Physician and APRN seeing the same patient on the same day

Colliemom

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If a physician sees a patient in the office, and then the APRN (same practice) sees the patient in the office later the same day, how would you bill?

If seen for the same reason?

If seen for different reasons?
 
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Colliemom

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We are just wondering if both visits can be billed, if the patient is seen for different reasons?

And if both are seeing the patient for the same reason, would "incident to" guidelines apply? (meaning can the visits be combined, and possibly a higher level visit billed under the provider?)
 
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thomas7331

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Here is the Medicare guidance on this from the Claims Processing Manual, Chapter 12:

If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

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 not met for the shared/split E/M service, the service must be billed under the NPP’s UPIN/PIN, and payment will be made at the appropriate physician fee schedule payment.

You may find different payers do this differently or have different guidelines, and some may or may not consider the NP to of the same specialty as the MD. You may also have to appeal denials with records to support two E&M services billed on the same day for different reasons if you decide to bill both.
 

Colliemom

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Here is the Medicare guidance on this from the Claims Processing Manual, Chapter 12:

If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

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 not met for the shared/split E/M service, the service must be billed under the NPP’s UPIN/PIN, and payment will be made at the appropriate physician fee schedule payment.

You may find different payers do this differently or have different guidelines, and some may or may not consider the NP to of the same specialty as the MD. You may also have to appeal denials with records to support two E&M services billed on the same day for different reasons if you decide to bill both.

Thanks Thomas, I did find that info, but I am still unsure on a couple points. Maybe I am overthinking this?
So if the "incident to" requirements are not met, it directs the coder to bill the service under the NPP. But if the physician already performed an E/M service that day, I would think you could not bill for the APRN's service, as that would entail two providers, from the same practice, billing for providing the same E/M service (est pt visit) on the same day.

Also, if the physician sees the patient for one problem, and the APRN sees the patient for a different problem, then "incident to" guidelines would not be met, as the APRN is creating a plan of care for the second problem. So the second E/M service would have to be billed under the APRN, and one site advised we would have to add the -76 modifier to the APRN's visit. But this does not sound correct to me. What do you think?
 
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thomas7331

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So to the first question, as I interpret this, if both visits are for the same problem, it's a shared visit and you can only bill one code. So if the "incident to" requirements aren't met, you can't bill the combined visit under the MD. So you'd have to choose between just billing the MD's visit using the E&M code supported by that note alone, or bill the entire shared visit using the combined notes under the NPP.

In the second case, if the visits are unrelated, I wouldn't recommend modifier 76 since that this isn't really a 'repeat procedure'. I would probably try using modifier 25, but you might check individual payer guidelines. For Medicare you probably won't need a modifier since NPs are usually classified as a separate specialty from MDs. But with or without modifiers I would still expect denials - I think most payers won't allow this without your appeal to show that it was a distinct service, but some may not allow it even then.
 
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