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, [...]