Photos, supervisors, cancer coding

March 1, 2007

The difference in payment between CPT codes 99211 and 99212 is approximately $16. If you undercode this just a couple of times a day, you could lose as much as $8,000 a year.

Q: I understand that there is a new CPT code for whole body integumentary photography. Is it enough to just take one or two photos? Or is there a minimum number of photos required to justify billing this code? Also, will carriers pay for it? And what kind of reimbursement can we expect? Is the code billed in units based on how many pictures we take?

96904: Whole body integumentary photography, for monitoring of high-risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma.

Several companies, I believe, have special equipment that can do whole body scanning or photography which is accurate and complete versus using an off-the-shelf digital camera. However, it doesn't matter what type of equipment you use as long as long as the entire body is photographed.

Since this is a new CPT code, carrier coverage policies are unknown. Providers who want to use this code for patients covered with commercial carriers should verify coverage before the service is rendered and/or have the patient sign a waiver in the event the service is not paid.

Medicare has allowed payment for this service at approximately $70. However, what type of criteria is required for coverage has not been published at this time. Providers who want to bill Medicare for this service should contact the carrier for guidelines or send one or two claims and carefully monitor payment before they implement the use of this code on a more frequent basis.

Note: HCPCS code 0044T was deleted as of Jan. 1, 2007.

Q: I know that the new CMS-1500 form has a space for the ordering versus the supervising physician. I get that part. What I want to know is, what exactly does a supervising physician do? Does the supervising provider have to sign the charts of the patients seen, or does he just have to peek his head inside the room and say "Hi" to the patient?

A: A supervising physician is a physician who is a member of your group who is present in the office when certain nonphysician providers or staff provides medical services to patients.

Two types of individuals are commonly supervised in the dermatology office setting: NPPs (nonphysician providers such as physician assistants and nurse practitioners) and auxiliary staff (such as medical assistants, nurses and technicians). Supervision is needed when the individual who is providing the medical service is not able to bill under his/her name to the insurance company because he/she has no contract with the carrier (such as medical assistants, nurses and technicians), or he/she is billing incident to the physician, in which case the service is billed under the name and NPI number of the physician, although it is provided by someone else. The criteria for incident to must be met before services can be billed as incident to (e.g., an established patient with an established problem performed under the direct supervision of the physician, which means the physician must be on site but does not personally have to see the patient).

NPPs who are not billing under their own name and NPI number can only render services when there is a physician or provider on site (e.g., the supervising provider) and the service rendered has been ordered by a provider (e.g., established patient with an established problem).

Medical assistants or nurses can only provide services that they are allowed to bill per their license (LPNs or RNs), those that are allowed by state law, and/or those allowed by the insurance carrier to whom the bill will be sent.