# A question regarding "incident to" - but with a twist



## Colliemom (Apr 15, 2010)

If you read the code description for a 99211 it specifies that the established patient office visit may not require the presence of a physician.  If you go to Appendix C in the CPT one of the examples of when to use the 99211 is: an office visit for an 82 year old established patient for a monthly B-12 injection.

So this suggests it is appropriate to bill an established patient office visit when a patient is only coming in for monthly injections.  (honestly though, I do wonder if medical necessity is being met in this instance, why would you need to bill an office visit if the patient is just coming in for an injection?  Would it be because the NPP wants to check the patient's current vitals and perform a constitutional exam to be certain the patient was not feeling ill before proceeding with an injection?  I could then understand the need to perform a 99211 before the injection if this were the case.)  My first question would be what kind of documentation would the NPP have to create to support a 99211?  If the patient is only coming in for monthly injections, and the physician does not need to be present, then you would not have a complete SOAP note.  What type of documentation would you need in order to bill this low level E/M visit?  Also, if the NPP is performing the injections at the request of the supervising physician, then would it be appropriate to bill the 99211 as "incident to?"  How about the actual injection, would you also bill that as "incident to," since the NPP is simply following the plan of care established by the supervising phyisican?

Now let's make it a little more complicated...suppose the established patient comes in to the office, is seen by our APRN for not only a Cimzia injection but to _*teach*_ the patient how to perform the injections herself.  In this instance the APRN spends 45 minutes with the patient, and 30 minutes of the visit is spent in counseling the patient on how to perform the injections.  Would it be appropriate for us to bill an established patient visit, 99215 based on time, as "incident to" along with 96401 for the injection?

Sorry for asking so many questions, we are trying to get a handle on how we should be billing for our new APRN.


----------



## dtricia (Apr 15, 2010)

*Incident to*

If you bill that injection with a 99211 it will bundle with the injection.  In Medicare Part B issue 260 it states, " If the sole purpose of a visit to the physician's office is to draw blook or receive an injection, then 99211 should not be billed and only the appropriate injection or blood drawing code should be billed.
There are two pages of clarification about when to bill 99211.
But I know your nurse cannot bill anything but 99211 no matter how long her education runs.  We have the same scenario in our infusion room.  The nurses educate about chemo and that is all we can bill.....till we get our NP.


----------



## Colliemom (Apr 15, 2010)

> But I know your nurse cannot bill anything but 99211 no matter how long her education runs. We have the same scenario in our infusion room. The nurses educate about chemo and that is all we can bill.....till we get our NP.



Ktricia,

Thanks for responding!  But I'm not sure I'm clear on your response - 
She isn't just an RN, but an APRN, our understanding is that this enables her to provide the same services that a PA would provide/bill.  She is considered an NPP.  Are we incorrect?  If a PA is conducting an established patient visit he/she can bill 99211 - 99215, so wouldn't an APRN also be able to bill those other levels?


----------



## dtricia (Apr 15, 2010)

*Incident TO*

I apologize.  I am not familiar with the scope of practice for APRN.  I just saw RN and made an assumption.


----------



## Colliemom (Apr 15, 2010)

That's ok, and I appreciate your input.  This is our first APRN with the practice, and she is taking over the injections from one of our physicians so we want to make sure we are submitting her billing correctly.


----------



## LLovett (Apr 15, 2010)

Is she credentialed with your payers? I am not familiar with this type of provider either but as with all new providers, you can't get paid for anything until they are credentialed.

If it is the same as a PA, coverage will vary with the different payers as well. So that is something that has to be looked into on a payer level.

Good luck,


Laura, CPC, CPMA, CEMC


----------



## Colliemom (Apr 16, 2010)

thanks Laura.  We are working on credentialing her, and most of the payers who credential the PA's will credential an APRN.


----------



## RebeccaWoodward* (Apr 16, 2010)

In speaking with my guru colleagues, I picked their brain just to confirm my hunch.  An APRN is a generic term for RN's who have gone on to become one of several types of advanced nurses; Certified Nurse Midwife, Certified Registered Nurse Anesthetist, Nurse Practitioner, etc.  Depending on what specific type of advanced practice nurse they are will, more than likely, influence the answer to your question.


----------



## Colliemom (Apr 16, 2010)

She is a nurse practitioner.


----------



## Colliemom (Apr 19, 2010)

If it makes it easier, you can subsititute the word APRN for PA - since that seems to be causing some confusion.  Our APRN can perform all the same services that our PA can perform.  What we really need to know is if it would be appropriate to bill the visit _*and*_ the injection as "incident to." 

So - In your opinion, 

Would it be appropriate to bill an established patient office visit, 99215, for a patient coming in to learn how to perform his/her own injections where our NPP is spending 45 minutes teaching the patient?

Would it be appropriate to bill the office visit AND the injection as "incident to" since the NPP is following the plan of care set up by the physician?  Or should the office visit be billed as "incident to" and the injection billed under the NPP alone?

(See my original post for a more detailed explanation)


----------



## LLovett (Apr 19, 2010)

Personally, I would not bill an office visit for this service at all. I would look at 98960.

I see no reason, assuming all incident to requirements are met, as to why you wouldn't bill both services as incident to.

Laura, CPC, CPMA, CEMC


----------



## Colliemom (Apr 19, 2010)

Laura,

We have considered using the 98960, but we discovered that a lot of our carriers are not reimbursing for that code.  (We actually contacted a few of our carriers on this issue.)  

But thanks for the input on the "incident to" issue, as that was my thinking also.  As "Incident to" refers to *services*, it doesn't specify only office visits, so I was thinking we could bill the injections along with the office visits as "incident to."  I just wanted to see if I was correct in my interpretation of the guidelines and also to see if anyone else is coding for these services.

Kat


----------

