Anesthesia Coding Alert

Question: We employ a nurse practitioner (NP) at our office to assist our pain management specialist. When she provides supervised services, should we append modifier SA? Our insurer just denied a claim because we didn’t include it; we’ve never heard of it.

Iowa Subscriber

Answer: You should use HCPCS Level II modifier SA (Nurse practitioner rendering service in collaboration with a physician) for supervised nurse practitioner services when the insurer requires the modifier.

For instance, some Medicaid programs require you to apply modifier SA to all nurse practitioner (NP) services you code under the physician’s national provider identifier (NPI) — also known as incident-to coding.

Knowing when to use modifier SA is vital if you want the NP’s services to be paid incident-to the physician. When the NP is supervising the performance of a service without the collaboration of the physician, however, you would not report modifier SA. In your example, it is not clearly indicated if the physician is present and supervising the NP.

Example: A nurse practitioner provides a level-two established patient office E/M to a Medicaid patient. The physician supervises the service. To indicate the NP provided the office visit under direct supervision, you would append modifier SA to 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making…).

The mod­ifier tells the insurer that the NP rather than the physician provided the service and the physician supervised the NP. Incident-to services are paid at 100 percent of the Medicare Physician Fee Schedule amount.