Pediatric Coding Alert

Don’t take appeals at face value--research before you write off.

It happens to every coder at least once: You bill a claim in your normal fashion, and are stumped when an unexpected denial comes back to you. When this happens, you may need to take a multi-step approach to remedying the claim—and even if you can’t recoup your charges this time, you’ll know how handle future, similar claims to ensure that you collect what you deserve.

Case in point: A subscriber wrote to report that she billed a claim to her insurer with a physician’s assistant (PA) listed on the claim as the provider. The secondary insurer denied the claim since they do not recognize PAs. She wondered whether she can change the original claim billing provider (the PA) to the supervising physician (MD) and submit to the secondary insurance carrier, or whether that would appear fraudulent.

Expert insight: Determining how to rectify this issue involves a multi-pronged process, advises Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. The following steps will help you figure out how to handle this type of denial.

Step 1: Get the Regs in Writing

“I recommend contacting the secondary provider and finding out their rules for mid-level providers,” Cobuzzi says. “We cannot assume that non-Medicare payers follow Medicare’s written incident to guidelines and their rules for billing mid-level providers. This includes your state’s Medicaid, which may have its own rule set,” she adds.

“There is a good chance, (but not definitive) that the PA was billed under his or her own number because incident to rules for supervision and/ or established plan of care were not met,” Cobuzzi says. “The provider needs to find out in writing whether the secondary provider will allow the PA to be billed incident to if those conditions have not been met, and make it clear that they could bill under the PA’s NPI under these conditions.”

Step 2: Check Internal Policies

Some practices bill their mid-level providers’ services under their own NPIs all the time, no matter whether they meet the incident to requirements or not, Cobuzzi says. “In this case, if the secondary payer pays for the mid-level provider only if supervision and plan of care requirements are met, then you can only bill the PA by changing the provider to the supervising provider and submitting it to the secondary if the mid-level met the incident to requirements.”

If, however, the payer does not require supervision and/or the plan of care to be met, the provider can be changed no matter the conditions under which the mid-level provided the care, Cobuzzi adds. In this case, keep in mind that the secondary payer may not be able to process the claim under the supervising doctor if the initial EOB is listed under the mid-level provider.

Step 3: Face the Music

If the secondary payer cannot process the adjusted claim because they cannot reconcile the supervising NPI on the claim to the mid-level provider’s NPI on the EOB, or if conditions are such that you can’t submit the secondary claim under the mid-level provider’s NPI, you will end up eating the balance owed, unfortunately, Cobuzzi says.

Step 4: Prepare for the Future

If you’ve had to eat the cost of such a visit, consider your lesson learned, but don’t let it happen again. Going forward, get your primary and secondary payer policies in writing, and keep a notebook showing which payers will allow claims with mid-level providers such as PAs and nurse practitioners as the provider of service, and which will allow incident to claims. Keep copies of each payer’s incident to requirements so you can refer to them for all types of practitioners, including dietitians and therapists, as well as other mid-level providers.