Coders Admit to Confusion About Billing Hospital Services

The process of coding and billing hospital services provided by nonphysician practitioners like PAs, NPs, CNMs and CNSs is fraught with problems. According to Quin Buechner, president of ProActive Consultants, a medical practice consulting firm based in Cumberland, WI, this area has been difficult because insurers-both government and private-have not kept pace with the rapidly changing dynamics in the health care environment.

"NPPs are an increasingly vital part of the patient care team," he points out. "But billing and being paid for their services to inpatients is still problematic. All too often, the regulations governing their role with inpatient care are unclear and contradictory between carriers." He notes that these difficulties arise when considering both admission services (99221-99223) and subsequent hospital care (99231-99233).

Can NPPs Bill Admits?

There are no fewer than five factors that impact an NP's or PA's ability to bill directly for admission services, Buechner says. These include:

• CMS policies for Medicare patients,
• each state's scope of practice laws,
• individual hospital bylaws,
• regulations created by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) and
• conventions established by state hospital organizations.

"NPPs can perform many, if not all, of the duties that are included in the CPT description for hospital admission services," he says. "Looking at that, some experts have taken the position that is it acceptable for NPPs to bill admissions. Others, however, say it is not appropriate. Coding and billing departments need to conduct in-depth research with their insurance carriers to find out how to bill for each carrier in their particular location."

CMS, for instance, has been unclear. "Generally, CMS refers the issue back to local Medicare carriers and to the hospital bylaws," Buechner says. When that occurs, these entities will defer to scope of practice laws and other applicable policies. "Although CMS does not appear to have a problem with PAs and NPs providing admission services, they allow the local authorities to make the final determination to grant these privileges to the NPP," he adds.

Contributing to the confusion is the fact that Medicare does not allow billing under the incident to rule in the hospital. Therefore, the NPP cannot perform and document parts or all of the admission E/M service, and then bill under the physician's provider identification number. "In order to bill for his or her services, the NPP must do the complete service and bill under his/her own number," Buechner points out. "The Medicare Carriers Manual (MCM), section 15501 B, states that when billing any service the physician and NPP 'must submit his/her bill to reflect the actual service or individual portion of the service performed.' Therefore, for NPPs to do only a history and physical and bill an admission under their own number would be wrong. Nor could the physician come in and perform the medical decision-making, including orders, countersign the note and bill the admit code."

CPT 99499 Represents One Way To Bill Split Services

Although CMS is crystal clear that NPPs and MDs should not bill a complete service when they actually only performed a portion of it, the agency has not provided a convenient way for both practitioners to receive partial payment. "In September, 2001, CMS issued Transmittal 1725, which attempts to clarify how NPPs should bill shared services," Buechner says. "It explains how CPT code 99499 (unlisted evaluation and management service) should be used in these instances." This particular portion of Transmittal 1725 modifies section 15501 of the MCM.

He notes that the revision does not change any Medicare policy, but merely clarifies the intent of 99499. The CMS modification says, "When a service performed is less than the CPT description of the level of the service, the physician and/or the nonphysician practitioner must document and bill the service he/she provided. A physician and/or nonphysician practitioner may submit a claim for CPT code 99499, price the code and write a letter stating why the lesser service was medically necessary as provided. The carrier has the discretion to value the service when the service does not meet the full terms of the CPT description (e.g. only the history was performed). The carrier will also determine the payment based on the applicable percentage of the physician fee schedule depending on whether the claim is paid at the physician rate or the limited licensed practitioner rate."

Code 99499 may used to describe both split hospital admission services and subsequent hospital care, Buechner says. "For instance, an NP may conduct rounds and perform an interval history and exam. Based on the findings, the NP may then write suggested orders. However, she may also leave a couple of questions for the physician as part of the medical decision-making. Later, the MD is on the unit, scans the note and then briefly visits the patient to clarify the issues outlined in the note." In this instance, the NP would code the visit with 99499, identify the work performed, establish a fee for these services, and submit an explanation of the work. The physician would do the same. The carrier would then make the final determination about the payment to each, based on the Medicare allowable for the service.

One exception to the policy governing the option to use 99499 occurs when an established patient's condition worsens, Buechner adds. "The NP or PA may make changes in treatment and do a subsequent visit. The physician simply checks the NPP's work, according to his/her or hospital policy. In this case, the NPP did virtually the entire service while the physician only served as a supervisor and therefore, the NPP may bill the proper subsequent hospital care code."

In theory, Buechner says, it's advantageous to have a clear method for reporting dual services. "However, coding and billing professionals are less than thrilled that this approach means the claims drop to paper and attachments must be added. Not only is there greater chance for human error, it slows the system down a great deal. It may take up to four or six months to receive payment."

Use of 99499 Controversial

Many reimbursement experts are strongly opposed to the direction that seems indicated by Transmittal 1725, according to Ron Nelson, PA-C, clinical practitioner; reimbursement policy analyst; president of Health Services Associates, Inc., a practice management consulting firm specializing in staffing and reimbursement issues for physicians and nonphysician providers in Fremont, Mich.; and past president of the American Academy of Physician Assistants (AAPA). He notes that this policy is considered impractical and is further undermined by the fact that CMS has assigned no value to 99499.

Because the policies outlined in Transmittal 1725 do not follow current clinical practice, Nelson says, there is significant discussion about this issue at the highest levels. "I have spoken to high-ranking officials at CMS who say that billing 99499 in these services is an option that practices may use. However, it is not mandatory. CMS officials realize that this change carries with it a whole host of attendant issues that make it difficult to implement.  Most reimbursement experts don't expect that this approach will stand, but anticipate that CMS will interpret this issue further in order to make it practical."

"While I understand Ron's concern and am personally against the impracticality of the clarification," says Buechner, "15501 insists we 'must' bill this way. I believe Ron misses the point when noting that 99499 has no RVU. It has no RVU because the individual Carrier is to make the decision for value and payment. "Ron also is in error when he says the clarification is not mandatory", says Buechner. Until CMS issues a memorandum or new transmittal, this is the written policy of CMS and the policy is enforceable by Carriers and OIG. One has the option of holding the charges affected by this clarification until and if CMS changes its mind. That option means you won't get paid for what could be a long time.

The policy is no more burdensome than the policy concerning routine exams. In that policy you must separately bill to Medicare any portion of the exam that is related to an illness. You are to deduct your normal charge for the sick visit from your normal charge for the Preventive Exam. You may only charge the patient the difference, if any, of the two charges. People did not believe this cumbersome rule would be enforced when it was first implemented. It is now the standard way to bill that situation