Oncology & Hematology Coding Alert

... if a qualified supervising physician is on-site

Many oncology offices employ at least one, and sometimes several, nonphysician practitioners (NPPs). But even offices with a whole staff of NPPs may have missed out on a rule that can allow your office to report NPP services more frequently. 

Did you know? When an NPP provides services incident-to the physician, you can list two different doctors as the ordering and supervising physicians, says Jean Acevedo with Acevedo Consulting in Delray Beach, Fla.

Many oncology coders were unaware of this rule and decided to absorb the charges when the NPP performed a service for a patient whose plan-of-care author wasn't on-site. This course of action can cost offices reimbursement they are rightfully entitled to.

CMS has always allowed you to report NPP services when the plan author isn't available to supervise. But so many coders were misinterpreting this NPP rule that CMS released a clarification on incident-to billing when an NPP follows a plan of care for a physician who isn't present in the office.

Read on for an explanation of the CMS clarification, as well as some expert input on how your oncology practice can put this information to good (and profitable) use.

NPP Role Depends on Setting

The role of NPPs in an oncology practice varies by office, but they can be a huge boost for offices that treat patients with chemotherapy. "In our practice, the NPPs are a very important and integral part of the oncology team. The 'team' for an individual [chemotherapy] patient will consist of the MD, an NPP, and the registered nurse," says a compliance specialist in a large Boston practice.

Other NPP roles: NPPs can also provide other services incident-to the physician, such as patient education, follow-up visits, and some hydration and injection therapies.

For example: A patient undergoing chemotherapy for colon cancer reports to the office for a scheduled follow-up visit after his first round of chemo. Following the treatment plan author's (the physician's) written instructions, the NPP counsels the patient briefly and takes a blood sample for analysis.

On your claim, you should report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) incident-to the supervising physician.
 
Exception: In order to report an E/M service for the above scenario, the physician must have scheduled the patient for a medical service that did not require physician attendance. If the patient reported specifically for a blood draw, leave 99211 off the claim and report 36415 (Collection of venous blood by venipuncture) instead.

Transmittal Clarifies 'Supervising Physician'

To report this scenario properly, you should be aware of a September 2004 CMS transmittal, which stated that the supervising physician did not have to be the plan-of- care author for the patient. If your office uses an NPP to provide any services incident-to the physician, you'll want to note this CMS clarification.

Why bother? CMS issued the clarification so the agency can more closely track who the "supervising physician" really is. CMS is concerned that the NPPs are functioning without supervision and want the responsible physician's name and number for each service.

Plan Author Gone? Incident-to Still Possible

Medicare's clarification basically reported that another member of the same physician group can supervise an NPP who is following the plan of care of a physician who isn't present in the office.

Explanation: This clarification means that the supervising physician does not have to be the physician who originally authored the plan of care, says Shannon O. Smith, CRTT, CPC, consultant auditor with Doctors Management in Knoxville, Tenn.

Therefore, you can certainly bill for your NPPs' services when the plan-of-care author does not supervise - as long as another qualified supervising physician is  on hand. While this is good news, the clarification presents challenges for the coding staff - such as reporting the identification number of the individual physician responsible for supervising each service on the CMS 1500 claim line of the procedure supervised.

(For more information on reporting NPP services incident-to a physician who is not the plan-of-care author, see the article below, "Chemo Education Often Handled by NPP.")