College of Medicine Office of Compliance, Gainesville, Florida
COMPLIANCE TIP

New Rule For Billing For E/M Encounters That Are Shared/Split Between A Physician And An ARNP/PA
(Medicare Transmittal 1776, Oct 25, 2002)

Effective Immediately:    The following new rules apply to performing, documenting and billing for evaluation and management (E/M) encounters that are shared/split between a physician and a PA/ARNP. Note: the rules are different for the Hospital- Based Inpatient/hospital-based outpatient/emergency department setting than for the non-hospital based office/clinic setting.

Also note:    THESE RULES DO NOT APPLY TO SERVICES INVOLVING RESIDENTS AND DO NOT CHANGE IN ANY WAY THE EXISTING TEACHING PHYSICIAN PARTICIPATION AND DOCUMENTATION REQUIREMENTS FOR SERVICES INVOLVING RESIDENTS.

I.    HOSPITAL-BASED INPATIENT/HOSPITAL-BASED OUTPATIENT/EMERGENCY DEPARTMENT SETTING:

When a hospital inpatient/hospital outpatient/emergency department E/M encounter is shared/split between a physician and an ARNP/PA from the same group practice the E/M encounter may be billed under the physician's name and provider number if and only if:

1.    The physician provides any face-to-face portion of the E/M encounter (even if it is later in the same day as the PA/ARNP's portion); and

2.    The physician personally and cotemporaneously documents in the patient's record the physician's face-to-face portion of the E/M encounter with the patient.

If the physician does not personally perform and personally and contemporaneously document a face-to-face portion of the E/M encounter with the patient, then the E/M encounter cannot be billed under the physician's name and provider number and may be billed only under the PA/ARNP's name and provider number.

II.   NON-HOSPITAL-BASED OUTPATIENT CLINIC/OFFICE SETTING:

When a non-hospital outpatient clinic/office E/M encounter is shared/split between a physician and an ARNP/PA the E/M encounter may be billed under the physician's name and provider number if and only if:

1.    The patient is an established patient; and

2.    The "incident to" rules are met. (Note: Medicare has clarified that "incident to" billing is not allowed for new patients/first visits).

If the patient is not an established patient and the "incident to" rules are not met, then the E/M encounter cannot be billed under the physician's provider number and may be billed only under the PA/ARNP's provider number.

This means that a physician cannot combine the E/M services of an ARNP/PA and a physician for a NEW patient on a FIRST visit E/M encounter and bill under the physician's name and provider number.

Further, we strongly discourage the use of ARNP's/PA's as scribes for new clinic visits - as only the physician's work will support the physician's bill.  If "scribes" are used, some of the work performed by the "scribe", and not the physician could inadvertently be documented by the "scribe" and erroneously used to support the physician's bill.

SUMMARY:

RESIDENTS:

Teaching Physician rules are unchanged and still apply as described in the Medicare rules and in your departmental plan.   The Teaching Physician may either dictate the whole note; dictate or write a note linking to the resident's note by making a patient pertinent comments on the history, exam and medical decision making; or bill based on time (when > half the time is in counseling or coordinating care).

ARNP's  AND PA's:

Inpatient and hospital-based outpatient setting -  Can bill under physician name and provider number for combined service (even when the ARNP sees the patient in the morning and the physician sees the patient in the afternoon.)   Physician must see patient face-to-face and personally and contemporaneously document his/her face-to-face portion of the encounter in the patient's medical record.

Non-Hospital based outpatient clinic/office setting -

New patient first visit-   May NOT COMBINE E/M services with physician and bill under physician's name and provider number.    "Incident to" billing is NOT ALLOWED. ARNP/PA may see patient and bill under his or her own name and provider number.

Established patient return visit  - May bill under the physician's name and provider number if all "incident to" rules are met (physician has seen patient before and these subsequent visits are related/or part of the diagnosis and treatment plan.) OR the ARNP can provide the service for new problems and bill under his/her own name and provider number.

IF YOU HAVE QUESTIONS, CALL BEFORE YOU BILL!!!

If you have any questions about this tip, or another compliance concern,
the Office of Compliance for the College of Medicine is here for you.
Please call (352) 265-8359 or e-mail Nina Tarnuzzer at nwt@ufl.edu.

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