Pediatric Coding Alert

Your pediatricians won't have to pay back money for follow-up nurse practitioner (NP) and physician assistant (PA) services if initial documentation includes an authorizing statement -- or the nonphysician practitioner (NPP) uses her number.

Although CMS rescinded its May incident-to transmittal 87 stating carriers will not pay for services incident-to a physician's service unless there is documentation authorizing the incident-to service, your best bet may be to incorporate the changes. "I think CMS still intends that physicians must authorize a nurse practitioner or physician assistant to provide follow-up services," says Hugh Aaron, MHA, JD, CPC, CPC-H, presenter at the 2008 American Academy of Professional Coders National Conference in Orlando.

The change: For private payers that follow CMS' incident-to coverage requirements, an auditor could request repayment on NPP services when the physician's initial plan of care fails to mention that an NP or PA may provide follow-up care.

This new incident-to criterion applies to CMS Medicare services. "Medicaid and private-payer guidelines will likely follow suit," says Richard H. Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. Watch for changing criteria.

CMS pays a covered NPP office service reported under a physician's number at 100 percent when the encounter meets these three existing and one new criteria:

1. The NP or PA treats an established problem. A pediatrician with the same tax identification number must first treat the patient for that condition or illness.

2. A physician provides an active role in the continued management of that condition or illness. "CMS has no set time period for how long in between episodes the physician must re-treat the patient for the carrier to still consider the physician's role as active," Aaron says.

3. The physician must provide direct supervision. Although an NP or PA subject to state law may treat a patient without a physician on site, CMS requires a physician be in the office suite to bill a covered office service incident-to the physician, Aaron says.

4. Now CMS may also require that the physician indicate he approves an NPP provide follow-up services. For instance, if a pediatrician diagnoses a patient with attention deficit disorder (ADD, such as 314.00, Attention deficit disorder of childhood without hyperactivity) and wants the group's NP to be able to provide medication checks, the pediatrician must authorize this in the initial treatment note.

"To cover your incident-to pay, the best bet is for the physician in the initial service to make a brief authorizing statement," Aaron says. Notation could read, "OK to see NPP or f/u NPP," he says.

Example: A pediatrician sees an established patient for a new problem that he diagnoses as upper respiratory infection (URI, for instance, 465.8, Acute upper respiratory infection; other multiple sites) and codes as a level-three E/M (99213, Office or other outpatient visit for the E/M of an established patient ...). The doctor writes a prescription and tells the mom to call back if there are any problems. She calls two days later and reports that the medication is not working. The patient comes in and sees an NP while the pediatrician is in the office suite. The NP writes the patient a new prescription and circles a level-four service (99214).

This scenario would meet the original three incident-to criteria:

• A physician provides the initial service

• You can assume the time frame of two days later is in the active-role time period

• A physician is in the office suite.

Missing: The pediatrician gave "no express authorization to write another prescription," Aaron says. CMS might still believe that the physician must document in his notes whether the patient can see the NP for follow-up. Without such a statement, reporting 99214 incident-to the physician (using his national provider identifier [NPI] number) is questionable.

You don't have to forego payment for the E/M service. Instead, report the service (in the above case 99214) under the NP's NPI, Aaron says.

The incident-to umbrella was originally created in the 1960's as a billing method for auxiliary staff, meaning nurses and assistants. This was before the evolution of practices using NPPs.

When practices realized they could avoid the 15 percent reduction sometimes associated with billing services under an NPP's number, they started jumping through the incident-to hoops to prevent revenue loss, Aaron says. But incident-to wasn't really meant for NPPs. Therefore, even though writing a prescription without physician authorization is certainly within an NP's or PA's scope of practice, subject to state laws, incident-to makes these added measures necessary, he says.

Not all payers apply this reduction, Tuck says. Best bet: Check with your major insurers for payment and incident-to criteria.