Otolaryngology Coding Alert

You can protect your ENTs from incident-to paybacks for follow-up nurse practitioner (NP) and physician assistant (PA) services if initial documentation includes "F/U NPP" -- or the nonphysician provider (NPP) uses her number.

Although CMS rescinded its incident-to Transmittal 87 stating carriers will not pay for services incident to a physician's service unless there is documentation authorizing the incident-to service, your best bet may be to incorporate the changes. "I think CMS still intends that physicians must authorize a nurse practitioner or physician assistant to provide follow-up services," says Hugh Aaron, MHA, JD, CPC, CPC-H, presenter at the 2008 American Academy of Professional Coders National Conference in Orlando.

The change: For private payers that follow CMS- incident-to coverage requirements, an auditor could request repayment on NPP services when the physician's initial plan of care fails to mention that an NP or PA may provide follow-up care.

CMS pays a covered NPP office service reported under a physician's NPI at 100 percent when the encounter meets these three existing criteria and possibly one new criterion:

1. The NP or PA treats an established problem. An ENT with the same tax identification number must first treat the patient for that condition or illness and create a care plan.

2. A physician provides an active role in the continued management of that condition or illness. "CMS has no set time period for how long in between episodes the physician must re-treat the patient for the carrier to still consider the physician's role as active," Aaron says.

3. The physician must provide direct supervision. Although an NP or PA subject to state law may treat a patient without a physician on site, CMS requires a physician be in the office suite to bill a covered office service incident to the physician, Aaron notes.

4. Now CMS may also require that the physician indicate he approves an NPP to provide follow-up services. For instance, if an ENT diagnoses a new patient with an upper respiratory infection (for instance, 465.8, Acute upper respiratory infections of other multiple site with 99203, Office or other outpatient visit for the evaluation and management of a new patient -) and wants the group's NP to be able to provide medication checks, the otolaryngologist must authorize this in the initial treatment note. "To cover your incident-to pay, the best bet is for the physician in the initial service to make a brief authorizing statement," Aaron says.

Notation in the chart note could read, "F/U NPP." "Such a notation on the charge ticket would not count," notes Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. The charge ticket does not remain part of the clinical chart, and is instead part of the financial chart.

Out: When an NPP provides an E/M service that falls short of incident-to, you do not have to forego payment. Instead, report the service under the NP's NPI, Aaron suggests.