Gastroenterology Coding Alert

'Supervising physician' does not have to be the plan author

Most gastroenterology coders may have missed out on a rule that makes it a little easier to report NPP services: Did you know that Medicare permits reporting incident-to services provided by an NPP under a supervising physician other than the physician who authored the    care plan?

In a gastroenterology office, coders have to apply the rules of incident-to billing for nonphysician practitioners (NPPs) all the time - especially if your gastroenterologist treats patients with conditions requiring extended plans of care. But many coders have questions about this.

To clear up confusion about the rule for billing incident-to, CMS was compelled to release a clarification on incident-to billing when an NPP follows a plan of care for a physician who isn't present in the office.

Change Will Affect Some Long-Term Gastro Coding

While gastroenterologists can use NPPs in several capacities in a gastro office, they "are very important to the care of hepatitis patients. They can perform the follow-up visits, as well as the patient education," says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.

In addition to hepatitis patients, gastro offices are likely to use NPPs to provide incident-to services for patients with Crohn's disease or ulcerative colitis, Parks says.

If you're not aware of the contents of a recent CMS statement explaining the rules on coding incident-to for a physician who isn't present in the office, your office's policy on incident-to reporting may be askew. Read on for an explanation of the CMS clarification, as well as some expert input on how your gastroenterology practices can put this information to good (and profitable) use.

Supervising Physician Not Always Plan Author

In September 2004, Medicare released a statement explaining its rule on supervising physicians and NPPs. The statement basically reported that another member of the same physician group can supervise an NPP who is following the plan of care of a physician who isn't present in the office.

Explanation: This clarification means that the supervising physician does not have to be the physician who originally authored the plan of care, says Shannon O. Smith, CRTT, CPC, consultant auditor with Doctors Management in Knoxville, Tenn.

Therefore, you can certainly bill for your NPPs' services when the plan-of-care author does not supervise - as long as there is another qualified supervising physician on hand.

Example: Gastro A is the plan-of-care author for Patient X, who has Crohn's disease. One Monday, Patient X reports for a follow-up visit. Gastro A is away at the hospital, but Gastro B is in the office suite and available should the need arise.

The NPP takes a blood sample from Patient X, answers several questions and performs some counseling to calm the patient's anxiety about the care plan. The entire visit takes 12 minutes.

On your claim, you should report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) incident-to Gastro B.

Remember: You must report 99212 incident-to Gastro B, not Gastro A; you must report the service incident-to the physician who is in the building. You should also remember to report under the same group PIN as Gastro A, and must have signed a form 855R reassigning his right to bill to the group, Parks says.

On the claim, identify the supervising physician (Gastro B) "in 2310B loop" and list his PIN in REF02 and the IC qualifier in REF01, CMS instructs.

Heads-up: When there's no "suite of rooms" in the office, the supervising physician must actually be in the same room as the supervised provider, the CMS transmittal states.

Reporting Incident-to Diagnostics Now Prohibited

CMS also recently inserted into the manual its new interpretation that providers cannot report diagnostic tests on an incident-to basis, because these tests have their own benefit category. This interpretation has proved controversial because it means gastros in a group practice can't receive their share of reimbursement for diagnostic tests their NPPs order.