# NPP Admissions and Discharges ???



## cweavercpc (Dec 22, 2008)

Can Nurse Practitioners bill 99223 Admit code or a 99238 DC code in the hospital??? I did not think any hospital really gave NP's admitting privelages ... so when an NP sees the initial visit in the hospital and the doctor does not go behind the practitioner... can we bill and admit code for the NP or are we forced to bill a subsequent visit? Same scenario for a Discharge... Plz Help!


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## LLovett (Dec 22, 2008)

I have never billed it under any of the NPPs that I have worked with. I was reading thru the Medicare claims processing manual for Physicians and Non Physician Practicioners. Every time they refer to those codes they use the term "physician". Which leads me to think that is they only type of provider they will cover those codes for.

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

Good luck,

Laura, CPC


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## Lisa Bledsoe (Dec 22, 2008)

Actually I think it is based on the individual States Scope of Practice...but I'm not 100% sure on that.  Would like to see other comments here.


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## cweavercpc (Dec 22, 2008)

*Thank you Laura !*

I too think the same thing, however our providers seem to think it is possible to bill. So I am still struggling with this.  Even in reading the codes descriptors it states physician.. but it also states this for things such as the subs visits which we know we can bill under NP.  The physcian took one look at the Chapter 12 section 120 regarding NP's and states we can bill.  I guess my struggle is with the code itself. Does and admit code scream "admission" or is this the code for the work up of the patient, which would be okay if done by a NP? Any other thoughts would be appreciated ! Thank you !


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## Lisa Bledsoe (Dec 23, 2008)

You might be taking the term "physicians" too literally.  Even office E/M codes state "physicians" in the CPT manual.  Just a thought.


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## cweavercpc (Dec 23, 2008)

*Thanks Lisa...*

I very may well be... I have since talked with Medicare and they couldn't seem to find anything that specifically stated we could not.. but could not find anything that said yes for sure... of coarse one article will lead you to the next... which leads to another question and so on... Of coarse Medicare says they will consider the claim but that does not mean it will pay.  I do remember also reading that physicians do have to see all new patients even if it has to be a shared visit... so that posed another problem with the admits.. are they an established patient or new to our practice? I am still unsure and would love to see more posts. Thanks for all of your input !!!


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## Lisa Bledsoe (Dec 23, 2008)

As far as Medicare, I believe a new patient can be seen by an NPP, but they cannot bill incident to; they would have to bill under their own NPI.  I believe this is especially true for Nurse Practitioners...but it must fall under their state scope of practice.  Someone correct me if I'm wrong please.


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## aguelfi (Jan 9, 2009)

I am dealing w/ this very same thing and I have found this from CMS.
Under what circumstances are nurse practitioners (NPs) and clinical nurse specialists (CNSs) authorized to bill Medicare carriers directly for their professional services? 

  Answer 
  Effective April 26, 2007, NPs and CNSs are authorized to bill Medicare carriers directly for their professional services when furnished to hospital patients, both inpatients and outpatients. 

Reference: http://www.cms.hhs.gov/transmittals/downloads/R1168CP.pdf
http://www.cms.hhs.gov/mlnmattersarticles/downloads/MM5221.pdf

However, Medicare denies these claims when I bill them under the NP.  One thing I was wondering is if it mattered how the NP was actually credentialled thru Medicare.  Mine are actually Midwives and are credentialled as CNM and that is not listed in this answer.


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## sparkles1077 (Apr 23, 2011)

Our hospital makes nurse practitioners dependent in the inpatient setting.  So the bill automatically goes out under the doctor (the organization does not credential the NPs for inpatient).  We as auditors have a problem with this because the npp does most of the documentation and the physician adds a supervisory note.  There is poor communication in the organization and management has not dealt with the issue correctly.  We have recommended the minimal documentation by the physician to bill as a shared visit since incident to is not allowed in the hospital, but management believes this is a violation of the facility's policy because the midlevels are dependent.  They are suggesting use of a scribe note in this situation, but I feel this does not accurately portray the relationship between the NP and physician.  In my mind, it is a shared visit and should be documented appropriately.  I guess the bottom line question is, if the NP has a dependent relationship to the physician, can a shared service be billed?

Any thoughts?

Thank you
Sparkles1077, CPC, at Private


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## dphillips (Apr 25, 2011)

It does depend on the state in which you are billing. We bill admits and discharges for our NP's and have no problem whereas I have heard that Ohio and Penn don't allow it. I bill in Texas and Trailblazers does allow NP's and PA's to billthese codes.
Hope this helps.

Dawn CPC, CCC


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## mitchellde (Apr 25, 2011)

sparkles1077 said:


> Our hospital makes nurse practitioners dependent in the inpatient setting.  So the bill automatically goes out under the doctor (the organization does not credential the NPs for inpatient).  We as auditors have a problem with this because the npp does most of the documentation and the physician adds a supervisory note.  There is poor communication in the organization and management has not dealt with the issue correctly.  We have recommended the minimal documentation by the physician to bill as a shared visit since incident to is not allowed in the hospital, but management believes this is a violation of the facility's policy because the midlevels are dependent.  They are suggesting use of a scribe note in this situation, but I feel this does not accurately portray the relationship between the NP and physician.  In my mind, it is a shared visit and should be documented appropriately.  I guess the bottom line question is, if the NP has a dependent relationship to the physician, can a shared service be billed?
> 
> Any thoughts?
> 
> ...



To be a shared service the physician must document their own face to face encounter with the patient not just signing off on the NPPs note.  Go to CR1776 from 2002 this covers shared encounters.  You cannot share a new patient.  It states that if no face to face encounter between the physician and the patient is documented, even if the physician signs off on the documentation provided by the NPP, then the visit must be billed using the NPPs NPI.


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