NPP Visit Affects “New vs. Established” Status
If a non-physician practitioner (NPP)—but not a physician—has seen a patient within the last three years, is the patient new or established?
Although CPT® consistently uses the term “physician” in the context of the determining whether a patient should be considered “new” or “established,” most payers—Medicare payers in particular—don’t apply that instruction literally. For example, Medicare’s definition of a new patient, taken from the Medicare Carriers Manual, instructs:
“Interpret the phrase ‘new patient’ to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years” [emphasis added.]
Because the NPP would be a member of the group practice, if he or she has seen a patient within the past three years, that patient would be established with the group.
The Centers for Medicare & Medicaid Services (CMS) offers even more explicit instructions in its MLN Evaluation and Management Services Guide:
“For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider.
“A new patient is defined as an individual who has not received any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years.
“An established patient is an individual who has received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous three years” [emphasis added].
The bottom line: If the patient has seen an NPP in the practice within the previous three years, you should treat the patient as established.
But remember, a patient is established only if the physician or NPP provides a face-to-face service within the past three years.
“For example,” continues the Medicare Carriers Manual (chapter 12, section 30.6.7), “if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an X-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.”
Skin Lesion Excision: Documentation Quick Tips
When performing excision of benign (11400-11471) or malignant (11600-11646) skin lesions, physicians must document the location of the lesion, and should measure the lesion and margins prior to excision. The lesion will “shrink” when the incision releases the tension on the skin, which may lead to a lower-level code selection and lost reimbursement.
Because CPT® codes for lesion excision (as well as ICD-9-CM diagnostic codes) require that you identify a lesion as either benign or malignant, you should wait for pathology results before assigning a code (unless the diagnosis is confirmed in a previous biopsy of the lesion). Only those lesions specifically identified as malignant may be coded as such.
If a surgeon performs a re-excision to obtain clear margins at a later operative session, you may report the same malignant diagnosis linked to the initial excision because the reason for the re-excision is malignancy.
When the surgeon removes multiple lesions, treat each as a separate procedure. Append modifier 59 Distinct procedural service to the second and subsequent codes for excisions in the same general location.
Example: The physician removes three lesions from the right arm: sizes 1 cm (benign), 1.5 cm (benign), and 2.5 cm (malignant). Report: 11603 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 2.1 to 3.0 cm with diagnosis 173.6 Other malignant neoplasm of skin, skin of upper limb, including shoulder; 11402-59 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm with 216.6 Benign neoplasm of skin; skin of upper limb, including shoulder, and; 11401-59 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm with 216.6.
Per CPT® guidelines, all lesion excision codes include simple wound closure. CPT® allows separate coding for intermediate (12031-12057) and complex (13100-13153) repairs; however, payers who follow National Correct Coding Initiative (NCCI) edits will bundle intermediate and complex repairs into excision of benign lesions of 0.5 cm or less (11400, 11420 and 11440).
When (and When Not) to Follow Incident-to Guidelines
For Medicare patients in the physician office, services performed by a qualified non-physician practitioner (NPP) must meet incident-to guidelines. For a service to qualify as incident-to:
The NPP must be licensed or certified to provide professional health care services in the state where the physician practice is located.
In most cases, the NPP must be a full-time, part-time, or leased employee of the physician or physician group practice (in limited cases, the NPP may be an independent contractor).
The NPP must provide services as an integral part of and incident-to the physician’s services.
- The NPP must provide such services under the direct supervision of the physician. Per Medicare rules, direct supervision means the supervising physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. The physician does not need to be present in the room during the procedure, but must not be performing another procedure that cannot be interrupted, and must not be so far away that he or she could not provide timely assistance. Documentation should substantiate the physician was present, on site, to supervise.
Incident-to rules do not apply to a hospital setting; rather, per Hospital Outpatient Prospective Payment System (OPPS) rules, therapeutic services in an outpatient setting may be provided under the direct supervision of an MD or DO; or, under the direct supervision of a physician assistant, nurse practitioner, clinical nurse specialist, certified nurse-midwife, licensed clinical social worker, or clinical psychologist who could personally furnish the service “in accordance with State law.” The supervising NPP must be privileged by the hospital to perform the services he or she supervises, and must abide by any applicable hospital physician-collaboration or supervision requirements.
Medicare physician supervision requirements do not apply to hospital inpatient services. Rather, CMS defers to hospital policy and Joint Commission (JC) standards for inpatient services.
Incident-to rules apply specifically only to Medicare payers. Private payers have their own rules and may, for instance, allow non-physician practitioners to treat new patients. Know your individual payers’ rules to be sure you report your NPP servicers optimally.
How to Distinguish ROS from Exam
When reading a chart note, it can be difficult to distinguish between elements belonging to the review of systems (ROS), and those elements that are relevant to the exam.
The ROS are written or verbal “questions and answers” relevant to signs or symptoms the patient is experiencing at the time of service. Often, the ROS is gathered by having the patient complete a history or intake form given to the patient at the front desk check-in. The form includes a list of questions, on which the patient “checks off” and briefly explains his or her signs and symptoms.
The ROS may also occur verbally with the provider or other staff. For instance, an assistant may ask the patient, “Do you have any problems breathing? Do you have shortness of breath when exercising, walking, climbing the stairs?” If ancillary staff documents the ROS, the provider must review the information to use it for E/M selection.
The provider might document the patient’s response in a note as briefly as, ”Patient states his chest hurts when he coughs, but not when he takes a deep breath. No SOB. No complaints of pain in joints. No problems sleeping.”
If the provider uses a subjective, objective, assessment, and plan (SOAP) documentation format, the ROS elements should appear under the heading “Subjective.”
In contrast to the elements of the ROS, the elements of an exam are actual visual or “hands-on” findings. For example, the provider uses an otoscope to inspect the middle ear visually, an ophthalmoscope to check the eyes and their reaction to light, and a stethoscope to listen to lung, heart, and bowel sounds.
The bottom line: When reading the notes, decide if the notation is something the patient answered, or if it is something the provider observed. A question that is answered belongs to the ROS, whereas something the provider sees, hears, or measures upon examination is an element of the exam.
Coding for Robotic-assisted Prostate Surgery
A recent study in the Journal of Clinical Oncology compared outcomes of Medicare-aged men who had undergone open retropubic radical prostatectomy against those who had undergone the same procedure by robotic-assisted laparoscopic approach, and determined that outcomes were no better using the latter technique. The skill of the surgeon and the number of prostatectomies done at a particular hospital matter more than technique, according to a 2010 article in Urologic Oncology. Other studies have similarly concluded that robotic-assisted procedures do not improve surgical outcomes, but may allow shorter hospital stays and less blood loss.
Robotic surgery is covered by routine and customary laparoscopic CPT® and ICD-9-CM coding practices, existing medical policies for advanced laparoscopic surgery, and current payer contract rates. There is no need for unlisted procedure codes or modifier 22 Increased procedural service for robotic assist (except perhaps, for instance, when there is no existing laparoscopic code to describe a procedure). No additional payment allowance is made for the robotic surgical technique.
For example, if the surgeon performs radical, nerve sparing prostatectomy with robot assist, the appropriate code is 55866 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing. The payment rate for the robotic assist will be the same as for a “standard” laparoscopic procedure, with the same medical necessity and coverage implications, as well.
If your payer accepts HCPCS Level II S codes, you may report S2900 Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure) in addition to the primary procedure code to identify the procedure as robotic-assisted. Note that S codes are not payable under Medicare, and likely won’t result in additional payment from any insurer.
Have your own medical coding tips or resources? Please submit them for consideration in future editions of this publication.