Now, I'm going to talk about probably one of the hottest topics out there, which is update on advanced practitioner billing incident two and split shared services. And just to make a comment here, if you have, if you're an advanced practice provider listening or you are in a group that is going to have advanced practice providers, this is a very, very, very important topic. One of the biggest things is that this is high up on the recovery audit contractors and the OIGs, I call it their hit list, just because advanced practice providers are billing providers. And so when you're billing a service under the physician, we have to meet certain guidelines. So that's what I'm going to take you through is to make sure that you're billing correctly for these services. So we're going to talk a little bit about those things. But first, of course, we have a polling question. So which of the following scenarios best describes an incident to service? A new patient seen by both the physician and nurse practitioner. A follow-up patient seen by the nurse practitioner and changes the physician's care plan, but the physician is also in clinic. Don't ask me, this subject is way too confusing. Or a follow-up patient seen by the nurse practitioner with no change in treatment and a physician is also in clinic while that service is rendered. So 30% of you, a new patient seen by both the NP and physician, and then you go down to, it's actually the answer is the very last one. So a follow-up patient seen by the nurse practitioner, no change in treatment, and the physician is in clinic while that service is rendered. That is the definition of an incident to service. And so with that said, we're going to talk about who is an advanced practice provider and then we're going to get into incident to services. So who is considered an advanced practice provider? They're providers that have NPI numbers who can bill and provide services independent of another provider. Obviously, you need to be within the scope of your practice. There's also state guidelines that you have to follow. But just keep in mind, try to separate billing guidelines from state guidelines because they're completely different animals. So these guys are usually, they're not your medical assistants or RNs, et cetera. They are actually billing providers. So physician assistants, certified registered nurse practitioners, certified registered nurse anesthetists, midwives, clinical nurse specialists, and clinical psychologists. So those are the types of providers that are what we call physician extenders or NPPs, APPs, whatever you call them. I like to call them, refer to them as advanced practice providers. And again, they are their own billing provider. So in order to meet the criteria to bill under the physician, incident two has to be met or split shared. And I'll talk about split shared in just a little bit. So the definition, what's the definition of an incident to service? Okay. It's part of the patient's normal course of treatment during which the physician personally performed the initial service, remains actively involved in that course of treatment. Now you don't have to be in the room while that service is rendered by the nurse practitioner, but you have to be in clinic that day. The MedLearn Matter, there's a MedLearn Matters article published by CMS out there. We have the link to it. It is a very, it's got some good information on what an incident to service is. All right. So kind of a breakdown. The physician has to perform the initial service. They have to create the care plan. So the physician would bill as a new patient, and then follow-up visits can be incident to if those criteria are met. Okay. Once treatment, and I think this is the biggest confusion out there. Once treatment has been adjusted by the nurse practitioner or PA, then incident to services are no longer met, and you have to bill that service under the advanced practice provider that performed the service. Incident to services are not allowed in inpatient or nursing facility settings. So this is strictly place of service 11. And again, if it's an incident to service, the physician has to be in the office suite. They don't have to be in the patient's room. They just have to be in clinic. All right. Verify the supervision requirements and scope of practice is also met as well. Okay. So some more on incident to services. And again, this is per this MedLearn Matters article SC0441. Qualifying incident to services must be provided by a caregiver whom you directly supervise and who represents a direct financial expense to you. Okay. So you guys are in the same group. That's kind of the key here. Same group. So as of January 1st, 2016, only the physician or practitioner who directly supervises incident to services may be the physician billing on the claim. So here's the thing. If you've got multiple providers in your multiple physicians in your practice, Dr. A could be the one that establishes a care plan for the patient. But if Dr. B is in there is in clinic while that incident to service is rendered, you have to bill it under Dr. B, not Dr. A who established the care plan. So keep that in mind. It's whoever it's kind of like when Kathy was talking about infusion services, that it has to be the provider that's there, the physician that's there on site while that service is rendered and not next door in the endocenter or not across the hall or anything. They have to be in place of service 11. If there is no physician physically present in the office suite, you don't have an incident to service. You're going to bill that under the advanced practice provider, and you will receive 85% of the physician fee schedule by Medicare. Now, some of the other payers may differ. We have some payers out there that will actually pay 100% of the fee schedule for your advanced practice providers. Another comment here is if the patient presents with a new or worsening problem, the physician must see the patient and document the visit in order to establish the change in care plan in order to bill under 100%. But we recommend having the advanced practice provider fully document their E&M visit and mention the physician who provided the direct supervision, then authenticate with their note, sign it, okay? So it's a verification because I'm going to tell you this, if you get audited, you get your notes reviewed, et cetera, they can request schedules. The payer can request schedules to make sure that whoever you're billing under, the physician you're billing under, was actually there seeing patients as well. All right, so here's an example of an incident to service. You've got a 42-year-old female who presents new to the GI practice for evaluation of IBS symptoms. Dr. Gastro completes a full history and physical and decides to prescribe 20 milligrams of bental. He instructs the patient to return to clinic in one month. All right, so we were establishing a care plan for that patient. We're going to bill that as a new visit under Dr. Gastro. All right, the patient comes back to see the nurse practitioner for the one-month follow-up. Patient reports that she feels better. The NP instructs the patient to continue the same medication and return in three months for reevaluation or sooner if symptoms worsen. The physician in clinic reviews the NP's note. So we can bill that under the physician in clinic and get 100% of the fee schedule because incident to services were met. But what happens if that patient comes back for her three-month follow-up, sees the NP, and symptoms have reoccurred along with pain and diarrhea? After the NP examines the patient, she schedules the patient for a colonoscopy. Physician did not come in and see the patient. The physician did not document their note. Well, guess what? You have to bill this under the nurse practitioner. Incident to services were not met because the NP changed the course of treatment. All right, so you have to keep in mind that just because the patient comes in as a follow-up and sees your nurse practitioner doesn't mean, oh, I get to bill it as a physician. It has to be, you have to understand the guidelines on changing care plan. That's the key. If you don't, if the NP does not change a care plan, you can bill it under the physician if they're there in clinic. If they change the care plan, you have to bill it under the nurse practitioner or PA. All right, let's talk about shared services. And I know Kathy had went over this, so I'm just going to kind of comment on a few of these, but she went over this in the first talk this morning. All right, but this is the final rule on shared services. So definition of a split or shared service provided in the facility setting by a physician and an advanced practice provider in the same group. The visit is billed by the physician or practitioner who provides the substantive portion of the visit. So by 2023, the substantive portion of the visit will be defined as more than half of the total time spent. As of right now, it's the substantive portion of history, exam, and decision-making, or more than half of the total time and with the exception of critical care, and I'll talk about critical care in just a second, and split shared services. Shared visits can be reported for new visits and established visits subsequent visits. Okay, they can be shared as long as the documentation requirements are met. A modifier in this one, okay, a modifier is required on the claim to identify these services that are shared, but we don't know that modifier yet. Documentation of the medical record must identify those two individuals and they must sign and date it. On shared services with critical care, okay, so will be based on the performance of the substantive portion, so more than half the total time of the encounter. For non-critical care, it'd be based on the substantive portion. So we're going to move into right now, it's the substantive portion of the key components, history, exam, or decision-making, and then we're going to move into who performed the majority of the visit. So this is huge. This is huge. Right now, we can do a subsequent visit. The nurse practitioner can do the majority of the note. The physician can add an addendum, you know, and not have to document X, Y, Z. There are certain elements that have to be met right now, but not that I did more than half of the visit, and that's going to be required. Okay, again, new modifier also, so be on the lookout for that. So the documentation must readily and clearly identify which services were performed by each provider, okay? Overlapping time may not, cannot be counted. Let's talk a little bit about shared services in the office setting because we get this question, so can a visit in the office setting be a shared visit by the physician and the nurse practitioner or PA, et cetera? It can be. They can be, but only when the service is considered to have been performed incident two, okay? So incident two has to be met. If that's met, then they can share the encounter, okay? Make sure that if you do a shared services, and this is from CGS Medicare. This is a Medicare contractor. They've got some information out on their website regarding shared services, okay? So you can share the visit as long as the NPP and physician are in the same group. The physician must have a medically necessary encounter, okay? And they have to document a substantive portion of the visit. The encounter must consist of more than just a review of the record. You can't just, you have to examine the patient and document your key portions of the visit, okay? You also have to link both of those notes together. So what we like is, again, the NP or PA does the progress note, and then the physician piggybacks onto that note, adds an addendum with their personal observations, okay? We've got some examples from CGS Medicare because that's another question that we get. Well, what do I as a physician need to document to support a shared visit to where it's billed under my name? You can't just say, oh, saw and agree, seen and agree, or review the record. That is not enough to support a shared visit. So the first one, I have personally performed a face-to-face diagnostic evaluation on this patient. My findings are as follows. So information about the abscess, what they're going to do about it, et cetera. Another one, I have personally performed a face-to-face diagnostic evaluation on this patient. I have reviewed and agreed with the care plan. History and exam by me shows abdomen was tender to touch, no rebound. Lab CT were negative. I am total given for pain, patient discharged. So those are two excellent examples of a shared visit, of what the physician should document for a shared visit, okay? Now, look at the bottom of this slide. The following medical record documentation by the physician would not be considered adequate. So if you are adding an addendum, patient seen, seen examined, as above, et cetera, that is not enough. WPS, that is another Medicare contractor, they also addressed unacceptable addendums for a shared visit. Patient seen, seen and examined as above. Or sometimes no comment at all. You have to put your substantive portion. And I think because that was such, that's still a gray area, it's always been a gray area, that's probably why they updated and made a final rule that's going to say, well, you have to prove that you did more than half the evaluation. So I can definitely see shared visits going down, okay? Decreasing. Because most of the time, let's be honest, the nurse practitioner probably does the substantive portion of those visits. But not necessarily every one of them. So just keep that in mind. Now, UnitedHealthcare, they have a little bit different policies. And if you have a shared visit or like an incident to type of service, so if the service is rendered by your advanced practice provider, but you're billing under the physician, this has been in effect since September 1st of 2017, you have to identify that visit with modifier SA. Okay? So they've already gave you a modifier that you should have been using for a few years now. Okay? UnitedHealthcare will accept this modifier when services are provided by them, but you're billing under the physician. And it says, in addition, the rendering care provider's NPI number must also be documented in field 24J of the CMS 1500 form. And they tell you, use of modifier SA and documentation of the rendering care provider will assist UnitedHealthcare in maintaining accurate data with regards to the types of practitioners providing services to our members. And I kind of want to put in parentheses here. We'll also pin these claims occasionally to make sure that you are meeting the requirements to bill under the physician. AMPA Blue Cross. Okay? They have a little bit different policy as well. So it says certain services rendered in an office setting are separately reportable. These services are considered incident two when performed by qualified office personnel who, as determined by the health plan, are not eligible to directly submit claims to the health plan and therefore not eligible to receive direct reimbursement. So this could be registered nurses, medical assistants, et cetera. So those would be incident two services like infusions or, you know, any type of service that they're performing but not a billing provider is directly performing. Okay? They also address some other things. Incident two services rendered and reported under the supervising provider's ID number must meet the health plan's definition of medically necessary and be otherwise covered. The health plan requires that incident two services meet the following criteria. The supervising provider must be physically present in the office suite and immediately available when necessary to provide that direct supervision. So they tell you, you better be in the office suite when the service is rendered. The supervising physician also must stay involved and have an active part in the ongoing care of the patient. The health plan does not follow CMS's incident two reimbursement rules for any physician or non-physician practitioner who has been assigned or awaiting their own NPI number. Yeah, that's a big no-no. Okay? If you've got someone in your group that the credentialing process is a little slow and you're waiting on an NPI number for them, you cannot bill that under someone else in the group. You either, A, don't let them, you know, document and bill until they get their own NPI number or, B, let the provider and patient know that, hey, and the, you know, the credentialing process for, let's say, Anthem Blue Cross Blue Shield is delayed. So you're not going to see those patients, but you can see the patients that you are, that you do have a number for. So that's a big no-no. So the following services are not eligible for reimbursement as incident two. So incidental services are not separately reported, facility setting, emergency, et cetera. So more information, it's Anthem's policy number 32. Aetna also has their own policy. Cigna. Now Cigna says Cigna requires the APP be registered and will direct to a form that is available on their website. They specifically state that they will not credential, but they will register these providers and will accept claims under these providers. This is big. They expect that the provider that performs the service will be the billing provider. Okay. Now tips here. Majority of payers will accept a claim under your nurse practitioner and or physician assistant. As soon as you get their hire date, someone in the office should keep track of this. Get their numbers, get them credentialed, keep a spreadsheet on your top payers, including their policies. And we've been in practices and we've done reviews on practices and say, oh, yeah, we bill incident two and shared visits for Medicare, but all the commercial payers, we just bill under the supervising doctor. That is a no-no. You know, that was way, way, way back when, when nurse practitioners and PAs just started. So this takes work from your practice, takes reaching out to our provider reps, because a lot of this information you can't find online. And this can vary by plan, by state. So you have to know, if you are in contract with a payer, you have to know their guidelines and when it's appropriate to bill under the advanced practice provider or the physician. When reporting incident two and shared services, be sure the rendering provider is listed in 24J and the billing provider is on box 33. If you do have a specific payer that will not accept a claim under the nurse practitioner or PA, report the service under the supervising physician's NPI number. We understand that there are still some plans out there that do not accept a claim under them. And if they don't, that's the instruction, bill under the supervising. But otherwise, you've got to follow our guidelines.

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