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.

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.

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. However, there are still questions remaining about the new guidelines for split billing in these settings. An NPP, from the same practice, can bill for split services under the physician's PIN when two criteria are met:

1. The physician must provide any face-to-face portion of the E/M encounter

2. The physician must provide more than a simple review of the patient's medical record.

According to CMS, if these two criteria are not met, the service may only be billed under the NPP's PIN. An example that is in line with CMS guidelines is when an NPPvisits a patient with hepatitis. Later that day, the physician performs a face-to-face visit with the patient. In this case, you could report the combined services of the NPPand physician under the physician's PIN using the appropriate inpatient codes (99221-99239).

At this time, the policy does not specify how much of the face-to-face service the physician has to provide in order to be considered a shared service. It does not say that the physician has to get the history, perform the exam, and do the decision-making. Pohlig holds that, when taking the guidelines verbatim, it would not be "unacceptable" for the physician to go into the patient's room to establish a relationship, confirm a few findings, and leave the rest up to the NPP.

You may assume that the NPP can perform the history and examination portion of the visit but has to leave the medical decision-making up to the physician. However, the rule does not state this, since it does not define the extent of the physician encounter. That is why this policy should not be implemented until further clarification is received.

Although the transmittal does not explicitly spell out the details of this policy, some in the medical community have developed interpretations of their own. There are varying viewpoints concerning the requirements for split billing. Buechner believes that the physician would need to do more than simply establish the relationship and confirm some information, because this is more similar to the way a doctor uses a resident. He admits that this is a portion of the E/M visit, but he would be hesitant to apply the policy in such a manner.

Buechner interprets the policy as implying that the physician will need to play a large part in the medical decision-making (MDM). "It would make sense in reality and in practice if the NPPdoes the history, exam, and possibly even some of the MDM, such as reviewing x-rays, and ordering lab tests, while the physician comes in to review the visit and perform tasks, such as ordering medicine," he says. The physician makes the final call on the MDM portion, either agreeing with the NPPor ordering more tests, treatment or consultative services.

However, the language of the policy does not require this. Until further clarification, your only real option is to go strictly by the language of the policy transmittal. According to Pohlig, you want to capture the full benefits of the policy while not doing anything that you are not supposed to do: