Internal Medicine Coding Alert

How you can code your NP's services with confidence

If the term "incident-to" is a four-letter word to your ears, we have the information you need to code your nurse practitioner's (NP) services with confidence.
 
Medicare pays NPs' services at 85 percent of the physician's rate, but you can get paid at 100 percent when you bill them under the internist's personal identification number (PIN). But Medicare has specific criteria that an NP's services must meet before you can bill them incident-to.

Our experts can help you to break down Medicare's incident-to guidelines and spot the appropriate opportunities to get a physician-rate payment for your NP's services.

Tip #1: Locate Your Internist's Plan of Care

 When you're coding an NP's services, scan the patient's chart to determine whether the internist has seen him prior to his visit with the NP. Medicare's incident-to guidelines state that the physician must see the new patient, institute a plan of care and then the NP can follow up with the patient, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

Scenario A: A 70-year-old male patient makes an appointment for an initial visit with your internist to manage his uncontrolled type II diabetes and related peripheral circulatory disorders. After his initial visit with the internist, he has a follow-up appointment with your NP one week later to discuss any adverse reactions to the insulin.

What to do: Because the NP is carrying out the internist's established treatment plan, you can report the appropriate E/M code (99211-99215) under the physician's PIN for the follow-up. List ICD-9 code 250.72 (Diabetes mellitus; diabetes with peripheral circulatory disorders; type II or unspecified type, uncontrolled) to support the reason for the visit.

Scenario B: The same patient scheduled an initial visit with the internist, but called the office a few days before his appointment, complaining about chest pains. Because of a heavy schedule, the internist is unable to treat the patient and the NP sees him instead. Your NP performs an electrocardiogram (ECG).

Result: You must bill this encounter under the NP's PIN, says Carol Pohlig BSN, RN, CPC, a senior coding and education specialist at the University of Pennsylvania's department of medicine in Philadelphia. Because the physician didn't establish a plan of care for any of the patient's medical problems, this situation doesn't meet Medicare's incident-to guidelines, she says. Report code 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) for the ECG and 786.50 (Chest pain, unspecified) for the symptom that led to the ECG.

Tip #2: Get Straight Answers on 'Direct Supervision'

Another important incident-to billing requirement is that the NP must provide the services under a physician's "direct supervision." "Direct personal supervision in the office does not mean that the physician must be present in the same room with the NP," Falbo clarifies. Rather, your internist must be in the office suite and immediately available to provide assistance and direction to the NP, she says.

Do this: Tell your NPs to note which physician was present in the office while they performed their services on the patient's chart, Pohlig suggests. This will save you from looking through schedules to find which physician was present for supervision, she says.

When the physician who supervises the NP's services isn't the same internist who ordered the initial services or laid out the patient's treatment plan, you might be confused about whose PIN you should bill under. Despite CMS' flip-flopping guidance on this subject, our experts say that you should always bill under the supervising physician's PIN.

Scenario C: A 68-year-old patient has an initial visit with Dr. Jones to evaluate her emphysema 492.0 (Emphysematous bleb). He schedules her to come in for a nebulizer treatment the following week. Dr. Jones is on vacation the day of the patient's appointment with the NP, but Dr. Smith is present in the office suite.

In this case, you would still bill the NP's services as incident-to - but under Dr. Smith's PIN, Pohlig says. Report 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) for the nebulizer treatment. You can bill for the inhalation drug using J7613 (Albuterol, inhalation solution, administered through DME, unit dose, 1 mg).

Snag: If no physician is present in the office during the patient's visit with the NP - or the internist is only present during part of the visit - you must bill the visit under the NP's PIN, Pohlig says.

Tip #3: Watch Out for Incident-To's Hidden Traps

A patient's initial visit with your internist and direct supervision may not be enough to meet Medicare's incident-to guidelines, experts say. You must look to the patient's chart to detect any not-so-obvious pitfalls.

Scenario D: While an internist is present in the office suite, a patient sees the NP for a blood pressure check and to re-evaluate his hypertension 401.9 (Essential hypertension, unspecified) as a part of an established treatment plan. During the visit, the patient asks for a hepatitis A and hepatitis B vaccination and the NP gives him the shot.

Even though the original reason for the visit followed the internist's established course of care, you cannot bill the visit incident-to because the nurse gave the patient the hepatitis vaccine without a previous direct order from the internist.

Code it this way: Report the appropriate E/M code (99211-99215) for the hypertension re-evaluation. Then, report 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the vaccine administration and 90636 (Hepatitis A and hepatitis B vaccine [HepA-HepB], adult dosage, for intramuscular use) for the vaccine itself. Bill this claim under the NP's PIN.