Pulmonology Coding Alert

Rule: If NPP treats a new problem, incident-to coding is impossible Each time one of your nonphysician practitioners (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 pulmonologist. Why? More money for the same service. When you report services incident-to the physician, you can bill under the physician's Medicare National Provider Identifier (NPI) and garner full pay for services. If you do not bill an NPP visit incident-to the physician, the NPP must bill under her NPI, which reimburses at 85 percent of the full pay rate. (Note: NPI replaced the term "unique physician identification number" [UPIN] recently in official coding language.) Of course, Medicare has strict guidelines regarding what constitutes an incident-to service, and the carrier will deny any claim that does not meet these rules--- so if you're concerned with the bottom line, you should know the ins and outs of incident-to coding. Find Out if Patient Had Plan of Care To bill incident-to services, the NPP must be following an established plan of care for the patient and the physician supervision requirements, says Anna Rosario, CPC, coding and compliance officer for Affiliated Practice Group in Brockton, Mass. If the NPP is seeing the patient for a new problem, you cannot bill incident-to. Consider these two examples: Example 1: The pulmonologist sees a new Medicare patient with bronchiectasis and chronic rhinosinusitis, and schedules the patient for a follow-up visit. Two weeks later, the NPP provides a level-three E/M service to check on the patient's bronchiectasis and chronic rhinosinusitis. In this instance, the NPP followed the doctor's care plan, so you can report an incident-to service, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. On the claim, you should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) for the E/M under the physician's NPI. Don't forget to attach 494.0 (Bronchiectasis without acute exacerbation), 472.0 (Chronic rhinitis) and 473.9 (Chronic sinusitis, unspecified) to 99213 to prove medical necessity for the encounter. Example 2: An established patient with a plan of care for his previously treated extrinsic asthma reports to the office for a checkup. During the exam, the patient complains of a 10-day history of progressive cough, low-grade fever, fatigue and loss of appetite. During the course of a level-three E/M, the NPP checks the patient's asthma and also discovers that the patient has suspected pneumonia. She writes the patient a prescription and sends him home. In [...]