EM Coding Alert

Can you code incident-to for acute issues? Read on to find out.

We’ve gotten a number of queries recently regarding how to code E/M services that advanced practice nurses (APNs) provide. Coders want to know where these valuable providers stand in terms of incident-to and shared visit coding — because they know if they don’t, they’ll risk undercoding the APNs’ services.

And undercoding APN services can chip away at your bottom line significantly, especially if you employ a lot of these professionals. One reader who checked in with us about how to code for APNs said she had 18 on staff.

Note: Depending on the specifics of the encounter, the following rules and guidelines might also apply to services provides by:

• physician assistants (PAs),
• certified nurse specialists (CNSs),
• midwives,
• and several other types of providers under the “nonphysician practitioner” (NPP) umbrella.

In some circles, NPPs might be referred to as mid-level providers (MLPs) or physician extenders (PEs).

Whether you’ve got 1 or 1,000 APNs on staff, you’ll want to do right by them in your coding. We asked Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, of ACE Med Group in Pittsburgh, Pa., to weigh in on some of the big questions readers have about APNs:

Background
We have 18 APNs in our family practice clinics and code incident-to when appropriate for APNs seeing follow-up visit patients. We recently added a walk-in clinic to see patients needing follow-up exams for medication maintenance, etc., and acute care needs when their regular provider’s schedule is full. We have two APNs and one physician working daily in the walk-in clinic.

Question 1
If an established patient is seen in the walk-in clinic for an acute problem — for example, flu — can we bill incident-to for the APN if he/she has the physician assess the patient and document his findings in the medical record, or is this considered a shared visit? 

Hauptman
“Interesting question. It is important to understand what a shared/split visit is; both providers must write independent notes, and the physician then needs to link to the APN’s note for a shared visit.

“Next, in order to bill as a shared/split visit, we would need to know what type of clinic this is. If it is a hospital clinic, then the shared/split could apply. If it is a physician practice clinic, by definition, the shared rue would not apply. If the clinic is a POS [place of service] 22 [On Campus-Outpatient hospital], then the shared/split might be an option if both the physician and the APN see the patient.”

Question 2
Can an APN bill Medicare incident-to for acute problems, since the plan of care would change?

Hauptman
“Normally, the answer is no. If the patient is presenting with a new problem — one that has not been assessed by a physician yet — then the service must be billed directly under the APN’s NPI [national provider identifier] number. If a treatment plan for the acute issue was established a few days ago and the patient is still having the problem, then it is an established patient visit for an established problem, and incident-to could apply.

“But, if you are using the term ‘acute’ to mean the first time [the provider is] seeing the issue, then incident to would not apply, and the service would need to be billed directly under the APN’s NPI.”

Question
We have two house-call teams who go to patient homes along with their LPN [licensed practical nurse] to see patients with chronic problems unable to come to the physician’s office. They also see patients within 48 hours of their hospital discharges to help avoid readmissions. Although the APNs work under the supervision of the physician and the physician determines the initial care plan, can the visit be coded incident-to since the physician is not present at the home visit?

Hauptman
“Unless the physician goes to the house with the APN, the home visits are not reportable as incident-to. In reviewing the incident-to rules, there needs to be an established course of treatment. Another rule is that the physician must be physically available in the office suite, or area [of treatment], at the time the APN renders the service.

“Thus, the visits you describe do not qualify for incident-to. These should be billed directly under the APN’s NPI. These are certainly reimbursable, and with only a 15 percent discount.

“Also, your patients are getting terrific care, and your team is running at a great efficiency rate!”

(Have a question you’d like answered? Email chrisb@codinginstitute.com with your query!)