Pediatric Coding Alert

Question: Can a nurse practitioner bill for hospital visits? Our nurse practitioner is a lactation specialist who rounds in the morning with the pediatricians but sees the mothers for lactation at the hospital as well as in an office setting. Can she report these services to our insurers?

Answer: The issue of the nurse practitioner billing for solo visits at the hospital will come down to state law, but in a general sense, the issue of the nurse practitioner seeing the infants and mothers could get into the territory of CMS Transmittal 1776, which talks about combined visits. If the physician and nurse practitioner see the infants and families on the same date, they should combine the work they do and they’ll typically be able to reach a higher level of code to bill for that service. However, the nurse practitioner won’t be able to bill a separate visit. If the nurse practitioner is employed by the physician, a combined visit can be billed. The rule is that there can only be one E/M visit per day by the practice. If they’re employed by the hospital, no bill can be triggered by the nurse practitioner, as their services are considered covered in the facility fee.

If the nurse practitioner came on a separate day, the billing would depend on the reason for the lactation consultation—for instance, if the lactation consultant visits all patients just to make sure the baby is latching on, it would be hard to argue for medical necessity of the visit. There are often situations when the pediatrician asks the lactation specialist to consult on a specific patient who’s having issues with breastfeeding. 

Whether your NP can independently report a consultation (99251-99255 for inpatients) depends on whether the insurance company credentials NPs, as well as your state’s and payers’ limitations, hospital policies and credentialing. If your insurer allows consults, that would be the code to use for this. 

If the consultation option isn’t available (either due to state law or if your insurer stopped paying consults when Medicare stopped several years ago), you can always report a standard hospital visit for the NP’s services, and in this case it would be a problem-focused E/M if there is an issue with the breastfeeding.

So essentially, if your state and hospital allow a nurse practitioner to bill hospital rounds, whether you can bill a consult code (subject to insurance policies), or any other applicable hospital E/M, use the following guidelines:

• If the MD and nurse practitioner make rounds the same day, bill under the MD and use the applicable hospital-based E/M code
• If the MD asks the nurse practitioner to make rounds on their own and both the hospital policy and your state law allow it, bill under the nurse practitioner’s number. This is especially important to remember because "incident to" is typically not allowed in a hospital setting.