Document Shared Visits for Optimal Reimbursement
When billing these services, be sure documentation abides by payer requirements and state and employer rules.
By Sarah Todt, RN, CPC, CPMA, CEDC
When you think of health care professionals, you generally think of physicians. It’s important, however, to be aware that other providers, such as non-physician practitioners (NPPs), also report services. These services may result in different payment rates, depending on the payer and documentation within the record. For example, services reported to the Centers for Medicare & Medicaid Services (CMS) are paid at 85 percent of the physician fee schedule when reported by mid-level providers such as nurse practitioners (NPs) and physician assistants (PAs). When the physician is directly involved and documents appropriately, the services are typically paid at 100 percent of the Medicare fee schedule.
Scope of Practice Determines NPP Billing Eligibility
NPPs include NPs and PAs. NPs include acute care nurse practitioners (ANP), certified registered nurse practitioners (CRNP) and family nurse practitioners (FNP), to name a few. PAs include physician assistant-certified (PA-C) and registered physician assistant-certified (RPA-C) professionals.
NPPs are credentialed providers that may perform many of the same functions as physicians. State and employer rules dictate the amount of supervision required and the scope of practice. Scope of practice information and supervisory requirements by state may be found on the American Academy of Physician Assistants website: www.aapa.org/advocacy-and-practice-resources/state-government-and-licensing.
CMS indicates that NPPs are authorized to bill Medicare for services based on their own Unique Physician Identification Number (UPIN)/Provider Identification Number (PIN). Services reported by NPPs must meet the general supervision rules, and must be within the scope of practice for the state in which the billing NPP practices. The transmittal also reiterates that the services reported must be medically necessary.
Medicare Carriers Manual Part 3-Claims Process, Transmittal 1776, section 15501 (www.cms.gov/transmittals/downloads/r1776b3.pdf) gives specific instruction regarding the reporting of an evaluation and management (E/M) visit shared between an NPP and a physician.
- In the office/clinic setting, incident-to instructions should be followed to determine who should bill for the service.
- In the hospital inpatient/outpatient/emergency department (ED) setting, the shared service may be reported under the physician’s UPIN when certain criteria are met:
- The NPP and physician must belong to the same group practice.
- The physician must provide a face-to-face portion of the service.
- The documentation should demonstrate a meaningful interaction, specifically, more than a social salutation. Reviewing the NPP’s documentation and co-signing the record is not sufficient for reporting the visit as a shared service.
Shared Services Must Show Physician Involvement
To properly report E/M services when NPPs are involved in the care of a patient with a physician, it’s essential to apply the shared visit documentation instructions as outlined in Transmittal 1776. As a coder, you are necessary in the identification and proper reporting of services shared between an NPP and a physician.
Shared services need clear documentation showing the physician’s involvement in the care of the patient in addition to the work performed by the NPP. The services of the NPP and physician may be performed independently and documented separately. A physician’s co-signature—or simply a review of the NPP’s documentation—will not support a shared visit under Medicare guidelines.
The following situations illustrate when it is appropriate to report services under the physician’s UPIN:
A PA sees a patient on the medical-surgical floor of the hospital and documents a note supporting an E/M service. Later that day, a physician from the same group practice sees the same patient and also documents a note supporting an E/M service. The service meets the shared visit requirements and may be reported under either the PA’s or the physician’s UPIN.
In a second example, an NP sees and evaluates a patient in the ED. The NP identifies a potentially high-risk disease process. She discusses the case with one of the ED physicians, who then sees the patient, performs an exam, and documents a note clearly indicating a face-to-face encounter with a portion of the physical exam documented. This meets the shared visit requirements, and may be reported under the physician’s UPIN.
Critical Care May Not Be Shared
The shared service concept does not apply to critical care. NPPs may provide and bill for critical care services when all of the requirements have been met for CPT® 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service), in addition to three other requirements:
- The service provided must be within the scope of practice and licensure requirements for the state in which they practice.
- Both NPs and PAs must meet the collaboration, physician supervision requirements, and billing requirements.
- PAs must meet the general physician supervision requirements.
The critical care service should reflect the NPP’s E/M of the patient, and not a split/shared/combined service between a physician and a qualified NPP. Typically, such services may be reported under the NPP’s UPIN.
For example, a patient arrives at the ED with a complaint of chest pain. A PA initially evaluates the patient, performing a full cardiac work-up. The patient is having a suspected acute myocardial infarction. The NPP performs the majority of the care for the patient and documents 35 minutes of critical care time. The attending physician provides a review of the record and quick evaluation of the patient. A shared visit note is documented; however, the physician did not provide 30 minutes of care. Although there was a shared visit note, this visit would be reported appropriately under the NPP’s UPIN as critical care services. The critical care may not be a split/shared service.
For additional information, refer to MLN Matters MM5993, Revised Critical Care Visits and Neonatal Intensive Care (99291-99292), available online at: www.cms.hhs.gov/MLNMattersArticles/downloads/MM5993.pdf.
Sarah Todt, RN, CPC, CPMA, CEDC, is the director of quality and education at LogixHealth, an ED-specialized provider of coding, billing, and end-to-end revenue cycle services for top hospitals, office-based practices, and EDs nationwide. Ms. Todt is a registered nurse who specialized in emergency medicine and critical care. She served on the AAPC National Advisory Board (NAB) and the ED specialty exam steering committee, and presented on ED reimbursement topics.