Pediatric Coding Alert

Your NP can report service directly without satisfying criteriaYour pediatricians won't have to pay back money for follow-up nurse practitioner (NP) and physician assistant (PA) services if initial documentation includes an authorizing statement -- or the nonphysician practitioner (NPP) uses her number.Realize Guidance Is Gone, Not DismissedAlthough CMS rescinded its May incident-to transmittal 87 stating carriers will not pay for services incident-to a physician's service unless there is documentation authorizing the incident-to service, your best bet may be to incorporate the changes. "I think CMS still intends that physicians must authorize a nurse practitioner or physician assistant to provide follow-up services," says Hugh Aaron, MHA, JD, CPC, CPC-H, presenter at the 2008 American Academy of Professional Coders National Conference in Orlando.The change: For private payers that follow CMS' incident-to coverage requirements, an auditor could request repayment on NPP services when the physician's initial plan of care fails to mention that an NP or PA may provide follow-up care.This new incident-to criterion applies to CMS Medicare services. "Medicaid and private-payer guidelines will likely follow suit," says Richard H. Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. Watch for changing criteria.Check 4 Incident-to Service RequirementsCMS pays a covered NPP office service reported under a physician's number at 100 percent when the encounter meets these three existing and one new criteria:1. The NP or PA treats an established problem. A pediatrician with the same tax identification number must first treat the patient for that condition or illness.2. A physician provides an active role in the continued management of that condition or illness. "CMS has no set time period for how long in between episodes the physician must re-treat the patient for the carrier to still consider the physician's role as active," Aaron says.3. The physician must provide direct supervision. Although an NP or PA subject to state law may treat a patient without a physician on site, CMS requires a physician be in the office suite to bill a covered office service incident-to the physician, Aaron says.4. Now CMS may also require that the physician indicate he approves an NPP provide follow-up services. For instance, if a pediatrician diagnoses a patient with attention deficit disorder (ADD, such as 314.00, Attention deficit disorder of childhood without hyperactivity) and wants the group's NP to be able to provide medication checks, the pediatrician must authorize this in the initial treatment note."To cover your incident-to pay, the best bet is for the physician in the initial service to make a brief authorizing statement," Aaron says. Notation could read, "OK to see NPP or f/u NPP," he says.Example: A pediatrician sees an established patient for a new problem that he diagnoses as upper respiratory infection [...]