Pediatric Coding Alert

Question: Our NP (who specializes in diabetes education) is working with our pediatrician in the same outpatient clinic. We are planning to see new diabetes patients two days a month. He will have his own visit and cover certain topics with each patient, and our NP will then see the patient on the same day and cover diabetes-specific topics that he will not be covering. Our NP will mainly cover diabetes issues. Are we able to bill for the NP service if it occurs on the same day as the patient sees our pediatrician if the NP is covering an entirely different subject? The visit with the NP will be 45 minutes and is primarily counseling.

Michigan Subscriber

Answer: The general rule is one E/M service per patient per physician group per day. When your pediatrician and an NP both have a face-to-face encounter with the same patient on the same day, only one bill needs to be sent. Accounting for what the bill entails is dependent upon the service location. The notes of both practitioners based on key components of history, physical exam, and medical decision-making can be combined to decide on the level of service and one bill generated under the physician’s name and PIN.

Remember: The physician and NP must be employees of the same practice. In any shared service, both the physician and the NP must provide their portion of the services face-to-face. The incident-to rules are all still in effect. This means the NP time cannot be combined with the physician’s time to determine the code level. You must document medical necessity and what you actually did during the encounter.

Warning: If these services were provided in an office-based setting under “incident-to” rules, the counseling by the NP could not be billed under the physician. Counseling time cannot be counted when performed “incident-to” the physician; only the billing provider’s personal time can be attributed to the visit level selected.

Keep in mind: If the NP is also a certified nutritionist, you may be able to report medical nutrition therapy codes for the diabetes sessions if they meet the requirements. When an individual certified nutritionist consults with a patient in a noncertified physician setting, you’ll most likely report diabetic sessions with 97802-97804. But if your practice has an American Diabetes Association-approved program, you may also use Medicare-specific codes G0108-G0109.

Here’s how: For noncertified programs, select the nutrition session code provided by the registered dietitian based on the patient’s diagnosis and the number of individuals involved. Use 97802 (Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes) for initial medical nutrition therapy involving a single patient.