Primary Care Coding Alert

Question: The primary care practitioner (PCP) and the nurse practitioner (NP) both saw a patient during a follow-up visit. The notes in the patient record say that the PCP performed the physical exam, the NP interviewed the patient regarding history, and they both participated in medical decision making. The NP’s record of events matches that of the PCP, and the PCP signed it. In time spent, the PCP spent more than half the total time with the patient, and performed the substantive portion of the service, yet a colleague is telling me we can’t bill for a shared service. Is this true?

Tennessee Subscriber

Answer: This is technically true for Medicare patients if the visit did not occur in an institutional setting. Effective Jan. 1, 2022, the Centers for Medicare & Medicaid Services (CMS) updated Medicare policy by “limiting the definition of split (or shared) visits to include only E/M [evaluation and management] visits in institutional settings.”

However, practically speaking, this does not prohibit you from billing Medicare for an E/M service involving a PCP and NP in the office setting. In the office setting, as CMS noted in the final rule on the 2022 Medicare Physician Fee Schedule, Medicare’s incident-to rules apply. Those rules allow physicians to bill E/M services under their own Medicare provider number, even when the E/M service was provided in whole or in part by one of their qualified healthcare professionals (such as an NP), as long as all the incident-to requirements are met. For more information on Medicare’s coverage of incident-to services, see Medicare Benefit Policy Manual, Chapter 15, Section 60 (www. cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf).