NPP Versus Physician Visit

Question: I have a question that revolves around whether or not NPPs are considered a different specialty.

In this scenario an NPP sees a hospital inpatient and meets the documentation requirements for a 99291. A physician (internal medicine) from the same group sees the patient independently for critical care services for 45 minutes later that same day. Which billing is correct?

99291 with the NPP’s NPI, and 99291 using the physician’s NPI (because they are different specialties); or

99291 using the NPP’s NPI and a 99292 using the physician’s NPI (same group).

The question boils down to this. With critical care and NPPs do we focus on them having a different taxonomy specialty than an internal medicine provider and bill the services separately or do we focus on the fact that they are covering for each other in the same group practice?

Answer: Although the physician and NPP have separate taxonomy codes, and they could be recognized as separate provider types, the governing element regarding coding is more likely that they are practitioners from the same group providing care to the same patient on the same day. The taxonomy difference is somewhat technical. If they are in the same group (primary care) they would seem to be acting as the same specialty. Normally you’d bill under one physician’s number for the work of both providers in the reciprocal/covering mode.

However, since the difference in provider type has reimbursement implications, i.e. 100 percent of fee schedule versus 85 percent, we can’t just bill everything in the physician’s name and number as one could with two physicians.

Medicare has a quite a bit to say about all this that bears on your scenario:

Chapter 12, Section D of the Medicare Claim Processing Manual Section 30.6.12 Critical Care Visit and Neonatal Intensive Care (www.cms.gov/manuals/downloads/clm104c12.pdf ) states:

“Critical care services may be provided by qualified NPPs and reported for payment under the NPP’s National Provider Identifier (NPI) when the services meet the definition and requirements of critical care services in Sections A and B. The provision of critical care services must be within the scope of practice and licensure requirements for the State in which the qualified NPP practices and provides the service(s). Collaboration, physician supervision and billing requirements must also be met. A physician assistant shall meet the general physician supervision requirements.”

Section F states “The CPT code 99291 is used to report the first 30-74 minutes of critical care on a given calendar date of service. It should only be used once per calendar date per patient by the same physician or physician group of the same specialty. CPT code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care.

“Physician specialty means the self-designated primary specialty by which the physician bills Medicare and is known to the contractor that adjudicates the claims. Physicians in the same group practice who have different medical specialties may bill and be paid without regard to their membership in the same group. For example, if a cardiologist and an endocrinologist are group partners and the critical care services of each are medically necessary and not duplicative, the critical care services may be reported by each regardless of their group practice relationship.”

Section I states: “However, if a physician or qualified NPP within a group provides ‘staff coverage’ or ‘follow-up’ for each other after the first hour of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the ‘covering’ physician or qualified NPP in the group shall be billed using CPT critical care add-on code 99292. The appropriate individual NPI number shall be reported on the claim. The services will be paid at the specific physician fee schedule rate for the individual clinician (physician or qualified NPP) billing the service.”

There is also a statement that critical care service cannot be reported as a split shared service.

Since Medicare doesn’t allow this collaborative approach with these codes we also can’t really co-mingle the charges.

So, my read here is that in your scenario, with the NPP seeing the patient first, he or she will bill their services as 99291 with their name and NPI and get the 85 percent.
But the rest can vary. I don’t agree that the physician should bill another initial hour of critical care, as it is an extension of the work performed by a provider in the same group. So I think the conservative course is to bill the 99292, with the physician’s NPI and thus at 100 percent of fee schedule.

However, even this is a bit ambiguous. If the NPP qualified for 99291 by spending 45 minutes, then the physician spent 45 minutes, we have a 99291 and 99292 based on 90 minutes total. But if the NPP qualified by spending 60-74 minutes, and then the physician spent 45 minutes, we are now in the range of 105-119 minutes, which would give the physician 99292 times two. Although the Medicare reference above talks about “blocks of 30 minutes,” the table in CPT is quite clear on the total times involved.

Whichever way you go, you can be sure that different carriers will have different opinions. Really all you can do is give it your best interpretation using both CPT and CMS as a guide and make sure your logic is clear. Great question!

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or physicianspractice@ubm.com.

This question originally appeared in the October 2010 issue of Physicians Practice.