Pulmonology Coding Alert

If you do not consider billing "incident to" the physician when a qualified nonphysician practitioner (NPP) performs services for Medicare patients, you are letting deserved reimbursement fly out the door.

Bottom line: When you bill incident to, you garner 15 percent more per service than if you bill under the NPP's national provider identifier (NPI). But you do have to watch out for Medicare's strict incident to coding rules.Part of the Office of the Inspector General's 2009 work plan includes an examination of the qualifications of nonphysician staff who perform incident to services.

To ensure that all your incident to claims are on target, answer these questions before billing:

To qualify for incident to billing, the pulmonologist must see the Medicare patient during the initial visit and establish a clear plan of care, reported Sharlene Scott, CPC, CPC-H, CCS-P, CCP-P, PMCC, during a presentation at The Coding Institute's multispecialty conference in Orlando, Fla. (www.codinginstitute.com).

If the NPP is treating a new problem for the patient, or if the pulmonologist has not established a care plan for the patient, then you cannot report the visit incident to.

Example: An established Medicare patient reports to the pulmonologist on Dec. 13. The doctor performs an E/M service, diagnoses the patient with pneumonia, and writes prescriptions. On Dec. 23, the patient returns to the pulmonologist for a follow-up visit. The NPP checks the patient's vitals and evaluates the patient's lung function for any signs of improvement or the need to continue therapy.

In this example, you can report the NPP's service incident to the pulmonologist. On the claim, report the appropriate level E/M code. Don't forget to file the claim under the supervising pulmonologist's NPI rather than the NPP's NPI; this ensures you 100 percent pay for the E/M, while coding under the NPP's NPI results in 85 percent pay for the service.

Remember: The NPP's visit can be reported incident to the pulmonologist in this instance -- as long as the NPP is qualified to provide the service and the encounter meets pre-specified supervision requirements.

You must also be sure that the NPP has the proper credentials to perform the reported level of incident to services, stressed Scott, instructor with Coding Academy of America/American Coding Centers in Baltimore.

The NPP could be a physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist -- as long as the NPP meets state and federal guidelines to provide the service. The NPP must be "licensed by the state under various programs to assist or act in the place of the physician," according to the Medicare Benefit Policy Manual, Chapter 15.

Best bet: Check your state and local Medicare regulations for NPP qualifications. If the NPP does not meet one or both sets of guidelines, don't bill incident to for physician-level services (such as 99212-99215, Office or other outpatient visit ...). For example, an RN may be able to perform a limited evaluation but is not permitted to render medical decisions without the direction of the physician or qualified provider.

If the patient meets with the RN for evaluation and she reinforces the physician-outlined plan of care, the RN can only report 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician ...) in the physician's name, explains Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist with the University of Pennsylvania Department of Medicine in Philadelphia.