Primary Care Coding Alert

Warning: Check supervision, payer incident-to requirements

When ancillary staff perform office procedures, you can ethically open the door to increased private-payer reimbursement if you follow physician supervision guidelines and incident-to requirements.

Read how one practice's early morning can be a financial blessing or a coding nightmare.

Physician Supervision Doesn't Equal Incident-To

The office jump-start: A family physician (FP) wants a nurse practitioner (NP) to perform blood draws, x-rays and allergy shots before he arrives in the morning. "May an NP perform these procedures when the doctor isn't on the premises, if the doctor ordered the test?" asks a Missouri subscriber.

Taking advantage of this extra scheduling depends on the patient's insurer. Insurance companies almost entirely dictate testing supervision and incident-to criteria, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, health information management certificate programs coordinator at Clarkson College in Omaha, Neb. "Medicare's rules are the most stringent." Private payers may allow non-physician practitioners (NPPs) to provide more services without direct physician supervision.

Strategy: Find out what each insurer requires, and remember to keep the guidelines separate. "Do not confuse supervision rules with incident-to rules," says Jean Ryan-Niemackl, LPN, CPC, an application support specialist for QuadraMed in Fargo, N.D. "They are simply not the same."

Follow Medicare Supervision Guidelines

Physician supervision applies to diagnostic tests, such as allergy testing. The National Physician Fee Schedule uses numbers to indicate the supervision level an NPP must meet when she performs a service or procedure. Diagnostic test guidelines include three levels of supervision:

General: The NPP may furnish the service under the physician's overall direction and control, but the physician doesn't have to be present.

Direct: The physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. The physician does not have to be present in the room where the NPP performs the procedure or service.

Personal: The physician must be in the room during the procedure.

Method: Although the above stringent supervision levels are Medicare's, experts recommend following them for all insurers. "Coders should check the Medicare guidelines for each type of diagnostic test that their office performs to make sure they meet the test's supervision requirements," Bucknam says.

Take Advantage of Incident-To Variations

You don't, however, have to adhere to strict incident-to guidelines for all insurers. "In Nebraska, no other insurers follow Medicare's incident-to rules," Bucknam says. Private insurers allow you to bill incident-to even when the physician is not in the same state.

Benefit: To ethically maximize reimbursement, you should know the patient's insurer and its rules.

Watch out: To bill a service incident-to Medicare, the provider must perform the service while the physician is in the office suite.

NPP Could Offer Venipuncture, ECG, X-Ray

Let's consider some common FP services that an NPP could potentially perform, such as an x-ray and blood draw mentioned in the case study, and Medicare's supervision rules for each.

Example 1: The Physician Fee Schedule indicates a level "9" for 36415 (Collection of venous blood by venipuncture) and G0001 (Routine venipuncture for collection of specimen[s]). A "9" means that the service is not a diagnostic test. "Therefore, the supervision requirements for 'physician supervision of diagnostic tests' concept doesn't apply," Bucknam says.

The service, however, must still meet the insurer's incident-to requirements. If you bill the blood draw to Medicare (G0001), the physician must be in the office.

Payers in Nebraska don't require the physician's presence. If your insurers have more relaxed incident-to rules, you could submit the blood draw to commercial insurers with 36415 when the nurse performs the service before the physician arrives in the office.

Example 2: An electrocardiogram (93000, Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) has an indicator of "1," which means it must be performed under the general supervision of a physician. In other words, Medicare doesn't require the physician to be in the office when an NPP performs the test, says Lynn M. Anderanin, CPC, senior coding consultant for Health Information Services in Des Plaines, Ill. But the physician needs to read and interpret the findings.

Example 3: An x-ray must also involve the physician. Medicare requires general supervision for most x-ray technical components (modifier -TC), such as 71010 (Radiologic examination, chest; single view, frontal), Bucknam says. But the physician must perform the interpretation or professional component (modifier -26). So an NPP could perform an x-ray before the FP comes to work, if the insurer has lenient incident-to rules.

Example 4: Allergy shots (95115-95180), however, are not diagnostic tests. When an NPP administers them, you should follow the insurer's incident-to guidelines.

Example 5: Both physician supervision requirements and incident-to rules apply to allergy testing, which are diagnostic tests, Anderanin says. Allergy tests require either direct or personal supervision (in case the patient has an anaphylactic reaction to a test). Codes 95004, 95024, 95027, 95028, 95044, 95052, 95056, 95070 and 95071 require direct supervision, whereas 95060 and 95065 require personal supervision.