ED Coding and Reimbursement Alert

Your ED physicians no longer sacrifice full reimbursement when they recruit nonphysician practitioners (NPPs) to help with E/M services.

Effective Oct. 25, 2002, changes to Medicare's NPP rules have increased reimbursement for E/M services.

You can now bill an E/M service shared by a physician and an NPP under the physician's UPIN/PIN number, as long as the physician provides "any face-to-face portion" of the E/M encounter. In the past, you billed under the physician's full fee schedule only if the physician directly provided and documented the care. Otherwise, the ED had to bill under the NPP's reduced fee schedule. The new NPP policy is "very exciting news" for emergency physicians, says Nettie McFarland, RHIT, CCS-P, at Healthcare Billing Systems Inc. in Daytona, Fla. "As Medicare continues to decrease its reimbursement, this [rule] is a positive step to recapture lost revenue," she says.

Emergency departments will no longer lose reimbursement when NPPs assist in providing "quality, timely care," she says.

Take the following example: An NPP initially sees a patient with abdominal pain, completing the chart documentation required for a given E/M level of service. If the emergency physician comes in to examine the patient and documents that both practitioners reviewed the chart and agree with the disposition recorded, you may report the shared E/M service under either the physician's or the NPP's number. But remember: If the physician provides no face-to-face time with the patient, the service must be billed under the lower fee schedule determined by the NPP's UPIN/PIN, even if the physician reviewed the patient's medical records.

Also, if the provided service does not reflect a CPT code description, you must report it as an unlisted service with CPT code 99499, and a description of the service must accompany the claim. The carrier is entitled to determine the value of the service.

As a final reminder, do not use modifier -52 (Reduced services) with an E/M service.