Billing and coding for advanced clinical practitioners

Melissa’s Mention…

“A 67-year-old patient with diabetes shows up for her appointment. Her A1C levels are high. She reveals during the visit with the advanced practice clinician that she’s not taking her medication as prescribed. The patient’s physician is doing rounds at the hospital and is, thus, unavailable to consult with the patient in person.

At this point, the practice needs to answer a couple questions:

Can the nurse practitioner (NP) or physician assistant (PA) bill the visit under his/her own national provider identification (NPI) number?
Or, is the visit appropriate for “incident to” billing and, thus, billable under the physician who created the patient’s care plan?

It depends, says Kim Huey, CPC, president of Birmingham, Ala.-based KGG Coding and Reimbursement Consulting, which helps physician practices improve coding and documentation of service as well as ensure compliance with Medicare and insurance company regulations.

If the physician only recommended metformin in the care plan, and that medication hasn’t been used by the patient, the advanced practice clinician needs to create a new plan of care or bring another physician into the patient’s room to develop a plan of care, Huey says. In the first scenario, the practice can bill Medicare 85 percent for the visit because it’s billed under the advanced practice clinician, whereas in the second, Medicare is billed 100 percent because the newly-introduced physician developed the plan of care upon conducting a visit with the patient…”

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View all Articles by: Melissa Clark, CCS-P