Part of the Team: Non-Physician Services in Chronic Pain Practices
A veteran of the armed forces recently remarked that, in order to be an effective fighting force, a military unit needs some to operate weapons and others to peel potatoes. Both groups are equally critical, though one may seem more glamourous in the eyes of others. "An army marches on its stomach," is a well-known maxim that makes the same point. Cooks and commandos must work in unison if victory is to be assured. The glory is ultimately shared by all.
A medical group practice is like a military team. The success of its healing mission depends on everyone doing their part and actualizing their expertise. Every member of this operation is equally appreciated as a valued contributor to the patient's care, including providers who may not have an M.D. or D.O. behind their name. Because the involvement of these individuals can be critical from a clinical standpoint and confusing from a compliance standpoint, today's article will focus on non-physician practitioners (NPPs)—and specifically those in a chronic pain practice.
Practice Parameters
Nurse practitioners (NPs) can perform services that are allowed by their state scope of practice statutes and can generally bill for such services under their own name and NPI. However, Medicare pays NP claims at 85 percent of the Medicare Physician Fee Schedule (MPFS) allowable rate, whereas doctors receive 100 percent of the allowable. When an NP performs and bills for a service, he or she must work "in collaboration with a physician." This involves having and documenting an established professional relationship with a physician where the physician agrees to provide appropriate supervision regarding issues that are outside the practitioner's scope of practice.
Physician assistants, on the other hand, must work under the general supervision of a physician, meaning the service is performed under the doctor's overall direction and control, but the doctor's presence is not required during the performance of the procedure. However, the physician supervisor must be available by telephone unless state law requires otherwise. In addition, whereas an NP may be an independent provider, an employee or a leased employee, a PA must be a W-2 or contracted employee. This means that the PA's employer or contractor must bill out the PA's services (using the PA's NPI), which are generally paid at 85 percent of the MPFS allowable.
Incident-to Services
Medicare has historically allowed physicians to bill in their own name for services performed—at least in part—by an NPP who is part of the physician's practice and who is performing such services in a way that is incidental to the physician's overall direction and care plan for that patient. The advantage of billing their services as "incident-to" is that the reimbursement goes from 85 percent to 100 percent of the allowable.
Chronic pain groups should be aware, however, that incident-to services come with a few caveats. For example:
- Incident-to can only be billed for established patient visits. Some physicians incorrectly assume that a new patient visit performed by the NPP can be billed under the physician simply because the physician is present somewhere in the office.
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The plan of care in the initial patient
encounter must state that any subsequent care may be provided by the NPP.
If you are using an electronic record or template, the plan should be set
automatically to provide this statement.
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If an established patient is seen for a new
problem, the visit can't be billed as incident-to, because the MD must address
any new problem and create a plan of care for that problem. In the event
that the NPP sees the patient for a new problem for which there is no physician
care plan, that encounter would have to be billed in the NPP's name, rather
than the doctor's name.
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In order to bill incident-to, the physician must
be immediately available in the office suite. Based on one government
description, this means that the physician must be able to respond "without
delay." At least one healthcare attorney has suggested that, if a
physician is involved in another patient procedure (e.g., ESI, SIJ injection),
he or she would not be immediately available to the NPP, and thus the NPP's
service would have to be submitted in the NPP's name.
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The established patient must be seen
"periodically" by the MD over the course of care in order for the services to
be billed as incident-to. Therefore, doctors should document the extent
of their involvement in the patient's care.
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Unlike the "shared services" concept (a whole
other set of rules), there is no incident-to in the facility setting. In
other words, incident-to billing is limited to the office setting.
As you can see from the above, incident-to billing is not as easy as some may think and is fraught with potential "gotchas" from an auditor's perspective.
Enter the Anesthetist
Until a few years ago, the Centers for Medicare and Medicaid Services (CMS) did not allow CRNAs to bill for chronic pain services. In fact, these providers were not allowed to even bill for evaluation and management (E/M) services, except those limited to the pre-anesthesia assessment (typically bundled into the anesthesia service except in cancelled cases) and pain rounds. Since E/M services account for a significant amount of a pain practice's case volume, the inability of CRNAs to perform such services made their incursion into the subspecialty impractical.
However, all this changed in 2013, when the Medicare Physician Fee Schedule Final Rule for that year published the following language:
"Anesthesia and related care" means those services that a certified registered nurse anesthetist is legally authorized to perform in the state in which the services are furnished . . . In addition, we agree with commenters that the primary responsibility for establishing the scope of services CRNAs are sufficiently trained and, thus, should be authorized to furnish, resides with the states.
Though not addressing chronic pain and E/M services directly, the language was meant to further define the meaning of "related care" as found in the Code of Federal Regulations (CFRs). The Final Rule's wording has been interpreted by some healthcare attorneys, as well as the American Association of Nurse Anesthetists (AANA), as authorizing direct payment to CRNAs for chronic pain services, which would presumably include E/M services. Interestingly, a U.S. Government Accounting Office (GAO) report released in April of 2013 details that Medicare Administrative Contractors (MACs) in 24 states allowed CRNAs to bill E/M services in chronic pain cases. Significantly, that same report revealed that CMS had expressly authorized CRNAs to be able to practice in the area of chronic pain without having to be under a physician supervisor.
To summarize, a CRNA's ability to bill Medicare for chronic pain services will be up to the individual state scope of practice laws and regulations. If the state in which the CRNA practices allows that provider type to perform, for example, an epidural steroid injection, nerve stimulator service or E/M, then the CRNA can submit such services to Medicare and those payers that follow Medicare in this regard.
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While this has not been an exhaustive treatment of NPPs in a chronic pain practice, we hope that it has provided you with sufficient insights to sharpen your plans for utilizing these providers and to ensure that your practice is following the rules for proper usage of NPP services. If you have further questions about this topic, you can reach out to your account executive or contact us at info@anesthesiallc.com.