Pediatric Coding Alert

Private payers may implement these Medicare incident-to requirements

Want to capture an additional 15 percent reimbursement when a nonphysician practitioner (NPP) performs an E/M service? Depending on the payer, you can if the service meets "incident-to" criteria.

Studying private payers'various incident-to interpretations, however, can prove mind-boggling. You can more easily grasp incident-to coding if you learn Medicare's incident-to definitions and rules, which many third-party payers adopt.

When an NPP performs an E/M service, you have two options: You may either report the office visit under the individual's own personal identification number (PIN) or report under the supervising pediatrician's PIN.

Watch out: Not all staff qualify as NPPs. Alicensed NPP, such as a nurse practitioner (NP), a physician assistant (PA), a clinical nurse specialist or a certified nurse midwife, may provide a higher-level E/M service without the pediatrician's direct supervision, says Richard H. Tuck, MD, FAAP, pediatrician at Primecare of Southeastern Ohio in Zanesville. If other auxiliary staff, such as a medical assistant (MA) or registered nurse, perform an E/M service, you must report the appropriate code incident-to the supervising pediatrician's PIN.

Example 1: Suppose a pediatrician orders a mother to return with her child for follow-up on his tuberculosis test. An MAchecks the immunization site and records her observation.

You should report CPT 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...) because the MA performs a medically necessary and physician-ordered service.

Submit the pediatrician's name in box 24 of the CMS-1500 form, says Dennis K. Grindle, CPA, a healthcare consultant at Seim, Johnson, Sestak & Quist LLPin Omaha, Neb. Because an MA performed the service under direct physician supervision, you don't have the option of billing under the MA's own PIN.

The insurer should pay you 100 percent of its allowable 99211 payment, or about $21.28. Medicare pays incident-to claims at 100 percent, Tuck says. Because you submit 99211 with the pediatrician's name, the payer doesn't know that another individual performed the service. "The provider is transparent," he says. Therefore, Medicare reimburses the E/M in full.

Bottom line: Because Medicare doesn't reduce incident-to charges, you should always report an NPP's service under the pediatrician's PIN if the service meets incident-to criteria.

When you report a service under the pediatrician's PIN, the physician must first see the patient. "This rule doesn't mean that the pediatrician must treat the patient on the same day the NPP provides an E/M service," Grindle says. But before an NPP bills incident-to, the pediatrician must see the patient so she can make a diagnosis and initiate a treatment plan. The NPP can bill incident-to for the patient's subsequent visits.

Example 2: AP Aperforms a two-week checkup that the pediatrician ordered for a newly diagnosed diabetes patient (250.01, Diabetes mellitus without mention of complication; type I [insulin dependent type] [IDDM] [juvenile type], not stated as uncontrolled). The PA examines the child and discusses any adverse side effects of his insulin.

Choose the appropriate-level E/M code (99212-99215) based on the history, examination and medical decision-making that the NPP documents.

Report the PA's service under the pediatrician's PIN and claim 100 percent reimbursement, Grindle recommends. Because the subsequent checkup is an incidental and integral part of the physician's initial treatment, the service meets the first incident-to criterion.

Tip: The initial-treatment rule automatically excludes reporting 99201-99205 (Office or other outpatient visit for the evaluation of a new patient ...) incident-to a physician.

Illustration: An NP treats a new vacationing 5-year-old boy who complains of painful ears. The N cleans a large amount of cerumen out of the patient's ears, diagnoses otitis media, prescribes an antibiotic and discusses a Tylenol regimen with the mother. The NP documents an expanded, problem-focused history; an expanded, problem-focused examination; and straightforward medical decision-making.

You should report 69210 (Removal impacted cerumen [separate procedure], one or both ears) with 380.4 (Impacted cerumen) and 99202-25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) linked to 382.00 (Otitis media, acute; purulent) under the NP's number because the pediatrician has not previously treated the patient.

Some payers, including Medicare, will cut 15 percent from the service and procedure. In this case, if the pediatrician saw the patient in the otitis-media example, you'd add about $17 to the claim. You could bill 99202 at 100 percent (or $64.60) and 69210 at $48.17, based on Medicare's rates. If you bill under the NP's PIN, Medicare will pay the office visit at $54.91 and the cerumen removal at $40.94 -- a total difference of $16.92.

Good news: Not all insurers reduce NPP service payment. For instance, Medicaid generally pays NPP-billed services at 100 percent, Tuck says.

Because third-party payers may adopt individual schedules, make sure to check private payers' NPP incident-to policies, Grindle says. Get variations on Medicare's rules in writing to ensure correct coding.

Make sure your documentation reflects your pediatrician's ongoing involvement in incident-to cases. Medicare requires your physician to provide an active role in the patient's ongoing care. The pediatrician must provide services frequently enough to demonstrate that he actively participates and manages the treatment, Grindle says. "For each subsequent encounter, however, the pediatrician doesn't have to see the patient or provide a service."

Example 3: An NP performs a checkup on an adolescent who has a standing pediatric order to return every six months to check for any adverse birth-control reactions. The patient also saw the NP for her last follow-up visit.

Yes. Even though the pediatrician doesn't participate in the subsequent visits, she ordered the initial treatment. Thus, you may report the E/M service under the pediatrician's PIN.

Assign 99211-99215 based on the NP's documented history, examination and medical decision-making. If the teenager is asymptomatic, the visit will probably qualify as 99212-99213 with V25.4x (Surveillance of previously prescribed contraceptive methods).

Strategy: Look for carriers'interpretations of the ongoing-care requirement. "Medicare requires the physician to see the patient every three to four visits," Tuck says.

Before you bill 99211-99215 or a procedure incident-to the pediatrician, the service must meet one more requirement. The pediatrician must be immediately available in the office suite, such as on the same floor, to provide assistance if necessary, Grindle says.

Problem: When the child's primary pediatrician isn't on duty, you may wonder which physician's name you should use.

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

Example 4: APAperforms a blood pressure check that Dr. A ordered two days ago. But Dr. B is in the office suite while Dr. Ais off-duty.

You should report 99211 incident-to Dr. B. He provides direct supervision, not the patient's off-duty physician.