Part B Insider (Multispecialty) Coding Alert

Published on Tue Jul 25, 2006 PDF

Tip:  All NPPs in your facility should have a Medicare PIN

Don't let the rules for coding non-physician practitioners' (NPPs) services bog you down in confusion. Follow these steps to file a compliant claim, and see why billing incident-to is not always your best reimbursement option.

1. Get to know your state scope of practice.

Medicare will only reimburse NPP services if your state recognizes them, so familiarize yourself with your home turf's policies before memorizing Medicare's--because some states will impose stricter rules. This means getting familiar with your state's unique definition of nurse practitioner (NP), physician assistant (PA), clinical nurse specialist (CNS) and other mid-level provider services.

Example: In Alabama, a CNS is essentially a nurse educator and does not see patients in the same sense an NP would, while other states may see them as one in the same, recalls Quin Buechner, MS, MDiv, CPC, CHCO, president & CEO of ProActive Consulting, LLC in Cumberland, WI.

You should also know your state's policy on physician collaboration with NPPs. For instance, Medicare will reimburse a mid-level provider 85 percent for covered, new patient history, exam and medical decision-making (99201-99205), but a PA in Ohio cannot see a new patient even under her own provider number unless the supervising physician is on-site and evaluates the patient before the PA implements the treatment plan, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Deer Park, IL.
On the flip side, Arizona's practice act does allow PAs to see new patients and will even let NPs practice as completely independent practitioners, Buechner points out.

Warning: "Don't assume the doctor or the NPP automatically knows what their state says about collaboration," Buechner cautions. Many assume that Medicare has the final say, "but the state may ask for a closer type of supervision, or the state may discount certain NPP services--and this is where you'll get into trouble with denied claims and failed audits," he adds.

2. Know when Medicare gives a "thumbs-up."

Once you've nailed down your state regulations, Medicare's guidelines are fairly straightforward. 

The Medicare Carriers Claims Processing Manual sections 2156-2160 defines "collaboration" as a process in which an NP or CNS works with a physician (MD or DO) to deliver health care services, with medical direction and appropriate supervision as required by state law." (Medicare uses slightly different terminology for PAs.)

You can bill any level of E/M code for NPPs as long as the state allows it, Buechner notes, but you're not off the hook if your state remains silent on collaboration policies. Medicare says that these NPPs must "evidence" collaboration by documenting their scope of practice and indicating the relationships that they have with physicians to deal with issues outside their scope of practice. "This means having a written policy on hand in case of an audit," Buechner explains.

Next step: Medicare Covered NPP services include those "that traditionally have been reserved for physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting X-rays and other activities that involve an independent evaluation or treatment of the patient's condition."

Example: An NP removes stitches from a patient who had a laceration repair 16 days ago and bills it under the appropriate level E/M.

Watch for: The CMS manual states that Medicare will not cover services such as "routine foot care, routine physical checkups, and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury to improve the functioning of a malformed body member"--even if your state scope of practice for NPPs include these services. Remember, the stricter rule prevails.

You may also want to check with your other payors to see how they want mid-level provider services billed. Some major payors are starting to credential NPs. This means giving NPPs their own unique identifier number so they can bill like a physician.

Don't miss: Medicare just came out with a rule that non-physician practitioners may now do consults (99241-99245). Read Medlearn Matters article MM4215 and look for upcoming articles in "Coding Coach" for more details.

3. Use the right modifier for a NPP surgery assistant.

Medicare generally doesn't require special modifiers for collaboration with mid-level providers. But when an NPP assists during a surgery, you should append AS (Assistant at surgery service) to the appropriate code, Gilhooly points out.

But don't confuse modifier AS with modifier 80 (Assistant surgeon), Gilhooly warns. "In this case, Medicare wants a different modifier to distinguish the NPP's service during surgery because it helps ensure that the reimbursement is at the appropriate level." (Note: For more information on using modifier 80, see "Don't Let 2 Operating Surgeons Cause Claim Denials" in PBI  Vol. 6 No. 41).

How it works: Medicare pays 16 percent of the approved amount to the assistant surgeon, but if this service is provided by a NPP, the reimbursement will be 85 percent of the 16 percent, Gilhooly explains. "Regardless of whose provider number the procedure is listed under, the AS acts as a 'payment modifier' and needs to be reported."

4. Follow--don't force--incident-to rules.

As long as your state allows it, NPPs in your facility can get reimbursed 100 percent for services "incident-to" the physician's care. How: The patient must be established, the patient must be visiting for an existing condition for which the physician has provided a plan of care, and the supervising physician must be readily available in the suite (direct supervision). If these conditions can't be met, NPPs should bill under their own provider number for 85 percent reimbursement.

Tip: Coders can keep an eye out in data entry for incident-to compliance, Gilhooly suggests. "For example, if you get all of yesterday's encounters billed under the doctor's name, and you know that the doctor left at 3:00 in the afternoon, you should make sure that visits after 3:00 will be billed under the NPP's name."

And remember, when you're billing incident-to, make sure it's billed out under the doctor in the suite--not necessarily the one who established the plan of care. (For more on incident-to policies, see "Coding Coach" from PBI  Vol. 7 No. 4.)

Mistake: Some practices don't give their NPPs provider numbers because they want to bill every NPP service incident-to for the extra 15 percent reimbursement. Medicare doesn't require that NPPs have provider numbers--only that they be eligible for one, Buechner notes. But bending over backward to file all NPP claims incident-to is difficult, if not impossible to do 100 percent of the time--and ironically unprofitable.

Why? Often a patient will make a side mention of a new problem during a routine visit. For example, an NP sees a patient for a monthly diabetes checkup. After the history, exam and medical decision-making, the patient points out a rash on his stomach. "At that second, the NP is out of incident-to," Gilhooly says, "and while the NP scrambles to find a doctor to re-establish the patient, she's wasting time and money by tying up a room and hunting down a busy doctor."

And because a doctor is not always available, if you claim to bill all of your NPP services incident-to, you're probably committing fraud," Buechner warns.

The breakdown: An NPP billing an office visit 99212-99215 under his own number versus incident-to a physician, only means the difference between about five and 10 dollars, Gilhooly explains. "And you will waste more than five to 10 dollars in trying to be compliant for those occasions where you can't meet the incident-to requirements."

Solution: Petition to have all NPPs in your facility get a provider number. "In a facility where everyone has a PIN, you have maximum flexibility in terms of scheduling, compliance and managing unexpected cases," Gilhooly says. And you may see your overall reimbursement increase with the added efficiency.