ED Coding and Reimbursement Alert

Medicare will let the duo 'team up' to provide certain services.

ED coders that don't recognize every shared (or split) visit that the physician and qualified nonphysician practitioner (NPP) provide are costing their EDs money -- potentially a lot of money.

Breakdown: Billing appropriate split/shared visits means that you may be able to code the E/M service under the physician's National Provider Identifier (NPI), which will garner the ED full reimbursement for each code.

Alternative: You bill under the NPP's NPI even when you can use the physician's, which results in 85 percent reimbursement. Consider the payout for 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 ...), a common ED E/M service that NPPs provide.

The average national payout for 99283 is $61 (1.34 transition facility relative value units [RVUs] multiplied by the 2011 Medicare conversion rate of 33.9764). If you bill under the NPP's NPI, you'll only get about $45. That 15 percent can shrink a bottom line fast, especially if your NPPs work often with physicians to treat patients.

Of course, there are some pretty strict rules for billing split/shared visits. Take this expert FAQ to heart when considering whether or not to bill a split/shared visit.

What Are Split/Shared Visits?

A split, or shared, visit is a "medically necessary encounter with a patient, where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit with the same patient on the same date of service," explains Catherine Brink BS, CPC, CMM, CMSCS, president of Healthcare Resource Management, Inc., in Spring Lake, N.J. E/Ms are the only codes eligible for shared visit billing.

Also, you'll want to be sure that the insurer is either a Medicare payer or observes Medicare payer rules for reimbursement.

The news: "Certain health plans have indicated the future intention of adopting the shared visit approach, such as Aetna," says Ed Gaines, JD, CCP, chief compliance officer for Medical Management Professionals, Inc., in Greensboro, N.C. Aetna, however, delayed its adoption after the American College of Emergency Physicians (ACEP) and (EDPMA) both raised numerous issues with it, Gaines says.

Best bet: Code shared visits for any Medicare carrier, but be sure to check with the payer before doing so with a private carrier.

What Type of Encounter Qualifies for Shared Visit Billing?

In order to bill a visit as "shared," the physician has to perform, and document that he performed, a substantial part of the service," explains Brink. For example, with an ED E/M service the physician needs to perform, and document that he had a clinically meaningful face to face encounter with the patient. If the physician just documents "that he was in the presence of the NPP and agrees with his assessment" you cannot code a shared visit, Brink continues.

Importantly, a shared visit must include a documented face-to-face physician service. "General oversight, such as reviewing the medical record, is insufficient," says Gaines.

"My advice on what constitutes a face to face encounter has always been that the [physician] should do more than 'throwing back the curtain and asking if the patient is OK,' but not to the extent of a resident/teaching physician note," says Gaines. "The [physician's] comment on an element of the history, exam, decision making or course of treatment would be sufficient."

Gaines points out that Medicare Transmittal 1776 also incorporates state law in terms of the degree and extent of "supervision" that is required for the NPP.

So if you don't know what types of supervision rules your state has for physicians, be sure to check before coding shared visits.

"States vary widely in terms of whether the supervising physician must be 'present' or 'sign' the record, I believe that Medicare is stating that in addition to their specific requirements that the NPP must be supervised to the level required by state law," he says.

How About a Shared Visit Example?

Consider this shared visit scenario from Stacie Norris, MBA, CPC, CCS-P, director of coding quality assurance for Medical Management Professionals in Durham, N.C.:

For this encounter, you can bill 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 patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...) under the physician's NPI. Remember to append 493.91 (Asthma, unspecified, with status asthmaticus) to 99285 to represent the patient's condition, Norris reminds.