Coding insights: Home visit billing

Q: Under incident-to guidelines, does the physician have to see the patient for the initial new problem? If the physician assistant (PA) sees the patient for two visits, then our physician sees them and develops a new plan of care, can the PA carry out that plan of care and bill incident-to?

A: In the scenario you explained, these first two visits do not meet the incident-to guidelines, so the PA would bill the two visits under his/her National Provider Number (NPI) if the insurance company being billed credentials PAs. If the payer does not credential PAs, the claim would need to be billed under the supervising physician, meaning the physician on-site in the clinic when the services are rendered.

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Once the physician sees the patient and develops the plan of care, the PA can bill the subsequent services under the physician’s NPI if the payer recognizes incident-to guidelines. If the payer does not follow incident-to guidelines, the PA billing would follow my explanation in the first paragraph.

In our area of the country, we have only two payers who follow incident-to guidelines: Medicare and Aetna. Therefore, for all other payers we ask the following question to know how to bill the claim.

Does the payer credential the practitioner providing the services?

Yes-Bill under the practitioner’s NPI.

No-Bill under the NPI of the physician who is in the office at the time of service. Incident-to guidelines do not apply because the payer does not recognize them.

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Q: I have a mobile health care clinic in Florida. Does our physician medical director have to visit the patients or can the Advanced Registered Nurse Practitioner (ARNP) visit the patient under the supervision of the medical director?

A: Medicare addresses billing for home visits in the Medicare Benefit Policy Manual, "Chapter 15 – Covered Medical and Other Health Services, Section 6.4, Services Incident to a Physician’s Service to Homebound Patients Under General Physician Supervision."

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The only time that an ARNP or other midlevel practitioner can bill his/her home services under a physician’s National Provider Identifier (NPI) under general supervision (as opposed to direct supervision) is when the services are being performed in a medically underserved area where there are only a few physicians available to provide services in a large geographic area or to a large patient population.

If your service area includes medically underserved area(s), there are several additional guidelines that must be met:

• When a patient meets the definition of “homebound” and is confined to his/her “place of residence,”

• the service is an integral part of the physician’s service to the patient, and the services must be performed under the physician’s overall supervision and control,

• the services are included in the physician or clinic’s bill and are reasonable and necessary as defined in the Medicare Benefit Policy Manual, Chapter 16, “General Exclusions from Coverage,” §20.

When services are provided by a home health agency, the services cannot be furnished by a physician or clinic to a homebound patient. For instance, injections are covered skilled nursing home services, so they could not be covered as home health services if the patient is eligible for home health benefits and there is a home health agency available.

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Q: Our practice frequently trims the toenails of elderly patients. Is there a way we can code and bill for this service?

A: There is a specific CPT code for nail trimming:

• 11719: Trimming of nondystrophic nails, any number.

This code is used when the physician trims one or more fingernail or toenail usually with scissors, nail cutters, or other instrument(s) when the nails are not defective from nutritional or metabolic abnormalities.

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This code has restricted coverage, which means that special coverage instructions apply. If the service is covered, it is carrier priced. So you should check with each carrier to see if it is covered. If the patient’s insurance doesn’t cover this service, it would be the patient’s responsibility.

Regardless of coverage, this is the code that should be utilized. It would be inappropriate to bill an Evaluation and Management (E/M) code when a CPT code that describes the service is available.

Additionally, an E/M code can only be billed based on time when greater than 50% of the visit time is spent counseling and/or coordinating care.

Answers to readers' questions were provided by Renee Dowling, a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your billing and coding questions to medec@advanstar.com.