Urology Coding Alert

Careful: Not all NPPs are eligible to perform incident-to services in a urology practice

Before reporting incident-to services, you must know who in your office is eligible to provide incident-to services, and exactly what services they can provide - or you can risk losing payment for the entire visit.

Nonphysician practitioners (NPPs) who can perform incident-to services are invaluable in any urology office, because incident-to rules allow approved NPPs to provide certain services yet still bill them under the physician's personal identification number (PIN), says Tina Miller, CPC, biller and coder for Urology Associates of Central California in Fresno.

Requirement: To bill incident to, the urologist must be present in the office and immediately available for assistance, consultation or patient emergencies, should they arise, though not necessarily seeing the patient, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis. "If the physician is not present in the office suite, you must code the service under the NPPs number," Hause warns. Hause also notes that in a group practice the "ordering" physician on the claim may be different than the "supervising" physician.

"According to our research, the physician simply being present in the building (or elsewhere on the grounds) is deemed unacceptable," says Matthew Lautzenheiser, a senior administrative manager at Johns Hopkins Medicine in Baltimore.

Benefit: When an NPP uses the urologist's PIN to file the claim, Medicare will reimburse fully for the code; if the NPP uses his own PIN, Medicare pays only 85 percent of the code value, says Kimberly Green, CPC, project coordinator at the University of Pittsburgh Physicians.

Follow us for some expert advice on accident-free incident-to coding.

Expect Most Incident-To Payments from Medicare

Before you report incident-to services, know that incident-to is a Medicare phenomenon, and private companies don't consider these codes kosher. Most non-Medicare payers do not recognize staff as providers of physician services, experts say.

"Incident-to guidelines are particularly applicable to Medicare- and Medicaid-insured patients. In most cases, private carriers ... will establish policies to address services provided by an NPP while being supervised by an in-office physician," says Lautzenheiser.

Best bet: Before reporting NPP services to private carriers, Lautzenheiser recommends contacting the carrier to see how they would like the claim filed.

Code Incident-To Services for Many Ancillary Staff

A lot of different NPPs might be eligible to provide incident-to services, if they have been trained correctly, Lautzenheiser says.

"Most ancillary staff with proper training may provide incident-to services on behalf of an in-office, supervising physician," Lautzenheiser says. This could be a medical assistant (MA), registered nurse (RN), physician assistant (PA), certified nursing specialist (CNS) or nurse practitioner (NP) - among others.

For an NP or PA: "Proper training" for all incident-to services stipulates that these providers be enrolled in Medicare with a valid PIN and have a state license. The work that incident-to service providers perform in lieu of the urologist depends on their area of expertise.

"MAs and RNs typically provide educational services and administer injections, while higher-level E/M work and minor procedures are provided by CNSs and PAs," Lautzenheiser says.

Example: A PA at your urology practice sees an established patient who is being treated for a urinary tract infection. The urologist has seen this patient in the recent past and has established the diagnosis and initiated treatment or a care plan. The PA performs a follow-up history and examination and continues the prescribed treatment. The PA bills an established office visit - most likely a 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) or 99213  - in the urologist's name and numbers. Reimbursement will be 100 percent of the physician's global fee.

As long as the patient is not new or undergoing status change, and the urologist is in the office suite, the PA can provide the service and the office can use the urologist's PIN when filing with Medicare.

Warning: Never report incident-to services in a hospital setting, either outpatient, inpatient or in the emergency department. Medicare forbids it.