Medicare Compliance & Reimbursement

Question: I know I cannot bill services incident-to in the hospital setting. Is there any other option to capture the most value from time a non-physician practitioner (NPP) spent with a patient?

Answer: Yes, you can bill split/shared E/M services in the hospital setting under the doctor's National Provider Identifier (NPI).

The catch: The physician must provide a substantive portion of the service. This definition comes from the Medicare carrier First Coast: A split/shared visit is a medically necessary encounter with a patient where the physician and a qualified NPP each performs a substantive portion of the evaluation and management (E/M) visit, face-to-face with the same patient on the same date of  service.

A substantive portion of an E/M visit involves all or some portion of the history, examination, and medical decision making components of the E/M service. Simply signing off on the NPP's note does not meet the criteria for a split/ shared visit. The physician and NPP both must be in the same group practice or employed by the same employer. Furthermore, the split/shared visit applies only to selected E/M visits and settings; it does not apply to consultation services, critical care services, or procedures. View the First Coast split/shared visit policy at www.medicare.fcso.com/Wrapped/157200.asp.

When the encounter meets the criteria above, you may report the service under either the physician's or the NPP's NPI [unique physician identification number], states Medicare Claims Processing Manual, Chapter 12, Section 30.6.1. When you bill under the NPP's NPI, you'll receive 15 percent less for the same service.

If there was no face-to-face encounter between the patient and the physician (for instance, if the doctor participated only by reviewing the patient's medical record), then you would bill the service only under the NPP's NPI.

Example: On morning rounds, the NPP sees a patient with pneumonia (for instance, 480.2, Pneumonia due to parainfluenza virus). The NPP documents a level two subsequent hospital visit note (99232, Subsequent hospital care, per day ...). Later in the day, the doctor examines the patient and documents the substantive components of the face-to-face patient encounter in the medical record. In addition, the physician reviews and documents agreement with the NPP's note. In this example, it would be appropriate to bill a subsequent hospital care code (99232) under the internist's NPI, because the physician provided a substantive portion of the service that included a face to-face interaction with the patient.

Know this: CMS recently clarified whether an NPP billing under the split/shared rule would need to be NPIeligible to report the service. "Under the split/shared billing rules, NPI eligibility is not required for the NPP, because the bill would be submitted under the physician's NPI," said CMS's Rebecca Cole during a May 25 CMS Open Door Forum.