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Ophthalmology and Optometry Coding Alert

Reader Question:

Apply New NPP Rules to Hospital,Not Office,E/Ms

Published on Sat Feb 01, 2003

Question: I've heard that CMS has issued a memorandum regarding new NPP guidelines. How will this affect my inpatient hospital billing?

North Carolina Subscriber

Answer: The new regulations mainly affect billing for hospital visits (e.g., 99221-99233, Hospital care), rather than office visits (e.g., 99211-99215, Established patient office visit). Nonphysician practitioners (NPPs) can now bill E/M hospital services incident-to a physician when the NPPinitiates treatment, if the doctor visits the patient later that day.

Transmittal 1775 dated Oct. 27, 2002, states that "when a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPPfrom 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, however, no face-to-face contact occurs between the doctor and the patient, even if the physician reviews the records, you should bill the service under the NPP's UPIN/PIN.

The transmittal reinforces incident-to guidelines, which apply to Medicare Part B providers only. The memo outlines three billing methods:

1. The physician performs an E/M service and you bill the service underhis UPIN/PIN. For instance, an NPPvisits a hospital inpatient in the morning, and the physician follows with a face-to-face examination that afternoon. Either the NPPor the doctor can report the service (99221-99233).

2. The physician and an NPPshare/split an E/M. Report the service incident-to, provided incident-to guidelines requirements are met and the patient is an established patient. If incident-to guidelines are not met, bill the service under the NPP's UPIN/PIN.

3. In an office setting, an NPPstarts an E/M service, and the physician completes the examination. If incident-to guidelines are met, the physician reports the service (99211-99215). Otherwise, the NPPbills the service under his or her personal identification number.

The Medicare Carriers Manual section 2050, available at cms.hhs.gov/manuals/14_car/3b2049.asp, 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 a physician's 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 services of a frequency that 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 tenants.

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

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