Internal Medicine Coding Alert

Medicare allows NPP, internist to combine forces for some hospital services

In the office setting, incident-to billing is a vital cog in the practice's reimbursement machine: Under incident-to rules, qualified nonphysician practitioners (NPPs) can treat certain patients and still bill the visit under the physician's National Provider Identifier (NPI).

The hospital setting, however, is a different story. "There is no incident-to billing in the hospital," says Mary Falbo, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. "But shared/split visit billing is an option."

Shared-visit billing is not exactly incident-to, but it is a way to bill for services that are provided jointly by the internist and a qualified NPP. If the encounter meets shared-visit guidelines, you'll be able to report the entire visit under the internist's NPI -- thereby garnering you 15 percent more pay for the same service.

Remember that the shared-visit billing rules apply to Medicare and those commercial insurers that follow Medicare rules. You should not report shared visits to a private insurer before making sure it allows them.

In a nutshell: According to Suzan Hvizdash CPC, CPC-E/M, CPC-EDS, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board, here's how the typical shared visit works:

• The NPP visits and examines a patient. The NPP documents her work establishing medical necessity.

• At a different time, the internist sees the patient. The physician documents her work. This can be immediately after or even before the NPP's visit, but it "has to be on the same day," Hvizdash says.

• Then, you can add the documentation together to establish a billing level, Hvizdash said during The Coding Institute audioconference "9 Revenue-Boosting Billing Strategies for Incident-To Services."

Benefit: In many shared visits, the NPP conducts the preliminary interview and exam and then the internist sees the patient. This allows the internist to focus more on the medical problem and less on the other visit components.

To bill a shared visit under the physician's NPI, he must provide and document a face-to-face service for the patient. "Physicians must perform at least a portion of the E/M service that involves contact with the patient. General oversight, such as reviewing the medical record, is insufficient," according to the American College of Physicians Internal Medicine Web site.

According to Transmittal 178 of the Medicare Claims Processing manual, "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 NPI number.

"However, if there was no face-to-face encounter between the patient and the physician, the service may only be billed under the NPP's," the transmittal states.

Ideally, you'll bill a shared visit under the internist's NPI, but you could also bill a shared visit under the NPP's NPI.

When? "There might be instances where the MD's note may not include the face-to-face encounter that is required. Maybe he only writes that he 'looked at the CT scan and made recommendations,' " Hvizdash said.

Because the note Hvizdash described doesn't fully illustrate the internist's contact with the patient, you should bill this visit under the NPP's NPI.

Shared billing is an option only for select hospital E/M services -- you cannot bill shared visits for consultations or critical care, Hvizdash said. Shared billing is not an option for services in the skilled nursing facility or nursing facility settings either, and it is not for procedures in any setting.

Under shared-visit rules, the NPP can treat patients in the hospital in accordance with his scope of practice and hospital privileges granted. During these visits, general supervision requirements apply. "The physician must be accessible at all times by telephone or some other means of communication," Hvizdash said.

She offers this example: An advanced registered nurse practitioner (ARNP) makes rounds in the morning and visits a hospital inpatient with uncontrolled type II diabetes (the patient was admitted the day before). The ARNP writes a detailed note of the patient's condition (including the history and exam elements gleaned during the visit) and the recommendations. He also notes in the patient file that the internist will be in later that day.

A few hours later, the internist and the ARNP visit the same patient together. The internist performs an exam, gathers some history, and makes recommendations. The internist details his findings in the chart, and he links his notes to the ARNP's notes from earlier in the day. The compiled notes indicate a level-two hospital care service.

"Combined, these two notes can now stand as evidence toward the billed level of service selected," Hvizdash said.

For this claim, you would report 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem-focused interval history; an expanded problem-focused examination; medical decision-making of moderate complexity) for the shared visit. Remember to append 250.02 (Diabetes mellitus without mention of complication; type II or unspecified type, uncontrolled) to 99232 to represent the patient's diabetes.

Benefit: "The bill would go out under the physician's NPI, and the reimbursement would be at 100 percent of the fee schedule amount," Hvizdash said.

Your documentation must support the level of E/M service you are coding for, or Medicare could deny your shared-visit claim.

"Documentation should offer specific details [about both encounters] and physician input," says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

When submitting your shared-service claims, be sure that you remember to:

• clearly identify both providers in the medical record

• link the internist's encounter notes to the NPP's

• include legible signatures from the internist and the NPP.

Caution: Your documentation must prove the internist provided at least one element of the encounter for you to bill under the physician's NPI, Hvizdash said.

Example: To support physician review, Plummer says, the physician could note, "I interviewed and examined the patient. I discussed the patient's data and findings with the NPP, and I agree with the NPP's findings, assessment and plans."