General Surgery Coding Alert

Question: Two providers (one a surgeon and the other a nurse practitioner [NP]) worked together to remove a patients lesion. Because the NP usually does not do stitches, the surgeon was there to instruct him. They both turned in a charge ticket for 11403. Which provider should I bill under?

Missouri Subscriber

Answer: If your NP provided the majority of the work for the surgical procedure (removing the lesion and stitching the wound under the surgeons guidance), you could file the claim for 11403 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; lesion diameter 2.1 to 3.0 cm]) two ways, depending on payer policies.

For maximum reimbursement, you should file this as an "incident-to" claim under the physicians personal identification number (PIN). Medicare defines incident-to as services or supplies furnished as an integral, although incidental, part of the physicians personal professional services in the course of a diagnosis or treatment of an injury or illness. Although the physician is present in the examining room in this case, the physician does not have to be in the room with the NP just somewhere in the office suite for an incident-to claim to be filed. The incident-to claim is filed as if the doctor performed the service, and reimbursement is 100 percent of the Physician Fee Schedule.

Your other alternative is to file under the nurse practitioners PIN if the payer recognizes the services of nonphysician practitioners. Be sure to check payer guidelines, because requirements for NP reporting vary.

Answers to You Be the Coder and Reader Questions were provided by Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J; and Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb.