Pediatric Coding Alert

If you automatically report under your NPP, you're costing your doc 15%.

Being able to report an "incident-to" service when a qualified non-physician practitioner (NPP) provides care means you can file the claim under the physician's National Provider Identifier (NPI) instead of the NPP's. That allows 100 percent reimbursement for the codes you submit instead of the usual 85 percent reimbursement for claims filed according to Medicare guidelines under the NPP's NPI. More private payers are adopting this same policy, so check with your payer and remember three things to ensure you're following guidelines correctly.

1. Check the Plan of Care

The first rule for incident-to billing is that the pediatrician must see the patient during an initial visit andestablish a clear plan of care. These care plans can address issues ranging from asthma (493.00, Extrinsic asthma; unspecified) to chronic serous otitis media (381.10,Chronic serous otitis media, simple or unspecified) to infant feeding problems (783.3, Feeding difficulties and mismanagement).

"In my mind, a plan of care is as simple as a child who's had one ear infection and has been counseled about possible recurrence, who then returns with ear pain and another infection," says Nancy Bishof, MD, a pediatrician in Lexington, Ken.

Two cautions: If the NPP treats a new problem for the patient or if the physician hasn't already established a care plan for the patient, you cannot report the visit as incidentto. You also cannot claim incident-to for an established patient who comes in for a new, unrelated condition. Report those visits with the appropriate E/M code 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) under the NPP's NPI because she is caring for an established patient with a new problem.

Your next step in coding and collecting for incident-to services is determining whether the patient's care involved "direct" physician supervision. If so, the pediatrician must be in the immediate area while the NPP performs the incident-to services.

Definition: Most payers have policies regarding the physician's presence during procedures, so check your local guidelines. Some payers (and practitioners) might believe that "present" encompasses the actual room with the patient, somewhere within the office, or even in the same building. Guidelines often include the distinction "and immediately available," however, so verify that yourinterpretation of a physician's presence falls within the payer's parameters.

Example 1: A nurse practitioner in your office performs a patient's physical exam and the physician calls by phone in to complete the history portion of the exam. You cannot bill the encounter as incident-to because the physician was not immediately available or providingdirect supervision.

Example 2: A nurse sees an infant for follow-up concerning neonatal hyperbilirubinemia (774.6, Unspecified fetal and neonatal jaundice). The pediatrician doesn't see the child because she is treating another patient. You can bill this encounter as incident-to because the physician was in the office.

If you still wonder whether the pediatrician is near enough to count a patient's care as incident-to, answer this question from Bishof: "Do you really want to risk a reaction, or the patient or parent passing out and getting hurt, with the doctor not close enough to help out?" If your answer is no, maybe billing incident-to for a particular encounter isn't your best bet.

Saying that the pediatrician was in the vicinity when you provide incident-to care is one thing; proving it can be another. Keep these final tips in mind to smooth your claims processing:

• Retain physician work schedules on file to prove they were present when incident-to services occurred.

• Train your NPPs to indicate physician presence on the top of their notes: "Dr. Smith in office supervising today." That documents who provided direct supervision right on the patient's note.

• Remember that the supervising physician can be different from the one who wrote the care plan. Include the initial evaluating physician's name and NPI on your claim when another physician provides supervision for subsequent office care.

Bottom line: Incident-to requires that your NPP sees the patient for a follow-up exam instead of a new complaint and that the physician is around in the building,according to Charles Scott, MD, FAAP, a pediatrician with Medford Pediatric and Adolescent Medicine in southern New Jersey. "Evaluation of a new problem or a service given independent of a physician in the office needs to be billed at the lower NPP rate."