Pain Management Coding Alert

Question: An established Medicare patient with a plan of care in place to treat a chronic knee injury reports to the PM specialist for an evaluation and management (E/M) service. Dr. X initially diagnosed the patient and initiated the plan of care. During this E/M visit, however, Dr. X is not in the office suite. The nonphysician practitioner (NPP) performs a level-three E/M for the patient, with Dr. Y providing all the necessary supervision and guidance to code incident-to the physician.

Can I report the E/M incident-to the physician? And if I can, which physician's National Provider Identifier (NPI) should I report the service under?

Kentucky Subscriber

Answer: As long as Dr. Y provides all of the necessary supervision required to report incident-to, then you can report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) for the service. In order to snag full reimbursement for the code, report the service using Dr. Y's NPI. (If you report the same E/M under the NPP's NPI, you'll only garner 85 percent of the code value.)

This issue often comes up when reporting incident-to services, since the plan of care initiator doesn't always see the patient for every E/M issue that arises during the course of treatment. In your situation, it would be incorrect to report the E/M incident-to Dr. X, since she didn't provide any supervision for this particular encounter.

Remember: If there is no "direct supervision" by a physician, the NPP cannot bill incident-to even if she is following an established plan of care. If you have more than one physician in your practice and none are in the office suite when the NPP renders the E/M, you would report 99212 using the NPP's NPI.

Also, keep in mind that incident-to guidelines were developed by Medicare, and other insurance carriers do not necessarily follow Medicare's lead. It is important to check with third-party payers to ascertain if they follow Medicare's incident-to guidelines, or they have their own rules regarding NPPs performing services incident-to the physician.

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