Pain Management Coding Alert

Question: The physician saw a new patient for evaluation in the hospital outpatient setting. He determined that trigger point injections were needed and the PA performed the procedure. Can we bill for both services? Since I can’t bill “incident to” in place of service (POS) 22, can I bill separate claims for the two providers?

Oregon Subscriber 

Answer: Yes, you can bill both the services: a new patient office/outpatient visit and the appropriate code(s) for trigger point injection on the same date of service under the physician’s name. You’ll report the appropriate outpatient visit code from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components …). Then report the trigger point injections with 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) or 20553 (…single or multiple trigger point[s], 3 or more muscle[s]), based on the number of muscles the PA injected.  

However, you will not report the care as “incident-to” for two reasons. First, you can only report incident-to services for Medicare in the physician’s office, not a hospital outpatient department. Second, before billing incident-to for the NPP (non-physician practitioner), the physician must have seen the patient first at a previous encounter and established the plan of care. Services provided to a new patient or an established patient with a new health care problem may never be billed to Medicare as incident-to a physician service on the same day of diagnosis. If an NPP sees a new patient or assesses an established patient for a new problem, report that service under the NPP’s provider number, not the physician’s. Additionally the physician must be in the office suite when the services are performed and must stay involved with the patient’s care. According to Medicare rules, the services provided by the NPP must be within his or her scope of practice as mandated in the state where the practice is located.

In your scenario, the physician and PA can bill the services they provided separately under their respective NPI numbers.