Urology Coding Alert

Know your 'incident-to' coding rules

Coding right the first time for incident-to E/M services and other urology procedures done by nonphysician practitioners will spare you hassles - federal fraud charges and revenue loss - down the road.

While Medicare does not restrict the types of care NPPs (physician assistants and nurse practitioners) can provide, state laws and private carrier policies vary. Most NPPs are allowed great latitude in line with their training and level of experience. Know the Criteria for E/M Levels Most often, NPPs in your practice perform E/M services for your established patients (CPT 99211-CPT 99215) using medical decision-making (MDM) of low to moderate complexity.

The level of E/M services depends on three factors:
  the amount of detail in the history
  the amount of detail in the physical examination
  the complexity of the MDM required for diagnosis and treatment.

All E/M Services Must Have a 'Chief Complaint' For codes 99211-99215, only two of the three factors are required. Typically, the physical examination is not needed for this level, just a history and MDM. Given these criteria, when a PA or nurse practitioner sees an established patient, the patient's history should already be in the chart. The physical exam will focus on an established complaint, and the complexity of the MDM will be lower because it is within the context of an established course of treatment.

For example, a physician assistant at your urology practice sees an established patient who is being treated for a urinary tract infection. This patient has been seen in the recent past by the urologist, who has established the diagnosis and initiated treatment or a care plan. The PA performs a follow-up history and examination and continues the prescribed treatment. Code this as an established patient office visit (99211-99215) according to documentation and bill in the urologist's name and numbers.

The previous example constitutes an incident-to visit, and reimbursement is 100 percent of the global fee. Remember, the urologist must be in the office suite to render necessary assistance to the PA and must also see this patient at a frequency indicating his continued care.

Seeing the patient every third or fourth visit for this specific problem would be an indicator of the urologist's continued care. Incident-to billing is also limited to office care. Hospital, outpatient or inpatient care and nursing home visits should never be billed as incident-to (see below).

When an NPP sees a new patient (99201-99205), performs a consultation (99241-99245), or sees an established patient presenting with a new problem, as well as patients in hospitals and nursing homes, these are not considered incident-to the physician's service and must be billed under the NPP's UPIN/PIN for 85 percent reimbursement. In the latter case, [...]