Intensive Behavioral Therapy for Obesity in a Hospital Owned Provider Based Physician Dept

Pub 100-03 Medicare National Coverage Determinations //Centers for Medicare & Medicaid Services (CMS)//Transmittal 142//Date: February 03, 2012// Change Request 7641
CMS's Decision Memo indicates this NEW -IBT Obesity service is to occur under a Practioner's "coordinated approach" including an outpatient hospital setting, their intent is for "appropriate staff" to participate in providing this new service, that it is covered when face to face by a particular practioner. (MD, PA, ARNP)

It is our practice that one of the Implications of Provider-Based Status in addition to the seven criteria, is the Medicare rules expressly prohibit Medicare coverage of the services of physician-employed auxiliary personnel furnished to hospital outpatients as services “incident to” physicians’ services. 42 C.F.R. § 410.26(b)(1), under the Medicare Physician Fee Schedule.

We are experiencing pressure from Dieticians who insist that their organization has indicted they can now be involved in this service.

The Question:

Can a Registered Dietician who has assigned benefits to a Hospital owned Provider Based Physician department Outpatient Setting, perform the facility portion of this G0477 service in a Hospital owned Provider Based Outpatient Setting, submitted under OPPS on a UB04 claim?

Note:
Auxiliary staff are under the Physicians/Non Phys (PA, ARNP) Direct supervision, (immediately available) who is overseeing the overall care. Its our understanding if a dietician performs, then NO professional component could be billed to the MPFS by a practioner, where there was no face to face 15 minute encounter by a practioner as stated in the NCD.

We are reluctant to approve this dietician argument, as presented in the scenario in above. A dietician performing the five "A"'s with the patient, does not seem to stand on its own or satisfy the requirement where a 15 minute was performed by a "face to face" practioner (MD, ARNP, PA), as required in the NCD.

Our interpretation is that a Dieticians documentation in the medical record would not support a a facility resource encounter, when solely performed by the dietician, even if cosigned by the Physician. And that this documentation would not be defendable, and would leave us at risk for audit purposes according to the NCD guidelines under Medicare.

Also Remember The billing rules and supervision are different for Hospital outpatient Provider Based physician owned depts.

Billing for free standing Physician offices vs Hospital Provider Based (owned) Outpatient Physician Dept are as folows .

Free Standing: Normally a free standing physician office bills the professional component and technical component if applicable on one 1500 claim to the Medicare Part B Carrier . The charge is paid under the MPFS Medicare Physician Fee Schedule, and place of service is always 11=office.

But a hospital owned provider based Outpatient physician Dept, must split their charge into two components

A facility fee component, (representing overhead, supplies and auxiliary personnel resources) billed on a UB04 to the Intermediary* & payable under OPPS Outpatient Prospective Payment System. [G0447-pays at the assigned APC #0432, for the National Unadjusted Payment of $35.66] (Note: *intermediary is now combined under the MAC umbrella)

The profee component is billed on a 1500 to the Medicare Part B MPFS fee schedule code of G0447 . And pays at the National Unadjusted payment for facility at $23.15. Place of service is always 22=Outpatient dept of hospital [This is billed on a 1500 claim form to the Carrier** Many times there is a modifier attached for the technical component TC or the professional component 26 if applicable on the ONE 1500 claim. It is our understanding G0477 does not have a TC/26 split. (Note Carrier is **now combined under the MAC umbrella)]

Thx

re: Intensive Behavioral Therapy for Obesity in a Hospital Owned Provider Based Physician Dept

Based on CMS’s responses to public comments in the final decision memo as well as the one issued earlier for Intensive Behavioral Counseling for Cardiovascular Disease, it appears that CMS excluded RDs for two reasons:
1. CMS believes it lacks the statutory authority to include RDs as providers outside of diabetes and end stage renal disease; and
2. CMS believes it is important that preventive services be furnished in a coordinated approach as part of a comprehensive prevention plan within the context of the patient’s total health care. As such, they believe primary care practitioners are best qualified to offer care in this context...
The CMS decision memorandum also states that in the primary care office setting and primary care hospital outpatient setting, Medicare may cover these services when furnished by auxiliary personnel (e.g., RDs) and billed as “incident to” services in accordance with 42 CFR section 410.26(b) or 410.27, meaning:
a. There is direct physician supervision of auxiliary personnel (the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the service is being provided).
b. “Auxiliary personnel” means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician. Note: Medicare Part B MNT services for diabetes and non-dialysis renal disease cannot be billed as “incident to” services since they are recognized as a separate benefit category.
Rule:
Effective for services on or after November 29, 2011, Medicare will pay claims for
G0447, only when services are submitted by the following provider specialty types
found on the provider’s Medicare enrollment record:
• 01 - General Practice
• 08 - Family Practice
• 11 - Internal Medicine
• 16 - Obstetrics/Gynecology
• 37 - Pediatric Medicine
• 38 - Geriatric Medicine
• 50 - Nurse Practitioner
• 89 - Certified Clinical Nurse Specialist
• 97 - Physician Assistant
CMS determined it will cover screening and intensive behavioral counseling for obesity by primary care providers in settings such as physicians’ offices for Medicare beneficiaries with a body mass index (BMI) > 30 kg/m2. Specifically, Medicare will cover:
• One face-to-face visit every week for the first month;
• One face-to-face visit every other week for months 2-6;
• One face-to-face visit every month for months 7-12, if the beneficiary has achieved a reduction in weight of at least 3kg over the course of the first six months of intensive therapy.

The service must be furnished by a “qualified primary care physician or other primary care practitioner and in a primary care setting.” CMS refers to the Social Security Act for its definition of a “qualified primary care physician” to mean a physician who is a general practitioner, family practice practitioner, general internist or obstetrician or gynecologist. In similar manner, CMS defines “primary care practitioner” as a physician with a primary specialty designation of family medicine, internal medicine, geriatric medicine or pediatric medicine or a nurse practitioner, clinical nurse specialist, or physician assistant in accordance with the Social Security Act.

Lastly, the service must be furnished in the primary care setting. CMS defines a primary care setting “as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities and hospices are not considered primary care settings under this definition.”

re: Intensive Behavioral Therapy for Obesity in a Hospital Owned Provider Based Physician Dept

http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Intensive%20Behavioral%20Therapy%20for%20Obesity&bc=ACAAAAAAIAAA&NCAId=253&

re: Intensive Behavioral Therapy for Obesity in a Hospital Owned Provider Based Physician Dept

Dear NMaguire-thx for your response.

The confusion comes because we are a provider based outpatient hospital setting. So we differ from a Critical Access Hospital Outpatient Setting, or a free standing physicians office, where they are allowed to perform incident to services and bill them under the Medicare Physician Fee Schedule MPFS.

We are not allowed to bill incident to in a provider based setting for the split charge that is the professional component to the MPFS. So normally if an ARNP performs the service we are paid at 85% of the fee schedule on the 1500 side, and if an MD performs the service we are paid at 100% of the fee schedule. A nurse nor a ARNP can get paid under a MD's NPI number on the profee side/1500 claim.

So do you believe this decision memo supports the RD's performing the FACILITY portion under the direct supervision of one of the listed providers for a PROVIDER based physician's?

As provider based entities are required to split the charge and submit a FACILITY CHARGE ON a UB04 portion-to the MAC (this represents the auxilliary resources, overhead etc).
Often in our wound care setting we charge a facility charge based on a "GRID value" to measure auxilliary staff resource/supplies/overhead used. (since Medicare has advised Hospitals to set their own facility guidelines).

This NCD is so specific though-is it your INTERPRETATION that the RD's 15 minute face to face would stand up in the event CMS did an audit even if there was only a facility charge?

The facility charge G0477 would pay under OPPS not MPFS.
My experience is the OIG and or Part A wants to see the documentation as stated in the NCD-(they often don't even care what you billed to the Part B MPFS side)

Even if the Physician was present in the office suite and immediately available to provide assistance and direction throughout the time the service is being provided

re: Intensive Behavioral Therapy for Obesity in a Hospital Owned Provider Based Physician Dept

Gemerson, I'm wondering if you ever concluded on this issue. I realize these posts are almost a year old. We have the exact same issue in our provider-based hospital primary care office right now and I'm struggling with whether it is appropriate to bill the facility-only charge.