Pediatric Coding Alert

Don't let your staff attend school conferences unless they can bill independently, or your practice will be left footing the bill.

With the creation of the new nonphysician team conference codes, Pediatric Coding Alert "offered the 'idea' to have a nurse attend an off-site IEP in place of the physician," says Jen Krohn, CPC, CCP, coding specialist, at Waukesha Health Care Inc.-in Wisconsin. Unfortunately, the suggestion comes with a snag: What code and what name would you bill the service under, and would it have to meet incident-to guidelines? Krohn asks.

This instructional education program (IEP) code hang-up calls for an incident-to primer.

For a nonphysician to directly report a service, she must have a national provider identifier (NPI). Not all nonphysicians are eligible for an NPI. "A nurse (RN) or respiratory therapist (RT) cannot bill a service under her NPI because she is not eligible to have one," says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

Option: You would instead have to have an NPI- credentialed nonphysician attend an off-site IEP. For instance, Medicare allows nurse practitioners to register for an NPI.

Example: A nurse practitioner who has an NPI attends an off-site IEP in lieu of a pediatrician. The nurse practitioner should report the nonphysician team conference code under her NPI.

For a team conference that the parent(s) and/or patient attend, the nurse practitioner would report 99366 (Medical team conference with interdisciplinary team of healthcare professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified healthcare professional). If the patient and/or family does not attend, she would report 99368 (... patient and/or family not present ...).

Nonphysicians who are restricted from NPI status may report their services incident-to the physician -- if the encounter meets certain criteria. "Medicare incident-to rules require 'direct physician supervision,' " says Becky Dolan, health policy analyst with the American Academy of Pediatrics (AAP). In the case of an off-site team conference that a nonphysician provides when the physician is in the office, there is no direct supervision, she says.

Reporting the off-site service using the physician's NPI would incorrectly imply that either the pediatrician provided the service or a nonphysician performed it incident-to. (Remember: Incident-to services are blind on a claim -- there is no way to label them as nonphysician- performed.) Because the physician did not provide direct supervision, the service would not meet incident-to criteria, making this method improper.

Incident-to is a Medicare concept. CPT contains no language indicating that direct supervision is necessary when reporting a team conference code, Tuck says. Nor does CPT restrict team conferences to an office setting.

If a payer doesn't follow incident-to guidelines and the nonphysician's role in the off-site team conference meets your state scope-of-practice laws, you'll still find a hiccup when completing the payer-required CMS-1500 form. What do you enter in the NPI box (26J Rendering Provider ID Number)? If you use the physician's name with 99366 or 99368, he appears to provide the service, which is inaccurate.

Your best timesaver is to have an NPI nonphysician, such as a nurse practitioner (NP) or physician assistant (PA), attend conferences. She can report off-site services with 99366 or 99368, depending on whether the visit involves the patient and/or parents.

Alternative: If you bring the team conference on-site and the parent(s) and/or patient attend, you should report a new or established patient office visit (99201-99215). You can use the office visit codes to represent an NP or PA service provided incident-to the pediatrician. This claim would appear as though the physician attended the conference face-to-face.