Pulmonology Coding Alert

NPP can report service directly without having to satisfy CMS criteria

Your pulmonologist won't have to pay back money for nurse practitioner (NP) and physician assistant (PA) services if initial documentation includes an authorizing statement -- or the nonphysician practitioner (NPP) uses her number.

Although CMS rescinded its May incident-to transmittal 87, your best bet may be to heed the warning. "I think CMS still intends" to verify physician authorization of NP or PA follow-up services, says Hugh Aaron, MHA, JD, CPC, CPC-H, at the 2008 American Academy of Professional Coders (AAPC) National Conference in Orlando.

The concern: For private payers that follow CMS' incident-to coverage requirements, an auditor could question NPP services when the physician fails to initiate the care plan.

Currently, there are no requirements that the physician needs to authorize the NPP's involvement in patient care. Patients are typically verbally made aware that they could be seen by the NPP on a subsequent visit or informed at the time of scheduling the appointment.

Physicians are required to provide the initial service and develop the plan of care; NPPs participating in the group practice may execute the established care plan under incident-to requirements.

CMS pays a covered nonphysician extender office service billed under a physician's number at 100 percent when the encounter meets these three existing criterion:

1. The NP or PA treats an established problem. A pulmonologist with the same tax identification number must first treat the patient for that condition or illness.

2. A physician provides an active role in the continued management of that condition or illness. "CMS has no set time period for how long in between episodes the physician must re-treat the patient for the carrier to still consider the physician's role as active," Aaron says.

3. The physician must provide direct supervision. Although an NP or PA subject to state law may treat a patient without a physician on site, CMS requires a physician be in the office suite to bill a covered office service incident to the physician, Aaron notes.

You don't, however, have to forego payment for the E/M service if incident-to requirements are not met. Instead, report the service under the NP's NPI, Aaron suggests.

The incident-to umbrella was originally created in the 1960s as a billing method for auxiliary staff, meaning nurses and assistants. This was before the evolution of practices using NPPs.

When practices realized they could avoid the 15 percent reduction sometimes associated with billing services under an NPP's number, they continued jumping through the incident-to hoops to prevent revenue loss, Aaron recalls.

But incident-to is a catch-all policy that generalizes across many healthcare provider groups and doesn't depict the full scope of practice for some NPPs. Therefore, even though writing a prescription without physician authorization is certainly within an NP's or PA's scope of practice, subject to state laws, incident to makes these added measures necessary, Aaron explains.

Not all payers apply this 15 percent reduction, says Richard Tuck, MD, FAAP, of PrimeCare of Southeastern Ohio. Best bet: Check with your major insurers for NPP coverage, reporting and payment as well as recognized incident-to criteria.