ED Coding and Reimbursement Alert

When you bill under NPPs NPI, expect 15 percent less for service.

EDs that want to squeeze the most value from their nonphysician practitioners (NPPs) work need to avoid two missteps that can take serious juice out of payout for the NPPs services.

Check out these mythbusters and know when to take the higher-paying road for services your NPPs provide.

Myth 1: NPPs and ED Docs Cant Team Up on E/Ms

The NPP (or mid-level provider [MLP]) and the physician might share the load on certain E/M services; when this occurs, check to see if you can report a split/shared visit for the encounter.

While there is no incident-to billing in the ED, shared-visit billing is an option to capture E/M services the physician and the NPP provide jointly to Medicare patients (and patients with insurance that observes Medicare rules).

When you code for a shared visit, report under the physicians National Provider Identifier (NPI), confirms Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance with UPMC in Pittsburgh. This nets the ED 15 percent more for the same service, as Medicare pays at 85 percent for all codes you bill under the NPPs NPI.

To bill a shared visit under the physicians NPI, he has to provide a face-to-face service, confirms Kimberly Sullivan, CPC, coding specialist at Deaconess Physician Billing Services in Evansville, Ind.

So if the physician reviews the medical record for a patient, but the NPP provides all of the face-to-face evaluation, bill the encounter under the NPPs NPI, Sullivan says.

Berman offers this example:

A patient reports to the ED with a high fever. The NPP meets the patient, gathers a detailed history, does an expanded problem-focused exam, and suggests antibiotic therapy. The ED physician then comes into the room and gathers more history from the patient, performs a detailed exam, and orders a chest x-ray. He then writes a prescription for an antibiotic and suggests the patient follow up with an infectious disease specialist.

The two notes, added together, would equate to a 99283 and can be billed under the MDs billing number to Medicare, explains Berman.

Payout: The 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) code pays about $62 nationally (1.70 transitioned facility relative value units [RVUs] multiplied by Medicares 2009 conversion rate of 36.0666).

If you report the visit under the NPPs NPI, you have to subtract 15 percent, bringing your ED around $52 for the same service. This can add up if your physicians and NPPs provide a lot of joint E/M services.

Consider billing a shared visit only for certain hospital services -- most commonly ED E/Ms such as 9928x. You cannot bill shared visits for any procedures, or for E/Ms such as consultations or critical care.

Prove Service LinkWith Solid Notes

Including specific documentation along with your split visit claims will only increase chances of payment.

Sullivan recommends that your documentation:

" identify both providers

" link the MDs notes to the NPPs

" include legible signatures from both providers

" confirm that the MD performed an E/M element and a face-to-face service.

Best bet: The physician should write the link between his and the NPPs notes, as well as the description of his face-to-face encounter with the patient.

Myth 2: NPPs Cannot Provide Critical Care

If your NPP holds the qualifications to provide care for your critically ill or injured patients, you can report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (& each additional 30 minutes [List separately in addition to code for primary service]) for her work.

Official guidance: Check out this excerpt from Medicare transmittal 1530: A qualified NPP may perform critical care services within the scope of practice and licensure requirements for the NPP in the state where he/she practices. (Check out the transmittal at: www.cms.hhs.gov/Transmittals/downloads/R1530CP.pdf.)

NPPs providing critical care are governed by the same rules as physicians: in order to code 99291 the

" patient must have a critical illness or injury

" NPP must make a high-complexity medical decision

" NPP needs to assess the patients potential for deterioration, and be ready to act should patient deterioration occur.

Net Just Under $200 for NPPs 99291 Service

You must report an NPPs critical care service under her NPI, reminds Berman -- but you should still be on the lookout for 99291 NPP opportunities. Even with the 15-percent cut, this code pays significantly higher than the highest-level ED E/M code, 99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patients clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity &).

Payout: The in-full 99291 code pays about $212 (5.88 RVUs), while the NPP would earn about $180 for the same service. Conversely, 99285 pays about $170 in full (4.72 RVUs), and the NPP would earn about $144 for it.