Pulmonology Coding Alert

Can you bill incident-to when NPP requests consult? Answer may surprise you

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. Challenge yourself with our NPP coding quiz and make sure you're on the right track.

Is Established Patient, New Px Incident-To?

Question 1: Your nurse practitioner meets with an established patient for an annual asthma recheck. The patient complains of frequent sneezing and stuffiness.

The pulmonologist is in the suite but is unable to come into the examining room to evaluate the new problem, so the NP performs an ENT exam and gives the patient a prescription for seasonal rhinitis. 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, it would require the billing to be under the NP's number.

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 rhinitis (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.

Another spin on this issue: Suppose the patient's problem list identifies seasonal allergies, and a plan of care has been previously established. Because this is an exacerbation of an existing problem, the NP may report the service under the physician's name as incident-to the physician's plan of care, says Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Can NPP Request/Perform Consult?

Question 2: A physician assistant (PA) from a local college clinic asks your pulmonologist to evaluate a patient who he suspects has sleep apnea. 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 pulmonologist 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.