the provider performed: CO2 Laser Condyloma Ablation penile, Penile Biopsy and Cystoscopy. The op report reads: "Procedure:* Genitalia prepped appears fashion.* Lidocaine jelly placed per urethra.* Inspection of the penis revealed the 2 more prominent condylomatous lesions and then several flat condylomatous lesions about 3 millimeters x 4 millimeters.* Couple other small areas that look like new condylomatous lesions.* I did use dilute ascetic acid.* I did not see any other areas of his acetowhite.* I used local anesthesia to numb up the areas on the penis.*
Then placed flexible cystoscope per urethra bladder. He did have a ring stricture at the bulbar urethra.* Narrowed but just let the cystoscope pass.* Once inside the bladder trabeculations noted.* Circumferential protrusion of the prostate was noted.* No tumors no stones no diverticuli.* Pulling into the prostatic urethra he had reasonably open bladder neck but elements of potential early median lobe as well as lateral lobe hypertrophy noted.* Visual obstruction of bladder neck noted.
Then used the scalpel to remove a condylomatous lesion.* Ventral mid shaft distal.* Sent this for by pathology.* The remaining lesions were treated using CO2 laser ablation 2.5-3 watts.* Lesions treated in their entirety.* Good hemostasis.* At the ventral aspect with a biopsy used silver nitrate stick for hemostasis.* Excellent hemostasis.* Antibiotic ointment applied."
I believe this should be coded: 54057, 11420, 52000.
Any input would be helpful…
AAPC National Advisory Board Member Angie Clements CPC, CPC-I, CEMC, CGSC, COSC, CCS, helped bring clarity to three medical coding modifiers that are most problematic to physician practices. The three challenging modifiers include -59, -25, and -24. Clements advises coders to review documentation to ensure it supports the modifier. Read Clements’ tips on the Kareo blog.
AAPC Knowledge Center
How to Bill for Nurse Practitioners and Physician Assistants
You would be hard pressed to find a medical practice in 2017 that does not use Physician Assistants (PAs) and Nurse Practitioners (NPs), also referred to as physician extenders or non-physician practitioners (NPPs).
Understanding how to properly bill and code for services provided by NPPs is imperative to running a cost-effective and efficient medical practice. Regulations vary by insurance companies and states, so both the physician and the NPP’s must stay current with practice guidelines and ongoing changes.
Nurse Practitioners and Physician Assistants have increasingly become a staple in most medical practices. NPs are nurses who hold a Master’s Degree or Doctor of Nursing Practice (DNP). PAs are certified (PA-C), usually holding a Master’s Degree as well. There are a number of reasons that medical practices utilize these mid-level providers:
- Reduced Salary expenses (as compared to a physician)
- Lower overhead costs
- Higher patient volumes
- Reduced insurance and liability costs
There are 3 basic types of reimbursement that Medicare provides for these non-physician providers (NPPs).
Direct pay is when the NPP holds their own Provider Identification Number (PIN). This reimburses the NPP (or practice) at 85% of the billable physician rate. It is very important that each of your mid-level providers receives his/her own National Provider Identifier (NPI) and be credentialed with each payer to bill under his/her PIN number, if possible, based on payer rules and regulations. However, many payers will not credential NPPs. Having the NPP credentialed allows practices to bill insurance companies directly when the “supervising physician” is either not on site or has not provided any care or input into patient’s plan of care.
“Incident to” billing is a way of billing outpatient services rendered in a physician’s office located in a separate office or in an institution, or in a patient’s home provided by a non-physician practitioner (NPP) (See MLN Matters SE0441). With incident to billing, the physician bills and collects 100% of Medicare’s allowable reimbursement. This type of billing is used when an NPP sees a patient in which the physician has performed the initial service and has initiated a Plan of Care or treatment plan. There are specific rules for this type of billing, the physician must be on site, in the suite, not just in the building, and provides direct supervision (the rules for home visits varies).
By filing a claim “Incident to”, the physician can collect 100% of the Medicare Physician Fee Schedule (MPFS) instead of 85% of the MPFS for care provided by a qualified NPP. New patients should be seen by the physician to set up the Plan of Care and this would be billed under the rendering physician. After the initial visit, the NPP can provide follow-up care based on the Plan of Care, billing for direct care as “Incident to”. If adjustments are made to the plan of care such as medication changes, then the physician should see the patient face to face in order to adjust the original plan of care, otherwise, the visit may not qualify for “Incident to” billing.
“Incident to” billing was developed by Medicare and not all commercial insurance carriers follow Medicare guidelines, therefore knowing payer regulations regarding “Incident-to” billing is imperative prior to providing patient care.
Split/shared expenses: “A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer.”
Billing for shared/split services allows the practice to bill under the qualified physician versus the NPP at their lower reimbursement rate. As long as the criteria are met, billing for shared/split services allows for that extra 15% reimbursement.
Documentation is paramount in this type of billing. Each practitioner must thoroughly document the care they provided to substantiate reimbursement under the split/share guidelines allowing both parties to bill for care.
According to the Centers for Medicare and Medicaid Services (CMS), shared/split visits are applicable for services rendered in the following settings:
- Hospital inpatient or outpatient
- Emergency department
- Hospital observation
- Hospital discharge
- Office or clinic (when “incident-to” requirement are met)
Shared/split visits are not allowed:
- In a skilled nursing facility or nursing facility setting
- For consultation services
- For critical care services
- For procedures
- In a patient’s home or domiciliary site
With shifts in healthcare spending, patient care, and reimbursement, and physician shortages, the need for Nurse Practitioners and Physician Assistants is greater than ever. A Proper understanding of the billing and reimbursement guidelines for individual payers is necessary. Charting and documentation requirements must be met.
Does your medical practice use NPs or Pas? Are you billing “Incident to”? Let me know in the comments below.
— This post Coding and Billing for NP and PA Providers in Your Medical Practice was written by Manny Oliverez and first appeared on Capture Billing. Capture Billing is a medical billing company helping medical practices get their insurance claims paid faster, easier and with less stress allowing doctors to focus on their patients.
Felicia Knox, CPC, CPB, AAPC Professional
- O80, encounter for full-term uncomplicated delivery
- M06.9, rheumatoid arthritis, unspecified
- Z37.-, birth status
- O26.89-, other specified pregnancy-related conditions
- M06.9, unless you have more specificity regarding the rheumatoid arthritis
- Outcome of delivery; A code from category Z37, Outcome of delivery, should be included on every maternal record when a delivery has occurred. These codes are not to be used on subsequent records or on the newborn record.
- CPT code 59514-22 (cesarean delivery only, with increased procedural service)
- ICD-10-CM code O82.0, encounter for cesarean delivery without indication
- ICD-10-CM code Z37.2
- ICD-10-CM code Z3A.-
- A baseline rate of 110–160 beats/min
- Moderate variability
- No late or variable decelerations
- Early decelerations being present or absent
- Accelerations being present or absent
- If FHR accelerations or moderate variability are detected, the fetus is unlikely to be currently acidemic
- If fetal heart accelerations are absent and variability is absent or minimal, the risk of fetal acidemia increases
- Category II tracings should be monitored closely and evaluated carefully
- Absent variability plus any one of the following:
- Recurrent late decelerations
- Recurrent variable decelerations