Pain Management Coding Alert

Here’s why POS 11 is a pivotal piece of info on these E/Ms.

If one of your physicians and a nonphysician practitioner (NPP) team up to perform an evaluation and management (E/M) service, the visit could qualify as an incident-to service.

Caveat: The encounter notes might indicate that it is a split/shared visit instead, and coders need to know the difference. If you don’t code for incident-to or split/shared visits when you could, you’ll leave deserved reimbursement in the payer’s purse.

Check out these tips to assist you when deciding whether to code an E/M service as incident-to or split/shared.

Get 15 Percent More When You ID These Visits

Both incident-to and split visit coding are Medicare features, reminds Cynthia A. Swanson RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb. Only Medicare payers, and those that follow Medicare guidelines, are bound by incident-to and split visit rules.

“Other commercial plans may or may not follow Medicare,” says Swanson. Additionally, third-party payers may have different requirements for incident-to and split/shared visits.

Best bet: Check with the third-party payer if you don’t know its incident-to and split visit guidelines.

Also, incident-to and split visit coding can be beneficial financially. If a physician teams with a qualified nonphysician practitioner (NPP) for either of these services, you may be able to code the visit under the physician’s national provider identifier (NPI).

This could net 100 percent of the allowed payout — when a physician is involved. If you have to report the E/M under the NPP’s NPI, you’ll only net 85 percent of the allowed amount, confirms Jan Rasmussen, CPC, PCS, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions, Holcombe, Wisc. 

Code Incident-To Only at POS 11

According to Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash., there are three primary differences between split/shared visits and incident-to billing.

The first difference is that “split/shared visits are for hospital-based encounters like inpatient, observation [and] ED,” she explains. You would also report a visit as split/shared for E/Ms that take place in hospital outpatient departments or provider-based clinics. “In other words, these services only apply in a POS [place of service] other than 11 [Office],” Bucknam continues.

Explanation: In the clinic setting the encounter must first meet incident-to criteria before you even consider coding it as a shared encounter, Rasmussen says. “In the hospital/outpatient setting there is no incident-to, so the only option to bill a service partially performed by an NPP in the physician’s name is shared care,” she continues.

Prove Pair of Providers Before Coding Split/Shared

The second major difference between these two coding features is that split/shared visits must involve two “qualified” providers. Incident-to only requires a single NPP.

Split/shared visit coding “only applies to two physicians or a physician with a qualified NPP, or two qualified NPPs” who combine to perform an E/M for a patient, says Bucknam. The providers must both see the patient, and perform a significant portion of the service, before coding the E/M under the physician’s NPI. If the two providers are both NPPs, then the reimbursement rate will be 85 percent of the code regardless of whose NPI they use.

On the other hand, you might be able to code incident-to for work that an NPP does alone to care for a physician’s patient — if:

1. The patient is established.
2. The physician has seen the physician for the condition already and
3. The physician has established a plan of care for the patient’s condition.
4. A physician is in the suite and immediately available at the time the NPP is seeing the patient.

Look to Service Date for Clues

A third difference between split/shared and incident-to is that split/shared visits always involve two providers who must see the patient on the same date. Incident-to services may occur at another time under the physician’s direct supervision.

So if you’re considering split/shared coding, make sure that you can prove two providers teamed up to provide a complete E/M on the same date.

Keep Up With ‘Complex’ Medicare Rules

Remember, you’ll need to have a full understanding of Medicare’s rules and regs before using these features to report E/Ms.

“The Medicare guidelines for incident-to services and split/shared services are complex so it is important to be sure practitioners have a good understanding of the Medicare rules and are compliant in their reporting and billing,” Swanson reminds.

Example: You can only use split/shared visit codes “for certain E/M service codes and places of service. A split/shared service cannot be reported for critical care services, consultation services, new patient office visits, or in the skilled nursing facility/nursing facility setting,” reminds Swanson.

Learn more: To see Medicare’s rules on incident-to and split/shared visit coding, see: http://www.wpsmedicare.com/j8macpartb/resources/provider_types/mid-level-providers-qanda.shtml and https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf, sections 30.6.4 and 30.6.1.