Otolaryngology Coding Alert

If you know whose identification number -- the nonphysician practitioner's (NPP) or the allergist's -- you should bill under, you can ethically maximize your Medicare revenue. You should report the service "incident-to" the allergist and claim 100 percent payment, the equivalent of an extra $8 for CPT 99213, when the in-office encounter meets these criteria: 1.The Employees Belong to the Same Group To bill an NPPservice under your allergist's name, the same group must employ both parties. Both the supervising physician and the performing NPPmust be employees, leased employees or under contract with the same group, says Dennis Grindle, CPA, a partner in healthcare consulting at Seim, Johnson, Sestak & Quist LLPin Omaha, Neb. 2.Your Doctor Initiates Treatment You cannot bill a service incident-to unless your physician previously treated the patient. "This rule automatically excludes you from billing incident-to for new patient encounters," says Emily Hill, PAC, president of Hill & Associates, a consulting firm in Wilmington, N.C. Action: If your NPPtreats a new patient, you should bill the service under the NPP's personal identification number (PIN). Medicare will pay the claim at 85 percent of the dollar amount assigned to the particular code. Illustration: Anurse practitioner (NP) treats a new vacationing senior citizen for difficulty breathing at the beach. The NPdiagnoses effects from red tide, a local algae toxin, and recommends that the woman stay away from the water and take Benadryl as necessary.

You should report 99201-99205 (Office or other outpatient visit for the evaluation of a new patient ...) linked to 786.05 (Shortness of breath) under the NP's number. The allergist has not previously treated the patient. If the allergist first saw the patient in the red tide example, you'd add almost $10 to a 99202 claim. You could bill 99202, for instance, at 100 percent or $64.60 for Medicare. When you bill under the NPP's PIN, Medicare will pay the office visit at $54.91 -- a difference of $9.69. 3.The NPP Treats an Established Problem You should also bill the service under the NPP's number when she treats an established patient's new problem. Keep in mind that the allergist must establish the initial diagnosis and prepare the treatment plan before you can report the service under the NPP's number. Example: Your allergist previously diagnosed a 35-year-old established male patient with extrinsic allergic alveolitis (EAA) and created a treatment plan for his condition. The patient presents today to an NPPfor an EAAcheck. The allergist is present in the office suite. In this case, you should report the appropriate established patient office visit code (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) with 495.x (Extrinsic allergic alveolitis) under the allergist's [...]