Otolaryngology Coding Alert

Keep an eye on these federal and state guidelines.

Like most otolaryngology practices throughout the country, your practice or facility probably relies on the services of an advance practice provider (APP) such as a nurse practitioner (NP) or physician assistant (PA). However, how do you know if you are fully utilizing your APP’s role within the practice?

That’s the question posed by Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh. “The scope of an APP’s practice is often larger than a practice, facility, or payer will allow,” Hauptman observes, adding that this means APPs can not only ease scheduling burdens for busy practices but also help boost their bottom lines.

But, before taking the appropriate steps to fully maximize your APP’s potential within the practice, there’s a few points you need to know.

What Is an APP?

APPs come in all sorts of roles, such as physician assistants (PAs), certified registered nurse practitioners (CRNPs), or clinical nurse specialists (CNS).

To add to the alphabet soup, you might also refer to an APP by some other common acronyms, including NPP (nonphysician provider), LLP (limited license practitioner), or MLP (mid-level provider).

What Can an APP Do?

Hauptman identifies four ways APPs differ from other ancillary staff such as registered nurses (RNs), licensed practical nurses (LPNs), medical assistants (MAs), or technicians:

• APPs can bill for their own services and may be able to provide services independent of another provider.
• They can be credentialed by Medicare and have their own National Provider Identifier (NPI) number.
• They can have prescriptive authority if their state scope of license allows.
• They can supervise ancillary personnel.
• Their scope of practice is larger than ancillary personnel.

In an ENT setting, Hauptman continues, APPs may also:

• Perform any evaluation and management (E/M) service and do some procedures in the office, such as diagnostic endoscopies and removal of impacted cerumen.
• Have their own clinic schedules.
• Work with any type of patient, including new and postoperative.
• Provide emergent care.
• Provide patient education.

These services, however, are contingent not only on federal but also state regulations.

FYI: You should know about the Society of Physician Assistants in Otorhinolaryngology-Head and Neck (SPAO-HNS). The SPAO-HNS is the official specialty organization for Physician Assistants in ENT and is recognized by both the American Academy of Physician Assistants (AAPA) and the American Academy of Otolaryngology - Head & Neck Surgery (AAO-HNS). Physician Assistants who are members of the SPAO-HNS are trained specifically in Otolaryngology/Head and Neck care and procedures. More information about SPAO-HNS can be found at www.ENTPA.org.

What Is the Best Way to Bill for APP Services?

This is where it gets tricky, as there are times when a practice may find it advantageous to bill under the APP’s NPI number and times when it should bill for the APP’s services incident-to a supervising physician.

“Most often,”  Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC, points out, the advantage of “an incident-to billing arrangement lies in the difference in the rate of payment to nonphysician providers [NPP]. Incident-to billing,” Blanchard goes on, “is frequently paid at a significantly higher rate than services billed by an independently credentialed NPP.”

In fact, Medicare and payers that follow Medicare guidelines will reimburse 100 percent for incident-to services, whereas Medicare, various Blue plans, and some other commercial carriers will only allow reimbursement at 85 percent of the physician fee schedule if the APP bills for services under his or her own NPI.

However, Blanchard warns, “adhering to CMS requirements, on which many Medicare carriers base their agreements, can be difficult to do in outpatient general settings.” The national requirements for incident-to services include the following stipulations for APPs:

• “Services must be part of your patient's normal course of treatment;
• “Services must be performed in a physician's office, not in an institutional setting (facility outpatient or outpatient);
• “A physician personally performed an initial service and remains actively involved in the course of treatment" (in other words, the services cannot be for a new patient or a new problem; and
• “The physician is "present in the office suite to render assistance, if necessary.” If you are in a group practice, CMS allows “any physician member of the group [to] be present in the office to supervise” (Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf).

But this is just the tip of the regulatory iceberg. In addition to federal guidelines, Blanchard goes on to note that some state regulations also define the APP’s scope of practice and may also require APPs “to be employed by the clinician directing the care and may require the clinician to document an order for the service rendered, which means the APP cannot work with new patients or new problems.” Some states require co-signatures by the physician on some APP documentation, depending on the type of APP that provides the service. (For a comprehensive overview of the rules and regulations governing APP services by state, go to: https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment).

What Do Non-Medicare Payers Say?

In addition to federal and state regulations, practices must also know which non-Medicare payers follow Medicare’s incident-to rules exactly as written. The good news is that Hauptman’s research notes that many insurances, including Blue Shield, Highmark, various managed care products, PA Medical Assistance, United, Cigna, Aetna, and a number of local plans “all have very similar rules regarding incident-to billing.” Note that Hauptman indicates that the non-Medicare payers’ incident-to rules are “similar” to Medicare’s rules. This means that you must go to each payer, outline their requirements, and manage those differences so that the practice does not bill out an APP service incident-to when the rules set by the payer have not been met.

Even though Pennsylvania’s Medicaid follows rules similar to Medicare’s incident-to, do not assume that your state follows Medicare’s incident-to rules because they are partly federally funded. Each state set of rules should be viewed under an independent lens from other states. For instance, some states do not allow any incident-to billing and require all APPs to bill using their own NPI numbers. This is because it allows them to pay less for services provided by APPs. Kansas, for example, does not allow incident-to services and pays services billed out under the APPs NPI at 75 percent of the fee schedule. This saves the Kansas Medicaid program 25 percent on all services provided by APPs to Kansas Medicaid patients. Make sure you check with your state’s Medicaid program to determine how their rules may vary from those mentioned above.

Hauptman next makes the pertinent point that certain payers do not allow APPs to bill directly, under their own NPI. Those that do, Hauptman notes, include Aetna, Health America, Cigna, and United in some states. Hauptman also suggests that practices inquire about policies enacted by other local payers such as Kaiser, UPMC, and Gelsinger. In short, this means practices need to contact their payers to help them determine how they should bill for APPs appropriately.

What Can an APP Do to Ease Scheduling and Increase Capacity?

Ultimately, however, Hauptman argues, depending on federal, state and payer regulations, if an APP can see any kind of patient, including new, established, postoperative, and consults, and bill separately for the services, your practice could benefit substantially even if the APP’s services are not reimbursed at a higher level.

Not only might your office be able to accommodate more patients, but your otolaryngologist may also be free of the burden of supervising the services performed by the APP and having to take care of the paperwork associated with them. And these are all good reasons for your practice to consider reevaluating your APP’s contribution to the scope of your ENT services.