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Nonphysician Practitioners: Evaluation and Management Services

National Government Services recognizes the steadily changing composition of provider practices, with many groups now including membership by physicians (MDs/DOs), NPs and PAs. In both the inpatient and outpatient setting, each of these provider types may contribute to patient care in numerous ways. This article describes the CMS guidelines for performing and billing such services appropriately.

E/M services should always accurately reflect the level of care provided during any patient encounter. CMS considers duplicative or overlapping care as medically unnecessary and MACs pay or deny such services only within the confines of CMS rules and guidelines. When multiple same-day E/M services are billed for the same beneficiary by several provider types, the following rules apply:

  • When an MD and NPP from the same provider group each perform individual E/M services on the same day, for the same patient, the service is considered as “Split/Shared”, and should be billed as one service, using the MD’s billing identifier. These combined services may support a higher level of E/M coding than either service when billed alone.
  • Outpatient split/shared visits must meet “incident to” requirements as defined in CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.4 (1 MB). The billing physician must be present in the office suite during performance of an E/M visit by an NPP, in order to bill the service using the physician’s NPI, rather than the NPPs.The “incident to” concept does not apply in the inpatient setting.
  • When multiple NPPs perform individual E/M services on the same day, for the same patient, only one of the NPP claims will be paid per day by the MAC. We recognize that NPPs, particularly nurse practitioners, are now practicing within subspecialty groups, but we remind providers that, at present, CMS does not currently assign subspecialty designations to nurse practitioners. Specialty type 50 (NP) is applicable to all NP services billed to Medicare, regardless of the nature of the service performed, and only one of these NP services is payable per beneficiary, per day.
  • The rules for critical care E/M services vary slightly (please refer to a separately posted article on critical care services). An initial critical care service (99291) represents between 30-74 minutes of time spent by an individual practitioner, or multiple same specialty members of a group. Critical care time may accumulate through several shorter episodes over a calendar day. Critical Care services are not subject to the “Split/Shared” concept as it applies to services performed by both MD/DOs and NPPs. All such services must be performed and billed on an individual basis by either an MD/DO or NPP, and elements cannot be combined for an individual service. When subsequent periods of care (>30 minute segments) are performed by members of a group who are covering each other, these should be represented by 99292 and billed by either the MD or NPP who performed that additional unit of service. These services must, of course, meet all requirements for critical care, including time spent. Either total time or start-stop time must be recorded in the medical record. In addition please note that any time spent performing other needed services to a critically ill beneficiary such as spinal taps, tracheal intubations, or similar procedures, must not be included in the time spent as performing critical care services.

In response to CMS’ current initiative to reduce provider burden in the Medicare claim process, we are pleased to announce a significant change in submission and processing steps for E/M services performed by NPPs. This change applies to claims submitted by NPs (NP-Specialty 50) and PAs (PA-Specialty 97) and will be applied to claims processed on and after 9/15/2018. NGS offers the following list of frequently asked questions for this process change.

  1. Is more than one E/M service by a PA (Specialty 97) or NP (Specialty 50) payable on the same DOS?

    Answer: CMS permits one E/M service per beneficiary, per day, per provider specialty type. Since PAs and NPs often provide specialty care (e.g., family practice, psychiatry, orthopedics), multiple E/M services on the same DOS may be permissible, when each episode of care is addressing a different clinical condition.

  2. What are the changes in NGS processing NP and PA claims for E/M services?

    Answer: As of 9/15/2018, we have instructed NP and PA providers to include information on each E/M claim, defining the specialty of the physician group when care is rendered in a specialty practice environment.

  3. How do NP and PA providers include supervising specialty information on their claims?

    Answer: This information is to be included in the 2400 NTE Segment Loop on electronic claims or in Box 19 on paper claims. The claims are to be submitted with either NP (Specialty 50) or PA (Specialty 97) as the rendering provider as usual with this additional information describing the specialty of the physician practice in which the care was rendered.

  4. How is the physician group specialty information to be formatted?

    Answer: The information entered in the 2400 Loop or Box 19 should read e.g.: “Spec 06” (for a cardiology group) or “Spec 26” (for a psychiatry group).

  5. Where can a list of CMS provider specialty designations be located?

    Answer: We have posted a copy of the Medicare Provider/Supplier Specialty Codes on the Job Aids & Manuals page on our website. The list can also be found on the CMS website.

  6. How will NGS be processing these NP and PA E/M claims?

    Answer: The first E/M claim from an NP or PA on a DOS will process as usual; subsequent NP and PA claims on that DOS will be suspended for review of the physician specialty group information and also a comparison of the diagnoses on the paid claim vs. any subsequent claim.

  7. Please define the diagnosis requirements for these claims.

    Answer: When claims for services by multiple NPs and PAs on the same DOS are received, the diagnosis on each of these claims will be compared with any other paid E/M claims on that DOS. If an E/M claim has already been paid to an NP or PA for treatment of a particular diagnosis, any subsequent claims with that same diagnosis will be denied.

  8. In a specialty group, will two E/M claims with the same diagnosis be payable, if they are submitted by a physician and also an NP or PA in that group?

    Answer: In a group practice, it is not permissible to submit two separate E/M claims for care rendered by both a physician and an NP or PA that addresses the same clinical problem. For example: an NP elicits a patient history and decides to request a physician’s participation in the care. In this scenario, care rendered by the two practitioners is combined in level-setting the visit, but only one visit is billable to Medicare.

  9. If an NP or PA E/M claim is missing the physician group specialty information, will it still be considered for payment?

    Answer: As above, the initial E/M service may be payable; subsequent same-specialty E/M services on that same DOS will be denied if the physician group specialty information is missing.

  10. Do all NPs and PAs have to comply with these new billing instructions?

    Answer: This change is being effectuated to reduce unnecessary provider burden relative to frequently denied claims and their associated appeals. It is a voluntary process for the NP and PA providers, but we encourage all provider groups who have been experiencing denials and successful appeals to initiate this change as soon as possible.

  11. How does this change impact independent NP groups?

    Answer: An independent NP group must maintain a collaborative agreement with a physician and this physician’s specialty may be entered on the claim. This will not permit multiple E/M services within the NP group on the same DOS (since the physician’s specialty will be the same), but will permit comparison with another NP service on that date, performed within a different specialty group environment and addressing a different clinical condition.

  12. If a NP or PA E/M service is denied, what are the options for appeal?

    Answer: Denied NP or PA E/M services are still subject to the standard appeal process. Of note: claims denied prior to the 9/15/2018 processing change are still subject to the standard appeal process and will not be reopened. In addition, these claims may not be resubmitted for processing after the implementation date.

  13. How soon should NPs and PAs start including this information on their E/M claims?

    Answer: We encourage NPs and PAs to include this information as soon as possible, recognizing that this may require time to work with their billing vendors and electronic medical record software teams. On September 15th and after, having this information on previously paid claims will enhance our ability to compare specialty information with that submitted on earlier claims.

  14. How does this processing change affect NP and PA claims for new patient visits (99201‑99205)?

    Answer: When two NP or PA new patient visits are submitted on the same DOS, both may be payable, based on comparison of the specialty group information on the claim. This will only occur when no prior new patient visit has been paid to an NP or PA within the prior three years from that DOS.

  15. In a specialty group, can both a physician member and an NP or PA member submit a claim for a new patient visit within a three-year period?

    Answer: A patient is considered new to a specialty group only once within a three-year period. A claim for a new patient visit may be submitted once by the group within a three-year period; this visit may be performed and billed by either a physician or NP/PA member of
    the group, but may not be submitted by both group members.

  16. Please define the reason code that is associated with denials for multiple NP or PA services on the same DOS.

    Answer: The reason code associated with these claim denials is N20.

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