Pulmonology Coding Alert

Judiciously using shared visits can boost your bottom line while maintaining a high level of patient care, but you have to know the requirements for reporting these services and which services are eligible for shared visits.

A "shared visit" describes an E/M service during which a physician and a nonphysician practitioner (NPP) each see a patient for a portion of the same visit. To bill under the shared-visit rule, a physician must personally evaluate the patient and document his service. Because the NPP already interviewed the patient, conducted a preliminary examination and documented his service, the physician visit will be more focused on the medical problem.

CMS guidelines dictate that when a hospital inpatient/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 PIN."

No face-to-face with the physician lowers reimbursement: If, however, "there was no face-to-face encounter between the patient and the physician (for instance, if the physician only reviewed the patient's medical record), you may only bill the service under the NPP's PIN, according to CMS. "Payment will be made at the appropriate Physician Fee Schedule rate based on the PIN entered on the claim."-

Solidify your documentation: The key to complying with the shared-visit provision is that the physician must personally see the patient, review any history and exam performed and documented by the NPP, conduct an examination and be involved with the plan of care. This means your physician must get the documentation right.

Example: The pulmonologist cannot just sign off on what the NPP writes in the progress note -- he has to contribute to the E/M. And Medicare carriers don't like to see minimal notes, such as "Agree with above" or "Rounded, reviewed, agree," so you should encourage your physicians to provide enough documentation to show that they have carefully reviewed the NPP's work.

Documentation should offer specific details and physician input, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. To support physician review, the pulmonologist could note, "I interviewed and examined the patient. I discussed the patient's data and finding with the NPP, and I agree with the NPP's findings, assessment and plans."

Although you can use the shared-visit provision for most hospital-based E/M services, make sure you do not

apply them to consultations (99251-99255, Inpatient consultation for a new or established patient ...) or critical care (99291-99292, Critical care, evaluation and management of the critically ill or critically injured patient ...).

"The shared-visit policy does not apply to critical care, which is a time-based service, or consultation services or any other procedure codes or for services in other settings, such as skilled nursing facility services, home care or domiciliary care," according to a CMS spokesman.

Specifically, "an NPP may request a consult and may also perform a consultation and receive payment" under the NPP's name at 85 percent of the Physician Fee Schedule (PFS), the CMS spokesman says. But the NPP must perform all the work, or a physician can do all the work for 100 percent of the PFS.

You must meet "incident-to" reporting requirements for nonphysician E/M services in a private office setting, according to CMS regulations.

Impact: A physician has to be in the office suite and available for supervision to bill the NPP's E/M, such as an office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) under the physician's PIN.

"When an E/M service is a shared encounter between a physician and a nonphysician practitioner, 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," states Medicare's Internet Only Manual (IOM).

"If 'incident-to' requirements are not met for the shared E/M service, the service must be billed under the NPP's PIN," and payment will be made at the appropriate PFS amount (in other words, at 85 percent -- rather than 100 percent -- of the PFS amount for your area), the IOM says.

If an established patient develops a new problem -- for instance, a patient with chronic obstructive pulmonary disease (496, Chronic airway obstruction, not elsewhere classified) develops chest pain (786.5x) -- CMS has clarified that the NPP can address the new problem and still meet the incident-to provisions, as long as the physician also sees the patient.

In fact, the only situation in an office setting when you will report a shared visit is if an NPP sees an existing patient under the physician's plan of care (POC), and then the NPP discovers a new problem that the POC doesn't cover. The NPP calls in the physician, who treats the new problem.

What not to do: The NPP may not see a new patient. Nor may the NPP perform a workup on a patient with a new problem by performing the visit's history and physical portions, and then bringing in the physician to perform the medical decision-making. Rather, the physician must see all new patients and personally address any new problems the NPP discovers in an established patient.

If the visit meets the above requirements, you would bill both providers' services as one combined E/M visit under the physician's PIN to receive 100 percent of the service's fee schedule reimbursement.

Learn more: You can find the full text of Medicare's policy on shared visits in Medicare Transmittal 1779, available on the CMS Web site at www.cms.gov.