Gastroenterology Coding Alert

Gastroenterology practices that don't take full advantage of coding opportunities when their nonphysician practitioners (NPP) provide E/M services to Medicare patients are losing out on a valuable revenue stream --NPPs help lighten your physician's workload, and proper coding can also add weight to the bottom line.

In a nutshell: NPPs can provide some E/M services to Medicare patients that allow you to bill under the gastroenterologist's National Provider Identifier (NPI), garnering your office 15 percent more than the same service billed under the NPP's NPI.

Check out this quick guide on incident-to and shared visit billing, and max out your NPPs' services.

The physician's incident-to role is supervisory,confirms Lynn Anderanin, CPC, CPC-I, COSC, senior coding consultant for Health Info Services in Park Ridge, Ill. The NPP must be working under "direct supervision" of the physician in order to bill incident-to, she says.

Definition: "The physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide [NPP] is performing services," according to the Medicare Benefit Policy Manual, Chapter 15, Section 60.1.b. This means that the physician is physically in the office; if the physician is available via text messaging or phone, but out of the office during an NPP's services, you cannot code incident-to.

In order to bill incident-to the physician, the NPP must also be treating the patient for a problem with a physicianinitiated plan of care, says Louise Glynn, office manager at a practice in Sanford, N.C. So you need to take new patients, or established patients with new problems, off your incident-to radar.

Example: If the NPP performs a follow-up evaluation and medication adjustment on a patient who is following the gastroenterologist's plan of care for her stomach ulcer under direct physician supervision, bill the service under the gastroenterologist's NPI. If the NPP treats the same patient for a new complaint of rectal pain and bleeding under direct physician supervision, you should bill under the NPP's NPI.

In the gastroenterologist's office, NPPs might provide incident-to services for many of your patients suffering from chronic ailments.

Example: A 74-year-old established Medicare patient with a plan of care in place for her chronic ulcerative colitis reports to the gastroenterologist's office for a medication adjustment. The NPP meets with the patient, and performs a problem-focused history and examination. The NPP reviews the patient's symptom log and increases the amount of mesalamine medication used to control the ileocolitis inflammation. During the service, the gastroenterologist was in the next room treating another patient. The NPP's documentation supports a level two for this E/M service.

You can report this service incident-to the physician.

On the claim, report the following under the gastroenterologist's NPI:

• code 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key elements: a problem focused history; a problem focused examination; straightforward medical decision making ...) for the E/M

• code 556.1 (Ulcerative colitis; ulcerative [chronic] ileocolitis) appended to 99212 to represent the patient's current condition.

There is no incident-to provision when the gastroenterologist and NPP provide "incident-to" type services in the hospital. Some visits are eligible for split/shared billing, however, in which the physician and NPP "team up" to provide a complete E/M service to the patient, confirms Anderanin. You should bill shared visits under the physician's NPI, and much like incident-to billing, there are strict guidelines that govern split/shared visits.

The gastroenterologist has to provide a face-to-face service or you cannot report a shared visit, says Kimberly Sullivan, CPC, coding specialist at Deaconess Physician Billing Services in Evansville, Ind.

By the book: 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 physicianand 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 reviewing the patient's medical record) then the service may only be billed under the NPP's UPIN/PIN," the MCPM states. The MCPM provides the following shared visit description: "If the NPP sees a hospital inpatient in the morning, and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service."