Medicare Compliance & Reimbursement

If you glean anything from CMS's recent CERT report (see page 1 for more information), it should be that you've got to buckle up your coding for E/M services.

CMS paid out more than $1 billion in error for E/M codes between Sept. 30, 2006 and Sept. 30, 2007, according to the most recent comprehensive error rate testing (CERT) report.

We're here to help you stay on track with your E/M coding by sharing three common questions and answers.

Question: How should we code a mid-level provider's (MLP's) report of a consult that she performs on a hospital inpatient? Is incident-to consult billing allowed for inpatient MLP services?

Answer: Incident-to is not allowed in the hospital at all, says Suzan Berman-Hvizdash, CPC, CEMC,CEDC, senior manager of coding and compliance with the UPMC Departments of Surgery and Anesthesiology. "Shared/split visits are what can be done in the hospital, however, not for consultations," she advises. "The MLP would bill the consultation out under his/her own provider number. To Medicare, the reimbursement would be 85 percent of the physician fee schedule."

Question: I know that a MLP and a physician can share an E/M visit, with the nurse, for instance, taking the history and performing some preliminary work and then handing off the patient to the MD for the exam. Does this apply for consult services as well?

Answer: "The RN can only take the past, family, and social histories (PFSH), as well as the review of systems (ROS)," Berman-Hvizdash says. "The MLP would note his or her visit in the chart, making a statement that the doctor will also see the patient."

Keep in mind: The physician must reference back to the notes (which he or she wants to use toward the billed level of service). "The note must also include proof that he or she saw the patient," Berman-Hvizdash says. "The doctor can't just write that the records were reviewed or tests were viewed; but face-to-face time with the patient must be evident within the note written by the M.D."

Question: If a new patient presents for an office visit,sees the nurse but then has to leave suddenly, can we report 99211 for that visit? Also, can we bill 99211 for prothrombin time testing that the nurse performs on an established patient if the patient requires a brief evaluation?

Answer: There is no one complete source for the correct use of 99211, says Quinten A. Buechner, MS, MDiv, CPC, ACS-FP/GI/ PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis. "Each payer does its own thing. CPT hasn't been very helpful either, so some practices avoid using the code. That is a shame because just five encounters a week adds up to about $5,000 a year," Buechner says.

New patients: You'll find code 99211 listed under the established patient office visit codes, so you should not report it for the new patient.

Prothrombin time (PT): Under Medicare rules, you can report 99211 for PT testing if you meet the following requirements, Buechner says: