Urology Coding Alert

You'll earn 15 percent more billing under your urologist's NPI.

Still confused after reading recent advice from Medicare about how to bill now that you are unable to use the consultation codes? You're not alone. But there's good news -- CMS seeks to ease some of the stress by explaining that you can still report shared/split visits even when you would have used a consultation code in the past.

Stick With the E/M Shared/Split Rules

Although CMS eliminated payment for consult codes,contractors will continue to honor split/shared visits -- as long as they are billed using specific E/M codes and following the payment rules already in place for these E/M codes. That's the word from CMS, where staffers aimed to straighten out confusion stemming from the January MLN Matters article SE1010, which offered several questions and answers regarding how to bill Medicare following the elimination of consult code payment.

In the article, CMS noted that "the split/shared rules applying to E/M services remain in effect, including those cases where services would previously have been reported by CPT consultation codes."

"We understand that this has caused some confusion, as there were -- and are -- different split/shared rules for consultation services compared to E/M services," noted CMS's Rebecca Cole noted during an April 13 CMS Open Door Forum.

"We'd like to clarify that Q&A," Cole said. "As we're no longer recognizing the consultation CPT codes for purposes of payment under Part B, the split/shared rules regarding consultation services are no longer applicable. Since E/M visit codes are being billed for services that were previously reported by the CPT consultation codes, the split/shared rules pertaining to E/M services apply when billing E/M CPT codes," Cole stressed.

Remember: You can still report shared/split visits according tothe regulations using E/M codes, but you cannot collect from Medicare for any previously used consultation codes.

CMS is considering issuing a clarification in writing to dispel any confusion regarding the shared/split billing rule, Cole noted.

Prove Shared Work With Your Documentation

Split/shared rules come into play when a urologist and a qualified non-physician practitioner (NPP), such as a physician assistant, both see a patient face to face in the hospital where incident-to rules are not applicable, and each provide a distinct part of an E/M service. If the encounter meets shared visit guidelines, you'll be able to report the entire visit under your urologist's National Provider Identifier (NPI) -- thereby garnering 15 percent more pay for the same service.

How it works: Just like with incident-to services, your urologist receives 100 percent of the Medicare allowable when services are reported under his own NPI. If you report the same service under the NPP's NPI, the reimbursement is set at 85 percent of the Medicare allowable.

Under past coding policy you could not report the consultation codes as a split/shared visit. "The codes now used for consultations -- 99221-99223 and 99231-99232 -- by rule, can be billed as a split/shared visit, allowing the physician full pay when he shared the work for this patient with an NPP," explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. "As I see this, when using the initial hospital visits and subsequent hospital visit codes for consultations, as we have been instructed, we may bill a split/shared visit as these E/M codes are not bound by the rules of coding previously disallowing shared visits for consultation codes."

Focus on the Old Rules

Shared visit billing rules apply to Medicare and those commercial payers that follow Medicare rules. You shouldn't report shared visits to private insurers before making sure they allow payment for shared visits. Also, keep in mind that shared/split billing only applies to E/M services provided by nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives in the emergency department, outpatient hospital, and inpatient hospital.

To bill a shared visit under the physician's NPI, your urologist must provide and document a face-to-face service for the patient. He must perform at least a portion of the E/M service that involves contact with the patient. When reporting a shared visit, be sure to include the following:

a) documentation of the combined notes written by your urologist and the NPP that support the E/M level

b) a statement clearly identifying the NPP and urologist providing the service

c) a link between the urologist's documentation and the NPP's d) the urologist's and NPP's documentation of a face-to-face encounter with the same patient on the same day in the hospital

e) legible signatures of the urologist and NPP providing the E/M.

Plus, Rein in Your Initial Inpatient Billing

One caller during the CMS Open Door Forum wanted clarification on billing for hospital care now that consult codes aren't payable. She asked whether a physician can report two initial hospital care codes for the same patient on the same date -- for instance, if the physician saw the patient prior to surgery for one reason, and then saw the patient after surgery for another reason.

"I think you should consult the CPT rules as well as the manual, but I think our reaction to that is no," said CMS's William Rogers, MD, during the call. The initial hospital care codes refer to that physician's first visit with the patient, Rogers said. Later evaluations should be billed using subsequent hospital care codes, he advised.

However, CMS representatives indicated that they will look into the issue further to determine whether physicians should be able to report a second initial hospital care code if specifically requested to review a different condition. "We can consider this further and decide what our next steps will be," Rogers said. Until then, CMS staffers urged practices to continue billing according to published rules.

In black and white: "Both initial inpatient hospital care codes and subsequent hospital care codes are 'per diem' services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice," notes CMS Transmittal 1545. Watch for more about using hospital care codes in a future Urology Coding Alert article.