Ophthalmology and Optometry Coding Alert

Answer 1: You should report an established patient  visit, depending on the level of service--most likely a 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) or 99213--under your physician's name and PIN/NPI. You'll be paid 100 percent of the E/M code's fee.

Because the patient had a plan of care and is not new or undergoing status change and the physician is in the office suite, the NP can provide the service and you can use the physician PIN/NPI, filing the services incident-to the physician with Medicare.

Answer 2: No. Never report incident-to services in a hospital setting, either outpatient, inpatient or in the emergency department. Medicare only allows billing incident-to in the physician's office. But you may be able to report this hospital visit as a shared visit if the physician also sees the patient in the hospital on the same day, verifies the progress notes written by the NPP, notates his review and adds comments on any changes, additions or new information, plus provides some portion of the E/M service face-to-face with the patient.

Experts recommend the physician perform the "heart and lungs" examination (even if it was already done by the NPP). If the shared visit meets these criteria, you may report the service under the physician's name and PIN/NPI.

Answer 3: No. In this example, the patient is new to your office and received treatment for a new problem, meaning the NPP was not following an established care plan. Therefore, you should report the encounter using the NPP's UPIN/NPI. Anytime the NPP sees a new patient independently for a new problem, you should code for the service with her UPIN/NPI.

Tip: Even if the patient is established, if the NPP saw her for treatment for a new problem, meaning the NPP was not following an established care, you should report the encounter using the NPP's UPIN/NPI.

Anytime the NPP sees an established patient independently for a new problem, you should code for the service with the NPP's UPIN/NPI.

Answer 4: You can't report this service as incident- to. To bill an E/M service as  incident-to the physician, you must also be sure that the NPP provided the service under the "direct supervision" of a physician.

To meet "direct supervision" requirements, the physician must be present in the office suite and immediately available to render assistance if necessary. However, the physician does not have to be physically present in the exam room with the NPP and the supervising physician does not have to be the same one who established the patient's plan of care. If the supervising physician is different from the ordering physician, you should report the service with the supervising physician's name and UPIN/NPI.

Double-Check Private-Payer Rules

Keep in mind that although Medicare very specifically spells out its rules for NPP billing, private payers do not necessarily provide the physician their rules. You should ask your private payers to provide you their procedures are for billing NPP services in writing.

Caution: Remember that you can only bill Medicare for NPP services if they are permitted within the NPP's state license. Make sure you know what your state allows your NPPs to do within the practice so that your NPPs do not overstep their scope of practice.
 
Answers reviewed by Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.