Part B Insider (Multispecialty) Coding Alert

Published on Sat Aug 26, 2006 PDF

Don't let a doctor duplicate an NPPs decision-making, carrier warns

Can nurse practitioners and physician assistants bill for consults, initial inpatient visits and critical care? Yes, as long as the hospital and the state licensure authority both allow it, says Cigna Healthcare in a new set of answers to frequently asked questions (FAQs) for providers.

These non-physician practitioners must have the -background training and education to support the high-complexity work and medical decision-making included in codes such as critical care and the higher levels of consultations and initial visits,- explains Cigna.

Watch out: But for consults, the consulting physician or NPPs must have specialist knowledge outside the requesting physician's area, Cigna cautions. -We have seen instances when patients are referred to a specialty practice for consultations that are then done by NPPs ... who then refer the patient to a physician in the same group for a therapeutic procedure.- And then that physician performs a pre-procedure consult. This raises the question of -why multiple consults were necessary,- Cigna warns.

-As a consultation may include the initiation of diagnostic and/or therapeutic services, it would seem appropriate that the consult be done by a practitioner who has the expertise to do this--which further raises the question if the NPP who did the initial consult was truly -qualified- for performing consultations,- Cigna adds.

Don-t: So if you have an NPP perform a consult, you should make sure a physician doesn't later duplicate the decision the NPP supposedly made in that consult.

Separately, Cigna also says ancillary staff, including NPPs, can document some of a patient's history (such as review of systems or past family and social history) in a new patient visit and still bill under the physician's billing number. But you can't bill under the physician's billing number if the ancillary staff performs other components, such as examination or medical decision-making. You must meet the -incident-to- criteria to bill under the physician's billing number.

Finally, Cigna says that an initial hospital visit can be billed as a split/shared visit between a physician and an NPP--but only if the patient is an established patient of the group practice. If the patient is new to the group practice, Cigna would expect the physician would provide -the entire encounter- in the initial visit.

More Carrier Answers

-  Can you bill 99211 when a nurse reviews test results and discusses a patient's medication with the physician, then telephones the patient to give a medication dose change? No, because 99211 is only for face-to-face services, says Arkansas Medicare.

- Can you bill for prolonged services if the reason for the extended time was that the patient needed an interpreter? Yes, as long as the total face-to-face time was 55 minutes or longer and the service was medically necessary, says Palmetto GBA. The patient's inability to communicate is a valid reason for prolonged care.

- If a patient is in observation status for longer than 48 hours, how do you bill for physician visits? You should use the outpatient/office visit codes, says Palmetto. But this situation may be viewed as -not medically necessary- because -five to six days is a very long time to be in observation,- Palmetto warns.

- Does Medicare cover Nesiritide for an asymptomatic patient? No, says Mutual of Omaha. Medicare only covers Nesiritide for -patients presenting to the hospital with acutely decompensated congestive heart failure who have dyspnea at rest.-