SGO Issues Aug. 11, 2016
Documenting office visits with an NPP: How would you code?
Years That Way: Burnout and Gynecologic Oncology | Emily K. Hill, MD
SGO Allied Health Workshop Dec. 3-4 in Chicago
Gynecologic Oncology, August 2016, Volume 142, Issue 2
Gyn onc images needed for upcoming SGO projects
Update contact information in SGO member directory
When a physician is working with resident trainees and physician assistants or nurse practitioners, what are the best practices in documenting office visits to ensure maximum reimbursement rates?
The differences in documentation requirements by the Centers for Medicare & Medicaid Services (CMS) for outpatient Evaluation and Management (E&M) visits stems from the relationship that an attending has with trainees versus non-physician providers (NPP, or PA/NP). Interns and residents are in a training program supported by CMS through Graduate Medical Education (GME) funds, so their work is assumed to be paid for by these funds.
Non-physician providers have their own National Provider Identifier (NPI) and can bill CMS for services independently at a reduced rate. If you wish to bill at the higher physician reimbursement rates there are specific CMS guidelines that apply. The issue of midlevel providers and “incident-to” billing is very confusing and has generated many articles. For a NPP to bill under a physician’s NPI, the following requirements must be met:
- The NPP must be an employee of the physician;
- The initial visit (for that condition) must be performed by the physician. This does not mean that on each occasion of an incidental service performed by an NPP, that the patient must also see the physician. It does mean there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the services being performed by the NPP is an incidental part.
- There must be direct personal supervision by the physician as an integral part of the physician’s personal in-office service. The physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary;
- The physician has an active part in the ongoing care of the patient. The physician must be involved with any new or changing medical issues.
- Subsequent services by the physician must be of a frequency that reflects his/her continuing active participation in, and management of, the course of the treatment.
It is advisable to record a new Medicare patient Chief Complaint and History of Present Illness (HPI) for all patients. If working with a resident, they can record the rest of the history and physical, but the physician usually records the Medical Decision Making (MDM). The physician may then add an attestation “I performed a history and physical examination of the patient and discussed the management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care, except as documented.” The established patient visits are handled in a similar manner, but the resident can document the entire visit as long as you attest to the physician’s involvement.
The NPP may help with records review and history taking but the physician does a review of the history with the advanced practice provider (APP) and then the MD does the physical examination and the MDM and then dictates the encounter. This allows the physician to bill the entire encounter, since they have “performed the initial visit.” Established patient visits can be performed by the NPP and billed under the physician’s NPI if the MD is present in the office and there are no new or changing medical conditions. If the physician is unavailable, or if the NPP cares for a new issue without MD documentation (i.e., a UTI in a cancer patient), then billing should be submitted with the NPP’s NPI.
- Incident-to billing: Clearing up the confusion (Medical Economics)
- Guidelines for Teaching Physicians, Interns and Residents (CMS.gov)
- “Incident to” Services (CMS.gov)
As a resident and fellow, I had tunnel vision. For those eight years, I refused to let myself think in time increments longer than one week. I remember occasionally thinking about the big picture of the years I had left in training and quickly becoming overwhelmed. I’d dial back, to quiet the panic. For many of us, this works for a while.
It keeps us focused on the task at hand and somewhat oblivious to the sacrifices and stress that this job involves. Just don’t think about the fact that you don’t see your child for days at a time, that you haven’t exercised in years and eat mass-produced cafeteria food every day, that you are watching women die every day. I was fairly good at compartmentalizing all of that.
However, those of us that get good at this denial while in training have a new challenge when we become attending physicians. How do we redesign ourselves to function once this is not a temporary situation, but instead our ”real” life? To me, this has been an unexpected challenge but one that is innate to Gynecologic Oncology. What drew many of us to this specialty, the combination of complex surgery, medically complicated patients and continuity of care, leads this to be a singularly demanding field both technically and emotionally.
This is part of why burnout is so prevalent in gynecologic oncology. Not only are we responsible for the lives of the women on our OR table, but we are then called upon to diagnose recurrence when our treatment efforts have failed. We usher our patients and their families into death, and hopefully treat just long enough and palliate suffering when the time comes. It is an incredible privilege but also a damn hard job. And one that we are trained to do silently and stoically, without admitting the toll it takes on us and our loved ones, as that would be a sign of weakness.
Fortunately, we are starting to acknowledge our humanity and support each other in a way that is new in medicine. That is why I was eager to take part in the SGO Wellness Initiative.
I was fortunate enough to train with Dr. Skip Granai at Women & Infants Hospital, Brown University, in Providence, RI, in an oncology program that combines integrative care, music, art and self-expression, in addition to the traditional science of medicine. As a fellow, I saw this approach to the whole woman benefiting patients and their families. Now I am beginning to see how this can, and should, apply to us providers as well. Below is a poem that I wrote and recited as part of a required exercise during fellowship, which at the time felt torturous. In hindsight, it was a moment of powerful self-expression and recognition of my own humanity.
Years that Way
Emily K. Hill
Pressure cooker. Steam. Heat.
Wake. Go. Sleep brief.
Wants. Needs. Incessant beep.
Smile. Joke. Paper heap.
One week at a time. Years that way.
One day at a time. Afraid to say.
Approve, praise, not disappoint.
Nervous, angry, impending disjoint.
Surrounded by others’ loss and pain.
Petty excuses to drift – insane.
Too much thinking, dark spiral.
Busyness preserves survival.
If they go, why do this all?
Woman vs animal.
- The Epidemic of Burnout, Depression, and Suicide in Medicine, MedPage Today
- Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction, Mayo Clinic
- Three surprising truths about physician burnout, Advisory Board Session Document
“The moments of silence are gone. We run from them into the rush of unimportant things, so filled is the quiet with the painful whispers of all that goes unspoken. Busy-ness is our drug of choice, numbing our minds just enough to keep us from dwelling on all that we fear we can’t change.” L.M. Browning, Seasons of Contemplation: A Book of Midnight Meditations
Emily K. Hill, MD, is a Clinical Assistant Professor in Obstetrics and Gynecology at the University of Iowa Hospitals and Clinics in Iowa City, IA.
The SGO Allied Health Professionals Workshop will be held Dec. 3-4, 2016, gathering physician assistants, nurse practitioners and registered nurses who treat patients with gynecologic cancers for a unique workshop to discuss a variety of topics surrounding practice challenges. This year’s workshop is located in Chicago at the American College of Surgeons building at 633 N. St. Clair St., 28th Floor, Chicago, IL.
Editorial: Time for centralizing patients with ovarian cancer: what are we waiting for? Giovanni D. Aletti, William A. Cliby
Lead article: Centralized primary care of advanced ovarian cancer improves complete cytoreduction and survival – A population-based cohort study Pernilla Dahm-Kähler, Charlotte Palmqvist, Christian Staf, Erik Holmberg, Liza Johannesson
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