Internal Medicine Coding Alert

Question: How should I code incident-to when I am in the office? What modifier should I use when I am not in the office when the NP sees a patient by herself?


Colorado Subscriber

Answer: Provider identification numbers (PINs), not modifiers, tell insurers about an encounter's performer/supervisor. To indicate that a service meets Medicare's incident-to criteria, you should report the service using the internist's PIN. The claim is blind as to whether an NP or an internist performed the service, so carriers pay the claim at 100 percent. Remember: Incident-to implies the nurse practitioner (NP) provided the services under a physician's "direct supervision" following an established plan of care.

When an NP performs a service without an internist's direct supervision, following an established treatment plan or evaluating a new problem or complaint, you instead report the code under the NP's PIN. You should use the same codes as you would under incident-to.

Scenario: A 68-year-old female has an initial visit with Dr. Smith to evaluate the patient's emphysema, 492.0 (Emphysematous bleb). The internist schedules the patient to come in for a nebulizer treatment the following week, and is present in the office when the NP provides the treatment.

In this case, because the NP carried out a treatment plan under an internist's direct supervision, you should bill the NP's services as incident-to under Dr. Smith's PIN. 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. Offices may bill for the inhalation drug using J7613 (Albuterol, inhalation solution, administered through DME, unit dose, 1 mg).

If, however, the NP performed the treatment while the internist is on rounds at the hospital, you must bill this encounter under the NP's PIN. Because the internist did not provide direct supervision, the procedure does not meet Medicare's incident-to requirements. Be careful: Before providing services absent direct supervision, make sure your state scope-of-practice and licensure laws permit doing so.

You may be confusing teaching facility supervision with physician supervision. In a teaching facility, you indicate the TP's involvement with these modifiers:

• GC--This service has been performed in part by a resident under the direction of a teaching physician

• GE--This service has been performed by a resident without the presence of a teaching physician under the primary-care exception

• GR--This service was provided in whole or in part by a resident in a Department of Veterans Affairs medical center or clinic, supervised in accordance with VA policy.