Otolaryngology Coding Alert

Reader Question:

NPP Rules Affect E/Ms in the Hospital,Not Office

Published on Wed Jan 01, 2003

Question: I've heard that CMS issued a memorandum regarding new nonphysician practitioner (NPP) guidelines. My physician assistant often performs hospital rounds before me and sometimes does the initial patient workup at the office. Should I bill these services incident-to?

North Carolina Subscriber

Answer: The new regulations mainly affect billing for hospital visits, such as 99231-99233 (Subsequent hospital care), rather than office visits, for example, 99211-99215 (Established patient office visit). Your PA, as well as any other NPPs whom you employ, can now bill an E/M for the a.m. rounds, provided you visit the patient 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 workup incident-to, because incident-to requires that the doctor initiate the treatment.

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 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 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. The memo outlines three in-office billing methods:

1. The physician performs the service. Bill the E/M under the doctor's UPIN/PIN.

2. The physician and an NPP share/split an E/M. Report the service incident-to, provided 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. In an office setting, an NPP provides a portion of an E/M service, and the physician completes the examination. If this service meets incident-to guidelines, the physician reports the service (99211-99215). Otherwise, the NPP bills the service under his or her PIN.

The Medicare Carriers Manual section 2050, available at www.cms.hhs.gov/manuals/14_car/3b2049.asp, outlines incident-to requirements. 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 tenants.

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