E&M Coding: Incident-To Vs. Shared Visit Guidelines

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Rebecca Caux-Harry, CPC, the CodeRyte product specialist for cardiology with 3M Health Information Systems, contributed this blog.

I’ve written in the past about how to score the language within an E&M note. There are a number of ways to arrive at the same code, or in fact, a different code. But, there are also different types of providers and coding/billing rules associated with those different types of providers. In addition to physicians serving as providers of care, there are other healthcare members that provide E&M services, and can bill for them, but you have to know all the rules associated with each type of provider.

Mid-level providers, also known as Non-physician providers (MLPs, NPPs) can provide all visit types that physicians provide. Coding follows the same rules, but payment is 85% of the payment for physicians from Medicare. Commercial payers follow their own guidelines, but in general they are similar or equal to those published by CMS. MLPs include Nurse Practitioners, Physician’s Assistants, and Clinical Nurse Specialists.

In order to receive 100% of the payment allowed for any given E&M service by a MLP, however, there are specific guidelines. There are two types of guidelines, Incident-to, and Shared Visits. Incident-to guidelines require that the MLP provides the entire service to the patient “Incident to the physician’s plan of care.” What that means is the patient must be established with the physician, must have a plan of care in place, which is subsequently followed by the MLP; so, no new problems, no new patients, no consults, no changes to the treatment plan. Supervision requirements must be met as well. The supervising provider under which the MLP’s services are billed must be in the suite and immediately available and the MLP must be employed by the physician or clinic group.

Shared visits are a little different. A shared visit is performed partly by the MLP and partly by the physician under which the service is reported. Services are limited to established patient visits (99211-99215). CMS provides no direction on which portions of the service each one must provide, just that the combined service/documentation is used to support the reported code. In the office setting, these visits must also meet all of the above documented Incident-to guidelines.

In the hospital setting, where Incident-to guidelines do NOT apply, the rules are a little different. The visit is still provided by both the MLP and physician, each documenting their portion of the visit. A co-signature is not sufficient, regardless of place of service. Visit types allowed to use the shared visit rules include Initial inpatient visits (99221-99223), subsequent inpatient visits (99231-99233), observation (99217-99220, 99234-99236) ED visits (99281-99285) discharges (99238-99239) and Provider Based clinics (99201-99215). All services regardless of place of service must be face-to-face. The full guidelines can be found at the CMS website, section 15501.

All types of providers as well as ancillary staff can code/bill for 99211 in the office setting. Ancillary staff usually means an employed nurse or medical assistant. This code is usually called a nurse visit code because a provider is not required to report this code. As always, medical necessity is the first and most important criteria for any E&M code.

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