Dermatology Coding Alert

Coding decision might be based on POS.

Stop me if you’ve heard this one before. A physician and a nonphysician practitioner (NPP) work together to perform an E/M service …

Coding: Is this an incident-to service? Or a split/shared visit? You need to know if you want to keep your coding sharp.

Why? If you don’t code for incident-to or split/shared visits when you should, you’ll leave deserved reimbursement in the payer’s purse. Further, misusing either of these coding features risks raising eyebrows in claims processing departments.

Follow these rules to help you differentiate between incident-to and split/shared visits.

More Money Awaits Coder With NPP Smarts

Both incident-to and split visit coding are Medicare features, reminds Cynthia A. Swanson RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb. Only Medicare payers, and those that follow Medicare guidelines, are bound by incident-to and split visit rules.

“Other commercial plans may or may not follow Medicare,” says Swanson.

Best bet: Check with a third-party payer if you don’t know its incident-to and split visit guidelines.

Also, incident-to and split visit coding can be beneficial financially. If a physician teams with a qualified nonphysician practitioner (NPP) for either of these services, you’ll code the visit under the physician’s national provider identifier (NPI).

This could net 100 percent of the allowed payout — when a physician is involved. If you have to report the E/M under the NPP’s NPI, you’ll only net 85 percent of the allowed amount, confirms Jan Rasmussen, CPC, PCS, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions, Holcombe, Wisc.  

No POS 11? No Incident-To

According to Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash., there are three primary differences between split/shared visits and incident-to billing.

The first difference is that “split/shared visits are for hospital-based encounters like inpatient, observation [and] ED,” she explains. You would also report a visit as split/shared for E/Ms that take place in hospital outpatient departments or provider-based clinics (PBEs). “In other words, these services only apply in POS [place of service] other than 11 [Office],” Bucknam explains.

Explanation: In the clinic setting the encounter must first meet incident-to criteria before you even consider coding it as a shared encounter, Rasmussen says. “In the hospital /outpatient setting there is no incident-to, so the only option to bill a service partially performed by an NPP in the physician’s name is shared care,” shecontinues.

Locate Provider Pair, Then Report Split/Shared

The second major difference between these two coding features is that split/shared visits must involve two “qualified” providers.

Split/shared visit coding “only applies to two physicians or a physician with a qualified NPP, or two qualified NPPs” who combine to perform an E/M for a patient, says Bucknam. The providers must both see the patient, and perform a significant portion of the service, before coding the E/M under the physician’s NPI.

On the other hand, you might be able to code incident-to for work that an NPP does alone to care for a physician’s patient — if:

1. The patient is established.
2. The physician has seen the physician for the condition already and
3. The physician has established a plan of care for the patient’s condition.

Date of Service Could Provide Split/Shared Clues

A third difference between split/shared and incident-to is that split/shared visits always involve two providers who must see the patient on the same date. “Incident-to services may occur at another time under the physician’s direction,” Bucknam says.

So, if you’re considering split/shared coding, make sure that you can prove two providers teamed up to provide a complete E/M on the same date.

Know All Guidelines Before Coding These Encounters

Remember, you’ll need to have a full understanding of Medicare’s rules and regs before using these features to report E/Ms.

“The Medicare guidelines for incident to services and split/shared services are complex so it is important to be sure practitioners have a good understanding of the Medicare rules and are compliant in their reporting and billing,” Swanson reminds.

Example: You can only use split/shared visit codes “for certain E/M service codes and places of service. A split/shared service cannot be reported for critical care services, consultation services, new patient office visits, or in the skilled nursing facility/nursing facility setting,” reminds Swanson.