Dermatology Coding Alert

Question: Should we consider time as a factor when billing for educational/counseling services that are provided by someone other than our dermatologist (such as a registered nurse or physician assistant)?

California Subscriber

Answer: You should consider time as a factor depending on the location of the service as well as the provider of the service. When someone other than the dermatologist in your practice provides services in your private practice, you should refer to "incident-to" guidelines. 

Incident-to service guidelines allow the dermatologist's staff to provide services to an established patient as an integral and incidental part of the plan of care established by the dermatologist. In incident-to services, the dermatologist reports the services under his name as if he had provided the services.
 
The dermatologist must be present in the office suite (without the need to be present in the room with the patient) during the time the clinician delivers the incident-to services.
 
In the office setting, only your dermatologist can consider time as a factor in selecting the appropriate code for reporting the incident-to visit (such as, 99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...). Other than the dermatologist, you should not consider anyone else's time in choosing the most appropriate code to report that the clinician provided counseling and/or coordination of care in the office.

Exception: If a clinician other than the dermatologist provides a patient service in a facility setting, you should consider time as a factor in choosing the most appropriate code if the clinician is Medicare-enrolled (that is, he must have a Medicare UPIN; such as a physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse).
 
You should consider the services provided by both the dermatologist and the non-physician practitioner (NPP) as a cumulative effort. If more than 50 percent of the total service involves counseling/coordination of care, you can bill the service using only the amount of time when selecting the visit level and corresponding code.

Don't miss: You must have documentation of the counseling time as well as the total visit time in the medical record (that is, 15 of 25 minutes spent counseling re: ...). You should select the visit level based on the total visit time (such as, 99214 = 25 minutes).

Answers to You Be the Coder and Reader Questions were reviewed by Linda Martien, CPC, CPC-H, National Healthcare Review in Woodland Hills, Calif.; and William J. Conner, MD, founder of Conner Health Clinic, a multispecialty practice in Charlotte, N.C.