Advanced Search

Ob-Gyn Coding Alert

New NPP Rules Affect Inpatient E/M Billing

Published on Sat Mar 01, 2003

A recent CMS memorandum means that you may be able to report nonphysician practitioner (NPP) services provided in the hospital as "incident-to" those performed by the ob-gyn.

CMS transmittal 1776, released in October 2002, states that "when a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's unique personal identification number (UPIN)/personal identification number (PIN)." If no face-to-face contact occurs between the ob-gyn and the patient, even if the physician reviews the NPP's records, you should bill the service under the NPP's UPIN/PIN.

The transmittal mainly affects billing for hospital visits, such as 99231-99233 (Subsequent hospital care), rather than office visits (for example, 99211-99215, Established patient office visit). For example, your NPPs can now bill for the morning rounds at the hospital as incident-to, as long as the ob-gyn visits the patients later that day. Incident-to rules, however, require the physician to initiate the plan of care. Therefore, you cannot report hospital admissions or initial office workups incident-to because this requires that the physician initiate the treatment.

CMS used the memorandum to reinforce incident-to guidelines. The transmittal outlines three in-office billing methods:
1. If the physician performs the service, bill the E/M under the doctor's UPIN/PIN.
2. If the physician and an NPPshare or split an E/M, report the service incident-to, as long as it meets incident-to guidelines and the patient is an established patient. If the service does not meet incident-to guidelines, bill it under the NPP's UPIN/PIN.

For instance, an NPP visits a hospital inpatient in the morning and the physician follows with a face-to-face examination that afternoon. Either the NPP or the doctor can report the E/M service (99231-99233).

3. If an NPP provides a portion of an E/M service and the physician completes the examination in an office setting, the physician reports the service (99211-99215) if it meets incident-to guidelines. Otherwise, the NPP bills the service under his or her UPIN/PIN.

Section 2050 of the Medicare Carriers Manual outlines incident-to requirements. For you to report services incident-to a physician, the service must be:

  • an integral, although incidental, part of the physician's professional service
  • commonly rendered without charge or included in the physician's bill
  • of a type that is commonly furnished in physicians' offices or clinics
  • furnished by the physician or by auxiliary personnel under the physician's direct supervision.

    Direct supervision encompasses several issues. First, the physician must provide a direct, personal, professional service to initiate the course of treatment. Second, he or she must perform subsequent care frequently enough so that it reflects his or her continuing active participation in and management of the course of treatment. Third, the physician must be physically present in the same office suite and immediately available to render assistance if that becomes necessary. Therefore, the transmittal does not offer any way for NPPs to provide initial services to office or clinic patients and reinforces previously held incident-to tenets.

    Use Unlisted-Procedure Code for Incomplete E/M

    In addition to expanding the incident-to place of service, the transmittal notes that "when a physician (or NPP) provides a services that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499." In this case, you should submit a description of the service (for example, the ob-gyn performs only a history) with the claim to clearly show the payer what services the ob-gyn performed. And you may not use modifier -52 (Reduced services) with E/M services, CMS states, because "Medicare does not recognize modifier -52 for this purpose."

    For example, if an NPP performed only a patient history and there was no exam or medical decision-making on her part or by the physician who may have subsequently seen the patient, you would have to bill 99499 not 9921x-52.

    The carrier will determine the service's value and reimbursement based on the applicable percentage of the Physician Fee Schedule, depending on whether the claim is paid at the physician rate or the nonphysician rate, according to the transmittal.

    To view the transmittal, visit www.cms.hhs.gov/manuals/pm_trans/R1776B3.pdf.

    • Other Articles in this issue of

    Ob-Gyn Coding Alert

    View All