Pulmonology Coding Alert

Question: Our NP is working with our pulmonologist in the same outpatient clinic. We are planning to see new patients two days a month. He will have his own visit and cover certain topics with each patient, and our NP will then see the patient on the same day and cover additional topics that he will not be covering. Our NP will mainly cover health maintenance issues. Are we able to bill for the NP service if it occurs on the same day as the patient sees our pulmonologist if NP is covering an entirely different subject? The visit with the NP will be 45 minutes and is primarily counseling.

Michigan Subscriber

Answer: The general rule is one E/M service per patient per physician group per day. When your pulmonologist and an NP both have a face-to-face encounter with the same patient on the same day, only one bill needs to be sent. Accounting for what the bill entails is dependent upon the service location. The notes of both practitioners can be combined to decide on the level of service and one bill generated under the physician’s name and PIN if the service is provided in an outpatient hospital setting under shared/split billing rules. In the scenario you describe the combined face-to-face time will exceed 60 minutes for both your pulmonologist and your NP contacts with the majority of time spent in counseling. Documentation should describe the content of the counseling provided and/or activities to coordinate care. There must be sufficient detail to support the service billed.

So, if time is documented and the medical necessity supports both services, the practice could bill up to a level V service (99205, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components…Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family).

If the total face-to-face time exceeds 90 minutes, then you may add a prolonged services charge (99354, Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]).

Remember: The physician and NP must be employees of the same practice. In any shared service, both the physician and the NP must provide their portion of the services face to face. The incident-to rules are all still in effect. You must document medical necessity and what you actually did during the encounter.

Warning: If these services were provided in an office-based setting under "incident-to" rules, the counseling by the NP could not be billed under the physician. Counseling time cannot be counted when performed "incident-to" the physician; only the billing provider’s personal time can be attributed to the visit level selected.