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Medicare Carrier Loosening Some NPP E/M Rules

Published on Tue Sep 11, 2018

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NGS will allow NPPs to code same-day E/Ms under certain circumstances.

If you’ve heard of Medicare’s “Patients Over Paperwork” initiative, aimed to reduce the administrative burden on providers, then get ready for another component of the drive to make providing services more efficient and effective.

One of the nation’s leading Medicare payers will soon implement a documentation change that should make it easier for certain nonphysician practitioners (NPPs) to provide multiple evaluation and management (E/M) services on the same date of service (DOS) — provided the E/Ms are for different specialties.

Read on for more information on this new NPP-related coding convention.

NGS: NPs, PAs Will Get More Leeway on Same-Day E/Ms

After a lengthy pilot project, Medicare administrative contractor (MAC) National Government Services (NGS) announced a new policy during its “NGS Editing Change for Nonphysician Practitioner Evaluation and Management Services” seminar on August 23.

“CMS has really launched an initiative to reduce provider burden. ... Specifically, with nurse practitioners [NPs] and physician assistants [PAs],” explained Cathy Delli Carpini, NGS jurisdictional manager for provider outreach and education.

“Longstanding CMS guidelines restrict payments for concurrent E/M services performed on the same day by same-specialty providers. As practice trends have moved toward wider participation of NPs and PAs in direct patient care in multiple sub-specialty areas, NGS has seen a steadily growing trend of E/M services submitted by NPs and PAs providing services for distinctly different clinical problems on the same date of service,” according to the NGS webinar.

This change applies to claims submitted by nurse practitioners (NP, Specialty 50) and physician assistants (PA, Specialty 97) and will be applied to claims processed on and after September 15. According to its website, NGS “administers the Medicare Part B (medical insurance) contract for the states of Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont and Wisconsin serving over 380,000 Part B physicians and providers of service.”

During its pilot project, NGS created “Appeals Overturn Groups” designed to identify areas where the payer could reduce denials that prove costly to payer and provider. One of the major findings was that multiple E/Ms billed by the same NPP on the same DOS were often denied, and then overturned on appeal.

In an effort to get those claims paid without the unnecessary denial and appeal, NGS wants all NPP E/M services to contain supervising specialty information to make clear that the NPP is performing separate E/Ms in separate specialties on the same DOS.

The lowdown: “All NPP E/M claims need supervising specialty info in the 2300 or 2400 NTE loop; or box 19 on paper claims,” Delli Carpini explained. This will be essential for the payer, as it will use the information to consider the history of the claim.

With this information, NGS claim examiners will be able to compare supervising specialty information with paid history claims; “claims may be allowed when both specialty information and diagnoses are different,” said Delli Carpini.

So, for example, an NPP files same-DOS E/M claims for the PM specialist and the family physician for separate issues. “If the two-specialty information [boxes] and diagnoses are different, both claims will be paid,” Delli Carpini explained.

Reason: NGS noticed a lot of claims for same-DOS E/Ms denied, and overturned, because the NPs and PAs were providing care for multiple specialties, but the documentation did not make that clear. “Many of these [NPPs] are providing care within different sets of subspecialty groups. The claims are overturned on appeal because it’s obvious that the E/Ms were for separate specialties,” Delli Carpini explained.

The change to get supervising specialty information into the claims was designed so that when NGS gets another E/M claim from the same NPP on the same DOS, it will be clear whether or not the E/Ms were for separate services.