All right, we are going to go into the 2024 Split Shared CMS Guidelines and Documentation Requirements. So, again, I know Kathy touched on this briefly on the updates and said I was definitely going to elaborate on it more, so that's what I'm going to do. You know, for those of you that don't know very basic overview for advanced practice providers, who are they, who counts, what are they, how do they, how do payers view them, etc. And then we're going to talk about the CPT Update to Shared Services and the CMS Split Shared Policy, and then we're going to talk about, we're going to look at some examples, all right? And I know that was one of the questions that was asked earlier was, you know, seeing if there were any, if we knew or showed a clinical example of what would be, what defines substantive portion for decision making. All right, so we're going to get into that, hopefully answer all those questions. So who is considered an advanced practice provider? They are rendering providers with an NPI number who can bill and provide their services independent of another provider. And I think this is, that's where this big split share and the policy who to bill under comes from, because they are billing providers. So if we're billing something they did, but under a physician, we have to meet that requirement. We look to your malpractice insurer for compliant counsel and scope of practice guidelines and limitations. Those vary state to state, okay? This in general is much broader than that of your ancillary staff, such as your nurses, your LPNs, MAs, patient techs, etc., okay? So they're actively, they're actually seeing patients. They're pretty well doing everything that your gastroenterology providers are doing, except they are not doing, majority of them are not doing endoscopy procedures, okay? But again, they're seeing patients, they're reading diagnostic tests, they order procedures as well. They can supervise your ancillary staff and have prescription authority. So these are, they're often referred to as physician's assistants. We have certified registered nurse practitioners. Our CRNAs also fall under this category. We also have certified nurse midwives, clinical nurse specialists, and clinical psychologists. So those, they are all considered advanced practice providers. So question, before we get started, true or false? A split shared visit can be billed under the provider who performed the substantive portion of total time or medical decision-making. Good job, 93% say true, that is correct. So there was kind of a push by CMS last year that they wanted to make this year a shared visit only by time, but they tabled that. So we're going to kind of get into those guidelines. So what is the definition of a shared visit? It's a medically necessary encounter where both the physician and the non-physician practitioner or APP each perform a substantive portion of a visit on the same day to service with the same patient. You must bill under the practitioner who performed the substantive portion of the encounter. That's the definition of a shared visit. So physicians and qualified healthcare professionals may act as a team in providing care for the patient working together through a single E&M service. The split or shared guidelines are applied to determine which professional may report the service. If the physician or other qualified healthcare professional performs the substantive portion, then the physician or other qualified healthcare professional may report the service. If the code selection is based on total time of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service. So if the code selection is based upon the performance of decision-making, okay, so not necessarily, and this is CPT, this is in your CPT guidance. So if you are billing a split shared visit based on the substantive portion of decision-making, the provider you're billing under made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and or morbidity or mortality of patient management. So by doing so, a physician or other qualified healthcare professional has performed two of the three elements used in the selection of your level by decision-making. So we kind of went over that in the E&M guidelines. We broke down what are the three criteria for decision-making, and the two of the three supports the level, and that's what they're saying. If you're billing by decision-making for a shared visit, two of the three of those need to be met in that documentation of who you're billing the substantive portion under. If the amounting or complexity of data reviewed and analyzed is used by that provider to determine the reported code level, assessing an independent historian's narrative and the ordering or review of tests or documents do not have to be personally performed by that provider because the relevant items would be considered in formulating the management plan. So it could be one or the other doing it. It doesn't have to necessarily be the one that you're billing under. Independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other qualified healthcare professional if these are used to determine the reported code level. So CPT's got their own guidance here. Well, then you've got CMS, and CMS, basically, they're kind of coming at it as, you know, we were going to make you, we're going to force it to where by January 1st, you can only report a shared visit by time spent, okay, and well, they tabled that. It says for 2024, we are finalizing a revision to our definition of substantive portion of a split or shared visit to include the revisions to the CPT book guidelines. The substantive portion means that more than half of the total time spent by the provider performing the split or shared visit or a substantive portion of the decision-making, okay? So it's one or the other. Modifier FS is required, and I know we addressed this question earlier today. FS is required on the claim to identify a split shared E&M service assigned on the claim when billed as a shared visit. So again, you can bill them under Sally NP, or you can bill it under Dr. MD. It doesn't matter. You're still going to put a FS modifier to identify this as a shared visit. Shared visits can be new and established for your initial, subsequent, but again, has to be facility. Documentation of the medical record must identify the two individuals who performed the visit. Now, one thing I want to comment on this is making sure that when you are doing shared visits, make sure that if I'm looking at that note in front of me, I know who put what in that note. So I've seen sometimes when I've done reviews where I'm looking at one note, and Kathy probably is seeing the same thing. I'm looking at a note, and I'm like, who did this? It's like a four-page progress note, and there's two signatures on the bottom. There's one by the doctor, one by the NP. I can't justify a shared visit there because I don't know who did what part of the note. So best practice is, have the NP do their progress note, sign it, then the physician will go see the patient or review the chart or whatever they're doing, add their addendum to the NP's note. That would identify anything above the NP signatures done by the NP, anything in that addendum is done by the physician. That way it's clearly identified. The documentation must support that one of the providers had a face-to-face encounter with the patient, so they actually examined the patient, but it does not necessarily have to be the provider that did the substantive portion. For example, if you've got, let's say, an NP that went into the patient's room, rounded on them, spent about 10, 15 minutes, documented the chart, done, and then you've got the physician that comes by later in the day and ends up having a 30-minute conversation with the hospitalist and the cardiologist together and reviewed the chart and made recommendation, but didn't necessarily have to go and examine the patient because the NP just did earlier that day. But they're the ones that met more of the time threshold there. I can bill it under the doctor, okay? Overlapping time may not be counted. All right, so then we've got the distinct time definition, okay? Only distinct time can be counted. When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners can be counted. So if the NPP spends 10 minutes with the patient and the physician then spends another 15 minutes with the patient, their individual time spent would be summed to total 25 minutes. The physician would bill for this visit since they spent more than half of the total time. If in the same situation, the physician and NPP met together for five additional minutes beyond the 25 to discuss the patient's treatment plan, that overlapping time could only be counted once for the purpose of establishing the total time. The total time would be 30 minutes, okay? So no overlapping time can be counted. But NP's time plus doctor's time totaled can support the level that you're billing. All right, here's some examples. First of all, we've got a CMS shared visit based on medical decision making, okay? So the APN documents a hospital progress note which contains the chief complaint, interval history, and physical examination and portions of the assessment and plan of care as below. So number one, elevated LFTs. Number two, sepsis secondary to bowel perforation. Recommendations, continue supportive care including avoidance of hypotension. Okay, signed by Totally Awesome APN. Physician adds an attestation which contains the complete assessment and plan of care. So you've got GI, MD addendum. I personally reviewed the medical record, interviewed and examined the patient with Totally Awesome APN. I personally supervised here as outlined. So he did a GI examination and then the assessment. Okay, so this is an 81-year-old woman with hypertension, hyperlipidemia, hypothyroidism, COPD, asthma, and recurrent bowel obstruction, status post X lap with bowel resections, admitted with recurrent bowel obstruction, and pneumoperitoneum. Status post X lap with extensive lysis of adhesions, reduction of internal hernia, small bowel resection, subsequent abdominal washout, small bowel resection and anastomosis, and abdominal closure complicated by sepsis, shock, and elevated liver enzymes consistent with ischemic hepatitis. Right 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 improving. Continue supportive care, avoid hypotension, management of sepsis as per hospitalists, surgical and critical care teams, trend liver enzymes, avoid hepatotoxins, no further recommendations, and sign by the doctor. Okay, that is definitely a complete assessment and plan. So I've got the complexity of problems addressed. I even reviewed an outside record and I had a discussion with the patient's husband and I made recommendations, my recommendations. All right, so that is definitely a visit that can be billed under doctor even better at 100%. Time, time is simple. You both have to have it. You add up the time, you bill under the provider that spends more than half. Okay, so NP documents, their hospital progress note, she spends 15 minutes in the care of the patient. Doctor adds an addendum. He spends 20 minutes. I add up that time to support 35 minutes and I can bill that under the physician. Okay, so why is this such an issue? It's because it's a money issue. One of, that's the biggest thing with payers. This is a money issue. If like, for example, CMS, if I submit a bill, if I submit a claim under the nurse practitioner, I get 85% of the fee schedule. If I submit under the doctor, I get 100%. Okay, might be six bucks, but is six bucks worth doing it incorrectly? No, it's not. All right, so again, these are guidelines for shared visits and that is going to take me to top denials in GI and how to avoid them.

2024 Split Shared CMS Guidelines

Documentation Requirements

Advanced Practice Provider

Shared Visit

Billing and Documentation