Part B Insider (Multispecialty) Coding Alert

Published on Fri Apr 23, 2004 PDF

Follow 5 requirements and earn 100 percent NPP reimbursement

If you know whose identification number -- the non-physician practitioner's (NPP) or physician's -- you should bill under, you can ethically maximize your Medicare revenue.
 
You should report the service incident-to the physician 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 NPP service under your physician's name, the same group must employ both parties. Both the supervising physician and the performing NPP must 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 LLP in Omaha, Neb.

2. The Physician 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.

If your NPP treats a new patient, you should bill the service under the NPP's personal identification number (PIN). Medicare will pay the claim at 85 percent.

For example: A nurse practitioner (NP) treats a new vacationing senior citizen for difficulty breathing at the beach. The NP diagnoses 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 physician has not previously treated the patient.

If the doctor first saw the patient in the this case, you'd add almost $10 to a 99202 claim. You could bill 99202, for instance, at 100 percent or $64.60 for Medicare. When billing 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. The doctor must establish the initial diagnosis and prepare the treatment plan.

For example: Your physician previously diagnosed a 50-year-old established male patient with diabetes and created a treatment plan for his condition. The patient presents today to an NPP for a diabetes check. The doc 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 250.xx (Diabetes mellitus ...) under the physician's PIN. The physician has seen the patient, has provided a diagnosis for the condition, and has been previously involved in the treatment plan.

Tip: Stick with NPP billing for treatment-plan changes that don't involve the physician.

For instance, an elderly patient sees a PA for hypertension (401.1, Essential hypertension; benign) management. During the workup, he diagnoses the patient with diabetes.

In this case, the physician hasn't seen or examined the patient for the new complaint and didn't perform the medical decision-making required to establish a diabetes diagnosis. So, you should bill the office visit, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...), using the PA's provider number, not the docotor's. Medicare would pay $44.75 for 99213, rather than $52.65.

4. Care Involves the Physician

Make sure documentation reflects your physician's ongoing involvement in incident-to cases. Medicare requires your physician to provide an active role in the patient's ongoing care. Your physician must provide services of a frequency that reflect his continuing active participation and management of the treatment, says Hill, who presented the teleconference "Proven E/M Documentation and Coding Strategies for NPPs" for The Coding Institute in Naples, Fla.

Look for carriers' interpretations of the on-going-care requirement. "Some Medicare carriers require the physician to provide one out of every three encounters," Hill says.

5. Your Physician Provides Direct Supervision

To bill a service incident-to, your physician must be present in the office suite. That means the physician is immediately available, such as on the same floor, to help, Hill says.

Another way: When your physician doesn't provide direct supervision, bill the service under the NPP's number if your state permits NPPs to provide the service.

Reminder: Report service incident-to the on-duty physician. If an NPP provides a service to Dr. A's patient, but Dr. B is present, bill the service incident-to Dr. B, Hill says.

Ask "Who is providing the required level of supervision?" Grindle says. Because Physician B is the supervising doctor, you should bill using that identification number, Grindle says.

You try: A physician assistant (PA) treats off-duty Dr. A's asthma patient for wheezing. The PA administers a nebulizer treatment while Dr. B is in the office suite.

You should report 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) linked to 493.02 (Extrinsic asthma; with [acute] exacerbation) incident-to Dr. B. He provides direct supervision, not the patient's off-duty physician. Medicare will reimburse the procedure at 100 percent or $12.70 instead of at 85 percent or $10.79.

Note: To obtain a CD, tape or transcript of Hill's teleconference, call The Coding Institute at  (800) 508-2582 or visit www.codinginstitute.com.