ED Coding and Reimbursement Alert

Although mid-level providers assist your physicians, they can handicap your coding. The ED has different and relatively new rules for reporting nonphysician practitioner (NPP) services, so sticking to general office-based guidelines might lead to compliance problems.

If you're not sure about how NPP work reported in the ED differs from that reported in other outpatient settings, you should start with the basics. The mid-level providers who assist ED physicians with patient evaluation and managing include nurse practitioners (NPs) and physician assistants (PAs), as well as the regular nurses and techs who staff the ED. Read through the following reminders to make sure you're not violating specific ED mandates.

Golden rule: You cannot report incident-to in the ED. Reporting incident-to is a useful coding and billing option for offices, but not in the ED.

Incident-to is a Medicare reimbursement policy that, under certain circumstances, allows you to report services rendered by NPPs and other support staff under the supervising physician's number, says Kenneth Lambert, CPC, CCS-P, CPC-H, CCS-P, director of coding/quality services at MMR Management Team in Jacksonville, Fla.

Reporting services as incident-to outside of the office setting or patient's home, however, is "not an option," says Dennis Grindle, CPA, a partner in healthcare consulting at Seim, Johnson, Sestak & Quist LLP in Omaha, Neb. CMS argues that Medicare already includes payment for services rendered in a hospital under the supervision of a physician that is, incident-to the physician's services in diagnosis-related groups (DRGs), he says.

This means that you can't report services rendered by the ED staff (nurses and technicians) that you might have been able to report in the office. For example, a patient presents to the ED with abdominal pain, and the ED physician diagnoses urinary retention. The physician orders the placement of a catheter to drain the urine. In the office setting, you could report 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]) under the physician's Medicare personal identification number (PIN), even though other staff rendered the service. But you cannot report it in the ED setting. To bill for the catheter placement in the ED, the physician would have to document why the procedure required his or her skill and that he or she personally performed the service.

Work done exclusively by NPPs: Report services rendered exclusively by PAs and NPs under their PINs. When you report services that PAs and NPs provide in the ED, you must identify that assistant as the provider, Lambert states. This means, of course, that Medicare and others will reimburse such services at only 85 percent of the respective physician's full payment schedule, he says.

PAs and NPs therefore must ensure they have provider numbers, Lambert says, especially because EDs must accept Medicare patients, and Medicare mandates that PAs and NPs have provider numbers for reimbursement.

Pay attention to state licensure and scope-of-practice rules for PAs and NPs in your state. You should work from this "baseline" because if states bar your mid-level providers from rendering the services you see reported on the patient's chart, you shouldn't report them to Medicare, Grindle says.

E/M services shared by NPP and ED physician: Report E/M services shared by an NPPand ED physician under either provider's number if the physician has a face-to-face encounter with the patient. That means you can report an E/M encounter under a physician's number even if the NPP initially sees the patient and does the chart work for the E/M. As long as the physician provides a face-to-face encounter, most authorities agree that this implies a clinically meaningful interaction at the bedside, not just a social call. (To read more on the NPP rules CMS released in October, see Medicare transmittal 1776 at http://www.cms.hhs.gov/manuals/pm_trans/R1776B3.pdf. and read "Medicare News You Can Use: Changes in NPP Rules Increase Reimbursement" in the December 2002 issue of ED Coding Alert.)

Work done under teaching physician supervision: Be sure to follow the new teaching physician documentation rules released by CMS in November 2002. The guidelines relax documentation standards for TPs, Lambert says. To read the guidelines, go to the Medicare Carriers Manual, http://www.cms.hhs.gov/manuals/14_car/3b15000.asp#_15016_0, "Supervising Physicians in Teaching Settings"; the recent changes are in red. (To read more, refer to "ED Coders: Expect Less Documentation From Your Providers" and other related articles in the special supplementary issue of the February 2003 ED Coding Alert.)