Medicare Attestations and NPPs; Division of Payments; EHR Coding Mistakes

September 5, 2013

Coding questions? We've got the answers.

Medicare Attestations and NPPs

Q: I work in a teaching hospital with residents, physician assistants, and nurse practitioners. Our compliance department recently told us that we can't use the Medicare attestations when we are working with non-residents. This doesn't seem right since we utilize them in much the same manner as the residents. What is the rule here?

A:  There are a lot of factors that could influence this situation. Medicare does have very specific rules governing how teaching physicians work with residents, but those rules do not apply to the relationship physicians have with nonphysician providers (NPPs). Though you may work with NPPs in much the same way you work with residents, it is not considered the same from a regulatory perspective.

If your NPPs are employed by a hospital, you likely cannot bill for any work they do to support you. Your billings must reflect your own work, and unless there is some type of financial arrangement to offset some of their salaries, NPPs are considered part of the hospital charge. It is double dipping if the physician bills for the work of a hospital employee on the professional side. The "resident-style" attestation "captures" elements of the NPPs' work.

Depending on your particular circumstances with the NPPs, the employer of the NPPs, and the function of the NPPs, you may wish to document that much of what the NPPs document is in fact your work. If the NPPs are acting more as scribes, for instance, you could write, "My exam and plan as documented above" with some additional comments.

There are probably a few answers to your question depending on the circumstances in your facility. Hopefully your compliance department can give you the particulars. The notion that NPPs should be treated differently in terms of attestations or statements, however, is sound.

Division of Payments

Q: I have a patient that has X primary insurance and Y secondary insurance. I submitted to Y an unpaid superbill by X where the allowed amount was applied to the deductible, and I submitted another superbill to Y where X paid some and left a $20 copay. Y is now telling me they do not cover for those services, and that I cannot transfer the balance to the patient. Do you have any input on this?

A: The amount applied to deductible for the primary insurer is then the patient's responsibility. The secondary insurer, depending on the plan, may only pick up coverage after copays and deductibles are met for the first plan and a balance remains. The statement that "the insurer does not cover for these services" is pretty broad. This could speak to actual benefits and covered services, not just the division of payments between payers. On the last point, that you can't balance bill the patient, if you are a participating provider with this insurance entity look at your contract. It may confirm if this is the case. If you are not a participating provider with this plan, however, the insurer cannot tell you that you cannot balance bill the patient.

'Delivery Only' Code

Q:  If I bill a "delivery only" code for a C-section and I see the patient the next day or two in the hospital, can I bill a visit, or is it considered included in the delivery code?

A: The CPT subsection states: "When reporting delivery only services (59409, 59514, 59612, and 59620), report inpatient post-delivery and management using Evaluation and Management Services codes (99217-99239)." This gives you the green light to bill for these services.

This is not, however, the case with overall surgical services. For those services, the code includes immediate post-op components, such as wound care. The OB packages are a bit different than the normal surgical packages. The antepartum portion is eight-plus months long, the post-partum period is not well-defined.

You may also want to think about using the post-partum code 59430. This would extend beyond the hospital care and cover additional visits, and include assessment or counseling of post-partum depression and nutrition.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the September 2013 issue of Physicians Practice.