Pulmonology Coding Alert

Each time one of your nonphysician practitioners (NPP) provides services or treatment to a Medicare patient, you should be on the lookout for the opportunity to code the service incident-to the pulmonologist.

Why? More money for the same service. When you report services incident-to the physician, you can bill under the physician's Medicare National Provider Identifier (NPI) and garner full pay for services.

If you do not bill an NPP visit incident-to the physician, the NPP must bill under her NPI, which reimburses at 85 percent of the full pay rate. (Note: NPI replaced the term "unique physician identification number" [UPIN] recently in official coding language.)

Of course, Medicare has strict guidelines regarding what constitutes an incident-to service, and the carrier will deny any claim that does not meet these rules--- so if you're concerned with the bottom line, you should know the ins and outs of incident-to coding.

To bill incident-to services, the NPP must be following an established plan of care for the patient and the physician supervision requirements, says Anna Rosario, CPC, coding and compliance officer for Affiliated Practice Group in Brockton, Mass. If the NPP is seeing the patient for a new problem, you cannot bill incident-to.

Consider these two examples:

Example 1: The pulmonologist sees a new Medicare patient with bronchiectasis and chronic rhinosinusitis, and schedules the patient for a follow-up visit. Two weeks later, the NPP provides a level-three E/M service to check on the patient's bronchiectasis and chronic rhinosinusitis.

In this instance, the NPP followed the doctor's care plan, so you can report an incident-to service, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

On the claim, you should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) for the E/M under the physician's NPI.

Don't forget to attach 494.0 (Bronchiectasis without acute exacerbation), 472.0 (Chronic rhinitis) and 473.9 (Chronic sinusitis, unspecified) to 99213 to prove medical necessity for the encounter.

Example 2: An established patient with a plan of care for his previously treated extrinsic asthma reports to the office for a checkup. During the exam, the patient complains of a 10-day history of progressive cough, low-grade fever, fatigue and loss of appetite.

During the course of a level-three E/M, the NPP checks the patient's asthma and also discovers that the patient has suspected pneumonia. She writes the patient a prescription and sends him home.

In this example, the patient received treatment for an existing problem (asthma) and a new problem (suspected pneumonia), meaning the NPP was not following a care plan for the entire encounter. In this instance, you should report 99213 under the NPP's NPI. Remember to append 786.2 (Cough), 780.6 (Fever), 783.0 (Anorexia) and 493.00 (Extrinsic asthma; unspecified) to 99213 to represent the patient's symptoms until the pneumonia can be confirmed.

In a nutshell: Anytime the NPP sees a patient independently for a new problem, code for the service with her NPI, says Quinten A. Buechner, MS, MDiv, ACS-FP/GI/PEDS, CPC, CCP, CMSCS, president of ProActive Consultants LLC in Cumberland, Wis.

Suppose you are examining a claim in which an NPP followed an established plan of care. To bill incident-to the physician, you must also be sure that the NPP provided the service under the "direct supervision" of a physician, Rosario says.

Definition: To meet "direct supervision" requirements, the pulmonologist "must be present in the office suite and immediately available to render assistance if necessary. The physician does not have to be physically present in the exam room with the NPP," Rosario says.

Payers are adamant about the physician being in the suite and immediately available, Buechner says. "Generally, audit experience tells us that the requirements mean within the suite--- not outside smoking a cigarette or elsewhere in the building or upstairs--- and within 'hollering distance,' " he says.

Important: The physician supervising the incident-to service does not necessarily have to be the same physician who authored the patient's care plan if they are in the same provider group, Rosario says.

For example, an NPP is treating a patient, and Dr. X is the supervising physician. But the NPP is following Dr. Y's treatment plan, and Dr. Y is not present.

"In this scenario, although you are following Dr. Y's treatment plan, you would bill under Dr. X as the supervising physician," Rosario says.

According to Medlearn Matters article SE0441, to bill incident-to you must bill under the supervising physician's NPI. "CMS also states that any physician members of the same group may be present in the office to supervise incident-to," she says.

Caveat: You must make sure that the physician supervising the incident-to service is an eligible supervisor according to your state's law.

"Any doctor in the group is OK for Medicare incident-to billing, but that doctor may not be an eligible supervisor under state law. If you are billing incident-to, you must always comply with both state law and Medicare," Buechner says.

Best bet: Make sure to check a physician's state eligibility before billing incident-to with him as the supervising physician.

Remember, even if your NPP is following a physician's care plan for a patient, you cannot bill the service incident-to unless the NPP provides the service under direct supervision, Buechner says.

"Incident-to services go hand in hand with direct supervision; there must be direct supervision by a doctor," Rosario says. If the physician is not present in the office suite during the time of service, the NPP can only report the visit under the NPP's NPI.