Primary Care Coding Alert

Charging $21 for 99211 hinges on employee, facility

For a blood pressure check, you should report 99211, right? Not so fast: The answer depends on the service's provider and location.

Experts reveal answers to two common family practice incident-to billing questions:

1. Who Can Provide the Service?

"Can I bill 99211 only when a registered nurse performs the service?" asks a Family Practice Coding Alert subscriber.

No, any qualified "auxiliary personnel" can provide services to patients under the incident-to umbrella using 99211 (Office or other outpatient visit for the E/M of an established patient ...), says Kathy Pride, CPC, CCS-P, HIM applications specialist with the San Rafael, Calif.-based QuadraMed. You may report the services of a medical assistant, licensed practical nurse, technician or  other aide under the physician's number.

Caveat: Before you report 99211 incident-to your family physician (FP), Pride recommends checking that:

1. the service meets incident-to rules
2. personnel are qualified to perform the service
3. the encounter meets the "medical-necessity" requirement for billing an E/M code. 
 
You may also report nonphysician practitioners' (NPPs') services incident-to your FP. But you probably won't use 99211, which pays a Medicare unadjusted rate of $21.28, for NPP services.

Why: NPPs, such as nurse practitioners, clinical nurses, nurse midwives, and physician assistants, will usually provide encounters involving greater complexity of care than 99211 indicates. Therefore, you will often bill a higher-level E/M code (such as 99212-99215) for their services.

Report the code either incident-to the on-duty FP or under the NPP's personal identification number. Bill the service under your FP's name if the encounter meets incident-to requirements.

2. Can You Bill Incident-To Your Publicly Funded FP?

If your FP practices in a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC), Medicare's incident-to rules don't apply. You instead bill the service under the provider's number, says Heather Findlay, CPC, CCP, coding specialist at Family Health Centers in Okanogan, Wash.

Catch: You should only report direct services. "To bill the visit to Medicaid or Medicare, the patient must have a face-to-face encounter with a provider," Findlay says.

A provider includes physicians and mid-level providers. That means you may report a service that a physician (MD/DO), PA, NP, certified phlebotomist, clinical social worker or nurse midwife provides, but not a registered nurse's service, says George Ward, billing supervisor with South of Market Health Center in San Francisco.

Example: A mother brings her son in for a nurse to read the child's TB test result.

Hint: In the above case, billing 99211 incident-to the FP depends on the facility.

Office coding: In a private practice, you should report 99211 under the physician's number, Ward says.

Clinic alert: The same coding doesn't apply for RNs who work for FQHCs or RHCs. "In an FQHC or RHC, if the patient only sees a nurse, even if the service is technically 'incident-to' a prior provider visit, you cannot bill the encounter to Medicaid or Medicare," Findlay says.

Clinic answer: In the TB test result scenario, you may  instead internally code the service as 99211. But, you shouldn't report the nurse-only encounter.