Pulmonology Coding Alert

NGS Medicare announces new claim filing process that could impact your practice.

If your practice employs advanced practice providers, your claims submission process could change dramatically going forward, thanks to NGS Medicare’s new guidelines, which the Part B MAC is putting into effect on Sept. 15.

NGS is instituting a new step that you’ll have to perform if your advanced practice providers see the same patient twice in the same day but for different conditions, which often happens in multispecialty practices. Read on for the scoop.

Effort Will Reduce Denials

NGS Medicare had to update its claim processes for these providers as a way to cut down on denials, representatives from the MAC said during the company’s Aug. 23 webinar, “NGS Editing Change for Nonphysician Practitioner Evaluation and Management Services.”

“This year in particular, CMS has launched an initiative to reduce provider burden, under the heading of ‘Patients over Paperwork.’ CMS has encouraged the MAC contractors to seek solutions for areas where there is unnecessary provider burden,” said NGS’ Cathy Delli-Carpini during the call. In response to that initiative, NGS began studying claims that are denied, come back for appeals, and are subsequently paid.

In that analysis, the payer identified claims for E/M services that were submitted by nurse practitioners (specialty 50) and physician assistants (specialty 97) and the services were often performed more than once per day by advanced practice providers working in different subspecialty areas, despite being in the same practice. Traditionally, the first claim would be paid and the second claim would be denied, and then the practice would appeal it with information that supported care for a different clinical problem, resulting in payment upon appeal.

“There are enough of these that they are a volume quite burdensome to the providers who now have to submit all these appeals…and they are burdensome to the MAC as well because it accounts for a significant portion of our appeal workload,” said Delli-Carpini.

Here’s What Caused the Denials

CMS permits one E/M service per beneficiary per date of service for each provider specialty. But because only one specialty designation exists for NPs (50) and one for PAs (97), two claims by an NP on the same date for the same patient at your office will prompt a denial. “We recognize that that denial and appeal process is burdensome to the provider, and costly – both to the provider and the contractor,” Delli-Carpini said.

In an effort to fix the issue, NGS launched a pilot project to test whether a new solution might work, and it has been successful, so the MAC is extending the program to all providers.

Here’s What the New Program Entails

By submitting basic information on the initial claim, NGS can perform swifter analyses so the claims can be evaluated with all the information up-front. “So we’ve asked providers to include that additional information, which is the specialty of the group in which the NP or PA is performing that service,” Delli-Carpini said. The claim will still come in with a rendering provider of specialty 50 or specialty 97, “but what we’ve asked you to do now is go to that 2300 or 2400 NTD loop on the electronic claim or box 19 on the paper claim and insert the specialty of the group in which you are working that day,” she added.

That way, if a second or third claim comes in for specialty 50 or 97, the claim examiner can look at the claim history, see which specialty NGS paid it to initially, and if indeed those two specialties are different, the claim examiner will move on and compare the diagnosis on the history claim and on the current claim. “Remember, both of those have to be different. So a situation in which a claim coming in from cardiology and one from internal medicine with a NP on both claims, if the diagnosis information is the same, that claim will not be payable. But if the two supervising specialty information sets are different and the diagnoses on the current claim and history claim are different, the claim may be considered for payment,” she added.

Don’t Write Too Much

NGS stressed that you shouldn’t insert extra information into the field about your claim – simply add the supervising specialty. You’ll use the specialty code that CMS has assigned to your specialty. For pulmonology, that’s code 29, so in the appropriate field, your biller will write “SPEC 29” to reflect that an NP or PA in the pulmonology field performed the service.

“The physician specialties we are using are those that are recognized by CMS, and they are all available at our website,” said NGS’ Kathy Dunphy during the webinar.

The MAC expects practices to be pleased with the lower administrative burden that this change will prompt. “We would anticipate now having heard about this issue among provider groups for a long time, we expect there will be an increase in the provider satisfaction around these claims because we’ll be able to pay them at a higher rate up-front, there will be fewer denials, fewer appeals, we’ll see a significant decrease in the rate of denial when NPs or PAs submit multiple claims on same date of service and we’ll see a significant decrease in the appeals,” Delli-Carpini said.

NGS Will Review All Diagnoses

In some cases, your pulmonology PA might address COPD while another PA in the practice examines the patient’s diabetes – but because the coder assigns all conditions present and not just the primary one, it’s possible that both claims will list both COPD and diabetes. Fortunately, the NGS reps said that the PA need not worry about the diagnoses being similar, since claims reviewers will look at the primary diagnosis that each specialty PA listed first, said Delli-Carpini.

If your practice only employs pulmonology advanced practice providers and no other specialties, this new rule may not apply to you – and in that case, you are not required to write anything in the 2300 or 2400 NTD loop.