Part B Insider (Multispecialty) Coding Alert

Published on Mon Oct 06, 2003 PDF

Shared-visits rule has important differences to incident-to

It's been a year since the Centers for Medicare & Medicaid Services said physicians can bill for E/M services they shared with nonphysician practitioners, and still some coders are confused.
 
The change, issued last October in Transmittal 1776, reversed a policy that had stated "incident-to billing" wasn't allowed in the inpatient setting. "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 UPIN/PIN number," CMS wrote in the transmittal.
 
"Since 1999, there has been no incident-to (billing) in the hospital setting," says Terry Fletcher, a healthcare coding consultant with McVey Associates in Laguna Beach, Calif. "So the physician had to do all of the work for any visit in the inpatient setting to be able to bill out under his own provider number. If the NPP came in and did any part of the inpatient visit, he would bill it as his visit, under the NPP's number, which is only an 85 percent reimbursement."
 
Physicians wrongly assume that "shared visits" are the same thing as incident-to billing in the hospital setting, says consultant Quin Buechner with ProActive Consultants in Cumberland, Wis. Though the shared-visits rule "quacks like" the incident-to rule, it has important differences. For one thing, the physician must see the patient face-to-face as part of a shared visit.
 
Also, to bill incident-to in the clinic/office setting, the physician must already have examined the patient previously and formulated a plan of care, Buechner says. For shared visits, the likely scenario CMS gives is that the NPP examines a patient in the morning and then the physician visits the patient later the same day.
 
But to bill for a shared visit, the physician should actually "do something that is part of the evaluation and management code they are charging, and then they also must document that," Buechner says. Merely waving at the patient won't satisfy the requirement. The chart notes should have notes from both the NPP and the physician.
 
Another issue with shared visits that could have potentially destructive consequences: Physicians shouldn't bill for shared visits when  they're not paying for the NPP's services. Otherwise, the physician is receiving payment for an NPP's time without having to pay for it, says consultant George Alex with Iatro in Baltimore.
 
The NPP doesn't have to work for the same medical group as the physician, Alex adds. Instead, the physician can contract with the hospital or outside employer for the NPP's services. But beware paying for the NPP's services on a per-visit basis, which could lead to charges of violations under the Stark self-referral law.
 
You can also bill for shared visits in the office/clinic setting, which leads to some confusion, Buechner says. Unlike incident-to billing, which must be for an established patient with an established problem, shared visits in the office setting can involve an established patient with a set plan of care for an established problem and who develops a new problem or complication. In that case, the NPP can call in the physician to look over the new problem, and they can bill for the E/M service under the physician's number, Buechner says.