Neurology & Pain Management Coding Alert

Plus, you should report one inpatient care code per day, CMS reps say.

With consultation codes now out of the picture, it's easy to be confused by Medicare's recent advice on how to bill in their absence. But CMS offers a bright spot by still allowing you to use shared/split visits in cases where you used to report a consultation code.

Stick With the E/M Shared/Split Rules

Although CMS eliminated payment for consult codes, contractors will continue to honor split/shared visits -- as long as they are billed using specific E/M codes and following the payment rules already in place for these E/M codes.

That's the word from CMS, where staffers aimed to straighten out confusion stemming from the January MLN Matters article SE1010, which offered several questions and answers regarding how to bill Medicare following the elimination of consult code payment.

In the article, CMS noted that "the split/shared rules applying to E/M services remain in effect, including those cases where services would previously have been reported by CPT consultation codes."

"We understand that this has caused some confusion, as there were -- and are -- different split/shared rules for consultation services compared to E/M services," noted CMS's Rebecca Cole during an April 13 CMS Open Door Forum.

"We'd like to clarify that Q&A," Cole said. "As we're no longer recognizing the consultation CPT codes for purposes of payment under Part B, the split/shared rules regarding consultation services are no longer applicable. Since E/M visit codes are being billed for services that were previously reported by the CPT consultation codes, the split/shared rules pertaining to E/M services apply when billing E/M CPT codes," Cole stressed.

Remember: You can still report shared/split visits according to the regulations using E/M codes, but you cannot collect from Medicare for any previously used consultation codes.CMS is considering issuing a clarification in writing to dispel any confusion regarding the shared/split billing rule, Cole noted.

Prove Shared Work With Your Documentation

Split/shared rules come into play when a neurologist and a qualified non-physician practitioner (NPP), such as a physician assistant, both see a patient on the same date of service face to face in the hospital where incident-to rules are not applicable, and each provide a distinct part of an E/M service. If the encounter meets shared visit guidelines, you'll be able to report the entire visit under your neurologist's National Provider Identifier (NPI) -- thereby garnering the 15 percent more pay for the same service.

How it works: Just like with incident-to services, your neurologist receives 100 percent of the Medicare allowable when services are reported under his own NPI. If you report the same service under the NPP's NPI, the reimbursement is set at 85 percent of the Medicare allowable.

Under past coding policy you could not report the consultation codes as a split/shared visit. The codes you would now use for an in-patient consultation -- 99221-99223 and 99231-99232 -- can be used to bill for a split/shared visit. This means your neurologist can receive full pay if he shared a patient visit with an NPP.

Fulfill Your Payers' Requirements for Payment

Remember: Shared visit billing rules apply to Medicare and those commercial payers that specifically follow Medicare rules. You shouldn't report shared visits to private insurersbefore making sure they allow payment for shared visits. Also, keep in mind that shared/split billing applies to E/M services provided by nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives in the emergency department, outpatient hospital, and inpatient hospital.

Note: Shared/split billing can be reported in an office setting, but only if the service meets all requirements for incident-to billing.

To bill a shared visit under the physician's NPI, your neurologist must provide and document a face-to-face service for the patient. He must perform at least a portion of the E/M service that involves contact with the patient. When reporting a shared visit, be sure to include the following:

a) documentation of the combined notes written by your neurologist and the NPP that support the E/M level

b) a statement clearly identifying the NPP and neurologist providing the service

c) a link between the neurologist's documentation and the NPP's

d) the neurologist's and NPP's documentation of a face-to-face encounter with the same patient on the same day in the hospital

e) legible signatures of the neurologist and NPP providing the E/M.

Plus, Rein in Your Initial Inpatient Billing

One caller during the CMS Open Door Forum wanted clarification on billing for hospital care now that consult codes aren't payable. She asked whether a physician can report two initial hospital care codes for the same patient on the same date -- for instance, if the physician saw the patient prior to surgery for one reason, and then saw the patient after surgery for another reason.

"I think you should consult the CPT rules as well as the manual, but I think our reaction to that is no," said CMS's William Rogers, MD, during the call. The initial hospital care codes refer to that physician's first visit with the patient, Rogers said. Later evaluations should be billed using subsequent hospital care codes, he advised.

However, CMS representatives indicated that they will look into the issue further to determine whether physicians should beable to report a second initial hospital care code if specifically requested to review a different condition. "We can consider this further and decide what our next steps will be," Rogers said. Until then, CMS staffers urged practices to continue billing according to published rules.

In black and white: "Both initial inpatient hospital care codes and subsequent hospital care codes are 'per diem' services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice," notes CMS Transmittal 1545.