Pulmonology Coding Alert

Shockwaves reverberated through the coding community when Medicare announced its new split-billing policy, so it's time to address some issues about the proper way to use NPP services in the office and inpatient settings.

The Centers for Medicare & Medicaid Services issued Transmittal 1776 on Oct. 25, 2002, to revise section 15501 in the Medicare Carriers Manual regarding evaluation and management services. The most controversial issue in the  transmittal deals with "split-billing" for nonphysician practitioners. NPPs have never been able to provide services in facility settings and receive 100 percent reimbursement. Now it seems that NPPs have the option to bill under the physician's PIN in a variety of settings. The rules pertaining to this policy, however, are not clear.

According to Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia, the new split-billing guidelines are very vague. They simply state that whenever there is a shared service in a facility setting (OH, IH, ED) between a physician and an NPPon a given date, you are allowed to combine the service and report it under one individual's PIN. The options are for you to bill under the physician's number for 100 percent reimbursement or under the NPP's number for 85 percent reimbursement. "This policy is going to revolutionize the way you use NPPs in the facility and the way you can bill for them," Pohlig says. Incident-to Is Still Applicable in Office Setting Medicare holds that "when an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS, or CNM), the service is considered to have been performed 'incident-to'if the requirements for 'incident-to'are met and the patient is an established patient." If incident-to requirements are satisfied, the NPP would bill under the physician's PIN and the physician would receive 100 percent reimbursement of the appropriate Physician Fee Schedule amount. If the requirements are not met, then the NPP must bill under his own PIN and receive 85 percent reimbursement. The new split-billing policy does not change the incident-to rules for office settings. An example of split billing in the office setting is when an NPP performs portions of an E/M visit on a 15-year-old girl with asthma. He takes her interval history and begins performing a basic exam while the physician is in the office suite. The physician completes the last portion of the E/M service. If incident-to requirements are met, then the service can be reported using the physician's PIN. Split the Bill in Hospital and Emergency Department Settings Pohlig holds that split billing is going to impact the healthcare industry the most in the outpatient hospital, inpatient, and emergency department settings [...]