Tuesday, April 9, 2013

NPI (National Provider Identifier) and the relationship to the PTAN (Provider Transaction Access Number)

I rec'd this info from a work associate this week, it is GREAT information regarding the NPI number and the PTAN...  

National Provider Identifier (NPI)

The NPI is a national standard under the Health Insurance Portability and
Accountability Act (HIPAA) Administrative Simplification provisions.

• The NPI is a unique identification number for covered health care

• The NPI is issued by the National Plan and Provider Enumeration
System (NPPES).

• Covered health care providers and all health plans and health care
clearinghouses must use the NPI in the administrative and financial transactions
(for example, insurance claims) adopted under HIPAA.

• The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). The NPI does not carry information about healthcare providers, such as
the state in which they live or their medical specialty. This reduces the chances
of insurance fraud.

• Covered providers and suppliers must share their NPI with other suppliers and providers, health plans, clearinghouses, and any entity that may
need it for billing purposes.

As of May 23, 2008, Medicare has required that the NPI be used in place of all
legacy provider identifiers, including the Unique Physician Identification Number
(UPIN), as the unique identifier for all providers, and suppliers in HIPAA standard

You should note that individual health care providers (including physicians who
are sole proprietors) may obtain only one NPI for themselves (Entity Type 1

Incorporated individuals should obtain one NPI for themselves (Entity
Type 1 Individual) if they are health care providers and an additional NPI(s) for
their corporation(s) (Entity Type 2 Organization).

Organizations that render health care or furnish health care supplies may obtain NPIs (Entity Type 2 Organization) for their organizations and their subparts (if applicable).

For more information about the NPI, visit the NPPES website at https://
nppes.cms.hhs.gov/NPPES/Welcome.do on the CMS website.

Provider Transaction Access Number (PTAN)
A PTAN is a Medicare-only number issued to providers by Medicare contractors
upon enrollment to Medicare. When a Medicare contractor approves enrollment
and issues an approval letter, the letter will contain the PTAN assigned to the

• The approval letter will note that the NPI must be used to bill the
Medicare program and that the PTAN will be used to authenticate the provider
when using Medicare contractor self-help tools such as the Interactive Voice
Response (IVR) phone system, internet portal, on-line application status, etc..

• The PTAN's use should generally be limited to the provider’s contacts
with Medicare contractors.

Relationship of the NPI to the PTAN

The NPI and the PTAN are related to each other for Medicare purposes. A
provider must have one NPI and will have one, or more, PTAN(s) related to it
in the Medicare system, representing the provider’s enrollment. If the provider
has relationships with one or more medical groups or practices or with multiple
Medicare contractors, separate PTANS are generally assigned.

Together, the NPI and PTAN identify the provider, or supplier in the Medicare
program. CMS maintains both the NPI and PTAN in the Provider Enrollment
Chain & Ownership System (PECOS), the master provider and supplier
enrollment system.

IVF twins born on different dates: A coding case study

This post, is a synopsis of an article that I wrote for HCPro back in 2012.  This is a GREAT representation of a difficult coding scenario -  Definately worth reading!  : )  

Comprehensive maternity care and delivery can present some very difficult clinical cases which in turn create complex coding cases for OB/Gyn, Family Practice and Maternal Fetal Medicine based providers.

In a perfect clinical setting, everyone would like to have a happy outcome in all maternity and reproductive medicine cases, unfortunately, some cases do not have a happy outcome. As coders, we are lucky to be a part of the technological and scientific advances in reproductive medicine. However, these technical and scientific advances have created coding and billing challenges that were not part of our education just a few short years ago.

In Vitro Fertilization also known as IVF, is the process of fertilization by manually combining an egg and sperm in a reproductive laboratory setting. If the IVF procedure is successful, the next step in the process is a procedure known as an embryo transfer, which involves physically placing the embryo in the uterus. Reproductive medicine specialists may transfer more than one embryo at a time. The outcome of this transfer, can create a multiple embryo implantation within the uterus (multiple gestation) or can also result in none of the
embryo’s implanting.

According to the American Society for Reproductive Medicine, IVF brings with it the opportunity for a maternity patient to have more complex antepartum maternal risk factors such as

  • Preterm (early) labor (with possible risks to the infant)
  • Preterm (early) delivery
  • Maternal Hemorrhage
  • Cesarean delivery
  • Pregnancy-induced high blood pressure
  • Gestational Diabetes

Statistical data for IVF, notes that the rate of pregnancy loss and/or miscarriage following an IVF are similar to the rates of pregnancy and/or miscarriage from natural conception.

In the coding case study below, it brings to light a twin pregnancy, with each twin delivered
on different days.  Certainly, not the norm, but interesting!

Case Synopsis
In this case study, the patient is pregnant with twins via IVF and has gone into premature labor at 20 weeks gestation (and has had 5 antenatal visits with her Obstetrician) . In the patients’ course of care, she required an emergent admission, and the outcome was an unfortunate one.

Today, the patient is admitted to an inpatient hospital at 20 and 4/7’s weeks in preterm labor with cervical incompetence, pre-term labor and spotting. After a 2-day subsequent stay post admission to the Labor and Delivery unit, the first infant (baby A) delivered prematurely vaginally, and was born alive, and given comfort care only. The placenta did not deliver. The patient is still preganant with baby B.

Patient is still undergoing inpatient care, and on inpatient subsequent day 12, the patient has now progressed into labor again (despite many other antepartum interventions to prevent this from happening). The patient then has a spontaneous rupture of membranes for baby “B” now 9 days post delivery of baby A. This spontaneous labor and delivery produced a non-viable infant that was delivered vaginally without a visible heart rate. Both placenta’s were then delivered vaginally, as well. Patient was discharged 24 hours post the
second delivery,

The coder, then has the challenge of coding and billing this complex scenario for the delivering obstetrician. How this case is coded may be dependent upon how the 3rd party payer would like to have this done so here are some options for you to consider. It is advisable to code the entire case once the patient has been discharged from the inpatient facility.

Coding Consideration: All E&M codes to be reported would be dependent upon the provider documentation noted in the patient record, and subject to CPT criteria for history, exam and medical decision-making as per CPT guidelines, and audit by the coder.

Emergent Inpatient Admission for Pre-term Labor Codes 99221-99223
  • Subsequent Inpatient day 2: 99231-99233
  • Subsequent Inpatient day 3: 99231-99233-25 Delivery of Baby A (59409) as live birth
  • Subsequent Inpatient days 4-11 99231-99233
  • Subsequent Inpatient day 12 99231-99233-25 Delivery of Baby B (59409-51 -59) as stillbirth

The next coding issue becomes the diagnosis for the care rendered. Here are some diagnosis codes to be considered, but again would be coded based upon ICD-9cm coding guidelines, and the physician documentation within the medical record:
  • Twin pregnancy (code 651.XX)
  • Early onset of delivery (code 644.2X)
  • Cervical incompetence (code 654.5X)
  • Premature Rupture of membranes (code 658.1X)

Status “V” Codes:
  • V23.85 Pregnancy resulting from in vitro fertilization
  • V27.0 Single liveborn (first delivery baby “A “liveborn)
  • V27.1 Single stillborn (second delivery – Baby”B” 9 days later)

The delivery records can still show that initially there were twins on-board, but they were delivered as “separate, single infants”

The diagnosis of the above coding scenario is very complex, and again will require the coder and the 3rd party payer to communicate as to how best the payer would like to have the claim submitted. In a best case – best practice the steps below can help facilitate this process.

1) Review all services provided by each entity. Don’t forget to code any ancillary services if they were provided, such as a cerclage administration, cerclage removal, ultrasound interpretation, or fetal non-stress test interpretation, Review and audit all documentation for subsequent day stays, and associated diagnoses for each date.

2) Submit the complete claim after the patient is discharged. The entire length of stay should be included, and all services and diagnoses correctly associated on your claim form.

3) Submit the claim via a paper process, and include all records and documentation to the 3rd party payer.

4) Review and submit the antepartum care to the payer, for all antepartum services rendered prior to the deliveries. (In this scenario, the patient had received 5 antepartum visits, and the provider could bill CPT code 59425 in addition to the delivery codes (59409)

5) Once the patient has returned to visit the OB provider within the 2/6 week postpartum timeframe, the postpartum care can be billed with CPT code 59430.

6) Follow up with the 3rd party insurance payer to ensure they have received your claim, and answer any questions that may arise due to the complex nature of the case.

The case study above is not a typical representation of most maternity cases. These non-typical or difficult scenarios provide the coder an opportunity for critical thinking and insight as to how to code for these difficult cases.

References include:
ACOG - American Congress of Obstetricians and Gynecologists: http://www.acog.org/
American Society for Reproductive Medicine: http://www.asrm.org