Dermatology Coding Alert

Sharing services can pay off - especially with Medicare

Grasping state- or carrier-specific rules that regulate nonphysician practitioners (NPPs) can be tricky for any dermatology practice.

Follow our three easy steps to keep track of who, what, when and where you need to report shared services and nail your NPP billing every time.

Step 1: Learn What Services NPPs Can Provide

Medicare guidelines do not restrict the types of care PAs and NPs can provide - but state practice laws may, says William J. Conner, MD, founder of Conner Health Clinic, a multispecialty practice in Charlotte, N.C.

A lot of different NPPs might be eligible to provide incident-to services, as long as they have been trained correctly, Conner says.

Remember: NPPs can be a medical assistant (MA), registered nurse (RN), physician assistant (PA), certified nursing specialist (CNS) or nurse practitioner (NP) - among others, Conner says.

Clarification: "Proper training" for all incident-to services stipulates that these providers be enrolled in Medicare with a valid PIN and have a state license, coding experts say.

The work that incident-to service providers perform in lieu of the dermatologist depends on their area of expertise.

In a dermatology practice, most MAs and RNs typically provide educational services and administer injections, while higher-level E/M work and minor procedures are provided by CNSs and PAs, experts say.

Example: A PA at your dermatology practice sees an established patient who is being treated for a skin infection (686.9, Skin infection).

The dermatologist has seen this patient in the recent past and has established the diagnosis and initiated treatment or a care plan.

The PA performs a follow-up history and examination and continues the prescribed treatment.

Coding solution: The PA bills an established patient office visit, most likely 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...), using the dermatologist's name and number. Medicare should reimburse your practice 100 percent of the physician's global fee, Conner says.
 
Tip: As long as the patient is not new or undergoing status change, and the dermatologist is in the office suite, the PA can provide the service and the office can use the dermatologist's PIN when filing with Medicare.

Warning: Never report incident-to services in a hospital setting, either outpatient, inpatient, or in the emergency department, because Medicare forbids it.

Update: CMS now specifies that the ordering physician in a group practice who wrote the plan of care doesn't need to be present in the office suite for the NPP to see the physician's patient and follow the established plan of care.

But another physician in the group must be present in the office suite to supervise, says Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J. Previously, carriers assumed that the physician who ordered incident-to services also had to supervise them, she says.

In the instance above, with this CMS clarification, as long as one of the dermatologists in the practice is on-site to provide guidance to the PA, you shouldn't have any problems with your carriers.

Step 2: Follow Medicare Supervision Guidelines

You can save a lot of time working on denials if you nail down the supervision guidelines from the very start.

Physician supervision applies to diagnostic tests, such as allergy testing. The National Physician Fee Schedule uses numbers to indicate the supervision level an NPP must meet when she performs a service or procedure.

Diagnostic test guidelines include three levels of supervision: