Incident To And Split Shared Services Billing With Non-Physician Practitioners (NP and PA) Explained.

This lecture discusses incident to and shared/split services definitions and coding scenarios with physicians and non-physician practitioners (NPPs).  I think it's important to understand how the Centers For Medicare & Medicaid Services (CMS) defines these terms before proceeding on with discussion of detailed coding scenarios.  One Medicare carrier provide a brief descriptions of both terms as well as a few scenarios from a Q&A session.
  • Incident to billing is when a service is provided in an office setting by someone other than the physician. However, if the situation meets the guidelines, the physician may bill Medicare for the service. When incident to service requirements are met, the physician may collect 100% of the physician fee schedule amount.  Services billed incident to are billed under the physician's provider number.  Here is another great review of incident to services.    Incident to services do not apply to inpatient situations.  Since I am a hospitalist, I am not exposed to much incident to billing situations.  But for readers who have discovered this post, I think it's important to continue their education for the rules.  
    • A complete review of CMS regulations regarding incident to services can be found at this link to the Medicare Benefit Policy Manual pdf file starting at 60 - Services and Supplies Furnished Incident To a Physician’s/NPP’s Professional Service (Rev. 1, 10-01-03) B3-2050.  
  • Shared/split billing is for services provided in any location when both the physician and a non-physician practitioner (NPP) provide, document, and sign the work they each performed. There must be a face-to-face encounter with both the physician and NPP. The physician can bill the service to Medicare. 
    • The split/shared E/M visit rules are defined by CMS at this link to pdf Publication 100-04, Chapter 12 of the Medicare Claims Processing Manual, section 30.6.13 (H).  I have included this exact wordage here because of its importance to this discussion.
      • A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer. The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to critical care services or procedures.
      • This Medicare carrier resource also provides a good discussion on shared and split service situations and gives us examples of documentation that does not support for shared/split services coding scenarios. 
        •  "I have personally seen and examined the patient independently, reviewed the PA's Hx, exam and MDM and agree with the assessment and plan as written" signed by the physician 
        • "Patient seen" signed by the physician 
        • "Seen and examined" signed by the physician 
        • "Seen and examined and agree with above (or agree with plan)" signed by the physician 
        • "As above" signed by the physician 
        • Documentation by the NPP stating "The patient was seen and examined by myself and Dr. X., who agrees with the plan" with a co-sign of the note by Dr. X 
        • No comment at all by the physician, or only a physician signature at the end of the note
  • Medicare allows 100% of the Medicare fee schedule amount for coverable services submitted by a physician. Medicare allows a percentage of the physician fee schedule amount when services are submitted under an NPP provider number. (The percentage is 85% for physician assistants, nurse practitioners, and clinical nurse specialists.) If the situation does not meet the guidelines, the NPP would bill the services. 
A reader asked me a question on how to handle billing when patients are seen in collaboration with non-billing non physician practitioners (NPP).  I will attempt to explain the possible scenarios for both in-patient and observation admissions and which CPT codes the physician should submit in these situations.  Here is the reader's scenario:
 I know that most of your discussion focuses on the life of most hospitalists - as a direct care provider. What guidance is there about billing time of service when an admission was completed either by a resident/trainee or by a non-billing non physician practitioner (NPP) in the evening and "staffed" by the attending on the following day. Our guidance from compliance is that one bills for the date of service (for example - a patient admitted by the trainee at 6/25 @ 6:30 PM and staffed by Attending 8:00 AM on 6/26 - bill initial visit for 6/26). For patients placed in observation at 8:00 pm 6/25 by a trainee or non-billing NP/PA but staffed by the attending of record on morning of 6/26 and obtains necessary information for a safe discharge - can the same day billing codes be used since the attending is providing admission and discharge services on the same day - or can they not be used because patient's stay included two calendar dates.
Here are the rules (as I understand them) on how to bill the inpatient and observation codes for encounters seen by billing and non-billing non physician practitioners (NP, PA, interns, residents, fellows).  I am not a coding compliance officer, but I have spoken with folks who know about this stuff and have obtained a good sense on how we can be compliant with our billing and coding.

BILLING NPP SCENARIO:
  • Patient admitted to inpatient or observation  by a billing NPP on first date of service  but not seen by attending physician until the next  calendar date of service (past the midnight hour).
    • Since the nurse practitioner and the attending physician did not each provide a substantive portion of the face-to-face encounter on the same date of service, the shared/split visit rules do not apply.  The billing NPP should bill under their identification for the service provided on the calendar date they saw the patient.  The physician should not bill on this date.  Medicare, I believe, will pay the NPP at 85% of the rate of a physician claim.  When the physician sees the patient the following calendar date, they should bill the appropriate E/M code on the date they saw the patient .  So, if a billing NPP sees the patient Friday night and the physician sees the patient on Saturday, the NPP bills the admit code for Friday and the physician bills the appropriate follow up code, critical care code or discharge code on Saturday. 
NONBILLING NPP SCENARIOS
  • INPATIENT ADMISSION
    • Patient seen face-to-face on one date of service by a non-billing NPP and face-to-face by physician on the same date of service
      • The split/shared rules apply if both the physician and NPP both perform a substantive portion of the history, physical and medical decision making of the E/M face-to-face encounter on the same date of service.  The physician should submit a claim for the appropriate CPT code on this shared/split service encounter.
    • Patient seen face-to-face on first date of service by a non-billing NPP but not seen by a physician until the following day.
      • The split/shared rules do not apply since the physician and NPP did not both perform their face-to-face requirements on the same date of service.  No claim can be submitted for the the work provided by the non-billing NPP (usually a PA, NP, intern, resident or fellow) if the physician did not also see the patient on that same date of service. Do not submit a bill for the work provided by the NPP in this scenario.  But how should the physician bill their work on the following date of service? 
        • Patient not discharged on day of first physician encounter
          • The physician should submit a claim that accurately depicts the work provided on their initial encounter.  If the physician provides enough documentation for an admit code, they should submit a claim for 99221-99223.  Alternatively, they could bill the hospital follow up codes 99231-99233 if their documentation does not support the use of an initial admit code.  In addition, the critical care codes 99291 and or 99292 are an option as well.  
        • Patient discharged on the day of the first physician encounter.  
          • If the physician provides a substantive portion of two separate face-to-face E/M encounters at least 8 hours apart on this same date of service and the patient is discharged, the physician  should submit an admit/discharge same day CPT code (99234-99236).  This code can be used in inpatient or observation settings.
          • If the physician does not provide at least two separate face-to-face encounters at least 8 hours apart on the same date of service, I think the correct code here becomes a little tricky.  I believe the physician should bill the CPT code that accurately reflects the work provided.  Choose from the admit code,   the discharge code (99238 or 99239) or even critical care codes if they meet documentation requirements..  In reality, I think the physician will pick the code that pays the most as defined by their respective  total RVU and work RVU.  I suspect this will  usually be the inpatient admit code, if their documentation supports it.   You cannot bill more than one E/M code on this day.  In other words, do not bill both an admit CPT code and a discharge CPT code. Pick one and make sure your documentation supports your billing.
  • OBSERVATION ADMISSION
    • Patient seen face-to-face on one date of service by a non-billing NPP and face-to-face by physician on that same date of service
      • The split/shared rules apply if both the physician and NPP both perform a substantive portion of the history, physical and medical decision making of the E/M face-to-face encounter on the same date of service.  The physician should submit a claim for the appropriate CPT code on this shared/split service encounter (Observation admission codes 99218-99220)
    • Patient seen face-to-face on one date of service by a non-billing NPP, but not seen by a physician until the following day.  
      • The split/shared rules do not apply since the physician and NPP did not both perform their face-to-face requirements on the same date of service.  No claim can be submitted for the the work provided by the non-billing NPP (usually a PA, NP, intern, resident or fellow) on their date of service  if the physician did not also see the patient on that same date of service. Do not submit a bill for the work provided by the NPP in this case.    But how should the physician bill their work on the following date of service in this observation scenario?
        • Patient not discharged on day of first physician encounter
          • The physician should submit a claim that accurately reflects the documentation provided on their initial encounter.  If the physician provides enough documentation for an admit code, they should submit a claim for initial observation admission 99218, 99219 or 99220.  If documentation for their initial E/M face-to-face encounter does not meet the criteria for the admit code, the physician should pick the hospital observation follow-up code (99224, 99225 or 99226) that matches the documentation provided. In addition, the physician can also bill the critical care codes if documentation supports their use.  
        • Patient discharged on the day of the first physician encounter
          • If the physician provides a substantive portion of two separate face-to-face E/M encounters at least 8 hours apart on this same date of service and the patient is discharged, the physician  should submit an admit/discharge same day CPT code (99234-99236).  This code can be used in inpatient or observation settings.  Remember, there must documentation to support two separate and identifiable face-to-face E/M encounters at least eight hours apart on this date of service to use these same day admit/discharge codes.  This applies even if the patient was admitted the prior calendar day.  
          • If the physician does not provide at least two separate face-to-face encounters at least 8 hours apart, I think the correct code is the code that accurately reflects documentation provided.  The only two options here are are an observation admission code (99218-99220) or the observation discharge code (99217).  The admission codes pay more than the discharge code.  If documentation by the physician supports the initial admission codes, that's the code that should be used.  If documentation does not support an admission code, by default, bill the observation discharge code, since there are no other options.
These are the rules for non-physician practitioners and how to handle the billing and coding aspect of their care when seen on different calendar dates of service for both in-patient and observation status.  This is going to become ever more important as hospitalists utilize nurse practitioners, physician assistants and other NPP to assist with their daily encounters.  And it's just another way for The Medicare National Bank to claim physicians are fraudulent when we don't get it right every time.

   

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