ED Coding and Reimbursement Alert

You don't have to forfeit $25 for an NPP's role in a level-five ED E/M provided the encounter meets shared visit guidelines.

There is no incident-to billing in a hospital setting, says Mary Falbo, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. "But shared/split visit billing is an option."

Shared visit billing allows you to bill for services that the ED physician and a qualified nonphysician practitioner (NPP) provide jointly. If the encounter meets shared visit guidelines, you-ll be able to report the entire visit under the physician's National Provider Identifier (NPI) -- thereby garnering you 15 percent more Medicare pay for the same service than if you had to bill the service under the NP's number.

According to Suzan Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board, here's how the typical shared visit works:

- The NPP visits and examines a patient. The NPP documents her work establishing medical necessity.

- At a different time, the physician sees the patient and documents his work. This can be immediately after or even before the NPP's visit, but it "has to be on the same day," Hvizdash says.

- Then, you can add the documentation together to establish a billing level, Hvizdash said during The Coding Institute audioconference "9 Revenue-Boosting Billing Strategies for Incident-To Services."

To bill a shared visit under the physician's NPI, he must provide and document a face-to-face service for the patient. "The rule of thumb is that the MD must document part of the E/M service. That can't be done without some kind of face-to-face service with the patient," says Jaime Darling, CPC, coder with EA Health Corporation in Solana Beach, Calif.

Eli Berg, MD, FACEP, points out the guidance in Medicare Carrier Transmittal 1776. "When a hospital inpatient/hospital outpatient or ED E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN," the transmittal states.

Most Medicare carriers have further defined "face to face" as "requiring a clinically meaningful interaction with the patient in the same cubicle or partitioned/curtained area," says Berg, who is chief executive officer of Medical Reimbursement Systems Inc., an ED billing company in Woburn, Mass.

Ideally, you-ll bill a shared visit under the physician's NPI, but technically you could also bill a shared visit under the NPP's NPI. Physicians receive 100 percent of the Medicare allowable when they report services under their NPI. If you report the same service under the NPP's NPI, the reimbursement is set at 85 percent of the Medicare allowable.

"There might be instances where the MD's note may not include the face-to-face encounter that is required. Maybe he only writes that he -Looked at the CT scan and made recommendations,- " Hvizdash said.

Because the note Hvizdash described doesn't fully illustrate the physician's contact with the patient, you should bill this visit under the NPP's NPI. Shared billing is an option only for select hospital E/M services, including ED E/Ms (99281-99285); you cannot bill shared visits for consultations or critical care or procedures, Hvizdash said.

Caution: Shared visit billing rules apply to Medicare and to commercial insurers that follow Medicare rules. You should not report shared visits to a private insurer before making sure it allows payment for them.

Under shared visit rules, the NPP can treat patients in the hospital in accordance with the scope of practice and hospital privileges granted.

Example: A 69-year-old male patient reports to the ED with pain in his right lower abdominal quadrant. An NPP sees the patient first and orders labs and a CT scan of the patient's abdomen. The NPP documents a comprehensive history and physical exam.

Due to concern about possible appendicitis, the NPP asks the attending physician to evaluate the patient. The ED physician evaluates the patient, documenting his performance of an abdominal exam and a personal review of the labs and CT scan. Compiled notes indicate a level-five ED E/M service.

Under shared visit rules, you can combine the notes when determining the level of service for this encounter and report it under the physician's NPI, Berg says.

For this claim, you would report 99285 (Emergency department visit for the E/M of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity) for the shared visit.

Remember to append 789.03 (Abdominal pain; right lower quadrant) to 99285 to represent the patient's abdominal pain.

Benefit: "The bill would go out under the physician's NPI, and the reimbursement would be at 100 percent of the fee schedule amount," Hvizdash said.

The 99285 code reimburses about $165 at 100 percent; if you reported 99285 under the NPP's NPI, the amount would be about $140. (Budget-neutral RVUs for 99285 are 4.26, multiplied by the Medicare conversion rate of 38.087.)

Your documentation must support the level of E/M service you are coding for, or Medicare could deny your shared visit claim.

"Documentation should offer specific details [about both encounters] and physician input," says Alan L. Plummer, MD, at Emory University School of Medicine in Atlanta.

When submitting your shared service claims, be sure that you remember to clearly identify both providers in the medical record, link the physician's encounter note to the NPP's note, and include legible signatures from the MD and the NPP.

Your documentation must prove the physician provided at least one element of the encounter for you to bill a shared visit under the physician's NPI, Hvizdash said.

Example: To support physician review, in the previous example, Berg says the notes might read: "Patient seen and examined. Tender RLQ, WBC 12 K, will check CT scan and consult surgery."