Internal Medicine Coding Alert

Question: A 70-year-old male patient makes an appointment for an initial visit with an 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 our NP one week later to discuss any adverse reactions to the insulin. Should I bill the NP's service incident-to the physician?


Georgia Subscriber


Answer: 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 personal identification number (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. Medicare will pay the visit at 100 percent because you billed 99211-99215 under the internist's PIN.

Be careful: If the internist didn't establish a plan of care for this patient's medical problems, the example wouldn't satisfy Medicare's incident-to guidelines.
 
Suppose the same patient in the above example scheduled an initial visit with the internist but called the office a few days before his appointment, complaining about chest pains. A heavy schedule prohibits the internist from treating the patient, so the NP sees him instead. Your NP performs an electrocardiogram (ECG).

You should bill this encounter under the NP's PIN. Report 93000 (Electrocardiogram, routine ECG ...) for the ECG and 786.50 (Chest pain, unspecified) for the symptom that led to the ECG. Expect Medicare to pay the nurse practitioner's services at 85 percent of the physician's rate.

Tip: When you code 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 and institute a plan of care--and then the NP can follow up with the patient.