Pulmonology Coding Alert

Make sure you know who is your supervising doctor on duty

If your pulmonology practice uses nonphysician practitioners but has a hard time keeping track of who's supposed to supervise them, you'll be glad to hear that any member of your physician staff can provide supervision - not just the physician who ordered the services.

The scoop: CMS in September 2004 clarified its incident-to requirements. Before that, carriers often assumed that the physician who ordered incident-to-services would also supervise them. But now you can list two different doctors as the ordering and supervising physicians, says Jean Acevedo with Acevedo Consulting in Delray Beach, Fla.

Keep in mind: "Incident-to" guidelines are only applicable when services are rendered in an office setting (place of service 11). They do not apply to anyservices provided in a facility setting (that is, outpatient or inpatient hospital, nursing facility, etc.), says Mary Mulholland, BSN, RN, CPC, senior coding and education specialist for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia.

Example: The physician assistant (PA) in your pulmonology practice performs an E/M visit on a 15-year-old girl with asthma (493.90) that a pulmonologist in the office requested the PA to complete. The ordering pulmonologist is not present in the office suite during the examination. The PA takes her interval history and begins performing a basic exam while the ordering pulmonologist is not in the office suite. Another pulmonologist, other than the ordering physician, is present in the office suite and supervises the PA's service.

Old way: Prior to this clarification, Mulholland says, CMS limited the direct supervision of incident-to services to the provider who established the patient's care plan. In the scenario above, your carrier would not reimburse you for the services provided by the non-ordering physician.

New way: With this new clarification, the supervising physician may be an employee, a leased employee, or an independent contractor of the legal entity billing and receiving payment for the services or supplies that satisfies the requirements for valid re-assignment, Mulholland says. (See CMS Manuals Publication 100-4, Chapter 1, Section 30.2.)

Therefore, in the above example, you can bill for the service even though a physician other than the ordering physician provided the supervision.

Don't Overlook Direct Supervision
  
CMS requires direct supervision when reporting incident-to services, Mulholland says. In the office setting, direct supervision means the physician must be personally present in the office suite and immediately available to provide assistance and direction during the incident-to service, if needed.
 
Red flag: Direct supervision does not mean that the physician must be present in the room with the patient when the service is performed.