Pediatric Coding Alert

But understand federal and state regulations before you do.

If, like many pediatric practices across the country, your practice employs an advance practice provider (APP), are you using that provider in the best possible way to ensure your practice runs smoothly and profitably?

That's the question posed by Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh. "The scope of an APP's practice is often larger than a facility or payer will allow," Hauptman recently observed, adding that this means APPs can not only ease scheduling burdens for busy practices but also help boost their bottom lines.

But before your practice can reap the full benefits of these valuable additions to your professional staff, there's a few things you should know.

What Is an APP?

APPs come in all sorts of roles, such as physician assistants (PAs), certified registered nurse practitioners (CRNPs), or clinical nurse specialists (CNS). Your peds practice may also employ a clinical social worker (CSW, or LCSW) or a clinical psychologist (CP), both of which would fall under the APP banner.

To add to the alphabet soup, you might also refer to an APP by some other common acronyms, including NPP (nonphysician provider), LLP (limited license practitioner), or MLP (mid-level provider).

What Can an APP Do?

Hauptman identifies four ways APPs differ from other ancillary staff such as registered nurses (RNs), licensed practical nurses (LPNs), medical assistants (MAs), or technicians:

• APPs can bill for their own services and may be able to provide services independent of another provider.
• They have prescriptive authority.
• They can supervise ancillary personnel.
• Their scope of practice is larger than ancillary personnel.

In a pediatric setting, Hauptman continues, APPs may also

• Perform any evaluation and management (E/M) service.
• Have their own clinic schedules.
• Can work with any type of patient, including new and postoperative.
• Provide emergent care.
• Provide patient education.

These services, however, are contingent not only on federal but also state regulations.

What Is the Best Way to Bill for APP Services?

This is where it gets tricky, as there are times when a practice may find it advantageous to bill under the APP's National Provider Identifier (NPI) number and times when it should bill for the APP's services incident-to a supervising physician.

"Most often," Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC, points out, the advantage of "an incident-to billing arrangement lies in the difference in the rate of payment to nonphysician providers [NPP]. Incident-to billing," Blanchard goes on, "is frequently paid at a significantly higher rate than services billed by an independently credentialed NPP."

In fact, Medicare and payers that follow Medicare guidelines will reimburse 100 percent for incident-to services, whereas Medicare, various Blue plans, and some other commercial carriers will only allow reimbursement at 85 percent of the physician fee schedule if the APP bills for services under his or her own NPI.

However, Blanchard warns, "adhering to CMS requirements, on which many carriers base their agreements, can be difficult to do in outpatient general pediatrics." The national requirements for incident-to services include the following stipulations for APPs:

• "Services must be part of your patient's normal course of treatment";
• Services must be performed in a physician's office, not in an institutional setting;
• "A physician personally performed an initial service and remains actively involved in the course of treatment" (in other words, the services cannot be for a new patient or a new problem; and
• The physician is "present in the office suite to render assistance, if necessary." If you are in a group practice, CMS allows "any physician member of the group [to] be present in the office to supervise" (Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf).

But this is just the tip of the regulatory iceberg. In addition to federal guidelines, Blanchard goes on to note that some state regulations also define the APP's scope of practice and may also require APPs "to be employed by the clinician directing the care and may require the clinician to document an order for the service rendered, which means the APP cannot work with new patients or new problems" (For a comprehensive overview of the rules and regulations governing APP services by state, go to https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment).

What Do Commercial Payers Say?

In addition to federal and state regulations, practices must also know which commercial payers follow them. The good news is that Hauptman's research notes that many insurances, including Blue Shield, Highmark, various managed care products, Medical Assistance, United, Cigna, Aetna, and a number of local plans "all have very similar rules regarding incident-to billing."

However, Hauptman points out the bad news that certain payers do not allow APPs to bill directly. Those that do, Hauptman notes, include Aetna, Health America, Cigna, and United in some states. Hauptman also suggests that practices inquire about policies enacted by other local payers such as Kaiser, UPMC, and Gelsinger. In short, this means practices need to contact their payers to help them determine how they should bill for APPs appropriately.

What Can an APP Do to Ease Scheduling and Increase Capacity?

Ultimately, however, Hauptman argues, depending on federal, state and payer regulations, if an APP can see any kind of patient, including new, established, postoperative, and consults, and bill separately for the services, your practice could benefit substantially even if the APP's services are not reimbursed at a higher level. Not only might your office be able to accommodate more patients, but your pediatrician may also be free of the burden of supervising the services performed by the APP and having to take care of the paperwork associated with them. And these are all good reasons for your practice to consider reevaluating your APP's contribution to the scope of your pediatric services.