Wiki nurse dating ultrasound

[ymendez2020]

need coding help I currently bill for an OBGYN clinic for medical the nurse is performing initial dating ultrasound with no provider in the office (billing 76817 and 76815 with Mod 59) we send the ultrasound to the dr to review and write a report, my question is can i bill with E&M code 99202-99205 even though there is no provider to establish the new patient? I can't use 99211 because they are not established. can I bill just for the ultrasound with no E&M code?

does anybody know where I can find the guidelines to where its states that a provider needs to establish the patient for us to be able to bill with an E&M code?

 

[sinman0531]

In order to bill for services, the provider needs to have an NPI, or otherwise be acting within the scope of their license. Since I am assuming you are keeping the ultrasound in office, simply billing the ultrasound codes covers the review of the images and writing the report. Since the nurse performing an ultrasound is acting within the scope of an RN license, that service can be billed under a supervising physician NPI.

The clue to E/M is in the description; all E/M code descriptions (other than 99211) include the phrase "which requires a medically appropriate history and/or examination". Since an RN is only qualified to take a history, not perform a qualified examination of the patient, either a mid-level provider or doctor must perform a visit to bill for the E/M codes.

 

[thomas7331]

need coding help I currently bill for an OBGYN clinic for medical the nurse is performing initial dating ultrasound with no provider in the office (billing 76817 and 76815 with Mod 59) we send the ultrasound to the dr to review and write a report, my question is can i bill with E&M code 99202-99205 even though there is no provider to establish the new patient? I can't use 99211 because they are not established. can I bill just for the ultrasound with no E&M code?

does anybody know where I can find the guidelines to where its states that a provider needs to establish the patient for us to be able to bill with an E&M code?

A nurse may not perform a new patient E/M service - it's outside the scope of their license. They should also not be performing ultrasounds or other services without a provider present in the office. This is per the Medicare guidelines on 'incident to' services which you can find in the Medicare Benefit Policy Manual, Chapter 15, section 60. Services performed in an office with no physician supervision would not meet the definition of a Medicare covered service. If this is a new patient, it also fails to meet the 'incident to' requirement that the service be part of an established treatment plan - the provider must have evaluated the patient and ordered the ultrasound as part of their treatment plan.

Other payers may or may not follow the Medicare rules, but as a general rule, this is an industry standard, so it's a best practice to always have the physician present any time the office staff are performing services to patients. I'd suggest two other things that need to be considered: first, is the nurse putting her license at risk by performing services without supervision - you may want to contact your state's nursing board to see if there are regulations regarding this; and second, does your physician's malpractice insurance require that the physician be on site when these services are performed - the physician could be exposing themselves to significant liability if they are allowing their employees to treat patients in the office with no physician present.

 

[sinman0531]

A nurse may not perform a new patient E/M service - it's outside the scope of their license. They should also not be performing ultrasounds or other services without a provider present in the office. This is per the Medicare guidelines on 'incident to' services which you can find in the Medicare Benefit Policy Manual, Chapter 15, section 60. Services performed in an office with no physician supervision would not meet the definition of a Medicare covered service. If this is a new patient, it also fails to meet the 'incident to' requirement that the service be part of an established treatment plan - the provider must have evaluated the patient and ordered the ultrasound as part of their treatment plan.

Other payers may or may not follow the Medicare rules, but as a general rule, this is an industry standard, so it's a best practice to always have the physician present any time the office staff are performing services to patients. I'd suggest two other things that need to be considered: first, is the nurse putting her license at risk by performing services without supervision - you may want to contact your state's nursing board to see if there are regulations regarding this; and second, does your physician's malpractice insurance require that the physician be on site when these services are performed - the physician could be exposing themselves to significant liability if they are allowing their employees to treat patients in the office with no physician present.

The various definitions of "supervising physician" when thinking of an RN scope of practice depend on each state, sometimes even depend on what activity is being performed. Some states only require that the billing physician be in the same building at the same time as the RN, so we can't say whether the RN is performing within their scope of practice or not. For example I am in Florida, and according to the FL Board of Nursing, a physician only needs to be "reasonably available" to an RN to be considered "directly supervising". So in that case the OP would want to maybe double check with who does their compliance!

 

[thomas7331]

The various definitions of "supervising physician" when thinking of an RN scope of practice depend on each state, sometimes even depend on what activity is being performed. Some states only require that the billing physician be in the same building at the same time as the RN, so we can't say whether the RN is performing within their scope of practice or not. For example I am in Florida, and according to the FL Board of Nursing, a physician only needs to be "reasonably available" to an RN to be considered "directly supervising". So in that case the OP would want to maybe double check with who does their compliance!

Yes, each state may have different regulations as to what the nursing license allows for. However, Medicare is not subject to individual states' regulations. Per the policy manual:

Coverage of services and supplies incident to the professional services of a physician in private practice is limited to situations in which there is direct physician supervision of auxiliary personnel.

Medicare's definition of direct supervision requires the presence of the physician in the office. If that supervision is not occurring, the services would not be a covered benefit and all of those services would be subject to denial or recoupment. In my opinion, it's not worth the risk that providers would be subjecting themselves to. But you're correct, this is something that each organization's compliance officers or legal specialists should be involved in - that is the best recommendation.

 

[ymendez2020]

thank you so much for all your input upon further investigation yesterday I found radiology billing method guidelines that state: Billing Method Guidelines Radiology CPT procedure codes 70010 thru 78816, 78999 thru 79445 and 79999 are billed by different methods. Although the method used depends on the contractual or other type of mutual agreement between the facility and the physician and applies to both inpatient and outpatient services, the principal determinants are the provisions of the contract that the facility has with the Medi-Cal program. Facilities that are not under contract to Medi-Cal may make an arrangement with the physician that is mutually agreeable within these policy guidelines. The Department of Health Care Services (DHCS) has defined the billing method options as follows: Split-Billable Split-billable services: These codes are separately reimbursable for the professional and technical component and they may be reimbursed according to one of the following scenarios: • The facility and physician each bill for their respective component of the service with modifiers 26 or TC. • Full-Fee Billing – Physician bills for both the professional and technical components and subsequently reimburses the facility for the technical component according to their mutual agreements. • Standard Billing – Facility bills for both the technical and professional components and reimburses the physician for the professional component according to their mutual agreements.



so those that mean i am able to bill an E&M code just add a MOD,

I am confused based on the fact that one guideline says one thing and another one states another

 

[ymendez2020]

I am thinking we fall under the standard billing since the nurse performs the ultrasound but it doesn't state anything on the E&M code so should I just be billing the ultrasound with MOD 26?

 

[thomas7331]

I am thinking we fall under the standard billing since the nurse performs the ultrasound but it doesn't state anything on the E&M code so should I just be billing the ultrasound with MOD 26?

You cannot bill an E&M service for a nurse, with the exception of 99211, but that would not apply here because you said it's not an established patient.

And are you billing for a provider's office or for a facility? The guidelines you're citing are talking about the relationship between the provider and the facility - you didn't mention that in your original post so I'm not understanding how that applies to your specific situation.

 

[ymendez2020]

You cannot bill an E&M service for a nurse, with the exception of 99211, but that would not apply here because you said it's not an established patient.

And are you billing for a provider's office or for a facility? The guidelines you're citing are talking about the relationship between the provider and the facility - you didn't mention that in your original post so I'm not understanding how that applies to your specific situation.

its a clinic where the md is the billing provider if that makes sense, is not the md private office sorry for the confusion

 

[thomas7331]

its a clinic where the md is the billing provider if that makes sense, is not the md private office sorry for the confusion

I'm still not understanding, I'm sorry. Is it a hospital clinic, i.e. a provider based clinic? Or a non-hospital clinic owned by a different provider? Is the nurse performing the ultrasound an employee of the clinic or of the physician? And are you asking about how to bill for the physician's services or for the services done in the clinic itself?