Urology Coding Alert

Take this quiz to see how well you know incident-to guidelines

You might think you have nonphysician practitioner (NPP) coding down pat, but the regulations change so frequently that you should test your skills from time to time. Take a few minutes to challenge yourself with our NPP coding quiz and make sure you're on the right track.

Established Patient, New Problem: Is It Incident-to?

Question 1: Your nurse practitioner (NP) meets with an established patient to replace a suprapubic tube. When the NP removes the tube, he discovers a deep skin infection that has formed around the ostomy site. The urologist is in the office suite but is unable to come into the examining room to evaluate this new problem, so the NP cleanses the area and prescribes an antibiotic.
 
Can you bill the visit incident-to, or should you bill it under the NPP's provider identification number (PIN)?

Answer 1: "This visit must be billed under the NP's number and is not an incident-to visit," says Ron L. Nelson, PA-C, president of Health Services Associates in Fremont, Mich., and past president of the American Academy of Physician Assistants. "This is clear-cut, and based upon the regulations would require the billing to be under the NP's number."
 
Here's why: Even though the NP saw an established patient, the visit doesn't qualify as incident-to because the physician should see the patient for any new problems. If the NP addresses the skin infection (a new problem) without the physician's input, the NP should bill the visit using his own PIN.
 
The incident-to guidelines require the physician to see any new patients or any new problems that may have arisen. Your NP can still bill the visit, but he must do so using his own identification number.

Can the NPP Request/Perform Consults?

Question 2: A physician assistant (PA) from a local family practice asks your urologist to evaluate a patient who he suspects has minor incontinence. Can you bill a consult when the request comes from a PA, not a physician?

Answer 2: Yes. "According to Medicare guidelines, nonphysician practitioners can request consults and can perform consults under certain circumstances," says Stephen Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Patient Care.

In black and white: Section 15506 of the Medicare Carriers Manual states, "Nonphysician practitioners, e.g., nurse practitioners, certified nurse-midwives or physician assistants, may request a consultation. They may also perform other medically necessary services, e.g., consultations when the performance is within the scope of practice for that type of nonphysician practitioner in the State in which they practice. Applicable collaboration and general supervision rules apply as well as billing rules."
 
And CPT's guidelines state that a consultation can be requested "by a physician or other appropriate source." A nonphysician practitioner would be an "other appropriate source."
 
If your urologist performs a consult that an NPP requested, remember to send a letter back to the requesting NPP that details your physician's findings following his examination of the patient.