Otolaryngology Coding Alert

Question: One of our nonphysician practitioners saw a patient during a follow-up visit -- what is required in order for us to report these services to Medicare as incident to the ENT?

Florida Subscriber

Answer: To qualify for incident to, the physician must have seen the Medicare patient during a prior visit and established a clear plan of care. If the nonphysician practitioner (NPP) is treating a new problem for the patient, or if the ENT has not established a care plan for the patient, then you cannot report the visit incident to.

Important: When meeting the requirements for a follow-up to an established plan of care, if the ENT does not directly supervise the NPP, the incident-to rules do not apply. Direct supervision means a supervising physician must be immediately available in the office suite. The supervising physician, however, does not necessarily need to be the same physician that established the patient's care plan.

Example: An established Medicare patient reports to the ENT on May 10. The doctor performs an E/M service,diagnoses the patient with allergic rhinitis (477), writes prescriptions and, as part of plan of care, asks the patient to return in one week to follow up with the nurse practitioner. On May 17, the patient returns to the office for a follow-up visit. The NPP evaluates the patient's signs and symptoms and performs an examination. The NPP recommends continuing with the prescribed medication and returning for follow up in one month.

In this example, you can report the NPP's service incident to the ENT. On the claim, report the appropriate level E/M code. Don't forget to file the claim under the supervising physician's national provider identifier (NPI) rather than the NPP's NPI; this ensures you 100 percent pay for the E/M, while coding under the NPP's NPI results in 85 percent pay for the service.

Best bet: Check your state and local Medicare regulations for NPP qualifications and credentials for billing incident-to. If the NPP does not meet one or both sets of guidelines, don't bill incident-to for her services.

Warning: Do not assume that private payers and your state's Medicaid follow Medicare's incident-to rules. For instance, Kansas Medicaid does not recognize incident-to billing of NPPs.