Otolaryngology Coding Alert

Can a nonphysician request consults? The answer may surprise you

You might think you-ve got nonphysician practitioner (NPP) coding down pat, but the regulations change so frequently that you should test your skills from time to time. Take a few minutes to challenge yourself with our NPP coding quiz and make sure you-re on the right track.

Established Patient, New Problem: Is It Incident-To?

Question 1: Your nurse practitioner (NP) meets with an established patient to replace the patient's surgical dressing, which got wet during a boat trip. When the NP removes the wet dressing, he discovers a deep skin infection that formed under it.

The otolaryngologist is in the suite but is unable to come into the examining room to evaluate the new problem, so the NP debrides the wound and gives the patient an antibiotic prescription. Can you bill the visit incident-to, or should you bill it under the NP's provider identification number (PIN)?

Answer 1: -This visit must be billed under the NP's number and is not an incident-to visit,- says Ron L. Nelson, PA-C, president of Health Services Associates in Fremont, Mich., and past president of the American Academy of Physician Assistants. -This is clear-cut, and based upon the regulations it would require the billing to be under the NP's number,- he says.

Here's why: Even though the NP saw an established patient, the visit doesn't qualify as incident-to because the physician should see the patient for any new problems. If the NP addresses the skin infection (a new problem) without the physician's input, the NP should bill the visit using his own PIN.

The incident-to guidelines require the physician to see any new patients or any new problems that the patient has. Your NP can still bill the visit, but he must do so using his own identification number.

Can an NPP Base the E/M Level on Time Spent?

Question 2: A patient who was diagnosed with cholesteatoma three weeks ago reports for a follow-up visit. The physician assistant (PA) draws blood for lab work and talks to the patient about her severe anxiety, lack of sleep and depression since she was diagnosed. The discussion takes 15 minutes, and the total visit takes 26 minutes. Which level of E/M service is it appropriate to report?
 
Answer 2: During E/M visits in which the PA must provide a lot of extra counseling to a patient, you may be able to determine the E/M level based on time -- if counseling and/or coordination of care dominated the encounter time and you properly document the visit. On your claim, you should:

- report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) for the office visit based on time.

- link ICD-9 code 385.33 (Cholesteatoma of middle ear and mastoid) to indicate the patient's cholesteatoma. 

- link 300.00 (Anxiety state, unspecified) to indicate the patient's anxiety. 

- link 780.5x (Sleep disturbances) to indicate that the patient had trouble sleeping.

Documentation and diagnosis coding will be vital to this claim's success. Make sure you have a detailed description of the PA's encounter with the patient before you send the claim.
 
Your claim must reflect the reasons that you-re reporting a level-four code when it appears that the PA provided a lower-level service. Otherwise, the claim could be rejected.

Best bet: Before filing this claim, make sure you can answer -Yes- to both of these questions:

1. Does the documentation detail what the NPP discussed with the patient? There must be some record of exactly what the PA talked about with the patient, so the payer can decide whether the PA was counseling or coordinating care.

2. Was the visit dominated by counseling/coordination of care time? Payers consider encounters to be counseling-dominated when more than 50 percent of the total time is devoted to counseling and care coordination. Remember that the physician should always document the total time of the visit, as well as the time that he spent counseling the patient.

If you answered -No- to either of these questions, you should not base the level of E/M service on time. Instead of 99214, you would report the E/M code based on the documented history, exam and medical decision-making, and the underlying medical necessity.
 
Can the NPP Request/Perform Consults?

Question 3: A physician assistant from a local allergy practice asks your otolaryngologist to evaluate a patient with nasal obstruction and who he suspects may have a deviated septum contributing to the problem. Can you bill a consult when the request comes from a PA, not from a physician?

Answer 3: Yes. -According to Medicare guidelines, nonphysician practitioners can request consults and can perform consults under certain circumstances,- says Stephen Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Patient Care.

In black and white: Section 15506 of the Medicare Carriers Manual states, -Nonphysician practitioners, e.g., nurse practitioners, certified nurse-midwives or physician assistants, may request a consultation. They may also perform other medically necessary services, e.g., consultations when the performance is within the scope of practice for that type of nonphysician practitioner in the state in which they practice. Applicable collaboration and general supervision rules apply as well as billing rules.-

In addition, CPT's guidelines state that a consultation can be requested -by a physician or other appropriate source.-

If your surgeon performs a consult that an NPP requested, remember to send a letter to the requesting NPP that details your physician's findings following his examination of the patient.

Do Private Payers Follow Incident-to Rules?

Question 4: Do other insurers allow practices to report their NPP's services incident-to?

Answer 4: You may not have to adhere to Medicare's strict incident-to guidelines for all insurers. In some states, no other insurers follow Medicare's incident-to rules. Some private insurers allow you to bill incident-to even when the physician is not in the same state. To ethically optimize reimbursement, you should know the patient's insurer and its rules and have them in writing.

Watch out: To bill a service incident-to for Medicare, the NPP must perform the service while the otolaryngologist is in the office suite. And always make sure you get all incident-to guidelines in writing from private payers, since many of them have their own rules.