General Surgery Coding Alert

Thanks to a recent CMS revision to its E/M rules, general surgery practices stand to gain when both the surgeon and a nonphysician practitioner (NPP) perform inpatient assessments.

According to CMS Transmittal 1776 effective Oct. 25, 2002 CMS allows incident-to billing for office and hospital inpatient, outpatient and emergency department (ED) evaluations when both the physician and a nonphysician practitioner see the patient.

In office settings, "when an E/M service is a shared/split encounter between a physician and a nonphysician practitioner" and the service meets the incident-to requirements, the physician reports the service using his or her provider identification number (PIN), the transmittal instructs.

For instance, an established patient comes to the office for wound infection after neck surgery. The NPP performs an initial assessment of the patient's infection, and the surgeon completes the examination and determines a plan of care for the infection. The NPP spent approximately five minutes with the patient, and the surgeon spent about 10 minutes with the patient. The surgeon would report 99213 (Office or other outpatient visit for the evaluation and management of an established patient ... Physicians typically spend 15 minutes face-to-face with the patient) under his PIN.

When an NPP and a surgeon from the same group practice share a patient evaluation in the hospital and  the physician provides any face-to-face portion of the E/M encounter, you may bill the service under either the physician's or the NPP's PIN, according to CMS.

For example, if the NPP sees a hospital inpatient in the morning for a complication of gall bladder surgery, such as wound hemorrhage, and the surgeon follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.

After performing his own exam, the physician can combine his notes with the NPP's documentation to determine the appropriate E/M service level and report it under his PIN number, says Jim Collins, CHCC, CPC, president of Compliant MD Inc. in Matthews, N.C., and compliance manager for Mid Carolina Cardiology in Charlotte, N.C.

"In the past, if both a nonphysician provider and a physician saw a patient in the hospital, the practice had to split the fee and bill an unassigned code, and the carrier got to choose the fee for that service since unassigned codes have no value," says Ron Nelson, PA-C, president of Health Services Associates Inc., a practice management consulting firm in Fremont, Mich., and past president of the American Academy of Physician Assistants (AAPA). "Now the NPPcan bill incident-to in the hospital setting as long as the physician has a face-to-face encounter with the patient."

However, if the surgeon's E/M service does not include face-to-face time with the patient, such as when he or she is reviewing the patient's medical record, then the NPP cannot bill incident-to and must bill under his or her PIN, CMS says.

Editor's note: The full text of the transmittal is available on the CMS Web site at www.cms.hhs.gov/manuals/pm_trans/R1776B3.pdf.