Pediatric Coding Alert

Nurse practitioners (NPs) are very useful to pediatric practices. They can relieve the pediatrician of much of the routine work, freeing him or her up to spend more time with complicated cases. And, bringing in an NP is more affordable than hiring another pediatrician.

But, Medicare has figured this out, as have a few state Medicaid programs. Medicare will only pay for the services of an NP at 85 percent of the physicians fee schedule , or 80 percent of the usual and customary reimbursement (UCR). Pediatricians generally dont deal with Medicare, so this isnt a problem.

However, commercial plans are also starting to reimburse NPs at less than what the pediatrician getsin one notorious case in Virginia, at only 60 percent.

In addition to the reimbursement problems, some practices are wondering if they should be using a modifier when the NP provides services. Susanne Seaman, practice manager for Pediatric and Adolescent Medicine, a six-pediatrician, one-nurse practitioner practice in New York City and Hartsdale, NY, had heard that she was supposed to use a modifier for her pediatric nurse practitioner. However, I cannot find a relevant modifier code, she says.

The answer is that there is no modifier for NPs. As of 1998, an NP can have his or her own provider number, explains Nancy Hinchcliffe, lead reimbursement educator at United Medical Associates in Johnson City, NY. The NP can bill under his or her own identification number under Medicare, notes Hinchcliffe. If the physician is on site and supervising, the NP can bill under the physicians number.

Instead of using a modifier, as Hinchcliffe says, the pediatric NP may use an identification number from the state for Medicaid and other third-party payers.

Medicaid and Private Plans

But a few states dont recognize the services of NPs, says Debra Hardy Havens, Washington representative for the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP). In these states, the NP would not be able to use an identification number, even for Medicaid.
But in most cases, state Medicaid pays for NPs. There is no federal legislation for Medicaid or private plans regarding NPs, says Havens. Its just for Medicare. So, in the majority of states that license NPs, Medicaid assigns an identification number for eachand reimburses them at 100 percent, says Havens.

Private plans are a different story. Some want NPs to submit their claims as if the pediatrician provided the services. Some have tried to take NPs off panels. Some simply refuse to pay for NPs.

In Pennsylvania, says Havens, one plan requires physicians (including pediatricians) and their associated nurse practitioners to follow stricter incident to rules similar to Medicare regulations. Under this plans rules, a nurse practitioner can only treat the patient every third visit, the physician has to be on site, and in the building when the services are being provided, and the physician has to do the initial evaluation of a new patient, explains Havens.

Its a big problem, says Havens. Some practices are refusing to deal with plans that dont reimburse nurse practitioners at a reasonable rate.

But, most NPs are simply billing under the pediatricians name, says Hinchcliffe. If the NP isnt using his or her own identification number, this is probably the best solution.