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services ordinarily performed by the physician such as minor surgery, setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patient’s condition. Nonetheless, in order for services of a nonphysician practitioner to be covered as incident to the services of a physician, the services must meet all of the requirements for coverage specified in §§60 through 60.1. For example, the services must be an integral, although incidental, part of the physician’s personal professional services, and they must be performed under the physician’s direct supervision. A nonphysician practitioner such as a physician assistant or a nurse practitioner may be licensed under State law to perform a specific medical procedure and may be able to perform the procedure without physician supervision and have the service separately covered and paid for by Medicare as a physician assistant’s or nurse practitioner’s service. However, in order to have that same service covered as incident to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician’s personal in-office service. As explained in §60.1, this does not mean that each occasion of an incidental service performed by a nonphysician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary. Incident-To Services on Form CMS-1500 Medicare Claims Processing Manual – Chapter 26 - §10.4 - Items 14-33 - Provider of Service or Supplier Information = (Rev. 1215, Issued: 03-30-07, Effective: 04-01-07, Implementation: 04-30-07) Item 17 When a service is incident to the service of a physician or non-physician practitioner, the name of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in item 17; Item 17a Enter the ID qualifier 1G, followed by the CMS assigned UPIN of the referring/ordering physician listed in item 17. Under Medicare’s NPI contingency plan, the UPIN may be reported on the Form CMS-1500 and MUST be reported if an NPI is not available. Item 17b Item 24J Enter the NPI of the referring/ordering physician listed in item 17 as soon as it is available. During Medicare’s NPI contingency plan, enter the rendering provider’s PIN in the shaded portion. In the case of a service provided incident to the service of a physician or nonphysician practitioner, when the person who ordered the service is not supervising, enter the PIN of the supervisor in the shaded portion. Enter the rendering provider’s NPI number in the lower portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower portion. OFFICE/OUTPATIENT VISITS – CPT CODES 99201-99215 A. Definition of New Patient for Selection of E/M Visit Code Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M 5-26 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient. Newby Note: If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physician should select a level of service representative of the combined visits and submit the appropriate code for that level. Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group. There is no difference if the group physicians are located in the same or different buildings. Therefore, even though a physician may be located on another campus, if a patient previously cared for by the same specialty physician in the same group within the previous three years is seen by a group physician of the same specialty at a setting apart from where his/her care is generally rendered and where his/her medical records may be located, for billing purposes, that patient remains an established patient for that same group, same specialty physician. It is the group’s responsibility to coordinate record keeping when different locations are involved. Changing Group Practices Dr. Smith leaves his/her practice in Indianapolis to join a new practice in Carmel. If Dr. Smith, or another physician of the same specialty in the Carmel practice, has not provided any professional services to that patient within the past three years, then Dr. Smith would consider the patient a new patient. If Dr. Smith has rendered professional services to the patient in either the Indianapolis or Carmel practice within the past three years, the patient is considered established to Dr. Smith. If Dr. Smith saw the patient in Indianapolis, but one of the Carmel physicians sees the patient, the patient would be considered new. B. Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems As for all other E/M services except where specifically noted, Carriers may not pay two E/M office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office or outpatient setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident). C. Office/Outpatient or Emergency Department E/M Visit on Day of Admission to Nursing Facility Carriers may not pay a physician for an emergency department visit or an office visit and a comprehensive nursing facility assessment on the same day. Bundle E/M visits on the same date provided in sites other than the nursing facility into the initial nursing facility care code when performed on the same date as the nursing facility admission by the same physician. D. Drug Administration Services and E/M Visits Billed on Same Day of Service Carriers must advise physicians that CPT code 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or nonchemotherapy drug infusion code (effective January 1, 2004). This drug administration policy was expanded in the Physician Fee Schedule Final Rule, November 15, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005). Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to one of these drug 5-27 *All CPT Codes, Descriptions, and Two-Digit Modifiers Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01 Copyright 2007 Newby Consulting, Inc.
Page 1 and 2: PQRI MEASURE CODING AND REPORTING P
Page 3 and 4: ! The line item charge should be $0
Page 5 and 6: ICD-9: 250.00-250.93, 648.00-648.04
Page 7 and 8: _____ _____ _____ _____ _____ Beta-
Page 9 and 10: Definition: Pharmacologic Therapy:
Page 11 and 12: Definition: Characterization includ
Page 13 and 14: eport the proper CPT II Category II
Page 15 and 16: • Physicians and qualified nonphy
Page 17 and 18: preoperative medical evaluation (if
Page 19 and 20: The excision of malignant lesion co
Page 21 and 22: complex repairs (CPT codes 13100-13
Page 23 and 24: HEMORRHOIDECTOMY BY SIMPLE LIGATURE
Page 25: Medicare “Incident to Clarificati
Page 29 and 30: HOSPITAL OBSERVATION SERVICES - CPT
Page 31 and 32: If the physicians are each responsi
Page 33 and 34: documented. If the time is not docu
Page 35 and 36: Follow-Up Consultation Service Effe
Page 37 and 38: A physician (primary care or specia
Page 39 and 40: typical severity of the problem(s)
Page 41 and 42: Medicare Part B payment policy does
Page 43 and 44: HOME SERVICES - CPT CODES 99341-993
Page 45 and 46: the medical records must clearly do

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