15% More Pay Awaits Coders Who Can Max Out NPP Benefit

Correctly code NPP’s hospital services, or you’ll sell the practice short.

If you don’t take advantage of all the E/M services a nonphysician practitioner (NPP) can provide, you are missing out on a serious revenue stream, as these providers can simultaneously lighten physicians’ loads and fatten the practice’s bottom line.

Check out these FAQs to get the lowdown on when it’s OK to take the higher-paying path for your NPP’s services.

What Is Incident-To Billing?

Incident-to billing occurs when you report an office E/M service the NPP provides under the physician’s National Provider Identifier (NPI). Using the physician’s NPI garners you 100 percent reimbursement for the E/M, while an NPP’s NPI pays 15 percent less.

The NPP must perform incident-to services “under the direct supervision of the physician as an integral part of the physician’s personal in-office service,” confirms Melanie Witt, RN, CPC-OGS, MA, an independent coding consultant in Guadalupita, N.M.

Incident-to billing is not legitimate unless the FP has seen the patient and established a plan of care for the problem; further, there should be “subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment,” Witt continues.

Remember this pair of rules when you consider billing incident-to:

• Incident-to billing is confined to Medicare payers and payers that observe Medicare rules. If a payer does not typically follow Medicare rules, it probably won’t accept incident-to claims.

• Medicare takes the “direct supervision” rule quite literally, so make sure you meet the supervision requirement before considering incident-to. In short, “direct supervision means the physician is on site and immediately available” during the NPP’s service, explains Susan Garrison, PCS, FCS, CCS-P, CHC, CPC, CPCH, CPAR, executive vice president of Magnus Confidential Inc. in Atlanta.

Example: A 67-year-old established Medicare patient with a plan of care in place for her type II diabetes reports to the FP for a medication adjustment. The NPP provides a level-two E/M for the patient; the FP is at one of the practice’s computers reviewing notes during the service.

This is an incident-to service. On the claim, you would report 99212 (Office or other outpatient visit for the evaluation and management of an established patient …) under the FP’s NPI with 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) appended.

Can You Code Incident-To in the Hospital?

The NPP and the physician might “team up” on certain hospital E/M services; when this occurs, check to see if you can report a shared (or split) visit for the encounter. While there is no incident-to billing in the hospital, shared visit billing is an option to capture E/M services the physician and the NPP provide jointly to Medicare patients (and patients with insurance that observes Medicare rules).

AUDIO EXTRA: Split visit vs. shared visit: Nail down the differences and the documentation requirements for each.

When an encounter satisfies the guidelines for a shared visit, report under the physician’s NPI, confirms Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance with UPMC in Pittsburgh. This nets the practice 15 percent more for the same service, as Medicare pays at 85 percent for all codes you bill under the NPP’s NPI.

(For more information on billing shared visits, see the Medicare Claims Processing Manual, Chapter 12, Section 30.6.1(B), online here .)

Example: At 7 a.m. Monday, the NPP performs interval history for an established Medicare hospital inpatient suffering from a concussion with moderate loss of consciousness and lacerations on his larynx and trachea. The NPP also conducts a physical exam and makes the medical decision to initiate nutrition. At 4 p.m. Monday, the FP visits with patient, reviews the NPP’s chart, and decides the patient needs a neurologic consult and antibiotics for fever and infection prevention.

In this instance, you can combine the documentation for both the FP and NPP and report an appropriate subsequent hospital care code, such as 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 service under the physician’s NPI, Garrison confirms.

Remember to append 850.2 (Concussion with moderate loss of consciousness), 874.00 (Open wound of neck; larynx and trachea, without mention of complication; larynx with trachea), and 780.60 (Fever, unspecified) to 99232.

Payout: The 99232 code pays about $67 nationally (1.85 transitioned facility relative value units [RVUs] multiplied by Medicare 2009 conversion rate of 36.0666). If you report the visit under the NPP’s NPI, you have to subtract 15 percent, bringing in approximately $10 less for the same service. This can add up if your physicians and NPPs provide a lot of joint E/M services.

Are All NPP-FP E/Ms Shared Visits?

You cannot code all NPP-FP hospital E/Ms as shared visits. According to the Medicare Claims Processing Manual (emphasis added): “When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician’s or the NPP’s NPI number.”

If there was no face-to-face encounter between the physician and the patient – even if the physician participated by providing some other portion of the E/M – then you must report using the NPP’s NPI, Garrison says.

So if the physician reviews the medical record for a patient, but the NPP provides all of the face-to-face evaluation, bill the encounter under the NPP’s NPI.

© Family Practice Coding Alert. Download you 2 FREE sample issues here.

Related articles:

1. Steer Your Incident-To Coding Using These 4 Questions 100 percent pay possible if NPP follows internist’s care…
2. Must Hospital Admit Codes and Admission Show Same DOS? Overlook this rule, and risk leaving rightful E/M dollars on…
3. Use This Incident-To Checklist to Breathe Easy During an Audit You don’t need to second-guess the way you bill…