Pulmonology Coding Alert

Can new patients get treatment incident-to the physician?

You might think you've got nonphysician practitioner (NPP) coding down pat, but the regulations change so frequently that you should test your skills from time to time. Take a few minutes to challenge yourself with our NPP coding quiz and make sure you're on the right track.

Established Patient, New Problem: Is it Incident-to?

Question 1: Your nurse practitioner (NP) examines an established patient with a COPD exacerbation.  During the evaluation for the COPD exacerbation, the patient complains of pain and redness around a recent cut on his arm.  The NP discovers a skin infection on the left arm.   The pulmonologist 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 NP'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 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 a care plan has not been established for the new problem. If the NP addresses the skin infection (a new problem) without the physician's input, then the NP should bill the visit using his own PIN.

That's because the incident-to guidelines require the physician to initiate the care plan for any new patients, or any new problems that the patient has.

Some insurers have interpreted this to mean that the physician must provide the visit associated with new patients or new problems.  Subsequently, the NPs will implement the physician-established plan of care (i.e. "incident-to" the physician's service).  Otherwise, your NP can still bill the visit, but he must do so using his own identification number.

Can the PA Request/Perform Consults?

Question 2: A physician's assistant (PA) from a local primary care physician asks your pulmonologist to evaluate a patient whom he suspects suffers from bronchitis. Can you bill a consult when the request comes from a PA, and not a physician?

Answer 2: Yes. "According to Medicare guidelines, PAs can request consults, and 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 15506 of the Medicare Carriers Manual states, "Non-physician practitioners, e.g., nurse practitioners, certified nurse-midwives or physician assistants, may request a consultation. They may also perform other medically necessary services, e.g., consultations when the performance is within the scope of practice for that type of non-physician practitioner in the State in which they practice. Applicable collaboration and general supervision rules apply as well as billing rules."

In addition, CPT's guidelines state that a consultation can be requested "by a physician or other appropriate source." If your surgeon performs a consult that a PA requested, remember to send a letter back to the requesting PA that details your physician's findings following his examination of the patient.

Does Incident-to Apply to Inpatients?

Question 3: Can a non-physician practitioner (NPP) report a consultation that she performs on an inpatient?

Answer 3: Yes, as long as you report the inpatient consults 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 if the patient is outpatient or inpatient) under the NPP's PIN. NPPs are also allowed to report inpatient evaluation and management (E/M) services under the physician's name, if the physician participates and you adhere to all of the the rules for shared/split billing.

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 as well before you bill an NPP's consult services, because state guidelines can vary throughout the country.