Maximizing Reimbursement with MLP Reporting

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Our provider utilization reports don’t make sense. The MLP data is skewed. 
Can you provide some insights into appropriate MLP reporting? 

Q. Our provider utilization reports don’t make sense. The MLP data is skewed.  
Can you provide some insights into appropriate MLP reporting?

A. First of all, let me commend you for paying attention to the details of your practice by reviewing these types of reports! There are two major considerations regarding appropriate reporting of MLP services:


1) documentation requirements for physician vs. MLP billing;
2) capability of the coding/billing platforms to accurately report physician/MLP
Let’s begin with some MLP clarifications for both shared E/M visits and billable procedures. 
CMS ‘Shared’ ED E/M Level Visit: When an E/M is shared between a physician and MLP from the same group practice and the physician provides any patient face-to-face portion of the E/M encounter, the service may be billed under either the physician’s or the MLP’s UPIN/PIN number. CMS definitively states that a face-to-face encounter by the physician must be documented for the physician to receive 100% of Medicare allowable payment for the E/M service provided. In absence of a documented face-to-face encounter, the E/M should be billed to the MLP’s UPIN/PIN number and reimbursed at 85% of Medicare allowable.

For physician reimbursement of 100% of Medicare E/M allowable, documentation best practices would indicate the physician provide documentation in the medical record to reflect the face to face with the patient. Examples:

1)I performed the exam with the MLP and provided discharge instructions to the


2)I saw and discussed treatment options with the patient.

While I strongly encourage the physician to provide their own documentation of the face-to-face encounter, in-depth research of the regulations speaks volumes. There are no regulations requiring written documentation directly from the physician about his/her care. As along as the physician face-to-face encounter is included in the documented patient encounter, it meets CMS criteria for the physician to receive 100% of the E/M Medicare allowable. 

Examples of MLP documentation
Does meet CMS physician reimbursement documentation requirements: 

1) Dr. X saw the patient and discussed test results
2) Dr. X has seen and evaluated the patient and agrees with treatment plan
Does not meet CMS physician reimbursement requirements (no physician face-to-face is indicated):
1) Dr. X reviewed patient chart as well as history
2) Treatment plan has been reviewed with Dr. X. Due to patient’s current presentation, patient will be admitted.

MLP Procedures Performed in the ED:  Procedures are never ‘shared’. Documentation should clearly state what provider performed the procedure – applicable procedure charge(s) should be coded to the provider (physician or MLP) that actually provided the service.


Other Payers: MLP billing is a payer-specific issue. It is best to check your state regulations to determine specific rules regarding MLP scope of practice and billing regulations.

Coding/Billing Platforms: What I am discovering is that many coding/billing platforms do not have a provision to appropriately distinguish and accommodate for a shared E/M billed to the physician and a separate procedure performed/billed to the MLP. This situation can certainly impact your provider utilization reports. The greater issue however, is this raises a compliance red flag. I would encourage you to make an inquiry regarding the set up of your coding/billing platform to ensure accurate, compliant reporting and billing.

Sharon Nicka, RN, CPC, is the founder and president of Nicka & Associates, Inc. Send her your reimbursement quandaries at

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