Gastroenterology Coding Alert

Coders who are not on the lookout for incident-to billing opportunities are costing their practices deserved reimbursement.

Impact: If a qualified nonphysician practitioner (NPP) provides a service to a Medicare patient incident-to the physician, then you can report the visit under the gastroenterologist's national provider identifier (NPI), netting you 100 percent pay for the service; when you bill under the NPP's NPI, you'll receive 85 percent of the full rate. Use this incident-to coding know-how and nail every opportunity to bill under the gastroenterologist's NPI.

Before you bill a service incident-to your gastroenterologist, check for two things:

1. In order to code an encounter incident-to, Medicarerequires that a qualified NPP work under "direct supervision" of a gastroenterologist, confirms Melissa Briggs, CPC, who works in coding and compliance at Cotton O'Neil Clinic in Topeka, Kan. The physician must be in-suite -- same floor, same office -- and directly available to see the patient if needed.

2. You can code incident-to the physician only when the NPP treats an established Medicare patient with a plan of care (POC) in place; this POC must also be the reason for the encounter. If the NPP addresses a new problem during the visit, then you cannot bill incident-to.

Example: The NPP provides a level-three E/M service to an established Medicare patient with a plan of care in place for his gastroesophageal reflux disease (GERD). The visit is a check-up to see how the patient is responding to GERD treatments and how she might fare with other options. During the encounter, Dr. G. is in the next room reviewing patient records.

Money-maker: Since the encounter meets the supervision and POC requirements, you can garner 100 percent pay, rather than losing $10 for direct billing.For the above instance, you can code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) with 530.81 (Esophageal reflux) appended under Dr. G's NPI. This will net the practice about $62 (1.70 transitioned nonfacility relative value units [RVUs] multiplied by the 2009 Medicare conversion rate of 36.0666). Using the NPP's NPI, the same visit would pay about $52.

Bill incident-to only for NPPs who have the credentials to perform the services, stresses Sharlene Scott, CPC, CPC-H, CCS-P, CCP-P, PMCC, instructor with Coding Academy of America/American Coding Centers in Baltimore. The NPP could be a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) -- as long as the NPP meets state and federal guidelines to report incident-to. The NPP must be "licensed by the state under various programs to assist or act in the place of the physician," according to the Medicare Benefit Policy Manual, Chapter 15.

Warning: Make sure that the supervising physician "is an approved supervisor/collaborator under the State Scope of Practice law," says Quinten A. Buechner, MS, MDiv, CPC, ACS-FP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. If one of the providers fails to meet credentialing requirements, then you cannot report an encounter incident-to the physician.

This does not mean, however, that the POC physician has to be the incident-to supervisor, says Briggs.

Example: An NP is treating a patient, and Dr. G is the supervising physician. The NPP, however, is following Dr. T's treatment plan for the patient's GERD, and Dr. G. is not present during the treatment. You can still bill the visit incident-to, using Dr. G's NPI since he supervised the encounter.

To protect your incident-to coding, Buechner says you might want to have the POC gastroenterologist include a brief authorizing statement confirming that:

• the patient has a POC for a condition

• it is acceptable for the patient to see the NPP for subsequent visits.

In order to do this, the gastroenterologist must remember to include the note when he performs the initial work-up and establishes a POC for the patient.

Example: Dr. G confirms a diagnosis of GERD for a patient and formulates a treatment plan. In the notes, he writes: "Established care plan for patient's GERD. NPP can treat patient on routine follow-ups."

This step is not necessary, but "this type of documentation would not be discouraged," Briggs says.