Note: The patient’s current insurance carrier is Blue Cross Blue Shield of Massachusetts (BCBS of MA). Under BCBS of MA, nurse practitioners and nurse practitioner primary care providers are not allowed to perform or interpret radiology services. Therefore, the physician would have to order and interpret the ultrasound to be billable.
The supervising physician was on site, so the NP was billing the service as incident to the visit. The practice allows their NPs to bill only under incident-to; therefore, its NPs are not credentialed with BCBS of MA. View the BCBS of MA nurse practitioners and nurse practitioner primary care providers payment policy at https://acr.tw/2LBISRk.
Note: If the physician had conducted the shoulder ultrasound, it would be coded as follows:
CPT: 99213, 76881
ICD-10: M06.9
History: The history of present illness was brief. The review of systems was extended, and two of the three of the past, family and social history were documented, making the history an expanded, problem-focused level.
Exam: Using the 1995 documentation guidelines, six organ systems were examined, a detailed level.
Medical decision making: The diagnosis was worsening of an established problem (right shoulder). The amount of data and/or complexity of data to be reviewed included orders for a diagnostic ultrasound and a lab review—limited level. The level of risk—one or more chronic illnesses with mild exacerbation—is moderate. This makes the medical decision making a low-complexity level for this visit.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at [email protected]g or call 404-633-3777 x820.
