Procedural Terminology Discussion

1. Prepare examples of various coding and billing issues that you have experienced in the clinical setting (Peds and women’s health).

2. Provide a brief description about the NPI numbers for nurse practitioners.

Answer:

According to the American Academy of Pediatricians. (2020), current Procedural Terminology (CPT) has specific guidelines for using time as a key factor in determining the level of evaluation and management (E/M) service. First, it is paramount to remember the key factors in determining the level of CPT code which include history, physical examination, and medical decision making for the service. The level of selecting most E/M codes would be determined by these three key factors. In the pediatric practice, pediatricians’ needs to take into consideration the additional time they spent with patients, because it might change the level of coding that is used. On the other hand, time is the key factor when the counseling, coordination of care, or both account for more than fifty percent of the face-to-face time with the patient and/or family. When this situation occurs, it is necessary to enter the total duration of counseling and/or coordination of care into the clinical notes, as well as a description of the counseling and/or coordination of care that took place.

For example, this future practitioner has performed a detailed history and examination, with the decision making as low complexity, and sixty minutes are spent with the patient; forty minutes of which are spent counseling the patient, the visit is coded 99205 which CPT guidelines indicate has a typical time of 60 minutes rather than 99203, which CPT guidelines indicate has a typical time of 30 minutes, for a new patient. (AAP, 2020). Besides, other issue in the office and other outpatient visits is that face-to-face time is defined as the amount of time the practitioner spends in the room with the patient. It does not include any other nurse time preparing the patient or giving injections. Coding to a general level or under coding could lead to a rejected or denied claim.

The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). The numbers do not carry other information about healthcare providers. As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that might need it for billing purposes

References

American Academy of Pediatricians. (2020). Coding Tips for Pediatricians: Evaluation and

Management Coding Strategies. Retrieved from https://www.aap.org/en-us/professional-resources/practice-transformation/getting-paid/Coding-at-the-AAP/Pages/Coding-Tips-for-Pediatricians-Evaluation-and-Management-Coding-Strategies.aspx

American Academy of Pediatricians. (2020). 2020 Coding and Reimbursement Tip Sheet for

Transition from Pediatric to Adult Health Care. Retrieved from https://www.gottransition.org/resource/? 2020-coding-tip-sheet

CMS. 2019. National Provider Identifier Standard (NPI). Retrieved from

https://www.cms.gov/Regulations-and-Guidance/Administrative-  Simplification/NationalProvIdentStand