# Utilizing PA in Inpatient Consults



## shell123 (Mar 24, 2010)

Is it okay to for the PA to go over to the hospital and perform the exam and then the provider come over behind the PA and document the plan of treatment and we bill the consult under the provider's npi?  We are trying to utilize our PA best as possible with the service still being billable under the providers npi.  Do you have any suggestions?


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## mitchellde (Mar 24, 2010)

You can bill a shared encounter for established patients only and the physician must see the same patient on the same day and document his own assessment of the patient.  CR1776 states
" If there is no face to face encounter between the physician and the patient (even if the physician signs off on the documentation provided by the NPP), the visit must be billed under the NPPs number."


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## RebeccaWoodward* (Mar 24, 2010)

shell123 said:


> Is it okay to for the PA to go over to the hospital and perform the exam and then the provider come over behind the PA and document the plan of treatment and we bill the consult under the provider's npi?  We are trying to utilize our PA best as possible with the service still being billable under the providers npi.  Do you have any suggestions?



Consults can not be shared visits.


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## mitchellde (Mar 24, 2010)

Thanks Rebecca I missed the part about this being a consult and you are correct.  You cannot share a consult or a new patient.


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## RebeccaWoodward* (Mar 26, 2010)

Debra,

I have been thinking about the consults for the last couple of days and re-thinking my statement.  Traditionally, we could refer to CMS for rules on split/shared billing. The "split/shared" rule was/is a Medicare concept. Now that Medicare doesn't recognize consultation codes, it's made me re-think if commercial carriers still refer to CMS' *former* guidelines on split/shared rules for consultations. I've seached for CPT Assistant articles, endlessly, trying to find some language that follows this concept but I've come up empty handed.  

Now...if the commercial carrier DOES follow CMS' policy on shared/split, then the answer is easy...(MLN bulletin).  

*Q.* How should E/M services previously reported by CPT consultation codes and provided in a split/shared manner be billed?

*A.* The split/shared rules applying to E/M services remain in effect, including those cases where services would previously have been reported by CPT consultation codes.

I know that many carriers hold Medicare as the "golden standard"; however, I have to wonder just how many carriers actually have a solid policy on this.

So this has prompted another question.  If the commercial carrier in question does not credential the mid-levels, this is probably a moot point and the split/shared concept isn't applicable.  However, if a payer *pays differently*, depending who provides the service...NPP versus MD, the split/shared concept could become an issue.

I think this is one of those areas that has become muddy and the only resolution I see is to contact each payer and question their policy on  split/shared consultations.

I'd love to hear other comments/thoughts...


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## RebeccaWoodward* (Mar 29, 2010)

*?*

Anyone?


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## mitchellde (Mar 29, 2010)

Now there is something to contemplate!   I reread this like oh a dozen times and you are right that the not recognizing consults does muddy the water alot.  Now let me throw something else out.  If you have an NPP go to the hospital to do an inpatient "consult"  which is now an initial inpatient visit, then this also does not go for a split encounter as it is probably new patient.  If it is not a new patient I still see a problem due to language of "initial" encounter.  So I feel the shared encounter rule will stand, and if an NPP sees the "consult" inpatient it will still have to billed under the NPP number.


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## RebeccaWoodward* (Mar 29, 2010)

*Hospital Inpatient*/Outpatient/Emergency Department Setting (MCR-Chpt 12)

When a *hospital inpatient*/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's *or* the NPP's UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient‟s medical record) then the service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim.


Since 99221-99223 allow split/shared visits, the "thought" is that the mid-level and MD can now share the visit (formally refered to as consultation).  My argument...if Medicare no longer recognizes consultations, then they can no longer refer to guidelines that no longer exist, per se.  Since Medicare has also stated that the guidelines for, lets say, 99221-99223 hasn't changed, then this is another arguement in our favor.


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## mitchellde (Mar 29, 2010)

LOL... You are correct, I was thinking for the split/shared as the subsequent visits, but you are right the guideline does not limit the type in inpatient visit to just the subsequent so I would say that this could be effectively argued.  So the case of an inpatient "inital encounter" ( previously referred to as a consult) may be billed as a split/shared encounter.


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## RebeccaWoodward* (Mar 29, 2010)

Debra,

Thanks for helping me think this out loud...  You're great!


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