Internal Medicine Coding Alert

NP Visits and New Problems

Question: One of our nurse practitioners (NP) is conducting an evaluation for a patient with uncontrolled type II diabetes who has an established plan of care. During the exam, the patient complains of pain in his left index finger. The NP examines the finger, which is bruised and slightly sprained, and "buddy tapes" it to the patient's middle finger. Two questions: Is the buddy taping considered a strapping procedure, and can we bill this visit incident-to the physician?

Connecticut Subscriber

Answer: For both of your questions, the answer is no.

Incident-to issue: In the scenario you describe, you cannot report the visit incident-to the physician; bill it under the NP's provider identification number (PIN).

Though the NP treated an established patient with a plan of care in place, she also treated the patient for a new problem (finger pain). In order for this visit to be considered incident-to, the NP must follow an established plan of care for the entire encounter, but a care plan had not been established to address the patient's finger pain.

Buddy taping issue: Whenever a healthcare provider performs buddy taping (taping one injured finger to another finger for added support), it is considered an E/M service. You should not report a casting/strapping code from the 29000 series.

Best bet: Review the physician's documentation, and code the entire visit with a single E/M code under the NP's PIN. So if the notes support level-four service for the E/M, report the following:

• 99214 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; moderate medical decision- making) for the E/M.

• 250.02 (Diabetes mellitus without mention of complication; type II or unspecified type, uncontrolled) linked to the E/M code to represent the uncontrolled diabetes.

• 842.10 (Sprains and strains of hand; unspecified site) linked to 99214 to represent the patient's finger pain.