Internal Medicine Coding Alert

Warning: Rules prohibit split/shared visit billing

There are some specific reporting rules you'll have to follow when one of your nonphysician practitioners (NPPs) provides part or all of a critical care service.

Medicare Transmittal 1530 groups all the NPP critical care information into one place for easy reference, says Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

"Previously, a lot of the critical care [coding] information was scattered in different areas, which created confusion. This transmittal is an attempt to defuse that and create uniformity among all Medicare providers," she says. Check out this FAQ on NPPs that provide critical care, and be sure to reference Transmittal 1530 (http://www.cms.hhs.gov/Transmittals/downloads/R1530CP.pdf) for any of your critical care coding questions.

Question: Can an NPP provide critical care services on her own?

Answer: Yes -- if the NPP has required licenses and it is within the scope of practice for the state she works in, according to the transmittal. "Collaboration, physician supervision and billing requirements must also be met," the transmittal says. A physician assistant shall meet the general physician supervision requirements.

When qualified NPPs provide critical care, you can report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]) for their services.

Question: What types of critical care can NPPs provide?

Answer: An NPP can provide any type of critical care a physician does, provided the NPP is properly qualified and licensed and the services meet Medicare's definition of critical care.

According to the transmittal, patients requiring critical care are suffering from a "critical illness or injury [that] acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition." Documentation should clearly support the provision of critical care services that encompass both treatment of "vital organ failure" and "prevention of further life-threatening deterioration of the patient's condition."

"'High probability' doesn't mean the patient is deteriorating right now; it means he could deteriorate if the provider does not treat him," says Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jacksonville, Fla.

"A description of the condition must be in the documentation," Edelberg said during her recent Coding Institute audioconference on hospital billing (http://www.audioeducator.com).

Some examples of conditions that could acutely impair a vital organ system include:

central nervous system failure

circulatory failure

shock

renal, hepatic, metabolic, respiratory failure.

Question: How should we code for NPP critical care services?

If the NPP provides any part of the critical care service, you must bill the service under the NPP's National Provider Identifier (NPI). You can never report critical care as a shared or split service -- even when the NPP and internist team up to provide critical care.

"Unlike other E/M services where a split/shared service is allowed, the critical care service reported shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified NPP," the transmittal says.

Critical care is treatment provided "by an individual physician or qualified NPP and shall not be representative of a combined service between the physician and NPP," the transmittal says.