Pediatric Coding Alert

Question: I work in a clinic located in a hospital building. Can a nurse run an allergy shot clinic under incident to?

Pennsylvania Subscriber

Answer: Clinics fall under the same incident-to requirements as offices do. Therefore, nurse-administered allergen immunotherapy (95115, Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection; or 95117, ... two or more injections) without the physician in the clinic suite would not meet incident-to criteria, which require the physician to be immediately available.

In an outpatient hospital (place of service code 22) instead of an independent clinic (POS 49), the encounter is usually assumed to meet CMS' incident-to supervision requirements. A physician/NPP (nonphysician practitioner), who is a member of the hospital staff, would have to be on the hospital premises at the time of the service and immediately available to render assistance and direction throughout the performance of the procedure. The hospital record or policy must identify this individual by job description.

Catch: The hospital, however, would then bill 95115 or 95117. In the outpatient hospital settings, the hospital with which the supervising physician/NPP has contractual relationships bills the service, regardless of whether the physician/NPP providing the initial service and/or patient care oversight are members of the hospital staff.