Part B Insider (Multispecialty) Coding Alert

Published on Sun Nov 26, 2006 PDF

Refresher:  The key to 100% payment lies in an established plan of care

You know Medicare pays nurse practitioners' (NPs') services at 85 percent of the physician's rate--but are you confident in your skills at securing 100 percent when you bill them under the internist's personal identification number (PIN)? Read the following examples and test your know-how on incident-to guidelines for NPs.

Example #1: A 70-year-old male patient makes an appointment for an initial visit with your internist to manage his uncontrolled type II diabetes and related peripheral circulatory disorders. After his initial visit with the internist, he has a follow-up appointment with your NP one week later to discuss any adverse reactions to the insulin.

Answer: Because the NP is carrying out the internist's established treatment plan, you can report the appropriate E/M code (99211-99215) under the physician's PIN for the follow-up. List ICD-9 code 250.72 (Diabetes mellitus; diabetes with peripheral circulatory disorders; type II or unspecified type, uncontrolled) to support the reason for the visit.

Example # 2: The same patient scheduled an initial visit with the internist, but called the office a  few days before his appointment, complaining about chest pains. A heavy schedule prohibits the internist from treating the patient and the NP sees him instead.  Your NP performs an electrocardiogram (ECG).

Answer: Bill this encounter under the NP's PIN, says Carol Pohlig, BSN, RN, CPC, senior coding and educational specialist at the University of Pennsylvania's department of medicine in Philadelphia. This example doesn't satisfy Medicare's incident-to guidelines because the internist didn't establish a plan of care for this patient's medical problems. Report 9300 (Electrocardiogram, routine ECG...) for the ECG and 786.50 (Chest pain, unspecified) for the symptom that led to the ECG.

Lesson learned: When you code an NP's services, scan the patient's chart to determine whether the internist has seen him prior to his visit with the NP. Medicare's incident-to guidelines state that the physician must see the new patient and institute a plan of care--and then the NP can follow up with the patient, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, PA.