Otolaryngology Coding Alert

If you know whose identification number -- the nonphysician practitioner's (NPP) or the allergist's -- you should bill under, you can ethically maximize your Medicare revenue.

You should report the service "incident-to" the allergist and claim 100 percent payment, the equivalent of an extra $8 for CPT 99213, when the in-office encounter meets these criteria:

To bill an NPPservice under your allergist's name, the same group must employ both parties. Both the supervising physician and the performing NPPmust be employees, leased employees or under contract with the same group, says Dennis Grindle, CPA, a partner in healthcare consulting at Seim, Johnson, Sestak & Quist LLPin Omaha, Neb.

You cannot bill a service incident-to unless your physician previously treated the patient. "This rule automatically excludes you from billing incident-to for new patient encounters," says Emily Hill, PAC, president of Hill & Associates, a consulting firm in Wilmington, N.C.

Action: If your NPPtreats a new patient, you should bill the service under the NPP's personal identification number (PIN). Medicare will pay the claim at 85 percent of the dollar amount assigned to the particular code.

Illustration: Anurse practitioner (NP) treats a new vacationing senior citizen for difficulty breathing at the beach. The NPdiagnoses effects from red tide, a local algae toxin, and recommends that the woman stay away from the water and take Benadryl as necessary.

You should report 99201-99205 (Office or other outpatient visit for the evaluation of a new patient ...) linked to 786.05 (Shortness of breath) under the NP's number. The allergist has not previously treated the patient. If the allergist first saw the patient in the red tide example, you'd add almost $10 to a 99202 claim. You could bill 99202, for instance, at 100 percent or $64.60 for Medicare. When you bill under the NPP's PIN, Medicare will pay the office visit at $54.91 -- a difference of $9.69.

You should also bill the service under the NPP's number when she treats an established patient's new problem. Keep in mind that the allergist must establish the initial diagnosis and prepare the treatment plan before you can report the service under the NPP's number.

Example: Your allergist previously diagnosed a 35-year-old established male patient with extrinsic allergic alveolitis (EAA) and created a treatment plan for his condition. The patient presents today to an NPPfor an EAAcheck. The allergist is present in the office suite. In this case, you should report the appropriate established patient office visit code (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) with 495.x (Extrinsic allergic alveolitis) under the allergist's PIN. The allergist has seen the patient, has provided a diagnosis for the condition, and has been previously involved in the treatment plan.

Make sure documentation reflects your allergist's ongoing involvement in incident-to cases. Medicare and most private payers require your allergist to provide an active role in the patient's ongoing care. Your allergist must provide services frequently enough so that they reflect his continuing active participation and management of the treatment, says Hill, who presented the teleconference "Proven E/M Documentation and Coding Strategies for NPPs" for The Coding Institute in Naples, Fla.

Look for carriers'interpretations of the ongoing-care requirement. "Some Medicare carriers require the physician to provide one out of every three encounters," Hill says.

To bill a service incident-to, your allergist must be present in the office suite. That means the physician is immediately available, such as on the same floor, to help, Hill says.

Another way: When your allergist doesn't provide direct supervision, bill the service under the NPP's number if your state permits NPPs to provide the service.

Reminder: Report service incident-to the on-duty allergist. If an NPPprovides a service to Dr. A's patient, but Dr. B is present, bill the service incident-to Dr. B, Hill says. Ask "Who is providing the required level of supervision?" Grindle adds. Because Physician B is the supervising doctor, you should bill using that identification number, he says.

You try: Aphysician assistant (PA) treats off-duty Dr. A's asthma patient for wheezing. The PAadministers a nebulizer treatment while Dr. B is in the office suite. You should report 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) linked to 493.02 (Extrinsic asthma; with [acute] exacerbation) incident-to Dr. B. He provides direct supervision, not the patient's off-duty physician. Medicare will reimburse the procedure at 100 percent or $12.70 instead of at 85 percent or $10.79.

Note: To obtain a CD, tape or transcript of Hill's teleconference, call The Coding Institute at (800) 508-2582 or visit www.codinginstitute.com.