Coding questions answered: midlevel billing, waiving copays, and more

January 22, 2015



Q: Can a credentialed physician assistant or nurse practitioner see, and bill for, new patients without the physician being on site?

A: First, always check and verify the licensing restrictions and scope-of-practice rules in your state. These rules can vary from state to state.

Keep in mind that billing incident-to isn’t required by any payer, and is only recognized by Medicare and Aetna. If the NPP wishes to bill incident-to, the physician first must have seen the patient and established the plan of care for the problem being addressed by the NPP. We advise that the physician see the patient for the initial visit and establish the plan of care so that subsequent visits for that problem to be billed incident-to.

However, again, payers do not require incident-to billing, and the NPP has the option to treat a new patient.

If the NPP bills the payer directly, the claim should reflect the NPP as the “Servicing” and “Billing” provider.

Q: Does Medicare pay for ultrasound screening for abdominal aortic aneurysms (AAA) or screening fecal-occult blood tests (FOBT)?

A: A MLN Matters publication from the U.S. Centers for Medicare and Medicaid Services (CMS) dated October 17, 2014, made a retroactive effective date of January 27, 2014, for the updated requirements of ultrasound screening for AAA and screening FOBTs. The modifications of these requirements are detailed below.

Ultrasound for AAA

Coverage of AAA screening is modified by eliminating the one-year time limit with respect to the referral for this service.

This modification allows coverage of AAA screening for eligible beneficiaries without requiring them to receive a referral as part of the Initial Preventive Physical Examination (IPPE, also known as the “Welcome to Medicare Preventive Visit”). The beneficiary only needs to obtain a referral from his or her physician, physician assistant, nurse practitioner, or clinical nurse specialist. All other coverage requirements for this service remain unchanged, per 42 CFR 410.19.

Medicare beneficiaries must be at risk to be eligible for an abdominal aortic aneurysm screening. They are considered at risk if they meet one of these criteria:

  • A family history of abdominal aortic aneurysms.

  • A male age 65 to 75 who has smoked at least 100 cigarettes in his lifetime.

Screening FOBT

In addition to the beneficiary’s attending physician, the beneficiary’s attending physician assistant, nurse practitioner, or clinical nurse specialist may furnish written orders for screening FOBTs, per section 42 CFR 410.37(b). All other coverage requirements for this service remain unchanged, per 42 CFR 410.37.

Screening FOBT may be paid for beneficiaries who have attained age 50, and at a frequency of once every 12 months (i.e., at least 11 months have passed following the month in which the last covered screening FOBT was performed).

NEXT PAGE: Can physicians waive a patient's copay or deductible?

Q: Is it ever appropriate to waive a patient’s copayment or deductible?

A: Providers should not reduce the cost of care to a patient by waiving or forgiving a copayment, cost-share or deductible. To do so is a violation of the Anti-Kickback Statute and is considered fraud and abuse, which can result in fines and other legal action.

The Anti-Kickback Statute provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce or reward the referral of business reimbursable under Federal health care programs as defined in section 1128B(f) of the statute.

The offense is classified as a felony and is punishable by fines of up to $25,000 and imprisonment for up to five years. Violations may also result in program exclusions under section 1128(b)(7) of the Act (42 U.S.C. 1320a-7(b)(7)), and liability under the False Claims Act (31 U.S.C. 3729-33).

Q: Is it too late to order our 2015 ICD-10 Codebook?

A: With the ICD-10 (The International Classification of Diseases-10th revision) conversion scheduled for October 1, 2015, you still have time to order your ICD-10-CM book and schedule training for your practitioners and staff.

Please note: If you still need to order your ICD-10-CM book, or if you’ve already ordered and received it, you may not have the most current version with updates that were made to the official coding guidelines. The latest version was released only a few weeks ago, but not until after the 2015 books were published.

Whether you’ve received your codebook or have yet to order it, you can update it by going online to ICD-10 Guidelines Update and downloading a copy of the most recent official coding guidelines.

Changes to the guidelines are in bold, underlined items are those that have been moved, and revisions

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.

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