Urology Coding Alert

For codes 99211-99215, only two of the three factors are required. Typically, the physical examination is not needed for this level, just a history and MDM. Given these criteria, when a PA or nurse practitioner sees an established patient, the patient's history should already be in the chart. The physical exam will focus on an established complaint, and the complexity of the MDM will be lower because it is within the context of an established course of treatment.

For example, a physician assistant at your urology practice sees an established patient who is being treated for a urinary tract infection. This patient has been seen in the recent past by the urologist, who 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. Code this as an established patient office visit (99211-99215) according to documentation and bill in the urologist's name and numbers.

The previous example constitutes an incident-to visit, and reimbursement is 100 percent of the global fee. Remember, the urologist must be in the office suite to render necessary assistance to the PA and must also see this patient at a frequency indicating his continued care.

Seeing the patient every third or fourth visit for this specific problem would be an indicator of the urologist's continued care. Incident-to billing is also limited to office care. Hospital, outpatient or inpatient care and nursing home visits should never be billed as incident-to (see below).

When an NPP sees a new patient (99201-99205), performs a consultation (99241-99245), or sees an established patient presenting with a new problem, as well as patients in hospitals and nursing homes, these are not considered incident-to the physician's service and must be billed under the NPP's UPIN/PIN for 85 percent reimbursement. In the latter case, the urologist must provide general supervision. He must be available by phone or beeper and be able to provide personal assistance within 30 minutes.

Modifiers -AS, -80, -81, -82 for Surgery Assistance

Depending on their training and state laws, NPPs may act as first assistant in surgery using modifier -AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) appended to the procedure code. Some carriers may also require modifiers -80 (Assistant surgeon) or -82 (Assistant surgeon [when qualified resident surgeon not available]) as well as modifier -AS.

"I would not recommend the use of modifier -81 (Minimum assistant surgeon) to indicate the assistance of a PA, as most carriers do not recognize this modifier," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York Health Science Center in Stony Brook.

"Our PAs also perform cystoscopic examinations, urethral dilation, removal of stents, changing Foleys, and administration of BCG and Lupron."

Expect Reimbursement With Home-Field Advantage

On Oct. 1, 2003, Medicare allowed the use of "shared visits" for the PA and the physician. This new policy regarding NPP coding and reimbursement depends on whether the setting is facility or nonfacility. In the facility setting, as long as the physician and NPP provide "a face-to-face service" for the E/M encounter, you can bill an E/M service as "shared" by a physician under the physician's PIN and receive 100 percent reimbursement.

The hospital inpatient, hospital outpatient or emergency department services must be shared by a physician and an NPP from the same group practice for these reimbursement rules to apply.

In the nonfacility setting, you must report E/M services using the physician's PIN when it is the physician who performs the E/M service.

Shared/split E/M services - between a physician and an NPP - may be billed under the physician's PIN if the services meet incident-to requirements and the patient
is established.

If incident-to rules are not met, bill under the PA's name and number and receive 85 percent of the reimbursement, according to the CMS.

The Medicare Carriers Manual defines incident-to as "Services furnished as an integral although incidental part of a physician's personal professional services."

Ask 'Is There a Doctor in the House?'

Incident-to claims require the physician to be present in the office suite when the NPP furnishes the service, that the NPP see an established patient without a new problem, and that the physician previously documented a plan of therapy if one is carried out by the NPP.

Be sure to thoroughly document the urologist's presence in your report. CMS policy says, "If incident-to requirements are not met ... the service must be billed under the NPP's UPIN/PIN."

If your practice is particularly busy and an NPP sees several patients, these services can be billed as incident-to as long as these are established patients being seen for a problem they've had before, and the NPP follows a course of care set by the doctor.

Ultimately, physician supervision means that the NPP only performs medical acts and procedures that have been specifically authorized and directed by the supervising physician, according to the American Academy of Physician Assistants.

Get Your Credentials to Ensure Reimbursement

Most Medicare carriers credential NPPs and assign UPIN/PINs, so the NPPs may submit Medicare claims under their own UPIN/PIN.

However, many commercial payers do not assign provider numbers to NPPs, and claims are usually processed under the physician's name. Without their own PIN, NPPs must see patients and bill services as incident-to. "NPPs are usually credentialed by Medicare," Ferragamo says.

Many commercial carriers resist giving credentials to NPPs, however, because they would have to completely revamp their fee schedule to accommodate the NPP's services, Ferragamo says.

"Medicare in North Carolina credentials the PAs, so we have them credentialed and follow their (Medicare's) protocols," says Roseann Lightbody, CPC, of Urology Specialists in Charlotte, N.C.

But with private carriers, some will credential PAs and some will not, Lightbody says. "In North Carolina, there are more and more plans that credential the PAs, so we are able to bill most of our plans now, and if not, we bill and appeal the claim and sometimes we can overturn it."