Cardiology Coding Alert

Tip:  Apply for your NPP's Medicare ID sooner rather than later

If you're still wondering whether your nonphysician practitioner (NPP) can share a consult with your cardiologist, the answer is yes--but you'll have to take a 15 percent reimbursement cut because the NPP took part.

CMS' recent clarification (referenced in the November 2005 Cardiology Coding Alert article "Think You Can Share Consults and Get the Full Fee? Think Again") is new and in direct conflict with how many cardiology practices now use NPPs.

But CMS has set its clarification in stone and has modified the Medicare Carrier Manual's section 30.6.10 to specifically illustrate this.

According to CMS, "the intent of a consultation service is that a physician or qualified NPP ... is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc., in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional's knowledge."

However, this revision states: "A split/shared visit may not be performed or reported as a consultation service" and "a consultation service shall not be performed as a split/shared evaluation and management service."
 
What This Means for You

If the NPP provides the consult service, you have to report the consult (99241-99245 or 99251-99255) using the NPP's UPIN/PIN. In that case, you can expect 85 percent of the reimbursement, says Julie Wagner, RHIT, CCS-P, cardiology coder at the Fond du Lac Clinic in Wisconsin.
 
If the cardiologist reports the consult service, you should report 99241-99245 or 99251-99255 using the cardiologist's UPIN/PIN. In this case, you can expect the full reimbursement.

Heads up: The term "NPP" encompasses nurse practitioners, physician assistants, and clinical nurse specialists, says Krista Jackson, CPC, coding and compliance coordinator at Northeast Cardiology Associate in Bangor, Maine.

CMS issued this revision Dec. 20, 2005, and it became effective Jan. 1, 2006. The agency actually implemented it on Jan. 17. This means that you should take this shared- visit rule into account now, not sometime in the future.

Keep in mind: You'll still have many benefits offered by bringing NPPs on board. They can share admits, subsequent hospital care, and discharges.

They can also work under the incident-to rule in the office setting or bill under their own number at a slightly reduced reimbursement rate (85 percent of the Physician Fee Schedule).

"Our NPPs take on more of the routine day-to-day follow-up and specialty clinics, etc., which enables our cardiologist the flexibility to concentrate on higher reimbursing procedures," Jackson says.

Best bet: You should apply for a Medicare ID number for your NPP as soon as possible because most carriers tend to drag out the process. Also, remember that the regulations stated above are specific to Medicare only. Non-Medicare payers typically have much more liberal policies regarding NPP billing.