Practice Management Alert

Question: We have some questions on billing hospital consults for NPPs. Our doctors would like to bill these under the physicians, but we are hearing contradicting stories if this can be done via the shared service

guidelines. The doctors are reviewing all of the notes and also seeing the patients themselves, making sure this is all being documented. How can we bill for using NPPs in this capacity?

Arizona Subscriber

Answer: When it comes to consultations specifically, you cannot bill the non-physician practitioner's (NPP-s) service under the physician's National Provider Identifier (NPI).

Why: In order to bill a service incident to the physician, there has to be a physician-written plan of care that the NPP is following. If the visit in question is a consultation, the physician hasn't yet developed and written a plan of care for the NPP to

follow.

CMS pays a covered NPP service billed under a physician's number at 100 percent when the encounter meets these three criteria:

- The NPP treats an established problem. A physician with the same tax identification number must first treat the patient for that condition or illness.

- A physician provides an active role in the continued management of that condition or illness.

- The physician must provide direct supervision. Although an NPP subject to state law may treat a patient without a physician on site, CMS requires a physician be in the office suite to bill a covered office service incident to the physician.

Additionally: You also need to remember that payers do not pay for incident to services in the inpatient arena. Incident to is only allowed in the office or outpatient facilities.

In this case: While you-re making sure the physicians in your practice are providing proper supervision and review of the case, they have not previously established a plan of care, so you cannot bill incident to, according to these guidelines.

Good news: You don-t, however, have to forego payment for the NPP's service. Instead, report the service under the NPP's own NPI. Medicare allows you to report services that the NPP provides in a hospital as long as you don't report the

services incident to the physician. Therefore, if your NPP provides a consult in the hospital and documents the "three R-s" of the consultation (request, review, and report back to the requesting physician or proper notation in the shared record),

you can report the appropriate consult code (99241-99245 or 99251-99255, depending on whether the patient is outpatient or inpatient) under the NPP's NPI.

Watch out: You may have to document the supervision requirements for some insurers. Check with your payers before you set up practices for the NPPs. And check your state and hospital scope of practice guidelines before you bill an NPP's

consult; state guidelines can vary.

Bottom line: Because a consultation, no matter the site of service, involves evaluating a new problem, an NPP may never provide this service incident to and must always provide consultations only under her own NPI.