Cardiology Coding Alert

Use NPPs and stop forfeiting $$$ for missed cardio consults and procedures

If your cardiologist is overloaded with admits, discharges and rounding, you can use Medicare's shared-visit provision when your practice's nonphysician practitioners (NPPs) lend a helping hand.  But make sure your physician personally documents face-to-face patient encounters.

Let NPs Get the Ball Rolling on Admits, Discharges

"The shared-visit provision has made hiring nurse practitioners and physician assistants a lucrative opportunity for cardiology groups," says Jim Collins, ACS-CA, CPC, CHCC, a cardiology compliance consultant with Compliant MD Inc. in Matthews, N.C.

"Once physicians realize that they can use nonphysician practitioners to conduct such time-consuming facility-based tasks as admissions and discharges, they recognize the benefits of the shared-visit rule," Collins says. For instance, nonphysician practitioners can "pre-round" on patients for physicians, allowing the cardiologist to get to the root of patient problems more quickly, he says.

And here's the best part: You can still receive full Medicare reimbursement when your physicians use mid-level providers in the hospital. Moreover, by delegating such tasks as admits and discharges to nonphysician practitioners, the physician is more available to take on higher-intensity -- and higher-paying -- services such as procedures or new patient consults, Collins says.

Coding scenario: Your cardiologist is swamped with a full hospital census requiring rounding, two inpatient admissions, two patients who have been waiting three hours for discharge, one coronary intervention, and three urgent requests for consults that will go to another practice if your physician can't get to them immediately.

Without using an NPP, the cardiologist may be forced to either forfeit the consultations, which could mean the loss of about $35-$190 per initial inpatient consult depending on the complexity of the consult, or postpone the admissions, discharges and inpatient rounding, which could upset patients or allow problems to worsen. 

Winning strategy: By working with an NPP, however, the cardiologists can focus on the urgent consult requests and procedures and direct the NPP(s) to initiate the hospital admissions, discharges and to pre-round on the patients already admitted. The NPP(s) will be able to assess the patients, document admissions, document discharge summaries and make progress notes on inpatients. Following the consultations, the physician can re-evaluate the patients just visited by the NPP, document his face-to-face service with the patients, and bill for the combined service of the NPP and the physician as if the entire service had been personally performed by the physician. 

Keep in mind: To bill under the shared-visit rule, the cardiologist needs to personally evaluate the patient and document his service, Collins says. Because the NPP already interviewed the patient, conducted a preliminary examination and documented his service, the physician visit will be more focused on the problematic issues and will be much more efficient.     

Know the Shared-Visit Basics

1. Offices: Follow "Incident-To" Rules

Don't get too excited about using the shared-visit provision for E/M services your nurse practitioners (NPs) and physician assistants (PAs) perform for established patients in the office. The Medicare Carriers Manual specifies that nonphysician E/M services must meet "incident-to" reporting requirements. In other words, a physician has to be in the office suite and available for supervision to bill the NPP's E/M under the physician's PIN.

"When an E/M service is a shared encounter between a physician and a nonphysician practitioner, the service is considered to have been performed 'incident-to' if the requirements for 'incident-to' are met and the patient is an established patient," the manual states. "If 'incident-to' requirements are not met for the shared E/M service, the service must be billed under the NPP's UPIN/PIN," and payment will be made at the appropriate Physician Fee Schedule amount, the manual further clarifies. This payment will be made at 85 percent of the Physician Fee Schedule amount for your area.  

Practical application: "In the office, we report these visits incident-to, meaning the E/M is billed under the supervising physician who is in the office suite for that day," says Sarah Tupper, CMC, a coding specialist for CNY Cardiology in Utica, N.Y. "The NP does the E/M, then confers with the doctor, and they sign the chart." 

If the established patient develops a new problem, such as hypertension, CMS has clarified that the NPP can address the new problem and still meet the incident-to provisions, as long as the physician also sees the patient, says Quinten A. Buechner, MS, MDiv, CPC, CHCO, president of ProActive Consultants in Cumberland, Wis. Before billing such a visit, you should check with your own carrier, he says.

2. Acute Care Settings: Use Either the NPP's or the Doc's PIN

When your physician and an NPP from your group practice share services in the hospital, the rules are different. "In the hospital, the incident-to guidelines do not apply," Tupper says. The main difference is that the physician must document direct face-to-face contact with the patient to bill a shared E/M.

In particular, the manual states, "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."

If, however, "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," according to the manual. "Payment will be made at the appropriate Physician Fee Schedule rate based on the UPIN/PIN entered on the claim." 
 
Get Your Notes Up to Speed 

The key to complying with the shared-visit provision is that the physician must personally see the patient, conduct an examination and be involved with the plan of care, Collins says.

This means your physician must get the documentation right.

"Be careful," Tupper says. "The doctor cannot just sign off on what the NP writes in the progress note; he or she has to contribute to the E/M. We recently did an 'off-the-cuff' audit of some progress notes and found that we were not able to use the shared-visit rule. I think it's a great rule, but use caution."

Slack notes reap rejections: Medicare carriers don't like to see minimal notes, such as "Agree with above," "Rounded, reviewed, agree" and "Seen and agree," so you should encourage your physicians to provide enough documentation to show that they have carefully reviewed the NPP's work.

Best way: Look to Medicare's teaching-physician documentation guidelines for help with the right content for your physician's shared-visit note taking. The teaching-physician guidelines have many parallels with the shared-visit provision, coding experts say.

Here's the sort of documentation you'll need to report shared visits: