Neurology & Pain Management Coding Alert

When incident-to’s impossible, split/shared coding could be a substitute.

When your physician and a qualified nonphysician practitioner (NPP) team up to perform a service for a Medicare patient, you can always rely on incident-to coding … right?

Well …: Not exactly. With few exceptions, incident-to encounters only occur at place of service (POS) 11 (Office), and can only occur if the physician has established a plan of care for the patient’s problem.

So when you have an encounter that could meet incident-to parameters, you might need to rely on split/shared visit coding in order to max out your reimbursement possibilities.

Check out this Q&A on the ins and outs of split/shared visit coding, and be sure to apply them when your physician and an NPP team up to provide an E/M service outside the office.

Q: What is split/shared visit coding?

A: Split/shared visit coding is for hospital-based encounters “like inpatient, observation, ED and also services that take place in hospital outpatient departments or provider-based clinics [PBCs],” explains Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash. In other words, these services only apply in places of service other than 11.

Also, split/shared visits must involve two “qualified” providers. In other words, you can only apply these coding rules to encounters when a combination of the following provide the service to the patient:

• two physicians
• one physician with a qualified NPP or
• two qualified NPPs.

This is an important distinction from incident-to, where a sole NPP can provide some services for a patient if the patient has an established plan of care in place and the encounter meets other parameters. “Split/shared visits always involve two providers who have seen the patient on the same date,” Bucknam reminds.

Q: What is the benefit of split/shared visit coding?

A: You can code a split/shared visit under the physician’s national provider identifier (NPI). This means Medicare will pay out 100 percent of the code’s value on split/shared visits.

If you aren’t using split/shared visit coding, you’ll have to code the visit under the NPP’s NPI, which will only bring in 85 percent of the code’s value, says Jan Rasmussen, CPC, PCS, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions, Holcombe, Wisc. 

Q: Do all payers accept split/shared visit coding?

A: No.

Split/shared coding is a Medicare concept, says Bucknam. “Although many other payers follow these rules, they are not universal and practices should follow the specific rules of each individual payer,” she advises.

Q: Clinically, what would a split/shared visit look like?

A: Consider this example from Bucknam: One of the practice’s Medicare patients is in the hospital for the second day after suffering stroke-like symptoms. The physician rounds on the patient at 7 a.m., and performs an expanded problem focused history and expanded problem focused exam. Notes indicate that she also ordered services, tests and a medication change meeting the high complexity medical decision making requirements.

Six hours later, a qualified NPP who works with the same practice sees the patient again. He notes a problem focused history, detailed exam, and reviews test results — but makes no changes to the patient’s treatment.

Even though both providers saw the patient, you’re only allowed to report one hospital E/M service per day for a patient. The solution is to combine the physician’s and NPP’s documented efforts and then choose a corresponding code. That means you can take the highest elements from each provider’s encounter with the patient and code accordingly.

In Bucknam’s example, you’d report 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity…) for the hospital care under the physician’s NPI.