Cardiology Coding Alert

Bonus: 2 special case studies show you which UPIN/PIN to use when

When your cardiologist sends his nonphysician practitioner (NPP) to take care of the preliminary workup for a consultation, he could be cutting out 15 percent of his usual reimbursement. 

Follow this field-tested advice so you know when you should use the cardiologist's UPIN/PIN and when you should use the NPP's.

How to Make Use of Shared Visits

By delegating such tasks as admits, rounding and discharges to an NPP, your cardiologist is more available to take on higher-intensity--and higher paying-- services. But if your cardiologist uses an NPP to assist with consultations, you'll have to avoid billing the service under the doctor's name and number for Medicare patients.

Example: 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 doesn't get to them immediately.

Get your money's worth: The cardiologist focuses on the urgent consult requests and procedures entirely by himself while sending the NPP to initiate the hospital admissions, discharges, and pre-round on the patients already admitted. Following the consultations, the cardiologist re-evaluates the patients just visited by the NPP, documents his face-to-face services with the patients, and reports for the combined service of the NPP and the cardiologist, as if the cardiologist had performed the entire service. Because he performed the complete consultations, you should report these consultations (99241-99245) under his UPIN/PIN.

Avoid this pitfall: Because the cardiologist believes the three consultations will take up to 45 minutes each, he sends the NPP in to obtain background information and narrow the visit down for him. When he goes in, he takes care of the end portion of the consultation visit.

You cannot report the consultations under his UPIN/PIN. Because the NPP participated in the consultation visit, you'll have to report the consultation under the NPP's UPIN/PIN and "receive 85 percent of the Medicare allowed amount for the NPP's work," says Nancy Lynn Reading, RN, BS, CPC, a coding educator with University Medical Billing at the University of Utah in Draper.

Didn't Know the Visit's Nature? Won't Help

If you're trying to use the shared-visit rule for consultations--even when your cardiologist didn't know the visit was going to be a consultation to begin with--then you're not reporting these visits correctly.

Special case 1: The emergency department (ED) pages your cardiologist. In responding to the page, the cardiologist does not know the nature of the service--whether this is consultative (99241-99245), transfer of care (99201-99205), an admission (99221-99223) or a request that he provide ED care (99281-99285). He sends his NPP to perform the preliminary workup. Should you report this consultation as a shared visit?

The answer is no. If this visit ended up being a consultation and your cardiologist sent his NPP to perform the preliminary workup, you must report the consultation under the NPP's UPIN/PIN. That means you'll be taking a 15 percent reduction of the Medicare allowed amount.

Reasoning: "We believe [a consult] is a unique type of E/M service and do not believe that it is a joint effort or team decision--this is Medicare policy; other payers may differ," says a CMS source. "We're currently updating the manual with this policy clarification."

In this case, the patient for whom the cardiologist is providing the consultation is a new patient--meaning that incident-to requirements are not met. Under incident- to, the patient must be an established patient for you to report the NPPs services under the cardiologist's UPIN/PIN.

What Happens to Shared Visits and Admissions

The rule of thumb is if the NPP provides the consult service, you have to report it using the NPP's UPIN/PIN. If the cardiologist provides the consult service, you should report it under the cardiologist's UPIN/PIN. Therefore, the shared/split visit does not apply to consultation services, says Cynthia Swanson, RN, CPC, senior management consultant for Seim, Johnson, Sestak & Quist LLP in Omaha, Neb. But what if the consultation becomes a hospital admission?

Special case 2: The NPP sees the patient in the ED as a consultation and documents the visit. However, after the patient evaluation, the cardiologist ultimately decides to admit the patient to the hospital on that day. Because you cannot report a consultation incident-to, does this mean you have to report the admission (99221-99223) under the NPP's UPIN/PIN?

The answer is no. You can report the admission service under the incident-to rule. Section 15504(C) of the Medicare Carriers Manual states that "the initial hospital visit includes all service provided to the patient on the day of admission." Therefore, you would roll the consultative work the NPP provided and the cardiologist's work into the admission service.

According to the CMS source, "if an NPP and a cardiologist do decide to share or split a consultation service, that is entirely a practice decision"--you just have to use the NPP's UPIN/PIN on the claim and not the cardiologist's. Keep in mind you'll be reimbursed 85 percent of the Physician Fee Schedule amount.

Make this your motto: The only way you can submit the consultation (99241-99245) under the cardiologist's UPIN/PIN and receive the full reimbursement is if your cardiologist performs all of the work alone.