Pulmonology Coding Alert

Question: I have a question about the 30-day rule for new providers. The sequence in our state of applying for the advanced practice registered nurse (APRN) license and then to Medicare could mean that the graduate has been providing services for six months before we can apply to National Government Services with the National Provider Identifier(NPI). The new rule indicates that we can go back only 30 days from the date of the Medicare application. Does the new rule disallow new Master's degree-prepared graduate nurses from providing services to Medicare members?

Oklahoma Subscriber

Answer: Under the old rule, physician and nonphysician practitioners (NPP) could submit claims for services provided up to 27 months prior to the date of enrollment into the Medicare program.

The new rule defines the enrollment date as the later of the dates an enrollment application was filed (assuming  subsequent approval of the application) or the date the enrolled provider started providing services at a new location and allows billing 30 days prior to a successfully filed enrollment application.

The rule applies to new physicians as well as certified registered nurse practitioners (CRNPs). The old concern was that a provider could treat Medicare patients for more than two years (27 months) before being classified as a successful or unsuccessful Medicare provider. This dramatically shortens the time frame. It is up to the applicant or her employer to have a completed application submitted to Medicare within 30 days of the new graduate treating these patients.

Consider this example of coding an NPP's services with 30 days of the Medicare application: A 67-year-old established Medicare patient with a plan of care in place for asthma reports to the pulmonologist for a medication adjustment. The NPP provides a level-two E/M for the patient; the pulmonologist is at one of the practice's computers reviewing notes during the service.

This is an incident-to service. On the claim, you would report 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) under the pulmonologist's NPI with 493.0 (Extrinsic asthma) appended.

Take note: CMS asserts that PECOS will improve enrollment processing to allow contractors to process applications in 30 to 45 calendar days. The current process requires 60 to 90 calendar days. Again, the important time is 30 days before an approved application was completed (the approval date could be after that period). So if taking the exam and getting the APRN license requires six months, you would bill the services to Medicare only for the final month.

The answers to the Reader Questions and You Be the Coder were provided and reviewed by Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy, and critical care at Emory University School of Medicine in Atlanta; and Carol Pohlig, BSN, RN, CPC, ASC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.