Practice Management Q&As

March 3, 2006



Billing for a phone conversation

Q. While a Medicare patient of mine was out of state, I spoke with her over the phone about managing her GERD. May I bill for the phone consultations?

A. No, Medicare will not reimburse you for any services you provide over the phone. The phone consultations are considered part of your billable GERD care.

Q. How can I determine whether a physician assistant or a nurse practitioner would be a better fit for my practice? I'm a solo primary care internist with privileges at two hospitals. I also see some nursing home patients.

A. The answer depends on your state's scope of practice laws, which dictate which clinical services NPs and PAs can perform. In general, both provide primary healthcare services, doing routine history and physicals, diagnosing and treating illnesses, and ordering and interpreting tests. They also counsel and provide patient education. For a summary of state laws on PAs, see the website of the American Academy of Physician Assistants, http://www.aapa.org/gandp/statelaw.html. The website of the National Council of State Boards of Nursing can direct you to information about a particular state's laws on NPs. Go to http://www.ncsbn.org and, under Updates and Contacts, click on Boards of Nursing. Then select the state.

You should also ask the health plans you contract with whether they limit the services either a PA or NP may perform. And find out if your hospitals or nursing homes have any restrictions regarding NPs or PAs rounding on patients. Your answers to these questions may point you toward which one to choose.

How to charge for group visits

Q. I invite patients whom I've diagnosed with vitamin D deficiency to attend a 30-minute group class on how to maintain a healthy level of vitamin D. I also provide individual instructions on taking the medication I prescribe. How should I bill for these visits?

A. Use CPT code 99411 (preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting [separate procedure]; approximately 30 minutes). Any personal instructions you offer will be bundled into the group visit. However, make sure your patients understand that Medicare and most insurance companies won't pay for this group service. Have them sign a form agreeing to be personally responsible for payment if their carrier denies the claim.

Choosing an Internet dictation service

Q. Internet-based transcription services sound very interesting. Before I start comparison shopping, however, can you tell me how the services work, and what questions I should ask vendors?

A. Internet-based services can speed up your transcription turnaround time and make it easier for you to file your chart notes by producing an electronic copy you can save on your computer or in your EHR. With some systems, you dictate into a phone; with others, you use a microphone at your computer (which needs an Internet connection). Your dictation will be transcribed by a voice-recognition program or a real person, and returned to you as an electronic file via the Internet.

To find a system compatible with your needs, ask vendors:

When you refer patients to your tenant

Q. To cut down on rental costs, I sublease my office space to a company that performs echo, ultrasound, and Doppler vascular studies. I charge them by the hour, with a $200 per month minimum. I refer my patients to this company, and they find it very convenient to have the tests done at my office. Does this arrangement break any rules?

A. The $200 per month minimum could be a problem. The rental rate should reflect the fair market value of the portion of the space they sublease and the length of time they use it. If that fair market amount is less than $200 per month, your monthly minimum might look like a referral inducement that violates Stark and federal and state antikickback laws. To determine how much you should charge, check the guidelines in the government bulletin, "Rental of space in physician offices by persons or entities to which physicians refer" (oig.hhs.gov/fraud/docs/alertsandbulletins/office%20space.htm).

You should also make sure the terms of your deal are set forth in a written agreement, which should be for at least one year. And your attorney needs to check for any state laws that may apply in this situation, such as a requirement to disclose the financial relationship to your patients.

Do doctors need EPLI?

Q. Does our four-doctor group need EPLI (employment practices liability insurance) to protect us against employment and workplace claims, such as sexual harassment suits?

A. Most small practices do without it because it can be prohibitively expensive. That should give you even greater incentive to reduce your liability in this area through good employment practices. Appoint one of your partners as human resource director, responsible for making sure your state's labor laws are followed and good management practices implemented.

How to get paid for venipuncture

Q. In the rural area where I practice there are no laboratory services, so we perform venipuncture ourselves and send the specimens to a distant lab by courier. Our reimbursements don't even cover our clinical and clerical costs. How can we get paid more?

A. There are several things you can do. Because most insurance plans bundle venipuncture into an office visit, plan to perform other necessary medical services when the patient arrives for the venipuncture. A more complex visit will allow you to bill at a higher level.

Also check the EOBs from the plans that reimburse you inadequately. If they pay by percentage of a given fee, try raising your fees. Your reimbursement should rise proportionately.

Editor's Note:

Our Feb. 3 item entitled "How to comply with CLIA" contained incorrect web addresses, due to recent changes in the CMS website. Here are the correct addresses:
For a list of tests granted waived status under CLIA: new.cms.hhs.gov/CLIA/downloads/CR4136.waivetbl.pdf
For the application for CLIA certification: http://www.cms.hhs.gov/cmsforms/downloads/cms116.pdf.
For a list of state CLIA contact agencies: http://www.cms.hhs.gov/CLIA/downloads/CLIA.SA.pdf.

In this issue, the answers to our readers' questions were provided by: Keith Borglum, http://www.PracticeMgmt.com, Santa Rosa, CA; William H. Maruca, Esq., http://www.foxrothschild.com, Pittsburgh; Rosemarie Nelson, MGMA Health Care Consulting Group, Syracuse, NY; C. Nancy Noonan, Bristol/Noonan, Inc., Yellow Springs, OH; Barbara Pappadakis, Union Pacific Railroad Employes Health Systems, Salt Lake City; Bruce Rappoport, MD, Rachlin, Cohen & Holtz, Ft. Lauderdale, FL; Karen Zupko, KarenZupko & Associates, Chicago.

Do you have a practice management question that may be stumping other doctors, too? Write PMQA Editor, Medical Economics, 5 Paragon Drive, Montvale, NJ 07645-1742, or send an e-mail to mepractice@advanstar.com (please include your regular postal address). Sorry, but we're not able to answer readers individually.