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Determine how to be appropriately compensated for combination of services provided.
A: You are to be commended for being sensitive to your patients' needs, and you can take some steps to be reimbursed for some of the services you provide.
• Lab services. Work out an arrangement with the lab you are using to put a draw station in your office several days per week. The lab should bear all costs associated with the draw station. You no longer will be able to bill for the draw fee, and all billing will be between the lab and patient (or third party). The staff member who is performing the draws will not be your employee, nor will he or she have access to your patients' records. If a patient has questions or requires care, the patient can be referred to your staff member for services, thereby delineating your current process. If the lab you currently are using isn't interested in providing a draw station, then seek out an alternative lab. This service simply would be a convenience for those patients who wish to use it.
Make sure your agreement is in writing, mentions all of the required Health Insurance Portability and Accountability Act forms, and includes a written understanding of the services to be performed by the lab employee (and the services that will not be performed, such as answering the phone for the physician or assisting with patient care during down times). To avoid the issue of improper referrals and anti-kickback rules, charge fair market value rent to the lab (and also include this stipulation in the agreement) for the space for a minimum of 1 year; the rent cannot be based on the number of lab draws performed.
Although the lab may not be in a position to refer patients to you, the simple process of lab staff referring patients to your staff could be construed as referrals. Meeting Occupational Safety and Health Administration requirements would be the responsibility of the employer, in this case the lab. A healthcare attorney can assist you in drafting an agreement with the lab that meets all of the requirements of safe harbor.
• Medically necessary services. Reporting symptoms, reactions, or changes in medication, and checking blood pressure levels because the patient believes that his or her blood pressure is elevated or doesn't feel "right"-all are medically necessary services and can be billed as such.
You may bill a nurse visit for those services or bill another, higher level of service if the staff member providing the services has independent credentials. Use that staff member's provider number if the documentation supports the level of care chosen. If you wish simply to bill a nurse visit by an uncredentialed staff member, registered nurse, medical assistant, etc., then those services must be billed "incident to." Direct supervision of the staff member is required (you will need to be immediately available in the office suite), as well as following the other "incident to" requirements, to bill in such a manner.
• Patient education. If patient education is required related to medication changes resulting from the interpretation of the lab work, diet, or other matters, you may choose to schedule a follow-up visit with the patient to accomplish the education. As much medicolegal liability exists for instructing a patient via phone call as it does for seeing the patient in person and knowing that he or she understands your instructions.
If lengthy phone calls are undertaken with the patient to explain medications, changes in treatment, etc., document the medical record appropriately. You must use that documentation when selecting the appropriate level of care the next time the patient returns. The interval level of support and interpretation of lab results is bundled into the visit code, and you may use the documentation supporting that detail when selecting the level of care.
The author is president of Healthcare Consulting Associates of NW Ohio Inc., Waterville, and a Medical Economics editorial consultant. She has more than 30 years of experience as a practice management consultant and also is a certified coding specialist, certified compliance officer, and certified medical assistant. Do you have a primary care-related coding question you would like to have one of our experts answer in this column? Send it to firstname.lastname@example.org