Gastroenterology Coding Alert

Shockwaves reverberated through the coding community when Medicare implemented its new split-billing policy, so it's time to address some issues about the proper way to use NPP services in the office and inpatient settings.

The Centers for Medicare & Medicaid Services issued Transmittal 1776 on Oct. 25, 2002, to revise section 15501 in the Medicare Carriers Manual regarding evaluation and management services. The most controversial issue in the transmittal deals with "split-billing" for nonphysician practitioners. NPPs have never been able to provide services in facility settings and receive 100 percent reimbursement. Now, it seems that NPPs have the option to bill under the physician's PIN in a variety of settings. But the rules pertaining to this policy are not clear.

According to Carol Pohlig, BSN, RN, CPC, lead coder at the University of Pennsylvania department of medicine in Philadelphia, the new split-billing guidelines are very vague. They simply state that whenever there is a shared service between a physician and an NPPon a given date, you are allowed to combine the service and report it under one individual's PIN. The options are for you to bill under the physician's number for 100 percent reimbursement or the NPP's number for 85 percent reimbursement. "This policy is going to revolutionize the way you use NPPs and the way you can bill for them," Pohlig says. Incident-to Still Applicable in Office Setting Medicare holds that "when an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS, or CNM), the service is considered to have been performed incident-to if the requirements for 'incident-to'are met and the patient is an established patient." If incident-to requirements are satisfied, the NPPwould bill under the physician's PIN and the physician would receive 100 percent reimbursement of the appropriate Physician Fee Schedule amount. If the requirements are not met, the NPPmust bill under his own PIN and receive 85 percent reimbursement. The new split-billing policy does not change the incident-to rules for office settings. Split the Bill in Hospital and ED Settings Pohlig holds that split billing is going to impact the healthcare industry the most in the outpatient hospital, inpatient, and emergency department settings because split billing means that the physician and NPPcan provide a shared service in settings where incident-to has been prohibited. You can bill under either the NPPor physician PIN, and you don't have to follow incident-to guidelines. Prior to "split billing," the NPPwas forced to bill under his own provider number at 85 percent of the Physician Fee Schedule. Essentially, this policy "provides incident-to in the hospital and makes it very easy for doctors to bill," says Quin Buechner, MS, M.Div., CPC, CHCO, the president of ProActive Consultants. [...]