Medicare Compliance & Reimbursement

Don't try to combine NPP/physician visits in the office setting.

Some things are better not shared, like toothbrushes, syringes - and office visits.

Providers are often tempted to use the shared visits rule in the office setting. But while they're allowed to bill for a shared visit under certain limited circumstances, they won't find the rule very useful in the office, according to experts. The Centers for Medicare & Medicaid Services introduced shared visits in last year's Transmittal 1776, which allows a physician and a non-physician practitioner (NPP) to perform parts of an evaluation and management service separately in the hospital and bill under the physician's number.

If physicians bill for shared visits in the office setting, they still have to follow all the rules for incident-to billing, says consultant Quentin Buechner with Proactive Consultants in Cumberland, WI. That means the NPP can only see existing patients under a plan of care (POC) the physician has established.

But some offices have gone wild. They allow the NPP to see a new patient or a patient with a new problem, perform the history and physical portions of the visit, and then bring in the physician to perform the medical decision-making portion. This is a misunderstanding of the shared-visit rule. The only thing to do with a visit like that is bill unlisted code 99499 and cross your fingers, says Buechner.

"We don't advocate billing for shared visits in the office setting," says Jan Towers, director of health policy at the American Academy of Nurse Practitioners. In fact, NPPs should bill under their own number in almost all circumstances, she recommends. They should only bill incident-to for routine follow-ups where they're closely following the doctor's plan of care, she continues.

There's only one situation in which physicians might bill for a shared visit in the office setting, says Buechner. An NPP is seeing an existing patient under the physician's plan of care, and then the NPP discovers a new problem that the POC doesn't cover. The NPP calls in the physician, who treats the new problem. In this case, you would bill both providers' services as one combined E/M visit under the physician's number.

"That gets to be a gray area," notes consultant Joan Gilhooly, president of Medical Business Resources in Evanston, IL. In that situation, the physician must perform 100 percent of the work-up on the new problem the NPP discovers. "My recommendation to practices that have nurse practitioners and physician assistants is only to use the split/shared rule when the provider has asked for the physician's opinion on the progress of the patient who's being seen on an incident-to basis," she adds.

Providers should remember that medical decision-making isn't something that happens after the history and [...]