Urology Coding Alert

Finally, CMS delivers news that urologists want to hear. Effective Oct. 25, 2002, changes to Medicare's nonphysician practitioner (NPP) rules will increase reimbursement for E/M services. The new NPP policy is "very exciting news," says Nettie McFarland, RHIT, CCS-P, at Healthcare Billing Systems Inc. in Daytona, Fla. "As Medicare continues to decrease its reimbursement, this [rule] is a positive step to recapture lost revenue," she says. Urologists will no longer lose reimbursement when they use services rendered by the nonphysician practitioners who assist in providing "quality, timely care," she explains.

NPPs provide valuable service to patients, and now their services will generate much more reimbursement, says Shirley Fullerton, CMBS, CPC, CPC-H, practice management and coding specialist in Las Vegas. Beware: The new policy differs for the nonfacility and facility settings. In the nonfacility setting, E/M services must be reported using the physician's UPIN/PIN when it is the physician who performs the evaluation and management service. Shared/split E/M services between a physician and an NPP may be billed under the physician's UPIN/PIN if the services meet the "incident-to" requirements and the patient is established.

CMS policy says, "if incident-to requirements are not met ... the service must be billed under the NPP's UPIN/PIN." Incident-to requires the physician's presence in the office suite, an established patient without a new problem, and a physician's previously documented plan of therapy to be carrier out by the NPP. For instance, suppose a physician assistant employed at a private urology practice performs a portion of an E/M service to an established patient complaining of discomfort during urination, and the remainder of the service is provided by the urologist. If the incident-to requirements are met, this service can be billed under the urologist's UPIN/PIN. In the nonfacility setting, nurse practitioners, physician assistants, certified nurse specialists and certified nurse midwives are considered NPPs. In the facility setting, you can now bill an E/M service shared by a physician and an NPPunder the physician's UPIN/PIN as long as the physician provides "any face-to-face portion" of the E/M encounter. CMS asserts that the hospital inpatient, hospital outpatient or emergency department must be shared between a physician and an NPPfrom the same group practice for these split-visit rules to apply.

The memo provides the following examples of shared visits in an inpatient facility:

"1. If the NPPsees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPPmay report the service. 2. In an office setting, the NPPperforms a portion of an E/M encounter and the physician completes the E/M service. If the incident-to requirements are met, the physician reports the service. [...]