Neurology & Pain Management Coding Alert

Question: I am trying to code a level-three evaluation and management (E/M) service our nonphysician practitioner (NPP) performed “incident-to” the physician for an established Medicare patient. There was already a plan of care in place for right-sided lumbago with sciatica, but I’m not sure the visit included “direct supervision.” For coding purposes, what does Medicare mean by “direct supervision”?

Minnesota Subscriber

Answer: Medicare stipulates that an NPP must be working under “direct supervision” of a physician to bill incident-to. If you cannot meet these supervision rules, don’t pursue incident-to billing for the claim.

The supervision question can cause some hesitation when making the incident-to decision, because coders can get flummoxed by the exact definition of “direct supervision.”

And sometimes, state laws make supervision guidelines clear as mud.

In short: Medicare’s federal incident-to rules supersede any state’s rules — and the feds’ rules are often more restrictive.

Best bet: Make sure your visit meets Medicare’s supervision rules before deciding to report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…). If there is no physician from the group practice physically present in the office suite during the time of the NPP service, the service must be billed to Medicare under the NPP’s name and national provider identifier (NPI), which will result in an 85 percent reimbursement rate for the E/M service.

If, however, the visit does pass muster by Medicare’s supervision rules, you’ll be able to code under the supervising physician’s NPI, which will net you 100 percent of the 99213 code.

Either way: Be sure to append M54.41 (Lumbago with sciatica, right side) to 99213 to represent the patient’s condition.

Some state boards only require general supervision, or that the physician be available by phone, in order to consider an NPP “directly” supervised.

In order to meet Medicare’s direct supervision guidelines, however, the supervising physician must be physically present in the office suite and available to provide assistance and direction to the NPP.  During the incident-to service, the supervising physician does not need to be physically present in the treatment room or actually see the patient. However, the supervising physician cannot be across the street, three blocks away, or available via cell phone but not in person.

It’s recommended that the NPP indicate this supervision within the text of the documentation for the visit. The NPP can add that the supervising physician was in the suite at the time of the service. This will allow for a clear illustration that the supervision requirement has been met.

These supervision rules are in place to protect patient safety.

For example, if the patient has an adverse reaction to an injection or passes out during a routine venipuncture, the physician must be immediately available to provide care to the patient.