ED Coding and Reimbursement Alert

Although Medicare and other payers may allow payment for specific services provided by nurse practitioners (NPs) and physician assistants (PAs), state legislation and individual hospitals regulate which procedures and services they are licensed to perform. Coders should keep five points in mind when reporting services provided by nonphysician practitioners (NPPs) in the ED:

1. Which services can NPs and PAs provide in the ED? According to Michael Powe, director of reimbursement for the American Academy of Physician Assistants (AAPA), Medicare does not restrict the types of care PAs and NPs can provide but defers to state practice laws. Most NPPs are allowed great latitude in line with their training and level of experience that ranges from performing physical exams to initiating basic and advanced life support, to reduction of fractures, to thoracentesis. State practice laws, the supervising physician or the institution determines the precise services an NPP can provide.

Most often, NPPs report the appropriate-level E/M ED service (99281-99285). They may also perform initial observation care (99218-99220) and observation discharge services (99217). "Medicare puts no limits on the level of service that may be provided, up to and including level-five codes," says Margaret Fitzgerald, MS, APRN, BC, FAANP, president of Fitzgerald Health Education Associates, a firm based in North Andover, Mass., that provides continuing education to nurse practitioners and advance-practice and ambulatory-care nurses.

NPPs also report any specific procedures performed in addition to the E/M services. For example, if an NP placed a peripherally inserted central catheter (PICC) line in a 68-year-old patient, you should also report 36489* (Placement of central venous catheter [subclavian, jugular, or other vein][e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy]; percutaneous, over age 2).

2. What supervision requirements govern NPPs? Supervision distinctions exist between NPs and PAs. Medicare requires NPs to have physician collaboration, while state law requires PAs to be supervised by a physician. "However," Powe says, "Medicare requirements contain no reference that the supervising physician must be in the hospital when a PA provides emergency services. They allow for electronic communication, which means the physician must be accessible by phone or a similar device. In addition, Medicare rules do not require that a physician sign off on notes PAs write in medical charts." Medicare rules for NPs are similarly nonrestrictive, Fitzgerald adds.

Institutional and individual payer policies may establish stricter guidelines stating, perhaps, that a physician must be in the ED while the PA provides care or that a physician must review and sign the chart after the PA has provided the service. "This is rare," Powe notes. "The trend is for private payers to follow state law, as opposed to something more restrictive."

3. Should an NPP's services be reported as "incident to" the physician's? No. Medicare's incident-to policies do not apply in any hospital setting, Fitzgerald says. NPPs must submit Medicare claims under their provider identification number (PIN). "Medicare will then reimburse at 85 percent of the Physician Fee Schedule," she notes.

For the physician to submit a bill to Medicare when an NPP has been involved with the patient, the physician must provide the services as described by the level of service billed. For an E/M level, the physician must perform all of the key elements of the E/M with the exception of the review of systems (ROS) and past medical, family and social history (PFSH), which may be performed by the PA and confirmed by the ED physician. Similarly, procedures cannot be billed under the physician provider number if the physician does not perform them. Instead, they should be billed under the PA's or NP's PIN.

Because NPP reimbursement within the Medicare program is less than physician reimbursement, you may be tempted to assign a physician to Medicare patients and an NPP to non-Medicare patients. "In my opinion, however, you should not establish payer-specific clinical guidelines," Fitzgerald says.

On the other hand, some coding professionals suggest there may be justification for setting up clinical criteria that maximize the opportunity for physicians to see Medicare patients. For instance, it might be very appropriate to determine that the physician see elderly patients or children under 3 because they often present with more severe conditions. Medicare or other public programs may also cover many of them.

4. Do other commercial payers reimburse for NPP services? Not always. Many insurers do not recognize NPPs and will reject claims that reflect services provided by these practitioners.

Some experts note that, when confronted with not being paid, certain professionals simply bill the NPP's services under the supervising physician's PIN. Although some private payers and Medicaid programs may require this, Medicare does not allow this practice. Misrepresentation of this sort exposes the physician to a tremendous liability. You should ask individual payers for their policy.

An alternative is for NPPs not to see patients covered by an insurer that doesn't recognize their status. Unfortunately, this is difficult to accomplish too, because federal law prohibits ED personnel from delaying initial triage or screening while ascertaining the patient's insurance status. These preliminary services are frequently provided by NPPs, so care has already been provided that may not be reimbursed. In addition, different types or levels of care cannot be provided based on the coverage offered by the patient's insurance.

5. Is it appropriate to submit split bills if a physician and an NPP see a patient in the ED? Under Medicare's traditional policy, when the NPP and the physician see a patient during an emergency visit, only one E/M service may be billed. "If both are involved, the practitioner who performs the history of present illness (HPI), the exam and makes the medical decisions is the professional who bills the service," Powe says. Coders should be aware that Medicare states services cannot be billed under the physician's name and PIN if he or she only reviewed the patient's record and cosigned the chart. In some cases the physician simply makes a notation, "seen and agree," to an NPP's notes and then bills the service under the physician's PIN. This is inappropriate under Medicare regulations and could be considered fraud.

For example, a 65-year-old woman presents to the ED because she is having difficulty breathing. The PA takes the patient's history, performs a physical exam and orders a nebulizer treatment, which relieves the woman's symptoms. The PA diagnoses asthma (e.g., 493.00, Extrinsic asthma without mention of status asthmaticus) and prescribes a metered-dose inhaler. The physician reviews the PA's notes, agrees with the PA's diagnosis and care plan, and countersigns the patient record. Even though both practitioners interacted with the patient, only the PA's services can be billed. Depending on the documentation, a level-four emergency services code might be assigned (99284) with 94640 (Nonpressurized inhalation treatment for acute airway obstruction).

Under different circumstances, the care might be billed under the physician's name and PIN. A 30-year-old male comes to the ED, complaining of a severe headache and blurred vision. The PA takes the history, conducts a physical and records a preliminary diagnosis of migraine (e.g., 346.00, Classical migraine without mention of intractable migraine). After reviewing the patient record, the physician examines the patient, performs the HPI, confirms the ROS and past history, makes a medical decision, and orders neurological tests to rule out other conditions like stroke or a brain tumor. Because the physician performed and documented the key elements of the E/M level, the encounter should be billed under his or her PIN.

Although CMS made it clear with Transmittal 1725 released in September 2001 that NPPs and MDs should not bill a complete service when they only perform a portion of it, the agency has not provided a way for both practitioners to receive partial payment for shared services. In the transmittal, which modifies section 15501 of the Medicare Carriers Manual, CMS notes that in these cases the physician and the NPP may report 99499 (Unlisted evaluation and management service).

The CMS modification states that when a service performed is less than that described in CPT, the physician and/or the NPP must document and bill the service he/she provided. A physician and/or an NPP may submit a claim for 99499 and explain why the lesser service was medically necessary. "The carrier has the discretion to value the service when the service does not meet the full terms of the CPT description (e.g., only the history was performed). The carrier will also determine the payment based on the applicable percentage of the Physician Fee Schedule, depending on whether the claim is paid at the physician rate or the limited licensed practitioner rate," according to CMS.

However, Powe notes that many reimbursement experts and professional organizations like the AAPA are strongly opposed to the direction that Transmittal 1725 indicates: "They point out that the policy is not attuned to current clinical practice, is considered administratively burdensome, and is undermined by the fact that CMS has assigned no value to 99499. Use of 99499 means that each local Medicare carrier must determine how to price the service, which leads to tremendous variability in the amount paid for the encounter. Because of this, officials at CMS have indicated a willingness to make substantial changes to this policy in order to eliminate confusion."