Warfarin therapy codes explained

Q: Can you provide additional information about the codes for warfarin therapy oversight that you mentioned in your November 19, 2010, column?

The Centers for Medicare and Medicaid Services (CMS) has elected to bundle the codes into any E/M service and, thus, they are not paid separately. Most commercial insurers follow these guidelines, but some practices have succeeded in negotiating with insurers (but not with CMS) to include payment for those codes separately. Other practices have carefully documented the level of support and contact needed in the interval between visits for those patients whose conditions are not well controlled and have added that documentation to the visit documentation. In doing so, however, it is imperative to contact the insurer and ascertain its policy.

BILLING FOR NURSE SERVICES

Q: I see patients in large assisted living facilities. A nurse follows up on medication management, vital signs with medication changes, wound care, and related tasks while I am in the facility but not with her. We review the patients' charts to determine whether I need to see someone she already has seen that day. She is my employee. I never have billed for her services. Should I be billing for them?

A: According to the Medicare Benefits Policy Manual, Chapter 15-Covered Medical and Other Services (Revision 131, dated 8.20.10), Section 60.1: the following is used to demonstrate supervision for "incident to" in an office setting and non-office setting:

"Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services. If auxiliary personnel perform services outside the office setting, e.g., in a patient's home or in an institution (other than hospital or [skilled nursing facility]), their services are covered incident to a physician's service only if there is direct supervision by the physician.

"For example, if a nurse accompanied the physician on house calls and administered an injection, the nurse's services are covered. If the same nurse made the calls alone and administered the injection, the services are not covered (even when billed by the physician) since the physician is not providing direct supervision. Services provided by auxiliary personnel in an institution (e.g., nursing, or convalescent home) present a special problem in determining whether direct physician supervision exists. The availability of the physician by telephone and the presence of the physician somewhere in the institution does not constitute direct supervision."

The only exception is when "incident-to" services are provided in a medically underserved area, and requirements must be met to bill those services.

In general, you were correct not to bill for the services of your nurse, because you were not physically present with the patient when the nurse rendered service. Direct supervision in a non-office setting requires that the physician be physically present with the patient when the service is rendered; this requirement is different from the one related to the provision of services in an office setting.

The author is president of Healthcare Consulting Associates of NW Ohio Inc., Waterville, and a Medical Economics editorial consultant. She has more than 30 years of experience as a practice management consultant and also is a certified coding specialist, certified compliance officer, and certified medical assistant.