General Surgery Coding Alert

Question: I've heard that CMS issued a memorandum regarding new nonphysician practitioner (NPP) guidelines. Will this affect me?

Illinois Subscriber

Answer: The new regulations mainly affect billing for hospital visits (for example, 99221-99223, Initial hospital care) rather than office visits (such as 99211-99215, Established patient office visit ...). Physicians can now bill E/M hospital services even if the NPPinitiates treatment, provided the doctor visits the patient later that day.

CMS Transmittal 1776 (change request 2321), dated Oct. 27, 2002, states, "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 personal identification number]/PIN [personal identification number]." If, however, no face-to-face contact occurs between the doctor and the patient even if the physician reviews the records bill the service under the NPP's UPIN/PIN.

The transmittal reinforces incident-to guidelines, which apply to Medicare Part B providers only, and outlines the following billing methods:
If the physician and an NPP share/split an E/M: An NPP visits a hospital inpatient in the morning, for instance, and the physician follows with a face-to-face examination that afternoon. Either the NPP or the doctor can report the service (99221-99223).
In an office setting, if an NPP starts an E/M service and the physician completes the examination, the physician reports the service (99211-99215) as incident-to, if incident-to guidelines requirements are met and the patient is an established patient. If incident-to guidelines are not met, bill the service under the NPP's UPIN/PIN.
If the physician performs the service: Bill the E/M under the doctor's UPIN/PIN.

The Medicare Carriers Manual, section 2050, available at www.cms.hhs.gov/manuals/14_car/3b2049.asp, outlines incident-to requirements. For you to report services incident-to a physician, the service must be:
1. An integral, although incidental, part of the physician's professional service
2. Commonly rendered without charge or included in the physician's bill
3. Of a type that is commonly furnished in physician's offices or clinics
4. Furnished by the physician or by auxiliary personnel under the physician's direct supervision.

Direct supervision encompasses several issues. First, the physician must provide a direct, personal, professional service to initiate the course of treatment. Second, he or she must perform subsequent care at a frequency that reflects his or her continuing active participation in and management of the course of treatment. Third, the physician must be physically present in the same office suite and immediately available to render assistance if that becomes necessary. Therefore, the transmittal does not offer any way for NPPs to provide initial services to office or clinic patients and reinforces previous guidelines.

To view the memo, visit www.cms.hhs.gov/manuals/pm_trans/R1776B3.pdf.