EM Coding Alert

Question: A pediatrician in my practice ordered a mother to return with her child for follow-up visit on his tuberculosis test. An NPP checks the immunization site and records her observation. How should I code the service?

Utah Subscriber

Answer: You should report a code from the 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) range, depending of which level of service your non-physician practitioner’s (NPP’s) documentation supports. 

You can submit the office visit code under the physician’s name and national provider identifier (NPI) as long as the service meets the incident-to criteria. The NPP must be under the direct supervision of a physician. If the criteria are met, Medicare should reimburse you the full amount of the E/M service. The documentation will be your guide as to which code is most appropriate. If the documentation is limited to a check of the immunization site, 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services) is likely your best bet.

Bottom line: If you can’t meet the criteria for reporting incident-to, you can still bill the visit under the NPP’s own NPI, and expect 85 percent reimbursement.