American College of Physicians: Internal Medicine — Doctors for Adults ®


Medicare issues new rules to bill for shared services

From the December ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Brett Baker

Q: Has Medicare improved its policy instructing physicians how to bill for evaluation and management (E/M) services provided jointly with a physician assistant or nurse practitioner?

A: Medicare recently revised its regulations on billing for E/M services provided jointly by physicians and nonphysician practitioners such as nurse practitioners, physician assistants and clinical nurse specialists.

While there are different rules to bill for services in office-based and inpatient settings, Medicare pays a reduced amount for services provided solely by nonphysicians in both settings. To determine who provided the service—and the proper payment amount—Medicare refers to the identification number on the claim form.

Medicare revised its regulations after physicians and nonphysician providers complained that the old policy was too complex. ACP-ASIM provided input to Medicare as it crafted the new regulations.

Medicare previously required physicians and nonphysicians to bill separately for their portion of the joint E/M service. Physicians and nonphysicians each had to submit a claim using Current Procedural Terminology (CPT) code 99499, unlisted E/M service, because no specific CPT code describes a partial E/M service. Physicians and nonphysicians also each had to submit a description of the service, which often required them to provide an attachment with each claim.

Q: How should I bill shared visits in the office setting?

A: When a shared E/M service is provided in an office setting, physicians can use their identification number on the claim form—and receive the higher payment—if the following Medicare "incident-to" criteria have been met:

  • Physicians perform the initial E/M service and subsequent services that reflect their active participation in the patient's treatment.

  • Physicians provide direct personal supervision of the nonphysician provider, are in the same suite (but not necessarily in the same exam room), and are immediately available to give assistance and direction.

If a shared service meets the "incident-to" criteria, Medicare will pay 100% of the fee listed on the physician fee schedule.

If the E/M service fails to meet these criteria, bill for the service using the nonphysician's identification number. If the nonphysician provides an E/M service to a new patient or without direct personal supervision from the physician, for example, the claim should list the nonphysician's identification number. Medicare will pay 85% of the fee listed on the fee schedule.

Q: How should I bill for shared visits in the hospital?

A: When a shared or joint E/M service is provided in a hospital inpatient, outpatient or emergency department setting, the billing rules are somewhat different.

Physicians or their group must use the nonphysicians' identification number when the physician has had no face-to-face contact with the Medicare patient. Medicare pays 85% of the physician fee schedule amount for these services.

To bill using their own identification number, physicians must perform at least a portion of the E/M service that involves contact with the beneficiary. General oversight, such as reviewing the medical record, is insufficient.

The following example helps illustrate Medicare's policy on shared services in hospital settings:

A nurse practitioner sees a hospital inpatient in the morning, and a physician from the same group practice follows up with a face-to-face visit with the patient later that day. The group can bill for the services using the physician's identification number because there has been face-to-face contact. The group should select the level of E/M service based on the total service provided in the two same-date visits.

Q: How do I bill if the new Medicare policy on shared E/M services does not address my particular circumstances?

A: According to Medicare, you must use CPT 99499 (unlisted E/M service) if you provide a service not captured by a specific E/M code descriptor. In the following examples, CPT 99499 would be appropriate:

  • A physician performs only a patient history during an encounter.

  • A physician and nonphysician provide a shared office-based E/M service that fails to meet the "incident-to" criteria (because the nonphysician takes a patient history on a new patient, for example).

You must provide a description of the service (a note or the relevant portion of the beneficiary's medical record) with the claim. The carrier has discretion to determine an appropriate payment value.

Using CPT modifier -52 (reduced service) in this situation would be inappropriate. Medicare expects this situation to occur infrequently.

Brett Baker is a third-party payment specialist in the College's Washington office.


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