Yeah, we're going to talk about the not so good subject right now, which is split share visits. And this is specifically, this is specifically related to CMS guidelines. So I just want you to keep that in mind when we go through this, this is CMS policy. So not necessarily everybody follows this policy, but they made quite a few changes to the split shared guidelines. Okay, so we're going to talk about those guidelines, what they are, what they mean, and what does our documentation need to look like to support a shared visit. All right, so we're going to just remind everybody, kind of the overview of an advanced practice provider and their role in the practice. We are going to again, talk about the shared policy. I have some clinical examples, and then we are going to do a little Q&A at the end. So who is considered an advanced practice provider? Your APPs are, they are rendering providers, they are billing providers with NPI numbers. And so this is why we have all these policies out there on when can we bill it under the doctor? When do we have to bill it under the nurse practitioner? The thing is, guys, is we have to keep in mind, they are billing providers. They are meant to extend, be a physician extender, and that's typically what we used to refer them as, but to allow them to see the follow-ups and the patients that are nearing discharge in the hospital setting, where the doctor can see, add on one or two more scopes, see the consult, see the extremely complicated cases. So that's why we have all these rules and these nuances, and guys, just to be honest with you, it's all about the money. It's all about the Benjamins, because if we bill a claim under the nurse practitioner or PA, we get 85% of the fee schedule, we bill it under the doctor, we get 100%. So we have to prove our 15% worth to get that reimbursement and RBU credit to the doctor. All right. So keep in mind, this stuff is billing information. It's not state guidelines, supervision guidelines. That's going to be state-specific. All right. So again, they're known as physician extenders, advanced practice providers, non-physician practitioners, whatever, however you reference, they are, I tend to call them APPs, advanced practice providers. GI practices tend to have physician assistants and nurse practitioners. All right. So let's get into the nitty-gritty. All right. So CMS updated their policy on split shared documentation criteria. And the definition of a shared visit by CMS, it's a medically necessary encounter where both the physician and the non-physician practitioner each perform a substantive portion of the E&M visit on the same data service with the same patient. This is the Debbie Downer. You must bill under the practitioner who performed the substantive portion of the encounter. So when I'm doing a review and I'm looking at documentation, I can't just go straight to the physician's addendum and say, oh, he touched the belly. He agreed with the above. I can bill it under him. Can't do that anymore. We're really looking at these records saying, okay, who did the substantive portion of the visit? All right. So this is out of the 2022 CMS final rule when they updated their policy. It says we're refining our longstanding policies for the split or shared E&M visits to better reflect the current practice of medicine, the evolving role of non-physician practitioners as members of the medical team, and to clarify conditions of payments that must be met to bill Medicare for these services. So they established the following. Definition of a shared visit provided in the facility setting by a physician and NPP in the same group. You guys got to be in the same group. The visit is billed by the provider who performed the substantive portion. The substantive portion can be one of two things, history, exam, decision-making, or more than half of the total time. Now except for critical care visits, but critical care is only time-driven service, so those can only be split by time, but these can apply to your established patients, your new patients, your subsequence in the hospital, prolonged services, anything that's in the facility. When you do a shared visit, we have to bill that service to Medicare with a modifier. It's modifier FS, so let's say I bill an initial visit as a shared visit 99222, I'm going to put an FS modifier on my claim. It doesn't matter who you bill it under. Whether you're billing it under the nurse practitioner or whether you're billing it under the physician, FS modifier is required. Documentation must identify the individuals who performed the visit and they both must sign the note. I kind of giggle every time I see this because of course anybody that's documenting the note, we should be able to identify that individual. We should have before this policy changed, so if I'm looking at a shared visit, I need to know that Nancy NP did this part of the note and I need to know Dr. MD did that part of the note. It's got to be clear. One thing I want to comment on in talking specifically to this issue is make sure that you, your nurse practitioners, your PAs are signing their note, locking it, sending it off to the physician to add a legal attestation to that record. That way we can timestamp, date stamp, we know who did what part of the note. This is another interesting one. This is actually I think a good one. The documentation must support at least one of the providers had a face-to-face in-person encounter with the patient, but it does not necessarily have to be the one that does the substantive portion and bills for the visit. Let's say, for example, the NP sees the patient, does a soap note, does a rounding note, whatever, doc comes in after clinic, he goes to see the patient, but he stops at the floor and he ends up having a 30-minute conversation with the hospitalist, documents, and doesn't necessarily feel the need to have to go in and examine the patient. You can bill that visit under the physician. For non-critical care encounters, if history, exam, or decision-making is used as the substantive portion of the encounter in lieu of time, the documentation must reflect the billing provider performed the component in its entirety. So how will we know? It's got to be in your addendum. Overlapping time may not be counted. If you bill for critical care services, which some GIs do occasionally, we don't bill this all the time. So prior to this implementation of the split shared policy that CMS created, split critical care was not allowed to be shared. It was never a shared service. Now it is. But again, you're billing by time on this one. So they made clarifications that if you guys are sharing visits, you have to be in the same group, meaning the GI doctor can't go over to the hospital and use the hospitalist PA to do a shared visit with. It has to be one of your nurse practitioners, one of your PAs. And again, place of service is 21, 19, or 22. This is not office setting. This is facility setting. So then we saw, so prior to this, when they came out with the 2022 CMS guidelines on shared visits, they said, we're going to allow you to pick one or the other, either substantive portion or total time for year 2022. But by 2023, it's only by time. Well, then they halted that, thank goodness. And now through 2023, they are going to delay, they delayed that. So you still, through 2023, you still get to either document substantive portion or more than half of the time. Now beyond 2023, that's up in the air, of course. So don't be surprised by 2024, it's only time services. So this is kind of a breakdown, non-critical care services who can bill, again, it's either the key component or time. And then non-critical care in 2023, same thing. And then of course, that one provider must have an in-person contact with the patient, but it doesn't have to be the one that bills it. All right, so I've got a question for you. When a shared visit is billed by time in the hospital, the following documentation is required, specific time spent by both the APP and MD, time spent only by the billing provider, a statement by the billing provider, I spent greater than 50% of total time. I don't know, we don't perform split shared services. So we have a few, I don't know, we don't perform split shared services, but you guys are, you guys ate your Wheaties and you guys are so smart. Correct. Specific time spent by both providers have to be documented. We have to know how much time the APP spent and how much time the physician spent to prove that greater than 50% total time. All right, so let's look at some clinical examples. We've got one by substantive portion, we have one by time. So APN documents a hospital progress note, which contains a chief complaint, an interval history, an exam, and portions of the assessment and plan as below. Assessment, elevated LFT, sepsis secondary to bowel perforation, recommendations, continue supportive care, including avoidance of hypotension, signed by totally awesome APRN. Physician adds an addendum with the complete assessment and plan. All right, so I've reviewed the medical record, interviewed, examined the patient. I agree with the above. Abdomen softly distended, abdominal incision, dressing CD1, assessment and recommendations. This is an 81-year-old woman with hypertension, hyperlipidemia, hypothyroidism, COPD, asthma, and recurrent bowel obstructions. Status post XLAP with bowel resections, admitted with recurrent bowel obstruction, and pneumoperitoneum. Status post XLAP with an extensive LOA reduction of internal hernia, small bowel resection and subsequent abdominal washout, small bowel resection and anastomosis and abdominal closure. Complicated by sepsis, shock, and elevated liver enzymes, consistent with ischemic hepatitis. Red upper quadrant ultrasound at outside hospital was unrevealing. Acute hepatitis panel negative on discussion with the patient's husband at bedside. The patient has no known history of liver disease. Liver enzymes are improving. Continue supportive care, avoid hypotension, management of sepsis per hospitalist, surgical and critical care teams, trend liver enzymes, avoid hepatotoxins. No further GI recommendations. Signed by even better MD. Okay, so this definitely proves to be substantive portion. Okay, that is a very good substantive portion, impression and plan. One thing I want to comment on, and this was brought up in the CPT symposium. One thing I want to comment on. The question appears to be, so when we move into the hospital documentation guidelines for January 1st, those guidelines are kind of going to mirror the office as far as you can select your level by medical decision making or total time. All right, well, there was a question posed. I'm like, well, this is a good point. If history and exam are not the element to choose your level, then does that impact which part of the substantive portion you can document for a shared visit? Are they going to recommend that substantive portion should really come out of the assessment and plan of care? And it honestly should. I mean, that's where your medical necessity is anyway. So that's my best practice recommendation is to, you know, for the physician, if you want to build a shared visit in your attestation, do a more substantive assessment and plan. Do not copy, and I think Kathy had mentioned this earlier in the updates, don't copy the assessment and plan by the APN. That's a no-no. We don't copy anything. We don't want to appear to be cloning. All right, so just wanted to throw that out there. All right, here's another example, and this is just a time example. APN Sally documents a hospital progress note where she spent 15 minutes in the care of the patient, and she has that documented. The physician adds an addendum, and he spends 20 minutes in the care of the patient, and he's got that documented. You're adding up the time to support your level of service, but I can bill this under the doctor. All right, some Q&As. Question, how do I know which provider to bill under? Documentation in the medical record must identify the two individuals who performed the visit. The individual providing the substantive portion must sign and date the record. Both the physician and NP are not required to sign the note anymore. They both must be identified in the note, but only one person you bill signs it. Well, no. Both providers, and I kind of mentioned this already, I have to know. If I've got that note in front of me, and I'm reviewing it for a shared service, I need to know who did what part of the note, period. And if I can't tell that, usually it's a cosign issue, then I can't tell, again, who did what part of that note. Another question, what does the physician and NPP do on the note that shows who did what? Do they have to put an attestation that breaks it down to show the substantive portion? Would the following attestation be okay? I've personally seen and examined the patient, reviewed the documentation. Based on total time, I performed more than 50% of the visit. And we already answered that in our polling question. That is not enough, okay? And we have to know how much time each provider spent. Question, do I still put the NP as rendering and the physician as supervising, or is the person who did the substantive portion of the note the only one listed as rendering and supervising? And we're talking about claim forms. So on the claim form, there is a box to put the rendering provider, and there's a box to put the billing provider. And UnitedHealthcare, for example, requires you to identify the APP in the rendering and the physician in the billing when you're doing shared visits and whatnot, okay? Well, Medicare really didn't address that. So just as long as you're billing the correct provider that did the substantive portion. That's the more critical piece of this question. Another question, with the new split-shared CMS split-shared policy changes, this is only guidance for visits in the facility. My providers also perform shared visits in the office. Do these changes apply to the office as well? Actually, CMS clarified that split-shared visits are no longer allowed in place of service 11. Whoever performs and documents the visit should be the billing provider, okay? There's no sharing anymore in the office for CMS, all right? So if your physician wants the credit and wants the RVUs, they need to examine the patient and document the note. Otherwise, you bill it under the NP or PA.

split share visits

CMS guidelines

advanced practice providers

shared visits

billing providers