“Incident-to” vs “Direct” Billing

Question:

Our nurse practitioner saw a new patient (Medicare) in the office to evaluate sinus complaints. The nurse practitioner developed the plan of care. The patient was scheduled to follow up with the Nurse Practitioner. The patient returned to the nurse practitioner for a return visit with the same problem, and there were no changes in the plan of care. Can the NP bill this “Incident to” the physician since it is an established patient with an established plan of care and the physician was in the office?

Answer:

This is a great question. While the second visit is for an established patient with no change in the care plan, the nurse practitioner must still bill it as “direct.” To move this to an “Incident-to” encounter, there must be an independent encounter with the physician develops the plan of care.

*This response is based on the best information available as of 12/5/24.

ENT Modifier 25

Question:

Does the following scenario meet the modifier 25, “significant, separate service” rules? 

The patient presents with watery eyes, sinus, nasal congestion, and drainage.   The physician evaluates the patient and does a nasal endoscopy to evaluate the upper airway further.   The physician diagnoses the patient as having acute sinusitis and writes a prescription for an antibiotic.  Instructions are given on taking the medications and following up if the patient has seen no improvement after 72 hours.   

May we report an E&M-25 and the nasal endoscopy?

Answer:

Yes, the scenario you present meets the definition of modifier 25. The E&M was not performed for the purpose of the nasal endoscopy, and the physician had additional decision-making related to the management of the sinusitis.

*This response is based on the best information available as of 11/14/24.

ENT Modifier 24

Question:

Q: My physician saw a patient three weeks post-op after an adenoidectomy. The patient is complaining of ear pain at this visit. Can I report am E/M service with Modifier 24?

Answer:

According to CPT and Medicare payment rules, an unrelated problem evaluated and managed during the global period is reportable. The unrelated diagnosis is the “key” to reporting the E&M service during the global period. Modifier 24 must be linked to identify the E&M as unrelated to the surgical procedure during the global period.

Verify that there is not a payor-specific rule, for example, that assigns different global days, e.g., 30 days versus 10 days, to the procedure. Appeal all inappropriate denials. Track the pattern of denials by payor to determine if the trend is payor-specific.

*This response is based on the best information available as of 10/31/24.

New Versus Established in the Office

Question:

We are an otolaryngology practice, and we added a facial plastic surgeon to our group. If he sees one of our established patients for the first time in the office, would that be a new or established patient for the plastic surgeon? He does not share the same taxonomy or specialty code with our Otolaryngologists and is credentialed as specialty code 24.

Answer:

This is a great question. Since the Facial Plastic surgeon is credentialed as specialty 24 and Otolaryngology is credentialed as specialty 04, the patient would be considered a new patient for the plastic surgeon. Understanding the coding rules for new versus established patients in the office or outpatient setting is important.

A new patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.

An established patient has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the same specialty and subspecialty who belongs to the same group practice within the past three years.

*This response is based on the best information available as of 10/17/24.

Neck Dissection

Question:

My physician did a total thyroidectomy with a modified radical neck dissection.  Can I report the radical neck dissection with the thyroidectomy?

Answer:

If your physician performed the total thyroidectomy using CPT code 60240 and modified radical neck dissection (38724), both procedures may be reported during the same operative session.  The first listed code on the claim should be CPT 38724. Modifier 59 should be appended to CPT code 60240 (lower RVU) since it is bundled under the National Correct Coding Initiative.

*This response is based on the best information available as of 9/5/24.

Microtia Surgery

Question:

What CPT code is appropriate for creating a cutaneous pocket fashioned for the framework for stage 1 of a microtia surgery? 

Answer:

The appropriate code for creating a cutaneous pocket in the context of stage 1 microtia surgery is CPT 14061 (adjacent tissue transfer).  This code corresponds to the procedure involving creating a cutaneous pocket in the right ear and transferring. The cutaneous pocket is essential for accommodating the framework created during reconstruction.  Since the code is selected based on anatomic location and sq centimeter size be sure to document this information in the operative report. 

*This response is based on the best information available as of 7/11/24.