Internal Medicine Coding Alert

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

Missouri Subscriber

Answer: It appears from your description that the NP performed most of the work, removing the lesion and then stitching the wound under the doctor's guidance. You could file the claim for 11403 (Excision, benign lesion, 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, file as an "incident-to" claim under the physician's provider identification number (PIN). Medicare defines incident-to as services or supplies furnished as an integral, although incidental, part of the physician's 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 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 practitioner's PIN if the payer recognizes the services of nonphysician practitioners. Medicare and most Medicaid plans recognize NPs and other nonphysician practitioners, while many commercial payers do not. Reimbursement will be less, however. When you file the claim under the NP's PIN, you are reimbursed at 85 percent of the Physician Fee Schedule.