Neurosurgery Coding Alert

Tip: Don't let Medicare's 2010 consultation changes alter your split visit billing.

When your neurosurgeon provides services in the hospital, he may opt to share the work with a non-physician practitioner (NPP) to maximize his time. If you don't know when you can bill those services as split/shared visits, you're costing your physician 15 percent every time. Make sure you're bringing in every dollar by learning these three split/shared visit guidelines.

1. Learn When to Apply Shared Visit Rules

Split/shared rules come into play when one of your physicians and a qualified nonphysician practitioner (NPP), such as a physician assistant, both see a patient face to face in the hospital where incident-to rules are not applicable. Each provider performs 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 physician's National Provider Identifier (NPI) -- thereby garnering 15 percent more pay for the same service.

Remember: Incident-to does not apply in a facility setting, says Cyndee Weston, CPC, CMC, CMRS, executive director of the American Medical Billing Association in Sulpher, Okla. While  "incident-to" billing indicates certain services performed by an NPP, incident-to is only appropriate for office visits meeting specific requirements, according to the Medicare Claims Processing Manual (MCPM), Chapter 12, Section 30.6.1.B.

How it works: Just like with incident-to services, your physician 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.

You should apply shared visit billing rules to Medicare and those commercial payers that follow Medicare rules. You shouldn't report shared visits to private insurers until you make sure they allow payment for shared visits. Also, keep in mind that shared/split billing only 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.

2. Prove Shared Services With Documentation

To bill a shared visit under the physician's NPI, the physician 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:

• Documentation of the combined notes written by your physician and the NPP that support the E/M level
• A statement clearly identifying the NPP and physician providing the service
• A link between the physician's documentation and the NPP's The physician's and NPP's documentation of a face-toface encounter with the same patient on the same day in the hospital
• Legible signatures of the physician and NPP providing the E/M.

Warning: According to Medicare, "if the physician doesn't document the face-to-face encounter with the patient, even if he signs off on the documentation supplied by the NPP, the visit must be billed under the NPP," Weston says.

3. Don't Scrap Split Billing Along With Consultation Coding

Although CMS eliminated payment for consult codes this year, contractors will continue to honor split/shared visit billing -- as long as you bill the visits using specific E/M codes and following the payment rules already in place for these E/M codes.

The problem: When Medicare and other payers stopped paying for consultations, billers were confused about whether they could report services that would previously qualify as consultations --and therefore would not have been eligible for split/shared billing -- as shared visits now.

Under past coding policy you could not report the consultation codes as a split/shared visit. You can, however, bill the codes now used for consultations -- 99221-99223 and 99231-99232 -- by rule, as a split/shared visit, allowing the physician full pay when he shared the work for this patient with an NPP. For example, your neurosurgeon provides consultation services at the request of an internist for an inpatient with severe back pain who has had spinal fusion in the past. If a PA with the neurosurgeon's practice provides and documents initial evaluation and management care for this patient in addition to the neurosurgeon's face-to-face evaluation services, the physician can recover full pay for his work (99221-99223)

Clarification: In MLN Matters article SE1010, CMS notes 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." "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," CMS's Rebecca Cole said in an Open Door Forum earlier this year.

"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 code."