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Practice Management Alert

Medicare Increases the Reimbursement for Physicians Rendering Split E/M Services

Published on Sun Dec 01, 2002

Good news, medical office billers: You'll be seeing more reimbursement from your split E/M services.

You can now bill E/M services claims under the physician's full fee schedule not the NPP's reduced schedule for more split services than before the changes effective Oct. 25, 2002. In the past, you billed under the physician's full fee schedule only if the physician directly provided and documented the shared E/M service. Otherwise, you had to bill under the non-physician practitioner's reduced fee schedule, says Karen Jeghers, PA-C, CPC, manager at Compliant Billing Services LLC in Carver, Mass.

Transmittal 1776 (Oct. 25, 2002) clarifies the split-billing issue and opens the doors to payment for physicians.

  • For office settings, if an E/M service is shared between a physician and a nonphysician practitioner (NP, PA, CNS, CNM), you can now bill under "incident-to" requirements if they are met and the patient is established. Under incident-to, you'll get reimbursed according to the physician's full fee schedule. Otherwise, you must bill the patient under the nonphysician practitioner's UPIN/PIN, which has a lower fee schedule.
  • For hospital settings, you can now bill an E/M service shared by a physician and an NPP from the same group practice under the physician's UPIN/PIN as long as the physician provides "any face-to-face portion" of the E/M encounter. If the physician provides no face-to-face time with the patient, the service must be billed under the lower fee schedule determined by the NPP's UPIN/PIN even if the physician reviewed the patient's medical records.

    In either setting, it is up to the provider to let the office staff know that the E/M service can be billed under the physician's number, Jeghers says.

    For the new rule, a few guidelines still apply. If the provided service does not reflect a CPT code description, you must report it as an unlisted service with CPT code 99499, and a description of the service must accompany the claim. The carrier is entitled to determine the value of the service. Also, do not report modifier -52 (Reduced services) with an E/M service.

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