Revenue Cycle Insider

Question: I work in a multispecialty practice that has different providers, including nurse practitioners (NPs) and physician assistants (PAs). If a patient sees, say, an NP who specializes in family practice and then a PA who specializes in cardiology, can we bill more than one evaluation and management (E/M) service on the same day?

Minnesota Subscriber

Answer: As always, you need to check with your patient’s respective payer. If the patient in question is a Medicare beneficiary, then you need to follow the Centers for Medicare & Medicaid Services (CMS) rules on billing E/M services, which is usually one E/M service per beneficiary, per day, per provider specialty.

According to Medicare Administrative Contractor (MAC) Noridian, billing multiple E/M services day on the same date of service (DOS) may be possible “when each episode of care is addressing a different clinical condition. The additional E/M service would need to be medically necessary to treat an illness or injury separate from the initial E/M service,” and would require a different diagnosis.

To bill such services successfully, NPs or PAs would need to include additional information on each E/M claim designating “the specialty of the physician group when care is rendered in a specialty practice environment … when both the specialty information and diagnoses are different, the second claim may be payable,” Noridian says.

In the situation you describe, where an NP or PA is in a multispecialty group, CMS defines NPs and PAs as their own respective specialties, and you need to include the subspecialty information, like family practice or cardiology, as well in the 2400 NTE Segment Loop on claims submitted electronically or in Box 19 on the CMS 1500 form. NPs are Specialty 50 and PAs are Specialty 97. Practices in Noridian’s jurisdiction can find other eligible specialties and their codes and definitions here.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC