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Medicare Q & A: Physcian Supervising PA at Clinic Print E-mail
Written by Benjamin L. Frosch   
Monday, 06 May 2013 07:35

Q. 
We have a physician supervising a PA at a clinic. They are both Medicare providers and enrolled in PECOS. Can we bill the visits/ services under the supervising physician's name and provider number if the doctor agrees? The PA is being paid a salary and does not want Medicare billed under his provider but the doctor is willing to allow us to bill for his supervised services. The doctor is too busy at another clinic and does not want to see patients.

A.  In order to bill the PA's services utilizing the supervising physician's NPI, all 3 components of the incident to provision must be met. The 3 points that need to be met are:
  • the services are rendered by a W-2 or 1099 employee
  • the services are provided under the direct supervision of the physician
  • the services are part of the physician's plan of treatment
Item number three is the point to be most careful with. As an example, new patient visits rendered by the PA cannot be billed "incident to" the physician because there is no plan of treatment by the supervising physician since this is a new patient.

About the Author
Mr. Frosch is the President of Frosch Medical Consultants, Inc. in Plantation.  Got a question for Ben? Click Ask Ben.  

Last Updated on Monday, 06 May 2013 07:39
 
Are Your Orders Medicare Compliant? Part III Print E-mail
Written by Benjamin L. Frosch   
Monday, 18 March 2013 08:29

MEDICARE Q & A

(To view/review Part I, click HERE.)  

(To view/review Part II, click HERE.)

Making sure that you provide appropriate orders for all diagnostic tests is a very important coding and compliance issue that causes problems for all radiology services. CMS (Centers for Medicare & Medicaid Services) has published numerous articles and transmittals on the requirements for proper ordering of diagnostic tests. Although the overwhelming liability is on radiology providers to obtain proper orders in accordance with Medicare, guidelines, it is a matter of time before the ordering provider also assumes liability for poor orders. 

The following addresses frequently asked questions on this subject.

Q:  If the treating physician provides clinical indications that are not specific, can the study be performed or should the physician be contacted for additional information?

A:  The ordering physician is required to provide valid indications for the imaging study being requested. For Medicare patients, you must have this information to determine whether an advance beneficiary notice (ABN) is necessary. If the indications for the exam are covered under a local coverage decision or are not specific enough for you to determine whether they are covered by it, then you have two options:

* You can contact the referring physician and request additional information because the clinical information provided does not meet Medicare's coverage requirements. Be careful with this step, as it would be inappropriate to provide the physician with diagnoses that are covered and ask if any apply to the patient.

* You can issue the patient an ABN informing them that the clinical indications provided by their physician are not expected to be considered medically necessary by Medicare.

If the patient is not a Medicare patient, then there is no ABN notification requirement, but the patient's payer may have its own coverage and notification requirements.

The determination to provide the study in absence of this information is both a financial decision and a clinical decision.

About the Author
Mr. Frosch is the President of Frosch Medical Consultants, Inc. in Plantation.  Got a question for Ben? Click Ask Ben.

Last Updated on Monday, 18 March 2013 09:02
 
Are Your Orders Medicare Compliant? Part II Print E-mail
Written by Benjamin L. Frosch   
Saturday, 09 March 2013 15:30

Medicare Q & A

(To view/review Part I, click HERE.)

Making sure that you provide appropriate orders for all diagnostic tests is a very important coding and compliance issue that causes problems for all radiology services. CMS (Centers for Medicare & Medicaid Services) has published numerous articles and transmittals on the requirements for proper ordering of diagnostic tests. Although the overwhelming liability is on radiology providers to obtain proper orders in accordance with Medicare, guidelines, it is a matter of time before the ordering provider also assumes liability for poor orders. 

The following addresses frequently asked questions on this subject:

Q: At what point does the CMS consider an imaging order a "stale order"?

A:  Hospitals or health systems may have a definition for stale orders at an enterprise level, which then applies to all types of services ordered within that hospital or health system. IDTFs or physician offices also should have a policy that addresses order validity. Payers that preauthorize or pre certify imaging studies often include an expiration date. However, unlike prescriptions for medication, there is not a standard expiration date for imaging orders.

If there is ever a question about the validity of an order received for imaging services, the referring physician indicated on the order should be contacted for verification.

Q:  When can an imaging facility perform a different exam without obtaining an updated order from the treating physician?

A:  For Medicare, if an order does not specify the exam protocol-for example, the number of views or whether contrast should be used-the radiologist may make this determination based on the patient's clinical indications without notifying the referring physician. This is usually referred to as a "test design" decision.
 
The radiologist also may change an order when it contains an error that would be obvious even to a layperson. For example, if the treating physician orders an X-ray of the left ankle to check the alignment of a patient's fracture, but it is the right ankle that is fractured, the facility can perform a right ankle X-ray without contacting the referring physician.

If the patient's condition will not permit the exam to be performed as ordered, the radiologist may cancel the exam without notifying the referring physician. Any medically necessary "scout" testing is payable.
 
There also is an exception to the ordering rules for situations when the radiologist determines that an additional exam is needed due to an abnormal result of the exam that the treating physician ordered but the treating physician is unavailable to provide an order. There are detailed requirements for providing and documenting the additional service (see Medicare Benefit Policy Manual, Chapter 15, Section 80.6.3).

Finally, the facility does not need a new or revised order to perform an exam that the treating physician conditionally ordered. For example, the physician orders a breast ultrasound after a diagnostic mammogram, if clinically indicated. You do not need an updated order if it is determined that the ultrasound exam is necessary.

If your system does not have the built-in capability for physicians to place conditional orders, updating your internal exam code to the conditionally requested study would not be considered an order change. If your computerized physician order entry system requires that you update the order to the conditionally requested study, you should verify that the original order with the conditionally requested study remains in the system.

Part III will appear next week.
  
About the Author
Mr. Frosch is the President of Frosch Medical Consultants, Inc. in Plantation.  Got a question for Ben? Click Ask Ben.

Last Updated on Saturday, 09 March 2013 15:41
 
Are Your Orders Medicare Compliant? Part I Print E-mail
Written by Benjamin L. Frosch   
Saturday, 02 March 2013 17:04

Medicare Q & A

Making sure that you provide appropriate orders for all diagnostic tests is a very important coding and compliance issue that causes problems for all radiology services. CMS (Centers for Medicare & Medicaid Services) has published numerous articles and transmittals on the requirements for proper ordering of diagnostic tests. Although the overwhelming liability is on radiology providers to obtain proper orders in accordance with Medicare, guidelines, it is a matter of time before the ordering provider also assumes liability for poor orders. 

The following addresses frequently asked questions on this subject.

Q:  What constitutes a valid order?

A:   A valid order must contain, at minimum, the patient's name, the test requested, clinical indications for the test, and the name and signature of the treating physician.

Q:  Where can I find the guidelines in the Medicare rules that define "valid physician's order"?

A:  Medicare's definition of a valid order can be found in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6. You also should review the following resources:
  • The Social Security Act (§1862.a.1.A) states that for a test to be reasonable and necessary, it must be ordered by a physician, and the results must be used by that physician in the management of a beneficiary's specific medical problem.
  • The Medicare Claims Processing Manual (Chapter 23, Section 10.1.2) states that the ordering physician must provide the diagnostic information at the time the study is ordered.
  • The Medicare Program Integrity Manual (Chapter 3, Section 3.2.4) provides information regarding signature requirements and examples of valid methods for authentication.
  • Medicare Conditions of Participation (42 CFR §482.26) provide the requirements for hospital outpatient departments.
Part II will appear next week.

About the Author
Mr. Frosch is the President of Frosch Medical Consultants, Inc. in Plantation.  Got a question for Ben? Click Ask Ben.
 
Coding Advice for an Orthopod PLUS Providing Care in an 'Opt Out' System Print E-mail
Written by Benjamin L. Frosch   
Monday, 18 February 2013 09:09

MEDICARE Q & A

Q. Can we bill an E & M code with a minor surgical procedure such as an injection 20610 for a new patient?   We have always billed the E & M code with a 25 modifier, but I have been reading that is no longer correct and it is not billable.

-Office Manager, Orthopaedic Group, Palm Beach County

A.   The 25 modifier depicts a "separate and identifiable" service. If the initial visit is for an unrelated evaluation, it would be covered.

Q.  Can a physician who is a Medicare provider work for a practice or urgent care etc. that does not participate in Medicare and provide care to Medicare patients who have contracted with the patient for private payment?

If the answer is no, does that not violate The Constitution's clause to allow two entities to privately contract with each other?

- Hospice and Palliative Physician, Central Florida

A.  The answer is Yes for a physician who is a Medicare provider and has reassigned his/her benefits to a practice or urgent care center that is non-participating. 

Mr. Frosch is the President of Frosch Medical Consultants, Inc. in Plantation.
Got a question for Ben?  Click Ask Ben.
 
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