference between a new and established patient?

How do Physicians Assistants (PA) and Nurse Practitioners (NP) bill for services they perform in an outpatient setting?

Can a PA or NP see new patients?

What levels of Evaluation and Management Services can a NP or PA bill?

What is "Incident-to" billing?

If the physician who initiated treatment for a patient is not in the office suite on the day the patient returns for a visit, can the PA/NP see that patient even though the physician is not available to provide direct supervision?

In that scenario, where the supervising physician is different from the treating physician, how should the claim be billed?

What is a Consultation?

What is the difference between a consultation and a new patient visit?

How do I document that I provided a consult?

Can physician ask another physician of the same specialty in the same group practice for a consult?

What is an Advanced Beneficiary Notice (ABN) and when do I need to use one?

What documentation is required when performing procedures?

When auditing Evaluation and Management services, what area or areas do you find that the physicians overlook the most?

For coding purposes, are there any special documentation requirements when Concurrent care is provided?

What is the reimbursement compliance program?

The goal of a reimbursement compliance program is to eliminate the coding and billing errors that will reduce the risk of a charge of fraud, to create a more accurate accounts receivable (A/R), to provide a resource for office staff to alert them to potential problems in billing and to identify system problems that can be changed through physician and staff education.

Why do we need a reimbursement compliance program for payers other than Medicare and Medicaid?

Physician offices must adhere to the coding and billing guidelines as defined by the Center for Medicare and Medicaid Services (CMS, formerly HCFA) for all government payors. However, claims to commercial insurance carriers are frequently not handled as precisely. The passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) has brought to our attention the need to assure that the billing process from physician offices and clinics adheres to correct coding and billing standards for all third party claims. 

The failure to bill correctly and the failure to provide appropriate documentation can result in significant penalties to the physicians involved as well as the individuals within the organization who have any knowledge of potential fraudulent coding and billing activities.

Why shouldn’t I undercode all my services just to be safe?

With all the talk about fraud and abuse, some physicians decide to play it safe and undercode their Medicare patient visits. Undercoding is a problem for every medical practice because it decreases earned revenue and establishes false utilization patterns. Utilization patterns are closely scrutinized by the government and by many payors. Most coding experts believe all inaccurate coding is bad coding. In some cases, undercoding can flag a physician as an outlier and lead to an investigation.
The first step to a health practice is to understand the guidelines. Many physicians undercode because of their lack of knowledge of the system. Learning to code should be an important part of every physician’s knowledge base. 

Why do I need to update my encounter forms annually?

Encounter forms or superbills are a tool that is supposed to help make the documentation and coding process easier for physicians. Formatted with current procedural terminology codes according to specialty, encounter forms, also known as charge tickets or superbills, allow providers to record the diagnoses and services performed simply by checking off the matching codes on the form. But these forms also put providers at risk for reimbursement problems and billing fraud. Common errors include obsolete codes, incorrect codes, incorrect descriptors, missing modifiers, mistyped codes, and missing codes. 

If a provider is unaware that the forms contain errors, they might end up choosing incorrect codes. Or they might end up selecting a code that is "closest" to the diagnosis or procedure that they performed. Choosing a code that is "closest" to the service performed is not correct coding and can land a practice in serious trouble. 

What is the difference between a new and established patient?

AMA’s definition of a new patient is one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group with in 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.

HFCA Transmittal 1690, released on January 5, 2001, added further clarification that if no evaluation and management 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 visit if the providers have rendered a non-face-to-face service for that patient within the past three years. An example is when a physician bills for an X-ray interpretation and sees the same patient two months (within 3 years) later for an office visit. This visit can still be billed as a new patient office visit.

How do Physicians Assistants (PA) and Nurse Practitioners (NP) bill for services they perform in an outpatient setting?

A PA or NP can bill either of two ways. They can bill "incident to" a physician’s service (under the physician’s UPIN) or they may bill under their own billing number. 

Can a PA or NP see new patients?

Yes, but only when they are billing under their own provider number. The rules for "incident-to" services require that a physician perform the initial service for patients being billed under the physican’s provider number.

What levels of Evaluation and Management Services can a NP or PA bill?

A PA/NP can use all code levels when they are billing under their own provider number. If billing "incident-to", they may only used established patient codes (99211-99215).

What is "Incident-to" billing?

"Incident-to" billing is any billing that is provided incidental to the physician’s services by the physician’s employee. In order to bill services incident-to, the patient must be an established patient of the physician or the physician’s group practice.

If the physician who initiated treatment for a patient is not in the office suite on the day the patient returns for a visit, can the PA/NP see that patient even though the physician is not available to provide direct supervision?

If the physician who initiated the treatment is not available, it is acceptable for that patient to be seen by the PA/NP as long as there is another physician from the same group practice able to provide the required level of supervision.

In that scenario, where the supervising physician is different from the treating physician, how should the claim be billed?

The claim should go out under the provider number of the physician who supervised the service.

What is a Consultation?

A consultation is a service provided by a physician whose opinion or advice regarding evaluation and management of a specific problem is requested by another physician or other appropriate source. A consultant may initiate diagnostic or therapeutic services. The request for the consult must be documented in the patient’s medical record. The consultant’s opinion and any services that were performed or ordered must also be documented in the record and communicated to the requestor. 

What is the difference between a consultation and a new patient visit?

If the requesting physician is asking for a transfer of the complete care of the patient, then the visit should be coded as a new patient visit and not a consultation. "Complete" care is defined as the total care of the patient.

How do I document that I provided a consult?

The following must be documented for every consult:

  1. The request and need for the consultation
  2. The consultant’s opinion as well as any services ordered/performed.
  3. The results of the consultation must be reported to the requesting physician and a copy maintained in the patient’s medical record.

Can physician ask another physician of the same specialty in the same group practice for a consult?

Yes, it is appropriate to report a consultation code when a consultative service between the same specialty in the same group practice is performed. Remember, however, that medical necessity and requirements for a consultative service must be met. 

What is an Advanced Beneficiary Notice (ABN) and when do I need to use one?

An ABN is a written notice that a provider or suppliers gives to a Medicare beneficiary before Part B services are furnished when the provider or supplier believes that Medicare will not pay for some or all of the services. If the provider/supplier expects payment to be denied by Medicare, the provider or supplier must advise the beneficiary before services are rendered that , in its opinion, the beneficiary will be personally and fully responsible for payment. To be "personally and fully responsible for payment" means that the beneficiary will be liable to make payment out of pocket, through other insurance or through Medicaid or other federal or non-federal payment source. The provider or supplier must issue notices each time and as soon as it makes the assessment that Medicare payment will not be made. 

What documentation is required when performing procedures?

A complete technical detail of the procedure is important not only for patient care but for reporting accurate CPT codes. A complete technical detail of the procedure should include the following:

  1. Pre-operative evaluation
  2. Medical necessity
  3. Separate note for the procedure
  4. Complete procedure note itself
  5. Signed and dated by the MD

When auditing Evaluation and Management services, what area or areas do you find that the physicians overlook the most?

When auditing charts for Evaluation and Management 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 higher level of services (levels 4 and 5) for Consultations and New Patient Visits. This particular problem is not limited to certain specialties. It occurs all across the board. Savvy physicians are able to understand the requirements and have utilized patient intake sheets, questions sheets filled out by ancillary staff, or even a simple check off list in their template to meet the documentation requirements. It must be evident however, that the physician acknowledges the intake sheets or question sheets filled out by the patient or ancillary staff. This can be done by referencing to it and/or by signing and dating it.

If the physician has indeed taken 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 everyone of the systems are essentially negative.

For coding purposes, are there any special documentation requirements when Concurrent care is provided?

Concurrent care is the provision of similar services (eg, hospital visits) to the same patient by more than one physician on the same day. CPT manual does not cite any special reporting requirements when concurrent care is provided. However, when concurrent care is provided, the ICD-9 diagnosis code reported by each physician should reflect the need for the provision of similar services to the same patient by more than one physician on the same day. In other words, medical necessity of why concurrent care is needed should be evidenced by the ICD-9 codes reported. It must be noted that reporting the same ICD-9 code(s) that is most specific in representing the service does not, in any means, preclude billing for the concurrent care.