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Answers to a Few Common Coding and Billing Questions

These days, you just can’t overemphasize how important it is to make sure every clinician is working at the top of his or her license. It simply isn’t cost-effective to have registered nurses, for instance, performing clerical duties.

Lots of practices seem to have this in mind when they ask about billing for their nurse practitioners (NPs), physician assistants (PAs), and other non-physician providers (NPPs). Most want to know about the basic advantages and disadvantages of billing for NPPs under their own Medicare billing numbers. Here’s my response:

The biggest advantage of allowing an NPP to bill under his/her own billing number is that you don’t have to worry about incident-to guidelines, which limit how and where an NPP-patient encounter can take place. Under his or her own number, for example, an NPP can see a new patient, or a patient in the hospital. By contrast, billing under the physician’s number requires direct personal supervision (that is, the physician must be in the office suite). NPPs also aren’t allowed to see new patients if they bill incident-to under the physician’s number.

The use of NPPs will allow your physicians freedom within their schedules to generate additional revenue through new patient encounters, surgery, etc. The main disadvantage is that payment under the NPP’s number is limited to 85% of the physician fee schedule reimbursement. If the same procedure or service is billed incident-to using the physician’s billing number, it is paid at 100% of the fee schedule amount.

Another common question I receive involves the correct coding of diagnostic tests for patients with signs or symptoms. Figuring out whether to report the pre-test or post-test diagnosis to support the claim can get confusing, because it depends on the result of the test.

Medicare guidelines state, “If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis.” So, for example, if a patient is referred to a radiologist with a diagnosis of abdominal pain, and an abdominal CT scan reveals the presence of an abscess, the correct diagnosis would be “intra-abdominal abscess.”

Medicare also says, “If the diagnostic test did not provide a diagnosis or was normal, the interpreting physician should code the sign(s) or symptom(s) that prompted the treating physician to order the study.” Using the same example above, a CT scan that didn’t show anything would be coded to the abdominal pain. (All of this information comes from the Medicare Claims Processing Manual, Chapter 23, Section 10.1.)

Remember that when there are no signs or symptoms, then the test is not considered a diagnostic test at all, but rather a screening test. When a screening test is performed, the appropriate screening diagnosis code must be the primary diagnosis, regardless of whether the test returns positive or negative.

Another frequently-asked coding question that’s really interesting to me pertains to distinct procedure modifier 59—which is something many claims editing functions help to address. The problem crops up when a practice uses modifier 59 to override a Correct Coding Initiative (CCI) edit, but the claim is still denied. Many coders and billers wonder if they’ve used the wrong modifier.

While possible, it’s unlikely. Modifier 59 was specifically introduced to bypass CCI edits. It’s more likely that the edit you were trying to override had a modifier indicator of “0,” which means it can’t be bypassed under any circumstances—even if you use a modifier. Many edits have a modifier indicator of “1,” which means they can be bypassed with modifier 59 (or another modifier, depending on the circumstances) when, for example, the two procedures are performed on different body locations or at different times on the same day.

There is no doubting the complexity of coding and billing practices. It’s tough to stay current with rules that seem to change every day. So, as questions arise, please feel free to submit them in the comment box below. We’d love to keep providing you with answers.