Internal Medicine Coding Alert

Question: Our nurse practitioner (NP) is working with our internal medicine physician in the same clinic. We are planning to see new patients two days a month. The physician will have her own visit and cover certain topics with each patient, and our NP will then see the patient on the same day and cover additional topics that the physician will not be covering. Our NP will mainly cover health maintenance issues.

Are we able to bill for the NP service if it occurs on the same day as the patient sees our physician if the NP is covering an entirely different subject? The visit with the NP will be 45 minutes and is primarily counseling.

Michigan Subscriber

Answer: In general, when your physician and an NP both have a face-to-face evaluation and management (E/M) encounter with the same patient on the same day, you should only report one E/M service reflecting the totality of the encounter, especially if the services are connected in any way. The notes of both practitioners can be combined to decide on the level of service and one bill generated under the physician’s name and PIN.

In the scenario you describe, the combined face-to-face time will likely exceed 60 minutes for both your physician and your NP contacts with the majority of time spent in counseling. As such, you may be able to report the level of E/M service based on time. If so, documentation should describe the content of the counseling provided and/or activities to coordinate care. There must also be sufficient detail to support the service billed.

So, if time is documented and the medical necessity supports both services, the practice could bill up to a level 5 service (99205, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components…Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem[s] and the patient’s and/or family’s needs. Usually, the presenting problem[s]are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family).

If the total face-to-face time exceeds 90 minutes, then you may add a prolonged services charge (99354, Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]).

Remember: Before following this route, the physician and NP must be employees of the same practice. In any shared service, both the physician and the NP must provide their portion of the services face to face. The incident-to rules are all still in effect. You must document medical necessity and what you actually did during the encounter.

Caution:  Per section 30.6.1.B of chapter 12 of the Medicare Claims Processing Manual, a shared/split encounter between a physician and a non-physician practitioner, such as an NP, 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. If “incident to” requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s provider number, and payment will be made at the appropriate physician fee schedule payment. Thus, in your example, it may not be possible to bill Medicare for these “shared” visits under the physician’s provider number if the patient is new, as indicated. Instead, you will need to report the encounter to Medicare under the NP’s name and number, which Medicare will pay at a discounted rate.

Possible exception:   If the services provided by the physician and the NP could be separately reported if provided by a single physician or NP, then it may still be possible to report them separately in this scenario. For example, if one of them provided a preventive medicine visit and the other provided a problem-oriented encounter, both services could be reported, with the appropriate use of modifier 25, as indicated in the lead article above.