Otolaryngology Coding Alert

Know Which Services Your NPs Can Report

Published on Sat Jan 01, 2005

Ask payers about direct versus personal supervision for allergy tests

When your allergist involves nurse practitioners (NPs) and other ancillary staff in allergy diagnosis or treatment services, you'll need to know what level of physician supervision your carrier requires to avoid denials and audits.

Physician Supervision Doesn't Equal Incident-To

The office jump-start: A physician wants an NP to administer allergy shots before the physician arrives in the morning. "May an NP perform such procedures when the doctor isn't on the premises, if the doctor ordered the service?" a subscriber asks.

Taking advantage of this extra scheduling depends on the patient's insurer. Insurance companies almost entirely dictate testing supervision and incident-to criteria, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, health information management certificate programs coordinator at Clarkson College in Omaha, Neb. "Medicare's rules are the most stringent." Private payers may allow non-physician practitioners (NPPs) to provide more services without direct physician supervision.

Strategy: Find out what each insurer requires and remember to keep the guidelines separate. "Do not confuse supervision rules with incident-to rules," says Jean Ryan-Niemackl, LPN, CPC, an application support specialist for QuadraMed in Fargo, N.D. "They are simply not the same."

Follow Medicare Supervision Guidelines

Physician supervision applies to diagnostic tests, such as allergy testing. The National Physician Fee Schedule (NPFS) uses numbers to indicate the supervision level an NPP must meet when she performs a service or procedure. Diagnostic test guidelines include three levels of supervision:

General: The NPP may furnish the service under the physician's overall direction and control, but the physician doesn't have to be present.

Direct: The physician must be present in the office suite and immediately available to furnish assistance and direction throughout the procedure's performance. The physician does not have to be present in the room where the NPP performs the procedure or service.

Personal: The physician must be in the room during the procedure.

Method: Although the above stringent supervision levels are Medicare's, experts recommend following them for all insurers. "Coders should check the Medicare guidelines for each type of diagnostic test that their office performs to make sure they meet the test's supervision requirements," Bucknam says.

Take Advantage of Incident-to Variations

But you don't have to adhere to strict incident-to guidelines for all insurers. "In Nebraska, no other insurers follow Medicare's incident-to rules," Bucknam says. Private insurers allow you to bill incident-to even when the physician is not in the same state.

Benefit: To ethically maximize reimbursement, you should know the patient's insurer and its rules.

Watch out: To bill a service incident-to Medicare, the provider must perform the service while the physician is in the office suite.

Allergy Tests Require Supervision

Both physician supervision requirements and incident-to rules apply to allergy testing, which are diagnostic tests, says Lynn M. Anderanin, CPC, senior coding consultant for Health Information Services in Des Plaines, Ill.

Allergy tests require either direct or personal supervision (in case the patient has an anaphylactic reaction to a test). Codes 95004, 95024, 95027, 95028, 95044, 95052, 95056, 95070 and 95071 require direct supervision, whereas 95060 and 95065 require personal supervision.

Allergy shots (95115-95180), however, are not diagnostic tests. When an NPP administers them, you should follow the insurer's incident-to guidelines.