ED Coding and Reimbursement Alert

Forget about incident-to in the facility,but consider this similar billing technique.

ED coders that have never heard of "incident-to"billing have nothing to worry about, as you cannot code for "incident-to" services in the hospital. Coders that don't understand shared visit billing, however, could be costing their ED practices.

Follow this advice on the "what's" of shared visit billing.

What's a Shared Visit?

During a shared visit, a qualified nonphysician practitioners (NPP) and the physician "team up" to provide a complete ED E/M service to the patient, confirms Lynn Anderanin, CPC, CPC-I, COSC, senior coding consultant for Health Info Services in Park Ridge, Ill.

The rub: The ED physician must provide a face-to-face service or you cannot report a shared visit, warns Kimberly Sullivan, CPC, coding specialist at Deaconess Physician Billing Services in Evansville, Ind.

According to the Medicare Claims Processing Manual (MCPM), Chapter 12, Section 30.6.1: "When a hospital inpatient/hospital outpatient or emergency department 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 [unique physician identification number]/PIN number.

"However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient's medical record) then the service may only be billed under the NPP's UPIN/PIN," the MCPM states.

Medicare payers, and payers that observe Medicare rules, allow you to report shared visits under the physician's National Provider Identifier (NPI) rather than the NPP's. When you bill under the NPP's NPI, you'll receive 15 percent less for the same service, so ethically bill under the physician's NPI whenever you can.

Hypothetical example: A physician and NPP provide a service that qualifies for shared visit billing, and pays out at $100. The coder's in a hurry, doesn't recognize the shared visit opportunity, and bills under the NPP's NPI. That $100 service is only worth $85.

At 7 a.m. Monday, the NPP performs a detailed history and physical exam on a 66-year-old asthma patient who is wheezing and exhibiting tachypnea. The NPP orders nebulizer treatments and steroids. Following several rounds of nebulizers, the attending physician performs a lung exam and finds that the patient has improved.

The combined documentation of the visit includes a note from the physician demonstrating a clinically meaningful face-to-face encounter. Notes indicate moderate MDM for the encounter, and the physician ultimately diagnoses the patient with an asthma exacerbation and discharges her.

On the claim you would report the following:

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: detailed history; detailed examination; medical decision making of moderate complexity ...) for the E/M
• 493.92 (Asthma, unspecified; with [acute] exacerbation) appended to 99284 to represent the patient's exacerbation.

Explanation: Since the physician documented a face to face encounter the claim could be submitted under the attending physician's NPI number.