Pediatric Coding Alert

Private payers may implement these Medicare incident-to requirements Want to capture an additional 15 percent reimbursement when a nonphysician practitioner (NPP) performs an E/M service? Depending on the payer, you can if the service meets "incident-to" criteria. Studying private payers'various incident-to interpretations, however, can prove mind-boggling. You can more easily grasp incident-to coding if you learn Medicare's incident-to definitions and rules, which many third-party payers adopt. NPP Services Provide Reimbursement Option When an NPP performs an E/M service, you have two options: You may either report the office visit under the individual's own personal identification number (PIN) or report under the supervising pediatrician's PIN. Watch out: Not all staff qualify as NPPs. Alicensed NPP, such as a nurse practitioner (NP), a physician assistant (PA), a clinical nurse specialist or a certified nurse midwife, may provide a higher-level E/M service without the pediatrician's direct supervision, says Richard H. Tuck, MD, FAAP, pediatrician at Primecare of Southeastern Ohio in Zanesville. If other auxiliary staff, such as a medical assistant (MA) or registered nurse, perform an E/M service, you must report the appropriate code incident-to the supervising pediatrician's PIN. Example 1: Suppose a pediatrician orders a mother to return with her child for follow-up on his tuberculosis test. An MAchecks the immunization site and records her observation. How should you code the service? You should report CPT 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...) because the MA performs a medically necessary and physician-ordered service. How should you file the claim? Submit the pediatrician's name in box 24 of the CMS-1500 form, says Dennis K. Grindle, CPA, a healthcare consultant at Seim, Johnson, Sestak & Quist LLPin Omaha, Neb. Because an MA performed the service under direct physician supervision, you don't have the option of billing under the MA's own PIN. What reimbursement will you receive? The insurer should pay you 100 percent of its allowable 99211 payment, or about $21.28. Medicare pays incident-to claims at 100 percent, Tuck says. Because you submit 99211 with the pediatrician's name, the payer doesn't know that another individual performed the service. "The provider is transparent," he says. Therefore, Medicare reimburses the E/M in full. Bottom line: Because Medicare doesn't reduce incident-to charges, you should always report an NPP's service under the pediatrician's PIN if the service meets incident-to criteria. The Pediatrician Must Initiate Treatment When you report a service under the pediatrician's PIN, the physician must first see the patient. "This rule doesn't mean that the pediatrician must treat the patient on the same day the NPP provides an E/M service," Grindle says. But before an NPP bills incident-to, the pediatrician must see the patient so she can [...]