Wiki How to bill NP or EP when pt seen for injection only

[gr8gal61]

I am working with a "wellness" clinic and the patients are seen for one specific company. Often, a patient comes in for a flu injection only. The patient has never been seen however in order to gain their wellness benefits, under their corporation they are required to get immunizations.

The patient comes in and simply is seen by the MA, receives an injection & out the door. I have been billing the flu shot along with administration code only. The patient then returns for a complete wellness exam with the MD. I then bill for a NEW patient exam along with any other services.

Is this correct? I have previously worked elsewhere & the reimbursement rate is better when the patient visits with the MD versus a low level NP exam. The MD should get paid for the services of the HPI, ROS, PE etc whereas the nurse does none of this.

HELP

 

[CodingKing]

Sounds correct to me. I dont think it's any differect than getting pre appointment blood work or going in to a practice for an xray prior to being seen for a visit with an orthopedic doc

 

[Pam Warren]

Are you getting paid for the new patient visit? I would argue that the flu shot (billed incident to the provider as a professional service) makes the following visit with the physician an established one. If you read the CPT book, the criteria for not meeting a new patient is not "a face to face visit", but "any professional service". The flu shot is a professional service.

Your call.

 

[lgardner]

Are you getting paid for the new patient visit? I would argue that the flu shot (billed incident to the provider as a professional service) makes the following visit with the physician an established one. If you read the CPT book, the criteria for not meeting a new patient is not "a face to face visit", but "any professional service". The flu shot is a professional service.

Your call.

I had thought the same thing and my boss kept telling me that flu shots (and a few other services) did not fall under "incident-to" guidelines. I wanted to see this stated in black and white and FINALLY...I recently found this from CMS:

"Must a supervising physician be physically present when flu shots, EKGs, Laboratory tests, or X-rays are performed in an office setting in order to be billed as ?incident to? services?
These services have their own statutory benefit categories and are subject to the rules applicable to their specific category. They are not "incident to" services and the "incident to" rules do not apply."

here is the link to MLN Matters #SE0441:
https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/se0441.pdf

see the 3rd page.

I really do learn something new every day.

 

[thomas7331]

Actually CPT does define a professional service as a face-to-face service, so if the documentation of the vaccination showed that the patient did not see the provider, then I believe you have a good argument that the patient was new.

Having said that, in actual practice I have found that it's very difficult to predict how a payer will make their determination as to whether or not the patient is new, and payers don't even follow their own policies all the time. The claims logic varies by payer as to what criteria they use and is never transparent.

A good question to ask is whether or not this is going to produce a lot of denials for you, and whether or not you will find that the benefits of billing new patient codes will be outweighed by any costs of having to deal with the denials and write appeals. I agree with Pam that it's really your call.