Orthopedic Coding Alert

Question: Our orthopedic surgeon and nurse practitioner (NP) worked together in our office to perform debridement of muscle but not bone. The NP does not typically perform stitches, but the surgeon guided the NP through the service. They both turned in a charge ticket for 11043. Which provider's personal identification number (PIN) should I report for the surgery?

Wisconsin Subscriber Answer: If your NP performed the majority of the surgical procedure (excising the skin and muscle and stitching the wound under the surgeon's guidance), you can file the claim for 11043 (Debridement; skin, subcutaneous tissue, and muscle) one of two ways, depending on your payer's policies.

For maximum reimbursement, you should file this as an "incident-to" claim under the physician's PIN. Medicare defines incident-to services as those services or supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of a diagnosis or treatment of an injury or illness.

Although the physician was present in the examining room in your case, the physician does not have to be in the room with the NP just somewhere in the office suite to file an incident-to claim. Your practice should submit the incident-to claim as if the orthopedist performed the service, and expect to be reimbursed the same as if the physician performed the service.

Your other alternative is to file under the nurse practitioner's PIN if the payer recognizes the NP's services. Be sure to check payer guidelines, because payers' NP claim requirements vary. If you take this route, your insurer will probably reimburse at 85 percent of the Physician Fee Schedule amount.

Incident-to applies to Medicare claims, and you should not apply this billing concept to other payers unless you have a written policy or permission that allows you to do so.