Discover the Perfect Weekly Billing Format for Supervision

Weekly billing format for Supervision

all right it's top of the hour so I think we'll jump in I'm David Glazer and I'm Katie Burkhart uh we're coming to you live from Geneva unfortunately it's the conference room version not the uh actual one I think Katie and I bit off more than we could chew today we've got the topic understanding medicare's supervision signature and Order policies in clinic and hospital setting um there's a lot of stuff to cover so we will do almost no housekeeping as usual I will just do a couple of quick things first remember over the lunch hour sound sometimes gets kind of hinky if it does you can always dial in um Robert's typing numbers in the bottom right corner and you can you can dial in that way our next webinar I'm hoping will be as popular as this one was on May 9th once again Katie and I are going to be talking about short hospital stays and what I think will make this one appealing is we're going to be talking about how you challenge denials so Physicians will probably be a little less interested in this one but for hospitals this is a big deal how you challenge short hospital stays all right so let's Dive In first understanding the big picture we're talking about Medicare here and so there are all kinds of signature requirements you could have state law private payers Medicaid you know all the various accrediting bodies including the Joint Commission um you have standards of care and you can have whatever your local whistleblower thinks at the moment um we may allude to a few of those things but we're really focusing on Medicare second point and this is a very important Point whenever you're talking about signatures there's kind of two things to consider there's the safest approach and there's the what could we aggressively argue in an appeal um I think both Katie and I like to be kind of creative and so we will often come to what we can think is most defensible in an appeal but that isn't to say that the Practical advice in most of these cases will be sign the darn thing um next point we will be talking some some we'll be talking more articulately than I am right now hopefully about conditions of participation which are different from conditions of payment we're really going to focus more on the conditions of payment than on the conditions of participation there's a reason for that which is we hope they're different unfortunately right now it's only a hope and so let me explain that first there's language in the program Integrity manuals and if you really jump down to the uh to the Bold uh on the second part of the slide if during a review it's determined that a provider doesn't comply with conditions of participation the carrier is not supposed to deny payment solely for this reason instead they turn it over for the person to be defrocked from Medicare that's been our historical position there's an interesting question evolving right now as to how that's going to play out in the future um our enrollment Guru who happens to be sitting next to me uh may offer some quick advice what's going on with Medicare enrollment right now well there's there's a lot going on um and most of it comes from Health reform but the first big thing that you should know is that CMS has announced that it is going to revalidate all of the Physicians not non-physician practitioners and suppliers at some point now they've started with um I think it's 105 000 Physicians and non-physician practitioners that have supposedly received requests for them to submit their revalidation information so if you want to know if you're on this list CMS has actually made it available and I'd be happy to check that for you but it's it's really important to respond to revalidation requests because this is where CMS is going to ask you to update your enrollment information and enrollment information is really important to get correct now why are we raising this right now one of the changes in the enrollment information is a change in the certification you sign when you submit it I have in front of me the 855a language which is what applies to facilities there's also a b and I should grab the B languages I don't know that it's identical but here's a scary sentence I understand that payment of a claim by Medicare is conditioned upon the claim and the underlying transaction complying with such laws regulations and program instructions and on the provider's compliance with all applicables conditions of participation so there's the condition of particip condition a participation element in there but there's also this requirement that you comply with program instructions so Katie do you think are the manuals program instructions well it's interesting because because most of the manuals are program instructions or our instructions to cms's contractors so my counter to certifying that you're complying with the program instructions would be that you don't have to comply with an instruction that isn't directed to you however some manuals are less clear they appear to be directed towards a general more General audience including Physicians suppliers Etc so what's interesting about this new certification statement is that it sort of brings in all of these perhaps manuals transmittals maybe even guidance from the carriers within the realm of things that now CMS thinks that you're certifying to complying with which is a scary scary thing and I would like to argue and we have not yet thoroughly researched whether you can make a straight-faced argument that manuals are not program instructions I I think that there may be such an argument to be made but I wouldn't bet the house on it right now I guess one of the lessons is um I I can feel the vice tightening on practice on you know Physicians and hospitals right now so I just mentioned that okay um next part of the big picture there's an increased focused on causing a claim to be presented which is one of the elements in a false claims action is that you can get in trouble either for submitting a false claim or for causing a false claim to be presented so you know Katie doctors routinely get certification forms to fill out for you know home health or something like that do they need to care about these puppies well sometimes all these forms seem just like a lot of paperwork that doesn't matter but as as this becomes a bigger deal where the where the government's focusing on causing a claim to be presented if you are indeed certifying something or signing something that says this is a certification statement then you could be arguing it can be argued that you're causing a claim to be presented that you certify is correct so it's bottom line paperwork is a big deal make sure you know what you're signing so all right and the last point and this is going to come up Katie will be dealing with this more probably than I but the regulation and guidance on signatures is often inconsistent sometimes you can harmonize it sometimes it's facially inconsistent but if you if you pay careful attention to the wording you can find a way to harmonize seemingly um disparate statements but in a few of the instances it's downright contradictory and so you can find a section that says you don't need to sign a form and then you can find a section that says you do and actually like I guess I'll be talking about an example when it comes to office notes for physician signatures all right I'm not going to spend any time talking about the agenda we did struggle a bit in how to organize today so we're going to start off kind of talking about supervision we'll move on then to incident two then signature requirements and orders and kind of end there all right big picture I'm not going to spend long going over the law especially because we don't want to bore um bore you to death but it is helpful to look at the friendly Medicare statute for a moment because it defines things in ways that affect the signature requirements and one of the things to understand is that the Social Security Act lists different benefit sets so the first benefit is Physician Services which is different than the benefit that is services that are an incident to a physician's Professional Services and we'll talk about that that everyone uses the phrase incident to and what that comes from is that the service is an incidental part of a physician's service it's really just I think designed to confuse and then there's a third benefit which is diagnostic x-ray tests these are three distinct benefits under the law and that ultimately is going to matter because um well we'll explain why and when we get there but it's just important to note that and we stuck the laws in here right now another thing that's just kind of worth a quick glance this is the portion of the act that refers to um nurse practitioner services and there's almost identical language for physician assistants and for clinical nurse specialists and it says basically if a service would be a physician's service and it's done by an NP or a PA or clinical nurse specialists then the NP or PA can bill it themselves a thing to note here I have often short-handed this as anything and doctor can do an NP or PA can do if it's in the scope of practice that's not right my shorthand to when I do that is wrong because it only talks about services and the importance of that will be clear in a little bit now let's talk about the supervision of diagnostic tests Medicare has created three levels of supervision personal Direct in general and the way you find out which limit so this is now we're only talking about diagnostic tests and and we're also only talking right now about in the office setting excellent point in the non-hospital setting and that's it though so this this is why this is going to be somewhat confusing Katie's going to talk about hospitals in a minute so this is offices and it's nothing that's therapeutic and she'll go more into that distinction but if basically if it's not a diagnostic test what we're about to say if it's not a diagnostic test in the clinic you can blow off what I'm going to say so every year Medicare puts out the fee schedule and the fee schedule lists all of the things that are considered diagnostic tests and actually that's one of the things you can check because some of the things you might think of as diagnostic tests really are not and those are listed in the code as no level of supervision is necessary otherwise it needs personal direct and general so what does that mean personal means the doctor has to be in attendance in the room during the performance of the procedure a classic example of that is the stress test um you know there so the doctor has to be literally in the room the next level of supervision is direct supervision this gets mushier it says that the physician must be present in the quote office suite and immediately available to furnish assistance throughout the performance of the procedure it then helpfully says that it does not mean the physician must be present in the room so we don't have to be in the room it tells us what it isn't it doesn't really tell us what it is so what does in the office suite mean this has been a question that's been around for as long as I've been a health lawyer which sadly is coming up on 20 years we don't know exactly what it means when I was a young pup we used to say it was the 30 second test can you get there in 30 seconds it wasn't the test after the 31st test um that's pretty decent it's not etched in stone we're not you know there's no legal authority to back that up do you have to be in the same building there have definitely been carriers that have said the answer to that is yes and it feels like if you're in a different building so situation gets a lot weaker um now that of course can be logically crazy because often especially in cold climates like Minnesota you may have two buildings connected by a Skyway and you could be in two different buildings and literally closer than you are if you're on the first floor in the third floor is that okay we don't know there have been very few published cases on this there's very little written guidance here's one of the few things that's ever been written by this and you'll notice it's not a final rule it's a proposed rule that came out in 1998 and I'm not just going to read it to you because it'll tell you as much as you can so we're not proposing that there must be any particular configuration of rooms to qualify as one's Suite however the physician must be in the office suite thus a group of contiguous rooms should in most in most cases satisfy this requirement well huh doesn't it in all cases which is what I would have thought we've been asked whether it would be possible for a physician to directly supervise a service furnished on a different floor we think the answer would depend upon individual circumstances the question of physician proximity is a decision that only the local carrier could make based on the layout of each group of offices a carrier might decide that in certain circumstances it's appropriate for one room of an office suite to be located on a different floor such as where a physician practices on two floors of a townhouse well that's helpful and clear isn't it practically I still stick with my 30 second test I think that if you can get there you know to respond to a code I'm going to feel very comfortable defending you but you take a little bit of risk if you get further than that okay last level of supervision we're talking about supervision of diagnostic tests all right let's try that General supervision now this is another one where I used to cavalierly say you had I used to define personalized in the room in the suite and then as general as on the planet but that's too Cavalier because if you read what the actual requirement is you have to be responsible for the training of non-physician personnel and maintaining the necessary equipment now this is an interesting one because the truth of the matter is I think very few Physicians meet this um I feel like it's asking me to be able to supervise the you know could I fix the copy machine can a doctor fix the X-ray equipment no that's not in their skill set um and so there's a really interesting question as to what this means and whether anyone in fact meets it but getting practical rather than esoteric I think the test for General supervision is who would the tech go to if they had a question if one group is providing all the tests I feel pretty good about it where this gets complicated are situations where more than one organization are sharing a piece of equipment or where techs are being leased and when that's happening you have to organize in such a way that your texts know who's supervising them and you have to be prepared because if Medicare were to show up and ask your texts you know you want to say who's your daddy who's supervising this test they have to be able to answer it and it's interesting David I've heard stories from actual clients who say that and you're going to get to idtfs but this the same idea applies that one of the easy ways for a carrier to to ding you is to call up a tech or an office and to ask the tech if he or she knows who they're supposed to be calling for supervision purposes I think this is even more important in the idtf setting because you have supervising Physicians but I think the bottom line is that the tech should have some idea of who's supposed to be in charge of these things so all right um now let's talk on a big trap so a big trap is that only doctors can supervise diagnostic tests so if we go back to that law which perhaps I should have stuck here you know it talks about a service any service a doctor can do an NPR PA can do well for whatever reason Medicare well Medicare doesn't consider supervision to be a service it's something else and so in their mind MPS Pas and that's supposed to be clinical nurse specialists not Canadian national railroad I lost a nest sorry um can't supervise tests so the doc physician extenders can order them they just can't supervise them and that's true in the hospital setting too for diagnostic tests so that's one commonality between office and hospital for Diagnostic and they also can perform the tests in certain situations they just can't supervise them um okay idtf supervision I want to mention this just quickly um because because it's supervision related in an independent diagnostic testing facility an idtf tests require additional supervision if you have the choice of being either a physician practice or being a hospital or being an idtf pick one of the first to do you don't want to be an idtf so an idtf a physician can only supervise three or fewer sites and the supervisor has to quote evidence proficiency unquote in the performance and interpretation of tests now what CMS says about that is basically um that that's left up to the discretion of the local carrier as to what it means and only the supervisor of record can do the supervision if you're looking to become nauseous you can read U.S xrl Hobbes versus medquest which is a case that came out in 2011 it's not great facts for the organization but an 11 million dollar false claims act verdict was rendered where the claim was that what had been a physician in practice was now actually an independent diagnostic testing facility but they have failed to update their enrollment forms and they lacked sufficient physician supervision reading that case is chilling on a bunch of levels but it highlights the need for supervision and it even gets to something Katie's going to talk about in a little bit which is how carefully do you record the level of supervision um one of the lessons for me on this I think that the case was misnamed I actually think it's uh xrel Hobbes versus Kelvin based on the following oh no I have to go to the bathroom monsters will get me as soon as I set foot on the floor and if you're like I am this was a real fear my last step into bed was always a leap because I was convinced an arm was going to emerge from under the bed and grab me and pull me underneath uh Hobb says I know put your pillow down as a decoy while they're eating that you can slip out and Kelvin thinks this is a great idea I'm coming out of bed now here I am all fat and Squishy well it works they took it man look at the feathers fly you'd better hurry this causes Kelvin to reconsider no I've decided to stay here and wet the bed but it's okay with me if you don't want to stay um this case is a chilling illustration that there really are monsters under the bed right now I think there's going to be a lot of enforcement on the supervision front and so we're going to have to pay attention to the stuff I'm talking about here and the stuff Katie is going to talk about now all right so what I want to do now is take you back real quickly to the Medicare statute because now we are switching benefit categories we are going from diagnostic tests in the non-hospital setting which David just talked about um to two new benefit categories um the first one being Hospital services that are incident to physician services rendered to outpatients that's the category we commonly know as Hospital Therapeutic outpatient services then the second one we're going to talk about is diagnostic services that are furnished to outpatients so there's an entirely new benefit category for diagnostic services in the outpatient setting so we're going to have different rules for that as well let me just briefly touch on what in the world therapeutic services are basically if it's not a diagnostic test and it's not a physician service and it's not a PT OT or speech language service then it's a therapeutic service this is a catch-all category um in in I think the best examples are things like infusion and chemo and observation services that are provided to outpatients I will note here just a reminder that incident to the language that you see in the statute for incident two in the outpatient services setting it's not the same as the incident to billing rules in the office so try to ignore that CMS is unfortunately used the same phrase to refer to two different things big picture when you're talking about Hospital outpatient services you need to think about all these supervision rules and then incident 2 services in the office there are different billing rules so if you've been even remotely in touch with CMS rulemaking over the past few years you know that the evolution of this supervision of outpatient services has been quite tortured but the good news is that I think CMS has finally settled on some Concepts that we can wrap our head around the only thing you need to know about the past is basically that at one time for a long time CMS used to assume that if you were on campus you are meeting the supervision requirements for outpatient therapeutic services and so people didn't really care about the rules because CMS wasn't enforcing them now we have to care about them because there are actual real standards we need to meet and there's no more reception so if you have a therapeutic service it needs to be supervised who can supervise differently than diagnostic tests it can be a physician or a non-position practitioner I've listed those here so long as that supervising practitioner is acting within their state law scope of practice can't be doing something that you're not licensed to do and you're also consistent with the Privileges that the hospital has given you I'm just going to chime in there because for a while we were hearing red herrings people would get really talked off about this privileges thing um and there and it turned into a whole bunch of well you know questions about privilege and I think that's something that's within the hospital's control and the way it's worded it really is you have to be outside the scope of your privileges right and so you know I think that that's a red herring but you will sometimes hear lawyers who turn this into a concern and I think it's a it's a concern as long as you're not doing something that the hospital forbids you're okay right the one exception to this who can supervise rule in it being a bunch of non-position practitioners is that for pulmonary and cardiac rehab it must be a physician who's supervising I've already had a question about whether that physician has to be board certified and I need to look at the rules so I will answer that person's question and if other people have it they can email me but it has to be a physician in those cases now interestingly just to confuse you the statute for pulmonary and cardiac rehab has put back in the assumption that if you're on campus you're meeting the supervision requirement so it's sort of this weird CMS doesn't assume anymore but for pulmonary and cardiac rehab they do assume you need it so long as you have a physician doing it the default rule for outpatient therapeutic services that you have to have direct supervision what CMS gives us for that for a definition of that is basically that the supervising practitioner has to be immediately available we've seen that before to furnish assistance and direction throughout the performance of the procedure it doesn't mean you have to be present in the same room so that's the right that's the rule definition what in the world is immediately available mean there have been various iterations of this by CMS there's still no official definition but we do know from their commentary that you have to be able to be interrupted if you're the supervising practitioner so you can't be in the middle of open heart surgery with your patient on the operating table and then be be called away because I would hope that you wouldn't be able to be interrupted in that situation you also have to be able to respond in time to change the course of treatment if that's necessary what CMS has done in its final determination is that it said we are not going to impose a geographic boundary so you don't necessarily have to be within the four walls of the hospital or on the hospital campus maybe you could be on the golf course that's next to the campus so long as you can go in and change the course of the treatment I don't know if that's actually possible but point is there's no Geographic boundary and this has been helpful particularly for um for hospitals that have a medical office building next to the hospital if you're in if the physician who's supervising is in is her office doing charts and they can still get to the procedure to change it if they need to then that's going to meet the standard here this caused these new standards caused a lot of angst for smaller hospitals because this is a this is a real Staffing burden to meet these these requirements um and so what we've what CMS has said is that they are going to delay the enforcement until January 1 of next year for any critical Hospital access hospital and a small rural Hospital which they're defining as 100 or less or fewer beds now there's of course as always a CMS another exception to this direct supervision requirement there's a new group of services called non-surgical extended duration therapeutic services fancy title basically for a list that CMS is going to going to publish each year with the outpatient prospective payment system role which I've linked at the bottom of the slide and it's a list of procedures that basically CMS has said okay so these aren't such a big deal that we need to have direct supervision all the time but we definitely want there to be direct supervision at the initiation of the procedure and then once the initiation is over then there can be General supervision and that basically means that's the rule that David talked about earlier where you have you're responsible for the you know the equipment and if I'm recalling it right but you don't necessarily have to be immediately available no I'm not totally certain how this works from a practical standpoint because even if you have are doing some of these non-extended duration services I don't know how you could sync it so that all of them started at the right time and then moved to General supervision at the same time such that that would somehow relieve the Staffing level but we'll take what we can get and pay attention to these to these rules or to this list because it could change right now it's basically infusions and injections but people are hoping that chemo will be put on there soon and then the other change for this year is is that there's now a panel that is going to be looking at various services to see if they either need to be have a lower supervision requirement or go up to personal supervision so be aware that there's a panel out there it's not a rule making process so they're basically going to post their recommendations they'll take comments and then they'll recommend to CMS what to do with these levels now the there's been a promising first meeting in that the panel didn't require more supervision for things and instead they said okay for things like smoking cessation we just we're only going to go for General there so we'll see how that plays out do you think that the Hop is either an invitation for uh a Kermit the Frog or is it really a pen is it something to do with pancakes hopefully means that the supervising practitioner can hop between on-campus and off campus and not have to meet certain immediately available requirements okay so now we're switching benefit categories again and we're talking about outpatient diagnostic services so new set of rules the same rule that only Physicians can supervise diagnostic tests applies in the hospital so this is a really big trap you got to have a physician supervising and it's sort of convenient in that you can look at the supervision level in the fee schedule to determine where you need to be the one thing being different is that for the office setting direct supervision means you have to be in the office suite whereas in the hospital setting you could be like I said at the coffee shop next to the hospital campus if you can interrupt or if you can be interrupted and respond now then of course we have another little carve out exception if basically if you are a provider-based department and you're off campus and the services are being provided under Arrangements in that case if the test requires direct supervision then that position has to be immediately available and present in the office suite so I'm going to call on David to sort of give me an example of when we might be in this carve out to the exception uh for in the office suite right for the off-campus under Arrangements uh and David's gonna blink right now and not come up with a very good one perhaps PT PPT would be okay so I think a good example of that would be um a clinic having a PT Imaging would be the other one yeah diagnostic tests so maybe the hospital is Contracting with the local clinic to get a CT scan done um and physical I think I've seen most with physical therapy and scanning and so you're using an off-site Physical Therapy location right off-site scanning something like that in your provider base in that case if you're if you need direct supervision you have to be present in the office suite and can't be at the building next door yeah and what's to something I mean I think this is really confusing for us and so I work but it's important to say therapeutic and diagnostic are different and both in kind of all settings it's always good to think about when you're asking yourself what level of supervision is required ask is this a therapeutic service or is it a diagnostic service that's sort of Step One um and I guess of Step One a is it in the hospital or is it in the clinic right um and if you know if you're in the actually the hospital and Clinic are sort of similar for diagnostic tests and that only Physicians can do them um and then you know in in therapeutic you only have to worry about stuff in the hospital therapeutic in the clinic actually we're going to talk about in just a moment that's really the incident two stuff right and it and one other point to think about with all this is how how do you document it how do you establish a record that you're meeting these supervision requirements because I think enforcement on this is going to be big we've seen key Tam lawsuits with whistleblowers bringing this up um so you don't want to have a documentation system that is confusing for people because I think you should also use your documentation system to for for people who are performing the service to be able to know who to call if there's something that goes on um and you know there's a question of whether if you document it for one day and then you forget the next day well does the government auditor that's coming in do they have proof that the supervision wasn't actually done well David and I mean in a defense setting we would say we have a number of other things to prove their supervision we have physician schedules we have testimony affidavits and those sorts of things but I guess the bottom line is you want to record this but you want to do it in a way that's going to be helpful to your organization yeah and we had a situation we had an appeal in the desert Southwest for an oncology group where Medicare wanted three million bucks from a doctor because of you know the question whether he was present to supervise chemo and we were able to prove that up as Katie just talked about with physician schedules I think what I struggle with you know a lot of places have a dock of the day which is great as long as it's real and the person's there if you have a doc of the day does that mean the Dock of the day can't go out to lunch and do you have a mechanism to trace it and and I think one of the biggest challenges is if you start having documentation and it's inconsistent is that worse than not having it at all and we can't answer that one um I don't know the answer I know I struggle with this okay incident two as we've talked about that's phrase that's confusing for incident two-way Physicians Professional Service so this is something that's designed to cover work that's normally initiated by The Physician and included as part of their bill so the requirements to Bill incident two um are both there's it's always good to think of the hierarchy there are actually regulatory requirements and then there's they're explained further in the Medicare manuals so the first thing is that the clinic has to be paying the expense of the ancillary person they don't have to be an employee it's interesting because the manuals even use the word employee but least employee is okay so it really is the clinic has to be on the hook economically for it um the clinic has to be providing the medical Direction and then that's not usually a big deal here's the one that I think is often the biggest trip up or maybe the second biggest trip up the first visit for a particular illness or injury has to be with a physician um later visits it can be with the non-physician practitioner and actually this is poorly worded by me in a way because you can be incident to an NP or PA you would just be getting paid you know 85 percent of the fee schedule so you could substitute physician there for NP or PA in some circumstances um uh you know oh Dawn's on me right now actually is a question is coming in I don't know that we've said you can always type in questions in the lower right part of the screen we'll probably do most of them at the end but we might pause it some way along the line so if we're confusing the socks off of you or if they're just something we haven't covered type it in the lower right all right let's look at how CMS describes course of treatment and this is worth just reading out of the benefit policy manual so it doesn't mean that each occasion of service by the auxiliary Personnel needs to be the occasion of an actual rendition of a personal Professional Service by The Physician it can be considered to be incident to when furnished during the course of treatment when the physician performs an initial service and subsequent Services of a frequency which reflect his or her active participation in and management of the course of treatment so what's interesting is what is a course of treatment generally people think if you have a new thing so um well let's let's operationalize it uh in the office setting ear infections your kid shockingly has multiple ear infections you have an ear infection and six months later you come in for a new ear infection is that one course of treatment because it's all ear infections or is each of those two independent there's no answer to that that's clear I could I'd feel comfortable trying to defend it's part of a course of treatment um I'd feel pretty darn comfortable saying that's part of a course of treatment because it doesn't really say each new illness that's often how things once again get short-handed it's how I short-handed it in the slide but it's not what the course of treatment says in the manuals so there isn't an operational definition of course of treatment I do feel like you know so I feel less good about broken arm and then you know if you're in an orthopedic practice come in for a broken arm and then they come in for a broken leg or the other broken arm that doesn't feel as course of treatment D to me as the ear infections do David what about if you haven't one illness and you believe that that was sort of the reason for the next illness yeah to me that feels like a course of treatment um and frankly you're all of our Collective judgment here is you know I don't have any any Authority I can point to so it's use your judgment as to what you feel like course of treatment feels like okay incident two Billings has to be something typically done in an office you can't do it with brain surgery here's the other really big trap the service can't be in a hospital or in a Skilled Nursing Facility places that have facility fee payment well actually that's even two so it really is hospital or sniff because there are other in fact Katie just taught me this recently I think in uh in icf's that's there is a facility fee payment but you can be incident too uh Katie is perpetually teaching me new stuff okay you have to have a clinic physician who's in the office suite as we've discussed the service has to be billed under the name of the supervising physician so this is you know let's say Katie ordered physical therapy for a patient and I'm the one who's around when the physical therapy is done Lord help that patient yeah in that situation it has to be billed under my name okay it can't be even though Katie ordered it I'm present um now you might you may be familiar with shared visits that can happen in the hospital context this is worth noting because you can do a shared visit in the hospital you can't do incident too so a shared visit is both the the extender and the physician seeing the patient on the same day and you're combining their work into one big visit that's still okay that isn't incident too it's a shared visit that's a different animal what you can't have as a physician extender conduct the visit without the physician being there or even being there but not being in the room um and then finally it can't be used for a service that's an independent benefit under the program and so a classic example of that and this is a change you know if in well it's a change from 10 years ago in 2002 when this change happened yes you you used to be able we used to think you could do diagnostic tests incident too diagnostic tests are a separate benefit so you can't do it now this raises an interesting question for Katie who's looked at this more recently than I can I bill one physician incident to another physician it's an interesting question the short answer is that there's not really a good answer to this now if if you look at what is an independent benefit under the Medicare program Physician Services are an independent benefit so that's an argument against using the physician build incident to another physician however CMS has said that the definition of auxiliary personnel which is remember those people who can do these incident 2 services that definition they've said they aren't specifically not going to Define in terms of practitioners because they want it to be flexible for people to use the incident to benefit so I would look at that language in the commentary and say well that's that's kind of support for the idea of doing physician incident to another physician I would actually probably only use this argument it's because it's a little bit precarious in the situation where you have a physician who needs to be doing maybe who isn't credentialed yet and you can't meet the Locum tenants billing rules and you can't meet the reciprocal billing rules and so in those cases I would maybe use this strategy but I wouldn't recommend it for a long well and I'd put it even a slightly I would say this is the classic example of where I might use it to defend something that's happened but I don't think I would try to get there on purpose you know I don't know that I would set it up to be relying on this one but I would gladly use this if it had happened you know in those many when you get the call oh by the way we've had these person providing services for a while um and just because I want to make sure I was really clear about this because it's come up so many times if you've got an NP or PA who's going to the hospital or who's going to a nursing home they've got to be billing independently you can't do that incident too we've had that come up a boatload okay so what are the pros and cons of incident two for most Services you get better reimbursement if you Bill incident two meaning you're billing Under The Physician um PT's paid the same way so there's no real Pro there um another Pro and this is not so much a pro but it's a it's a difference I guess for those of you who are into giving production credit understand um under Stark you can give production credit for stuff that's done incident too so if you want to pay an oncologist for supervising chemotherapy that has to be done incident too that's the only way you can get the production credit into the formula and still be Stark compliant at least if you're a for-profit type Clinic if you're a non-profit many of you guys think you can blow off Stark and you often can but if you're giving production credit just this isn't a side it isn't really exactly on our topic note that if you're giving production credit you you are now relying on the in-office ancillary exception which by the way would mean you'd have to give notice to people for Advanced Imaging different topic I just mentioned it here so what are the cons of incident two well perhaps the biggest is you can't take a patient who's coming in from the outside without initiating the course of treatment so you know for example Physical Therapy you can't you have to see the patient to initiate the course of therapy um and so that's a fairly significant negative if the person comes in with a new problem that's not part of the course of treatment they got to see a doctor you got a bill under the doctor who's there and you can't do it in the hospital so I think we've covered this real estate fairly well am I missing anything all right so we're going to talk for a couple minutes about signature requirements um now there are many signature requirement type entities we're focused remember on Medicare there's also Medicaid and private insurers there are the conditions of participations they're the accrediting bodies there's licensure um I I think we may have considered going into all of those here but we have an hour so we we ran out of the ability to do it now just know if we know if we're smart enough um I will note that when you're reading things it's easy to get trapped on the difference between written and signed or heck written and not written so let's say a physician order is necessary a physician order is necessary does not mean a written order is necessary a written order is necessary does not mean a signed order is necessary and I think the manuals even use the term authenticated which is not really a signature requirement it's sort of identifying that you did something I think so maybe it could be initials like a little or a thumb print or thumb print I don't know um but but this is important and it comes up a lot so do you need to sign all of your office notes here's one of those places where your defense position it's the short answer practically sign them legally do I think you have to no I base this on a few things but this is a place where there's internally inconsistent guidance if you go back to my young pup days as a lawyer what was then hikvah uh put out a joint question and answer sheet and you've heard me allude to this and the if it isn't written it wasn't done world if as if uh so that the 11th question on there was is the physician's signature required on each page of the documentation and the answer was no the guidelines only state the identity of the Observer must be legibly recorded um here's what the program Integrity manuals say they say if the signature is missing from an order Max and asserts are supposed to disregard the order in the review process now I don't know exactly what their Authority for that is Katie's going to talk about that a little bit but I don't think there is Authority for that but let's just put that one aside for the moment if the signature is missing from any other medical documentation other than an order then you can accept a signature attestation from the author of the medical record entry um now remember manuals aren't the law I just love to say this because it's so offensive to me a person relies on the manuals at his peril which I think would be a great quote if somebody comes back and says you said on your a55a that you are going you're certifying everything was in compliance with the program instructions and that includes manuals so just keep this in your back pocket yeah so the government is willing to say that we shouldn't listen to their stuff they've said it in courts of appeals but okay if you get a cert request the cert request will say things like you can sign these things when you you know if they're not signed you can sign them now so I don't want to go into that in gory detail but it all highlights the principle um that you don't have to sign charts and it's important I interrupted you David I'm sorry but I do know that Iraq near you is looking at this and they're probably wrong they're probably saying you have to sign the charts and there's a good legal argument that you don't have to and I've heard just today that Iraq is denying um claims on this basis so it's out there just to be clear that's recovery audit contractors and not the country in the Middle East yes yes all right um I learned something actually preparing for this about diagnostic tests there are actually in the regulations specific requirements about diagnostic test record keeping and this is just interesting to note I won't read it aloud because I put the text in here so you could kind of peruse it at your leisure um but basically note that it says that if whoever orders the service has to maintain documentation that it was medically necessary it doesn't say what it is the person submitting the claim has to document that it got um you know information from the res from the ordering physician so I didn't know this was in here but I think it bolsters the idea that you can supplement information later on because it talks about in the event of a claims review they'll go in and ask for the information and if they don't have it they're supposed to kind of go check on it so this just bolsters that if you don't have documentation you can back things up um okay and so I just left that material in here for you to read it's kind of it's it's an interesting interesting to note now what's really weird when you get into idtfs whole nother ball game okay and this highlights the differences between things and and CMS is increasingly saying you have to have written orders in all kinds of situations well here's one of the reasons we think that's not true so idtfs have to specifically have orders in writing that's in the regulation the number you see in the bottom right is the regulation when this came out in Halloween 1997 here's what CMS said they said why are you putting higher rules on idtfs well we'll tell you why what used to be ietfs which were then ipls which is I think independent physiologic Laboratories have offered free screening and we think they're really skanky basically so we believe that our experience with waste and abuse in ipls justify these additional requirements for idtfs and so they were explicitly setting a higher bar for idtfs than everyone else um so idtfs have to have a written order and this text is recognizing that at least in 1997 CMS thought you didn't need written orders in a wide variety of other settings um I'm now going to turn this over to Katie who's going to talk about some other sets of orders okay so the example of where we have a hierarchy a hierarchy of rules guidance manuals and they're all different so this is where we're going to employ the strategy of what's the advice going forward and what do we need to do to defend something so basically for demipos there are two separate regulations and the rule for DME items durable medical equipment items and the rule for Prosthetics and Orthotics which are separate say that CMS may require a written physician order before delivery of these items okay so that's all the rule says that's all the law says then the program Integrity manual so now we're at the guidance level says there must be a detailed written order that is signed by the treating physician for demipos so three different three differences from the rule the first detailed that's totally new that's not in the rule so CMS is basically now requiring a detailed written order second it has to be signed the signature requirement was not present in the rule so this is an additional requirement imposed by the manual and then they're also putting together DME items and Prosthetics and Orthotics so saying you have to treat these all the same which is again different than the rules which treats potentially treats them differently and then it also says the program Integrity manual that the sign that you have to have the signed order prior to billing or the contractor will deny the service now that's different than having it prior to delivery and all of you on the ground can I think attest to the fact that delivery and billing are going to be different times and um delivery might occur before or after billing so now we have a new kind of basic set of rules from the manual so then if that's not bad enough there's more manual guidance for example this the first bullet has the rule or the guidance of the manual that says for leg arm back neck braces trusses and other artificial items those things are covered under Part B when they're finished incident two of Physician Services or on a physician's order so this implies that you don't have to have an order at all if they're incident too that's totally different than a detailed written order signed by the treating physician before the billing so remember when we talked about how sometimes the manual guidance is uh internally inconsistent this would be exhibit a yes and then this the next bullet is basically showing you that there's some there's this weird language about how the physician doesn't have to necessarily complete the detailed description but they definitely have to review it and sign it and date it in order to indicate their agreement so there's this interesting language about who can do it um which is just another added layer of confusion so point being for risk management purposes I would say sign make a detailed no write it down make a detailed sign it and have it before you Bill going forward then I think you're the safe in the safest position under the manuals and guidance but if I'm looking at an audit and I'm defending somebody I'm going to say well actually the only thing that the rule said that CMS can require is a written order so if we have that then we're okay I also want to mention this new fairly new rule like in the past I think two years or so that I don't think people are really very aware of and it it echoes the rule about documentation for diagnostic tests that that David just mentioned basically this is sort of I want to call it a hybrid rule because it's under the section that's that lists the reasons why CMS can revoke your billing privileges so it's not exactly a condition of participation but it's not necessarily a condition of payment it's just sort of a rule that can get you kicked out so it's important and it sort of relates to payment obviously so looking at the rule basically it says that provider supplier who furnishes these buckets of services basically has to maintain the documentation about um who ordered it and how they were billed and look at the last three sentences it says relating to written orders and requests for payments of these certain services this implies that you have to have written orders for all of these things which would include Imaging specialist services I don't even know what that means and I don't think that's defined anywhere in the rules so there's this be aware that there's this sort of funky regulation out there that could be used as a basis to argue you have to have written orders for everything I think you know my defense is that you have to have documentation of requests for payments for everything which you have and claims and written orders when the rules otherwise requirement require it but it's not entirely clear and one important point an order does not have to be a separate freestanding piece of paper I mean a dictation in the doctor's note that says give this person a piece uh give give them a crutch that's an order so I mean I think that I don't think there's any dispute about that part of things okay um we have a lot of questions so I'm going to do standing orders in about 30 seconds they're okay Medicare doesn't really focus on them and in their mind an order is an order and I'm not going to read to you but I included in here the backup which is some language from the oig lab compliance guidance where they basically talk about standing orders and say you know they can be sketchy at times but Bob you know basically goes on to recognize they should at least have a fixed term of validity and must be removed renewed their expiration which is pretty conclusive proof that a standing order is still in order and I mean that's what I'd say standing part it's an order and so if a physician has ordered it you're okay all right Lab Services unfortunately another area of confusion I want to tell you what's out there and then talk about what's good going forward and what's good going back so the last rule we heard about retaining documentation implied you had to have a written order for Lab Services we don't exactly know if that's really a rule the Halloween 1997 rule that David talked about said that basically there or it implied that it doesn't don't have to be written orders for anything besides an idtf so that's good for Lab Services we don't have to have a written order um recently CMS proposed a policy and interestingly not in a manual or a rule just in the Preamble that the ordering physician or non-physician practitioner has to sign lab requisitions so laboratory requisitions I learned are basically the form that you complete and like check the box where for the lab test that you want and then the ordering person has to sign it well people were up in arms because this is sort of ridiculous and not not the precedent so CMS actually retracted that and said no fine we don't have to sign the lab requisitions you do have to document that the order of the test is there and then it referenced this long-standing policy that requires orders clinical lab tests and other things to be signed by the ordering physician or non-physician practitioner now I don't think and I'm pretty sure David hasn't seen any sort of long-standing policy that requires all orders to be signed and written as we've just demonstrated but know that CMS is confused about this and going forward it's good to just dot all your eyes and cross through your t's get things signed but don't be just in despair if you haven't done that going backward okay I want to get to questions so I'm going to try to Breeze through certifications pretty quickly which is hard because certifications are important but I'm going to make the basic point at the beginning that's the most important important Point here to take away certifications for home health and for hospice are extremely uh counter-intuitive and how they're supposed to be done so every time I give advice on this I have to look at the rule like five times and then look at it again the next day so I put the rules in here and make sure you before you especially before you create a form that people are going to be using for these things make sure that you read the rule over a few times so that you know exactly what the form is supposed to say and what the physician has to do and then how you're supposed to sign it so for home health The Physician is certifying and it has to be a physician to a number of different things which I've listed here the biggest new thing is that the physician has to perform a face-to-face encounter with the patient interestingly to certify that they're homebound so this is David's pointed this out and it is crazy you have to get the patient out of their home to the physician to certify that they're homebound it's not exactly helpful but that's the rule and there's a certain time frame for when this has to happen so make sure you pay attention to that the face-to-face encounter certification isn't just dating you know I saw the person and here's the date and here's my signature it ha it requires a few different things um you can have a physician non-position practitioner do them but then they have to communicate all the findings to the physician you have to have the face and face encounter has to be related to the reason for home health so if you saw the patient last month but it didn't relate to anything that had to do with them being Homebound and needing services in their home then you have to basically see them again to do another face-to-face to get the certification and then you also have to say why the clinical findings support the fact that the patient is homebound so it's not just you know a sign and date type of thing now in some cases which I'm not going to go into the specifics but in some cases the rule requires you to write a narrative um and if you have to write a narrative make sure that the physician is signing both the narrative if it's an addendum and the certification itself if you don't sign the thing that you attach to the certification then arguably you're not you don't have a valid certification you gotta love government and then if your head isn't spinning enough you have to make sure you re-certify every 60 days all right so we're moving to hospice new benefit category we'll run over by a couple of minutes but we will answer the question there are a bunch of good questions so we'll cover them all right so same ideas here the regulation is key read it five times and then read it the next day um you have to have a face-to-face encounter but only if the patient is anticipated to reach their third benefit cat benefit period And I think the benefit periods are 90 days um so if they're going to get to the third one of those then you have to have the face-to-face encounter and that has to occur 30 days at least somewhere within the 30 days prior to that third benefit period so there's a face-to-face account here but it's not automatic um again with the narrative thing if you have a narrative make sure that the signature is immediately following the narrative whether it's on the certification form or it's on the addenda I sometimes think it's just a good idea to have the position sign and date every part of the certification if you want to be super careful but definitely make sure if you have agenda that they sign those too and then you have to include the benefit period dates there are funky timelines for hospice too um the general rules you have to have the certification prior to billing but you have some flexibility there and that you can get a verbal certification and then that followed up by a written certification so long as it's not later than 15 days after the start of the hospice and then you do need a re-certification for each 90-day benefit period and it has to be 15 days prior to the benefit start date so take away from here read the rule run it by somebody and make sure your Physicians know how important it is to get this certification right all right all right questions we've got a ton of questions um I'll do the first couple here and then I think we're going to probably split a bunch of these so the first one you've said two different things about the presence of a physician when billing incident two in one slide you said the clinic a clinic physician had to be present and in the other you said the billing physician had to be present the question is whether we can Bill incident to one physician if another physician is present but the incident 2-1 is not and so in my mind at least that was not two different things which is you do need to have a clinic physician present and then whichever Clinic physician is present is by definition the billing physician because you've got a bill under the person who's providing the supervision it's it's I guess this is almost good to think of the ordering physician here I mean order is the wrong word but the person who established the plan of care is not the billing position the billing physician is the supervising physician yeah and the reason is that is because you're billing for the supervision that's provided by that person who's present yeah so the name that goes on the claim of an incident to service is a doctor who is present in the suite at the time so hopefully that made sense um okay kind of a related question I would like to know if a physician assistant can see a new patient for consultation and let's I'm going to use the word consultation even though Medicare got rid of their consultations of lower extremity pain in an office setting and built under their own number can you Bill incident two using the supervising Physicians NPI or are you saying a PA cannot see a new patient for the first evaluation I'm getting a little con