Cardiology Coding Alert

Although the clinics operate under the medical direction of one or more cardiologists (or other physicians, such as endocrinologists), patients will most likely regularly encounter an NPP when visiting the clinic.

From a coding and reimbursement standpoint, all NPPs are not equal. Although any NPP can bill in the physician's name (assuming Medicare's incident-to guidelines are met and the NPP is permitted under state law to perform the service), PAs, NPs and CNSs are the only NPPs who can bill under their own names and report an established patient visit at a level higher than 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician).

This means that the NPPs most frequently encountered in the lipid clinic RNs, LPNs and dietitians can bill only 99211, regardless of the time they spend with the patient.

Although 99211 is typically used for minimal services such as checking vital signs, in the case of lipid clinics it is the only code that nurses or dietitians can use for patient education and counseling. They should also use it to bill for a blood pressure check or reviewing a lipid profile.

Medical technicians can also provide such services at the lipid clinic if there is "direct personal supervision" by a physician. Medicare defines physician direct personal supervision in section 2050.1 of the Medicare Carriers Manual: "Direct personal supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services."

The patient's chart should indicate that the physician was in the office when the services were provided. If no physician is present, you may not bill services as incident to. That means that if an NPP other than an NP, a, PA or a CNS performed the service, it may not be billed. When you bill incident-to, you should use the name of the physician who is in the suite, not the patient's regular physician.

But if the patient sees an NP, a PA or a CNS, you may be able to bill 99212, 99213 or even 99214 (Office or other outpatient visit ...) if the NP, PA or CNS bills under his or her own name, says Stacey Elliot, CPC, a cardiology coding and reimbursement specialist in Los Angeles. "If the state's scope-of-practice laws permit the NP, PA or CNS to perform the service," you can use the NPP's personal identification number (PIN), she says.

If a nurse (LPN or RN) sees the patient to draw blood only and does not provide any counseling, 99211 may be billed only if a legitimate E/M service (such as taking the patient's vital signs or changing the patient's medication) is documented. However, if the patient visits the clinic and sees a nurse (or a dietitian) after visiting the cardiologist on the same day, you may not bill for a nurse visit because it would be billing under the cardiologist's name, and physicians may not bill for two E/M services on the same day, Cox says.

In addition to counseling, clinics often measure cholesterol. Although most patients will have had a cholesterol test, some will not, and even those who have had the test may need remeasuring.

Although both CPT and HCPCS include codes for drawing blood for the test (CPT 36415*, Routine venipuncture or finger/heel/ear stick for collection of specimen[s]; HCPCS G0001, Routine venipuncture for collection of specimen[s]), Medicare carriers and most private payers do not reimburse this service, Elliott says.

But the actual lab work is payable and should be reported as 80061 (Lipid panel). According to CPT, for you to bill this code, the panel must include the following: