Wiki Shared Visit: Doctor treats new problem & mid-level treats follow-up problem

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CatchTheWind

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CMS has stated explicitly that if a shared visit is not incident to, it must be billed under the mid-level. But one of my doctors is questioning why we can't bill it under him if the patient has two problems: the mid-level provider only treats follow-up problem, and he (the doctor) evaluates and treats the new problem.

Technically, this is a shared visit, and it is not incident to. Yet it seems that it would be perfectly fair to bill the visit under the doctor, since the mid-level is only performing that portion which is incident to. Can we do this?
 
The CMS rule (quoted below), as I read it, would only require that the mid-level's service portion of the shared visit meet the 'incident to' requirements. The visit can be both shared and also meet 'incident to', it's not necessarily one or the other. I'm not sure why you say your specific visit is not 'incident to', but if the patient is established and the services performed by your mid-level provider otherwise would meet the requirements for 'incident to' billing, then you may bill the shared visit under the physician's credentials. You would only be required to bill under the mid-level if 'incident to' requirements for some portion of the NPP's service were not met.

When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed “incident to” if the requirements for “incident to” are met and the patient is an established patient. If “incident to” requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s UPIN/PIN
 
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The problem is that the requirements for "incident to" were not met because the patient has a new problem.

Where it gets complicated is that the patient saw both the PA and the doctor: the doctor treated the new problem and the PA treated the existing problem.

Someone has suggested to me that as long as it is clear who performed which part (ie: by the doctor and PA each making a separate note), then we can bill it under the doctor. Correct?
 
CatchTheWind said:
The problem is that the requirements for "incident to" were not met because the patient has a new problem.
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It does meet "incident to" requirements if the physician handled the new problem - "incident to", by definition, only applies when something that was done by an employee is billed by the physician. Think about it - services that are personally performed by a physician are not subject to this restriction because you are not billing those services under a different provider - physicians do not bill "incident to" themselves. Only the mid-level services that you are seeking to bill under the physician's credentials will fall under "incident to" restrictions that the physician must have seen the patient and established the plan of care for the problem. If the PA treated only the existing problem and did not change the plan of care, then you should be fine billing this encounter under the doctor.
 
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I have a question in a similar realm to the original poster. Our physicians are utilizing PAs during patient visits (new, established, established with new problem) to perform a history and exam while the physician then re-performs the exam, diagnoses the patient, and does the medical decision making. This is being done in an office setting (POS 11).

Is an attestation by the physician, that they saw and examined the patient with the PA and agree with the findings, assessment, and plan of care documented by the PA, sufficient to bill under the physician?

They are sharing the visit but not by CMS’ definition because of the office place of service.
 
Queizati said:
I have a question in a similar realm to the original poster. Our physicians are utilizing PAs during patient visits (new, established, established with new problem) to perform a history and exam while the physician then re-performs the exam, diagnoses the patient, and does the medical decision making. This is being done in an office setting (POS 11).

Is an attestation by the physician, that they saw and examined the patient with the PA and agree with the findings, assessment, and plan of care documented by the PA, sufficient to bill under the physician?

They are sharing the visit but not by CMS’ definition because of the office place of service.
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The split shared concept does not apply in the office.
Also, this process seems odd, why would the provider utilize the PAs in that way? Double doing the work?

30.6.18 - Split (or Shared) Visits (Rev. 11842; Issued; 02-09-23 Effective: 01-01-23; Implementation: 05-09-23)A. Definition of Split (or Shared) Visit A split (or shared) visit is an evaluation and management (E/M) visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be billed by either the physician or NPP if furnished independently by only one of them. Payment is made to the practitioner who performs the substantive portion of the visit. Facility setting means an institutional setting in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under our regulations.
 
amyjph said:
The split shared concept does not apply in the office.
Also, this process seems odd, why would the provider utilize the PAs in that way? Double doing the work?

30.6.18 - Split (or Shared) Visits (Rev. 11842; Issued; 02-09-23 Effective: 01-01-23; Implementation: 05-09-23)A. Definition of Split (or Shared) Visit A split (or shared) visit is an evaluation and management (E/M) visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be billed by either the physician or NPP if furnished independently by only one of them. Payment is made to the practitioner who performs the substantive portion of the visit. Facility setting means an institutional setting in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under our regulations.
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I agree it’s an odd set-up; I would think the PA would be utilized in a way to increase efficiency within the clinic. Since the PA has been hired on I have not seen them document a visit without the physician attesting they also saw and examined the patient.

Would this just be an un-billable service since neither Split-Share nor Incident-To requirements are being met as per CMS guidelines?
 
I'm assuming the PA is enrolled with Medicare. In that case you can bill the visit under the PA's name and NPI, but make sure you level the visit based solely on the PA's work.
It sounds like your providers are just a bit confused about team-based care. Which is understandable.
Some things to keep in mind:
1. There are people who use the term split/shared to refer to incident-to and split/shared services. I wish they wouldn't. Every so often I receive questions from someone who works for a physician who has heard split/shared used in that way and thinks they can report split/shared visits for Medicare patients in the office setting. They cannot.
2. To make everything more confusing - the 2024 CPT Manual's definition of split/shared is similar to CMS's rule, but it is not limited to a specific setting. So, according to the CPT manual, a split/shared visit in the office is OK. However, the AMA creates the CPT Manual, it does not pay claims so CMS rules (or the private payer's policy) control what you can report.
 
Queizati said:
I agree it’s an odd set-up; I would think the PA would be utilized in a way to increase efficiency within the clinic. Since the PA has been hired on I have not seen them document a visit without the physician attesting they also saw and examined the patient.

Would this just be an un-billable service since neither Split-Share nor Incident-To requirements are being met as per CMS guidelines?
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It's not unbillable but you have to figure out who you're billing it to and what their rules are according to the documentation. It's hard to say without an actual note. Are you sure the physician is actually seeing the patient and not just slapping an attestation to the note? Not to stir the pot but...
Depending on the documentation you would have to determine if the PA was acting more as a scribe or almost like an MA where they take the history & vitals or something but the physician is doing the rest.
This scenario seems a bit worrisome.
I would also have questions like, is the PA credentialed, new grad, etc. etc.? Because I have seen where providers in clinic have an uncredentialed PA and that PA is acting more like an MA until the time they are credentialed or have enough hours of supervision (depends on state).
There is something else going on here it feels like.
 
amyjph said:
It's not unbillable but you have to figure out who you're billing it to and what their rules are according to the documentation. It's hard to say without an actual note. Are you sure the physician is actually seeing the patient and not just slapping an attestation to the note? Not to stir the pot but...
Depending on the documentation you would have to determine if the PA was acting more as a scribe or almost like an MA where they take the history & vitals or something but the physician is doing the rest.
This scenario seems a bit worrisome.
I would also have questions like, is the PA credentialed, new grad, etc. etc.? Because I have seen where providers in clinic have an uncredentialed PA and that PA is acting more like an MA until the time they are credentialed or have enough hours of supervision (depends on state).
There is something else going on here it feels like.
Click to expand...
jkyles said:
I'm assuming the PA is enrolled with Medicare. In that case you can bill the visit under the PA's name and NPI, but make sure you level the visit based solely on the PA's work.
It sounds like your providers are just a bit confused about team-based care. Which is understandable.
Some things to keep in mind:
1. There are people who use the term split/shared to refer to incident-to and split/shared services. I wish they wouldn't. Every so often I receive questions from someone who works for a physician who has heard split/shared used in that way and thinks they can report split/shared visits for Medicare patients in the office setting. They cannot.
2. To make everything more confusing - the 2024 CPT Manual's definition of split/shared is similar to CMS's rule, but it is not limited to a specific setting. So, according to the CPT manual, a split/shared visit in the office is OK. However, the AMA creates the CPT Manual, it does not pay claims so CMS rules (or the private payer's policy) control what you can report.
Click to expand...
Hello, I apologize for the late reply. Thank you both for taking the time to respond and for your input. Our compliance team got involved and a few things were discovered:
The MD claimed they were performing all of the medical decision making while the PA performed the history and exam. However, the PA was then documenting the history and exam but also scribing the MDM portion for the MD. As you can imagine, this was not easy to glean from the notes alone.

Since then, the PA has now been documenting for each visit that they were acting as a scribe and that the MD created the care plan for the patient.

The PA will be seeing patients on their own soon so hopefully those notes will be less tricky.
 
I would just add that the PA must be extremely careful to just serve as a scribe. They cannot include any of their clinical impressions in the note.

For example:

The MD/DO sees the patient, but forgets to review some lab results that would otherwise count toward the visit. The PA (serving as a scribe), wants to be helpful and puts their own review of the labs in the note. Bzzzt! Nope. The PA can't do that. Neither can the MD/DO say to a PA who is in scribe mode "I'm running behind. Order labs x,y,z for John Eod," and get credit for it.

Contaminated clinical records have always been a risk associated with using NPPs as scribes, which I think is why compliance professionals recommend against it. But so long as everyone understands that when the PA is a scribe, they are just writing down what the MD/DO does during the visit and someone keeps an eye on the documentation, you should be good.
 
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