Medical Review Frequently Asked Questions - January 2006
The following represent a variety of questions the Medical Review department has received. CIGNA Government Services will address at least quarterly quarterly "Frequently Asked Questions" related to coverage and local coverage determination issues. Providers may submit questions to the Web site at http://www.cignagovernmentservices.com/customer_service/disclaimer.html.
- Physician Extenders
Q: Can "physician extenders" such as nurse practitioners, physician assistants, certified nurse midwives, or RN's perform subsequent hospital visits or discharges from the hospital?
A: "Nonphysician practitioners" such as nurse practitioners, physician assistants, etc. could perform subsequent hospital visits and discharge visits provided these were billed under their own performing provider number. They could not perform the work then bill these services under a physician's performing provider number as this would be "incident to", and "incident to" is not allowed in the hospital setting.
There are no services that could be performed by a registered nurse (i.e. as an employee of the billing provider) that could be billed to Medicare.
Non-physician practitioners (NPP) may perform subsequent hospital and discharge visits as "split/shared" services (i.e. billed under the physician's provider number) if the NPP visits are medically necessary according to the individual patient's circumstances and performed and documented independent of the physician's visit. The physician's visit must be a separate, medically necessary face-to-face encounter with the patient. The physician's visit cannot simply be for signing off behind the NPP's note/visit.
- Modifier 25 and Ear Lavage
Q: Can an established patient visit and ear lavage be paid the same dos?
A: Ear lavage to remove ear wax would be considered part of an evaluation and management visit. Ear lavage may be done by either the physician or his/her staff. If a patient had impacted cerumen removed by the physician (e.g. via curettes) then CPT code 69210 could be billed. (Removing wax that is not impacted does not warrant the reporting of CPT code 69210)
As far as billing an E&M visit in addition to removal of impacted cerumen, visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to irrigating the ears if, for example, a neurological assessment was medically necessary — i.e. done because the patient exhibited symptoms beyond those attributable to impacted cerumen: but, billing for a visit would not be appropriate if the physician only identified the need to remove the impacted cerumen. (See CMS Publication 100-4, the Claims Processing Manual, Chapter 12, section 40.1, subsection C via the attached link: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf
). - Split/shared visits and Consultations
Q: Can a consultation be "split/shared"?
A: No, a consult visit cannot be "split/shared" as asserted in attached Medlearn Matters article as published by CMS. Other services that cannot be "split/shared" include critical care procedures, and E&M services in nursing facilities and skilled nursing facilities.
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4215.pdf
- Pharmacists' services and Office Visits
Q: Can a pharmacist bill "incident to" when providing medication counseling in a physician's office?
A: No, because there is no benefit category under Medicare for pharmacists so the only level they might qualify for billing under the physician's number (provided all "incident to" requirements were met) would be CPT code 99211 (the lowest level established patient office visit); and pharmacists may not "split/share" visits with physicians/non-physician practitioners.
- Marriage Counseling and Family Psychotherapy
Q: Can CPT codes 90867 and 90847 be billed for marriage counseling?
A: No, marriage counseling is not family psychotherapy as represented by CPT codes 90846 and 90847. Family psychotherapy is covered by when the primary purpose of such counseling is the treatment of the patient's condition. For example, two situations where FAMILY counseling services would be appropriate are as follows:
- where there is a need to observe the patient's interaction with FAMILY members; and/or
- where there is a need to assess the capability of and assist the FAMILY members in aiding in the management of the patient.
See CMS Publication 100-3, the National Coverage Determinations Manual, Chapter 1, Section 70.1 via the following link:
