Pulmonology Coding Alert

Remember, Medicare rules prohibit split visit billing

You'll have to follow specific reporting rules when a non-physician practitioner (NPP) provides part or all of a critical care service, or the service could end in denial.

Medicare Transmittal 1530 groups all the NPP critical care information into one place for easy reference, confirms Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

"Previously, a lot of the critical care [coding] information was scattered in different areas, which created confusion. This transmittal is an attempt to defuse that and create uniformity among all Medicare providers," she explains.

Check out this FAQ on NPPs that provide critical care, and be sure to reference Transmittal 1530 (http://www.cms.hhs.gov/Transmittals/downloads/R1530CP.pdf) for any of your critical care coding questions.

Question: Can an NPP provide critical care services on her own?

Answer: Yes, if the service meets the NPP's state scope of practice and licensure requirements, according to the transmittal. "Collaboration, physician supervision and billing requirements must also be met," the transmittal states. A physician assistant shall meet the general physician supervision requirements.

When qualified NPPs provide critical care, you can report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 ( each additional 30 minutes [List separately in addition to code for primary service]) for their services.

Question: What types of critical care can most NPPs provide?

Answer: Provided an NPP is properly qualified and licensed, she can provide any type of critical care a physician does.The services must meet Medicare's critical care definition. According to the transmittal, patients requiring critical care are suffering from a "critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition."

"'High probability' doesn't mean the patient is deteriorating right now; it means he could deteriorate if the provider does not treat him," according to Caral Edelberg, CPC, CCS-P, CHC, president of Medical Management Resources for TeamHealth in Jackson-ville, Fla.

"A description of the condition must be in the documentation," stressed Edelberg during her recent Coding Institute audioconference on hospital billing (http://www.audioeducator.com).

Examples of conditions that could acutely impair a vital organ system include:

central nervous system failure

circulatory failure

shock

renal, hepatic, metabolic, respiratory failure.

In addition, either the pulmonologist or the NPP must perform high-complexity medical decision making (MDM) in order to code 99291. During this MDM, the NPP must assess the patient's deterioration potential, perform services to prevent deterioration and provide support if the patient's condition worsens.

Question: How do we code for an NPP's critical care services?

Answer: If the NPP provides any part of the critical care service, then you must bill the service under the NPP's National Provider Identifier (NPI). You can never report critical care as a shared or split service -- even when the NPP and pulmonologist team up to provide critical care, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

"Unlike other E/M services where a split/shared service is allowed, the critical care service reported shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified NPP," according to the transmittal.

Critical care is treatment provided "by an individual physician or qualified NPP and shall not be representative of a combined service between the physician and NPP," the transmittal states.