Pulmonology Coding Alert

In the office setting, incident-to billing is a vital cog in the practice's reimbursement machine: Under incident-to rules, qualified nonphysician practitioners (NPPs) can treat certain patients and still bill the visit under the physician's National Provider Identifier (NPI).

The hospital setting, however, is a different story. "There is no incident-to billing in the hospital," says Mary Falbo, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. "But shared/split visit billing is an option."

Shared visit billing is not exactly incident-to, but it is a way to bill for services that are provided jointly by the pulmonologist and a qualified NPP. If the encounter meets shared visit guidelines, you'll be able to report the entire visit under the pulmonologist's NPI -- thereby garnering you 15 percent more pay for the same service.

How? Pulmonologists receive 100 percent of the Medicare allowable when services are reported under their own NPI. If you report the same service under the NPPs NPI, the reimbursement is set at 85 percent of the Medicare allowable.

Remember that the shared visit billing rules apply to Medicare and those commercial insurers that follow Medicare rules. You shouldn't report shared visits to private insurers before making sure they allow payment for shared visits.

In a nutshell: According to Suzan Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board, here's how the typical shared visit works:

• The NPP visits and examines a patient. The NPP documents her work establishing medical necessity.

• At a different time, the pulmonologist sees the patient and documents his work. This can be immediately after or even before the NPP's visit, but it "has to be on the same day," Hvizdash says.

• Then, you can add the documentation together to establish a billing level, Hvizdash said during The Coding Institute audioconference "9 Revenue-Boosting Billing Strategies for Incident-To Services."

Benefit: In many shared visits, the NPP conducts the preliminary interview and exam and then the pulmonologist sees the patient. This allows the pulmonologist to focus more on the medical problem and less on the other visit components.

To bill a shared visit under the physician's NPI, he must provide and document a face-to-face service for the patient. "Physicians must perform at least a portion of the E/M service that involves contact with the patient. General oversight, such as reviewing the medical record, is insufficient," according to the American College of Physicians Web site.

Ideally, you'll bill a shared visit under the pulmonologist's NPI, but you could also bill a shared visit under the NPP's NPI.

When? "There might be instances in which the MD's note may not include the face-to-face encounter that is required. Maybe he only writes that he 'looked at the CT scan and made recommendations,' " Hvizdash said.

Because the note Hvizdash described doesn't fully illustrate the pulmonologist's contact with the patient, you should bill this visit under the NPP's NPI. Shared billing is an option for only select hospital E/M services, including ED E/Ms (99281-99285); you cannot bill shared visits for consultations or critical care, Hvizdash said.

Under shared visit rules, the NPP can treat patients in the hospital in accordance with the scope of practice and hospital privileges granted.

Hvizdash offers this example: An advanced registered nurse practitioner (ARNP) makes rounds in the morning and visits a hospital inpatient with chronic obstructive bronchitis who has an episode of acute bronchitis (the patient was admitted the day before). The ARNP writes a detailed note of the patient's condition (including the history and exam elements gleaned during the visit) and the recommendations. The ARNP also notes in the patient file that the pulmonologist will be in later that day.

A few hours later, the pulmonologist and the ARNP visit the same patient together. The pulmonologist performs an exam, gathers history, reviews the data and makes recommendations. The pulmonologist details the findings in the chart, and links her note to the ARNP's note from earlier in the day. The compiled notes substantiate a level-two hospital care service.

"Combined, these two notes can now stand as evidence toward the billed level of service selected," Hvizdash said.

For this claim, you would report 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem-focused interval history; an expanded problem-focused examination; medical decision-making of moderate complexity) for the shared visit.

Remember to append 491.22 (Obstructive chronic bronchitis; with acute bronchitis) to 99232 to represent the patient's chronic bronchitis complicated by an acute bronchitis episode.

Benefit: "The bill would go out under the physician's NPI, and the reimbursement would be at 100 percent of the fee schedule amount," Hvizdash said.

Your documentation must support the level of E/M service you are coding for, or Medicare could deny your shared visit claim.

"Documentation should offer specific details [about both encounters] and physician input," says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. When submitting your shared service claims, be sure that you remember to:

• clearly identify both providers in the medical record

• link the pulmonologist's encounter note to the NPP's note

• include legible signatures from the pulmonologist and the NPP.

Caution: Your documentation must prove the pulmonologist provided at least one element of the encounter for you to bill a shared visit under the physician's NPI, Hvizdash said.

Example: To support physician review, Plummer says, the physician could note, "I interviewed and examined the patient. I discussed the patient's data and findings with the NPP, and I agree with the NPP's findings, assessment and plans."