General Surgery Coding Alert

Physician must see the patient if there's a new problem

A -shared visit- describes an E/M service during which a physician and a nonphysician practitioner (NPP) each see a patient for a portion of the same visit. Judiciously using shared visits can boost your bottom line while maintaining a high level of patient care, but you have to know the requirements for reporting these services.

Physician Evaluations Are Crucial

To bill under the shared-visit rule, a physician must personally evaluate the patient and document his service. Because the NPP already interviewed the patient, conducted a preliminary examination and documented his service, the physician visit will be more focused on the medical problem.

CMS guidelines dictate, -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 PIN.-

No face-to-face with physician lowers reimbursement: If, however, -there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient's medical record), then the service may only be billed under the NPP's PIN,- according to CMS. -Payment will be made at the appropriate Physician Fee Schedule rate based on the PIN entered on the claim.- 

Solidify your documentation: The key to complying with the shared-visit provision is that the physician must personally see the patient, review any history and exam performed and documented by the NPP, conduct an examination and be involved with the plan of care. This means your physician must get the documentation right.

For instance: The doctor cannot just sign off on what the NPP writes in the progress note -- he has to contribute to the E/M. In addition, Medicare carriers don't like to see minimal notes, such as -Agree with above- or -Rounded, reviewed, agree,- so you should encourage your physicians to provide enough documentation to show that they have carefully reviewed the NPP's work.

Documentation should offer specific details and physician input, such as, -I agree with the NPP's note, except the heart murmur is louder, so I will obtain an echo to evaluate.-

Don't -Share- Consults and Critical Care, CMS Says

Although you can use the shared-visit provision for most hospital-based E/M services, make sure you do not apply them to consultations (99251-99255) or critical care services (99291-99292).

-The shared-visit policy does not apply to critical care, which is a time-based service, or consultation services or any other procedure codes or for services in other settings, such as skilled nursing facility services, home care or domiciliary care,- according to a CMS spokesman.

Specifically, -an NPP may request a consult and may also perform a consultation and receive payment made at 85 percent of the Physician Fee Schedule [PFS]. But all the work must be performed by the NPP or all the work by the physician for 100 percent of the PFS,- the CMS spokesman says.

Take-away advice: Make sure you don't inappropriately use your NPPs to perform the above-listed services if you plan to bill under the doctor's Medicare identification number.

Follow -Incident-to- Rules for Shared Office Visits

You must meet -incident-to- reporting requirements for nonphysician E/M services in the office, according to CMS regulations.

In other words: A physician has to be in the office suite and available for supervision to bill the NPP's E/M under the physician's PIN.

-When an E/M service is a shared encounter between a physician and a nonphysician practitioner, 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,- states Medicare's Internet Only Manual.

-If -incident-to- requirements are not met for the shared E/M service, the service must be billed under the NPP's PIN,- and payment will be made at the appropriate Physician Fee Schedule amount (in other words, at 85 percent -- rather than 100 percent -- of the Physician Fee Schedule amount for your area), the IOM says.

Bottom line: You won't receive full reimbursement for your NPPs- services in the office unless you meet incident-to requirements.

New Problem Offers -Shared Visit- Opportunity

If an established patient develops a new problem, such as hypertension, CMS has clarified that the NPP can address the new problem and still meet the incident-to provisions, as long as the physician also sees the patient.

In fact, the only situation in an office setting when you will report a shared visit is if an NPP is seeing an existing patient under the physician's plan of care (POC), and then the NPP discovers a new problem that the POC doesn't cover. The NPP calls in the physician, who then treats the new problem.

What not to do: The NPP may not see a new patient. Nor may the NPP perform a workup on a patient with a new problem by performing the history and physical portions of the visit, and then bringing in the physician to perform the medical decision-making. Rather, the physician must see all new patients, and perform 100 percent of the workup on any new problems the NPP discovers in an established patient.

If the visit meets the above requirements, you would bill both providers- services as one combined E/M visit under the physician's PIN to receive 100 percent of the service's fee schedule reimbursement.

Learn more: You can find the full text for Medicare's policy on shared visits in Medicare Transmittal 1779, available on the CMS Web site at www.cms.gov.