Primary Care Coding Alert

Question: I've heard that CMS issued a memorandum regarding new NPP guidelines. Will this affect me?

North Carolina Subscriber

Answer: The new rules mainly affect billing for hospital visits (e.g., 99221-99223, Initial 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, provided the doctor visits the patient later that day.

Transmittal 1776, dated Oct. 25, 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, 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 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 NPPshare/split an E/M: If the incident-to requirements are met and the patient is an established patient, bill under the doctor's UPIN/PIN.

3. The physician and an NPP share/split an E/M: If incident-to requirements are not met, the NPP bills 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: