Primary Care Coding Alert

Can you bill incident-to in the hospital?  The answer may surprise you

You might think you-ve got nonphysician practitioner coding down pat, but the regulations change so frequently that you should test your skills from time to time. Challenge yourself with our NPP coding quiz and make sure you-re on the right track.

Est. Patient, New Problem: Is It Incident-To?

Question 1: Your nurse practitioner meets with an established patient to remove a patient's arm cast, which recently got wet during the patient's boating trip. When the NP removes the cast, he discovers a deep skin infection that formed under it.

The FP is in the suite but is unable to come into the examining room to evaluate the new problem, so the NP debrides the wound and gives the patient an antibiotic prescription. Can you bill the visit incident-to, or should you bill it under the NPP's provider identification
number (PIN)?

Answer 1: -This visit must be billed under the NP's number and is not an incident-to visit,- says Ron L. Nelson, PA-C, president of Health Services Associates in Fremont, Mich., and past president of the American Academy of Physician Assistants. -This is clear-cut, and based upon the regulations, it would require the billing to be under the NP's number,- he says.

Here's why: Even though the NP saw an established patient, the visit doesn't qualify as incident-to because the physician should see the patient for any new problems. If the NP addresses the skin infection (a new problem) without the physician's input, the NP should bill the visit using his own PIN.

The incident-to guidelines require the physician to see any new patients or any new problems that the patient has. Your NP can still bill the visit, but he must do so using his own identification number.

Can the NPP Request/Perform Consults?

Question 2: A physician assistant (PA) from a local college clinic asks your family physician to evaluate a patient who he suspects has diabetes. Can you bill a consult when the request comes from a PA, not a physician?

Answer 2: Yes. -According to Medicare guidelines, nonphysician practitioners can request consults, and they can perform consults under certain circumstances,- says Stephen Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Patient Care.

In black and white: Section 30.6.10 of chapter 12 of the Claims Processing Manual clearly states that qualified NPPs may request and perform consultations within the scope of practice and licensure requirements for that type of nonphysician practitioner in the State in which they practice. Applicable collaboration and general supervision rules apply as well as billing rules. To read the chapter in its entirety, visit www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.

And CPT's guidelines state that a consultation can be requested -by a physician or other appropriate source.-

If your FP performs a consult that an NPP requested, remember to send a letter back to the requesting NPP that details your physician's findings following his examination of the patient.

Does Incident-to Apply to Inpatients?

Question 3: Can an NPP report a consultation that she performs on an inpatient?

Answer 3: Yes, as long as you report the inpatient consult under the NPP's own PIN.

Medicare allows you to report services that the NPP provides in a hospital setting, as long as you don't report the services incident-to. Therefore, if your NPP provides a consult in the hospital and documents the -three R-s- of the consultation (request, review, and report back to the requesting physician or proper notation in the shared record), you can report the appropriate consult code (99241-99245 or 99251-99255 depending on whether the patient is outpatient or inpatient) under the NPP's PIN.

Caveat: -Other insurers may allow you to bill these services as well, either by assigning a provider number to the NPP or by outlining the supervision requirements,- says Suzan Hvizdash, BS, CPC-EMS, CPC-EDS, physician educator for the University of Pittsburgh Physicians department of surgery.

-It is vital to check with your payers prior to instituting practices for the NPPs,- Hvizdash says. In addition, always check your state and hospital scope-of-practice guidelines before you bill an NPP's consult services, because state guidelines can vary throughout the country.