Part B Insider (Multispecialty) Coding Alert

Published on Thu Jul 19, 2007 PDF

Each time a nonphysician practitioner (NPP) provides services or treatment to a Medicare patient, you should be on the lookout for the opportunity to code the service incident-to the physician. But if you don't follow Medicare's strict guidelines for incident-to billing, you-ll only see partial payments and denials. Take this quiz to test your NPP knowledge.

Question 1: One of your practice's nurse practitioners (NP) sees an established patient whom the physician has been treating for a urinary tract infection. The physician has seen the patient in the recent past and has established the diagnosis and initiated treatment or a care plan. The NP performs a follow-up history and examination and continues the prescribed treatment. The physician is in the office suite but does not see the patient. How should you code this encounter?

Answer 1: You should report an established patient office visit, depending on the level of service--most likely 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) or 99213--under your physician's name and PIN/NPI numbers. You-ll be paid 100 percent of the E/M fee.

Reason: This patient had a care plan established by the physician, is not a new patient, is not presenting with a new problem and isn't undergoing status change. In addition, the physician is present in the office suite so the NP can provide the service, and you can use the physician's PIN/NPI/ when filing with Medicare.

Question 2: A physician assistant (PA) from your office sees a patient in the hospital whom your physician admitted the day before. Can you report this visit incident-to the physician?

Answer 2: No. Never report incident-to services in a hospital setting, either outpatient, inpatient or in the emergency department. Medicare doesn't allow incident-to billing in these places of service, only in the physician's office.

Question 3: A new patient complaining of urinary retention comes to the office. The physician is present in the office but is involved doing a minor surgical procedure and is unable to see this emergency. In his place, one of your NPPs treats the patient, inserts a Foley catheter to relieve the obstruction and establishes a care plan of treatment. Can you bill this NPP's service as incident-to the physician who was in the office suite at the time of the appointment?

Answer 3: No. In this example, the patient is new to your office and received treatment for a new problem, meaning the NPP was not following an established plan of care. Therefore, you should report the encounter using the NPP's NPI/UPIN, and you-ll receive 85 percent of the global fee (the fee the physician would have received if he had personally rendered the care). Anytime the NPP sees a new patient independently for a new problem, you should code for the service in the NPP's name with his UPIN.

Answers reviewed by Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.