All right, so now I'm going to go back to talking, and we had some questions and some comments earlier about split-shared, incident-to, things like that. So we're going to kind of dive into what the definition of a split-shared service is, what's an incident-to service, and the big thing is, is this is not just Medicare, okay? Medicare has very clear guidelines on what a split-shared visit is for them, what an incident-to service is for them, but again, like we've been saying all day, each payer has their own policy, and you have to really dive into payer policy to make sure you're billing under that appropriate provider. And so we're going to again talk a little bit about, you know, the definitions between shared visits, the definitions between incident-to, go into a little bit of the commercial payer policies, and just give you some overall billing tips. So what is an advanced practice provider? Well, we all should know what an advanced practice provider is. I think when I first started doing talks for ASGE and others and working for Cathy, you know, we asked this question way back when, we would ask the audience, you know, and it's like there was just a few hands that went up, that do you have a, you know, do you have nurse practitioners or physician's assistants or both in your practice? You know, just a couple hands went up. Now we get an audience together and majority of practices have APPs. So the thing is, though, the billing's a little tricky. You can't just bill everything under the doctor. If you've got APPs, you have to make sure that the documentation requirements are met, the services are met, because these providers are billing providers. The majority of payers accept a claim under an APP. So we have to make sure we're billing that correctly. So again, we kind of all know who they are. They have NPI numbers. They are, they can provide services and bill for those services. So the list of the APPs that we refer to, physician assistants, certified registered nurse practitioners, those are our two common ones. And then we also see CRNAs on the anesthesia side of things. We also have other names for APPs. I always like to refer to them as advanced practice providers, but you could also refer to them here or see references as non-physician practitioner, physician extenders, mid-level providers, and or limited licensed practitioners. So question, true or false? I can bill a split-shared visit under the physician, even if they didn't examine the patient. All right, 30% of you say true, 70% of you say false. It's actually true. Medicare and we'll get into these guidelines in just a minute, but when they first came out with the changes of the split-shared guidelines, there is reference that even the billing provider does not necessarily have to be the provider that examined the patient. But there's all sorts of aspects that go into billing a split-shared visit under the physician and other things that are required as well, but it doesn't necessarily have to be the provider that examined the patient. So let's take a look at split-shared policy. It is a medically necessary encounter where both the physician and NPP, APP each perform a substantive portion of an E&M visit on the same date of service with the same patient. You must bill under the practitioner who performed the substantive portion of the encounter. And so that's kind of our hiccup. It's like, okay, which one performed the substantive portion? Physicians and qualified healthcare professionals may act as a team in providing care for the patient working together through a single, to provide that single E&M service. The splitter shared guidelines are applied to determine which professional to bill the service under. If the physician or other qualified healthcare performed substantive portion of that encounter, the physician or qualified healthcare professional may report the service. If the code selection is based on total time on the date of that encounter, the service is reported by the professional who spent the majority of face-to-face or non-face-to-face time performing that service. So a little bit about time. We're going to talk a little bit about time for substantive portion, and then we're going to talk about decision-making for substantive portion. So for time, it's distinct time. That's what it's defined as per CPT. 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 it can't double-dip. Example, if the NPP first spends 10 minutes with the patient, the physician then spends another 15, their individual time spent would be summed to equal 25 minutes. The physician would bill for the visit since they spent more than half of the total time. If in the same situation, the physician and NPP meet 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 that total time, which would be 30 minutes. You're basically just adding five more minutes to that scenario because you can only report it one time. If your visit is based upon the performance of substantive parts of the decision-making, the provider has to, they have to perform and document part of those decision-making components, right? Two of the three elements is what is referenced. So remember when Dr. Sun and I kind of went through the decision-making table and those components, the complexity, the data, the risk, all right, two of the three of those have to be met by the billing practitioner, by the billing provider. They go on to say if the amount and or complexity of data reviewed and analyzed is used by the physician or qualified healthcare professional to determine the reported code level, assessing an independent historian's narrative and the ordering or reviewing of tests or documents do not have to be personally performed by the one you're billing it under. You can kind of formulate it all and add it all up together. But independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the provider that you're billing under, okay? So that's just part of the data component of things. So CMS really came up with all these, you know, guidelines. They actually threatened, you know, so they came out with these guidelines that these are the requirements that have to be met for a shared visit. Then they said, all right, well, we're going to let you do decision-making or time for a while. But then after 2024, or 20, I think it was actually 2023, they were going to make us only bill, be able to bill shared visits by time only, all right? Well, they did not address that and they did not force that through. So we still can bill a shared visit either by decision-making or time. So excerpts from their final, from the CMS final rule, split or shared E&M visits refers to visits provided in part by both in hospitals and other institutional settings. Medicare or CMS specifically states office, there's no shared visits in the office anymore. It's hospital and institutional settings, that's it. And then they also said, we are finalizing a revision to our definition of substantive portion of a split shared visit to include the revisions that are in your current CPT book. So if you actually go open up your CPT book and you go to the E&M parenthetical advice, they have a section in the CPT book now that is on split shared documentation and the guidance. So that substantive portion means that more than half of the total time was spent, or a substantive part of that decision-making was performed. When you bill a shared visit, you identify that visit with an FS modifier. FS is required on the claim to identify the shared E&M visit assigned on the claim when you billed as the shared visit. So it doesn't matter if you're billing it under Sally NP or Doc MD. If it's a shared visit, it gets that FS modifier. You can do shared visits on initial visits, follow-up visits, discharge, et cetera. Documentation in the medical record must identify the two individuals who performed the visit. I read that. I'm like, well, duh. Of course, they both have to be identified in the record. But actually, we sometimes see what we call co-signing versus addendum. And what happens with that instance is, you know, if the NP leaves their old note unlocked, the doctor makes all these changes and then signs it, we don't know who did what part of the note. So don't do that. Make sure that the NP finalizes the note, sends it to the physician, the physician then adds that attestation. 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 provider who performed the substantive portion and bills for the visit. So that was the polling question. So yes, it could. And it could be a situation where NP sees the patient in the morning, does her rounds, does the progress note, doc gets there, and ends up having a 30-minute conversation with the hospitalist and looking through the record and then make the recommendations, but didn't actually go in and physically examine that patient. Well, if they're the ones that provided the substantive portion, you can bill under the doctor. Overlapping time can't be counted. We talked about that. All right. So again, one big thing is making sure that if you are billing a shared visit under the doctor, under your physicians, that addendum must show two of the three components of decision-making. If you're choosing to bill those split shared visits by time, both providers document the time, you bill under the provider that spends the majority of the time. That one to me is easier, but it's not necessarily easier for your providers, all right? They don't have stopwatches. They don't want to put time on everything. So when we do reviews for split shared services, majority, majority of practices are still doing shared visits by decision-making, and that's completely fine still. And it's now published in CPT. All right. Now we're going to look at incident two. Incident two is completely different than a shared visit. Incident two, this is the CMS definition, and I've referenced their article SE0441 that has this very clear what an incident two service is. So it is part of your patient's normal course of treatment where your physician personally performed the initial visit, remains actively involved in the course of treatment, okay? You do not have to be physically present in the treatment room, but you must provide direct supervision. That is, you must be present in the office suite to render assistance if necessary. The patient record should document the essential requirements for incident two services. And I did do some research, because I know we had a question earlier about supervision AV. You can't supervise anymore virtually for incident two visits. There are still certain procedures and services, like testing, things that required direct supervision that can be supervised virtually, but visits in the office still have to be in the office suite if you're billing under the physician. Again, they don't have to walk into the patient's room, but they just have to be there in clinic, maybe seeing their own patients while that incident two service is rendered. So again, your physician performs that initial service, establishes a care plan for that patient. We also recommend that they document in their note which physician provided the direct supervision. The physician, again, has to remain actively involved in the patient's care. You can't just see the patient once and drop off the face of the earth, that you have to be actively involved. Once treatment, this is the kicker, this is a fourth bullet down. Once treatment has been adjusted by the NPP, Incident 2 services are no longer met, and services must be billed under the NPP who performed the services. Okay, so what that means is, and they're very, Medicare is very strict on this. If I increase a medication, I order a new test, I see the patient for something else, that's not Incident 2, because I'm changing the treatment course. But if I continue on with what the physician recommended, that's Incident 2. Incident 2 services are not allowed in the inpatient or nursing facility settings. And again, that has to be on site while the NPP is providing that service. So place of service 11 only, not a hospital-based clinic either. Verify the supervision requirements and scope of practice for services with your malpractice insurer, and be sure to document what that supervision level was met. This is some Incident 2 audit tips, okay, so from your Medicare contractors. So review your practice's schedule for the date of service, the claim, and the visit note to check up on Incident 2 billing. The schedule will tell you if the physician provided direct supervision, so they were also in the office seeing their separate patients. If the physician was not available during that encounter, skip straight to the claim to determine who billed the encounter and flagged for repayment. Remind staff that this does not, it doesn't matter if the NPP is experienced, direct supervision is a must for Incident 2 services, okay, so they have to be in the office. Check to the chart to see the nature of the visit, okay, was it a new patient, was it established, was there a new problem, worsening problem, look at that treatment plan and compare. That's the thing, that is why Incident 2 is very, very, very tricky. You can't just say, all right, doc bills, the doctors bill all the new patients, the APPs bill all the follow-ups, and that's it. No, you have to look to make sure that treatment plan was followed and doc was in the office when the service was rendered, those are the two key points there. Noridian is a Medicare contractor, they actually have a little, you know, chart, and I gave you the reference on Incident 2. So it says the clinical scenario, established patient, no new problem, performed by the NPP. If Incident 2 requirements have been met, you can bill it under that physician that's in clinic. If it's an established patient with a new problem, the visit or the APP sees the patient, you have to bill directly under them. Established patient with a new problem, both see the patient, may be billed under the physician if Incident 2 requirements are met, but the physician has to document their part of that assessment. All right, so here's an example, and these are very, very, very straightforward examples, just to kind of let you grasp the concept of what an Incident 2 service is if you don't know. So this is a 42-year-old female, presents new to the GI practice for evaluation of IBS symptoms. Dr. Gastro completes a full history and physical, then prescribes 20 milligrams of dental. He instructs the patient to return back in a month. So new visit, Dr. Gastro. That patient comes back for their return appointment to see the nurse practitioner. Patient says, yes, I feel great, wonderful. NP instructs the patient to continue the same medication and return back in three more months or call if symptoms worsen. Physician in clinic reviews the NP's documentation and agrees with the treatment plan. They don't have to put an addendum that says, I agree with the treatment plan. Typically, they just electronically sign it, but just make sure you're billing it under the doctor in clinic. So in this case, we still kept with that same plan of care. So this visit can be billed directly under the doctor at 100%. All right, so remember, Kathy had already addressed this. If you bill, if you submit a claim under your APP to Medicare, it's 85% reimbursement, 85% of the fee schedule. If you submit it under the doctor, it's 100. That is why this is one of the number one issues. Medicare is making sure you're following the guidelines, because if not, guess how much money they could take back if you were doing it wrong for five years? That's a lot of money. You might think 15% is really not that bad. Yeah, it's really not. It's $6, so I wouldn't do it. In my opinion, it's too risky. Bill it under the provider that performed the service. So here's another scenario. Same patient. Okay, this is the same case. With problems noted above, returns to see the patient, or sorry, returns to see the nurse practitioner for her three-month follow-up and symptoms have recurred. Now she's having pain and diarrhea. After the NP examines the patient, she schedules the patient for a colonoscopy. Physician did not see the patient that day. You're billing that encounter directly under the NP, and you will get 85%, because we did not keep to that incident two. Then you got your commercial payers. Well, good luck finding most of their policies on how to bill under the physician versus the APP. Here's UnitedHealthcare. They put a policy out. This is back in 2017, and it's actually regarding a modifier. So they said advanced practice healthcare professional E&M procedure policy, effective for claims with dates of service on or after September 1, 2017. UnitedHealthcare will require physicians reporting E&M services on behalf of their APPs. They will have to be reported with a modifier to denote the services were provided in collaboration with physician. In addition, UnitedHealthcare will accept the modifier SA on claims for these services provided by nurse practitioners, physicians' assistants, and clinical nurse specialists. In addition, the rendering care provider's NPI number must also be documented in 24J of the CMS 1500 form or its equivalent. 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 seeing our members. And then I also kind of have a little sidebar to this, is I add to audit later to make sure you're doing it right. Then you've got Anthem Blue Cross Blue Shield. You can find their policy. So they go to say certain services rendered in the office setting are separately reported by CPT. These separately reported services are considered incident two when performed by staff, 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 would be services your MAs and your nurses perform. Examples of such qualified office personnel, registered or licensed practical nurses, medical assistants, technicians. Incident two services rendered by such qualified office personnel and performed under direct supervision by the physician or other qualified health care provider are eligible for separate reimbursement when separately reported under that supervising provider. And then they've got this little different instances. A, incident two services rendered and reported under the supervising provider's identification number must meet the health plan's definition of medically necessary and be otherwise covered services. 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 assistance and direction throughout the E&M visit or other rendered service. The supervising provider must stay involved and active part of the ongoing care of the patient. This sounds familiar, kind of sound they're referencing Medicare's type of policy. Although here, this is where they change their their policy here. The health plan does not follow CMS incident two reimbursement for any physician or NPP who has been assigned or is waiting for his or her own NPI number. Therefore, if a provider has an NPI and is recognized by the health plan as eligible to submit claims directly to the health plan, then the provider is required to report the services under their own NPI number. Separately reported incident two services are only eligible for reimbursement under the supervising NPI number if the specific type of NPP or qualified office personnel who rendered the service is ineligible to submit the claims directly to the health plan. This rule will apply even when a provider is in the process of applying for his or her own NPI number. If the provider is a type who is eligible to receive an NPI and is recognized by the plan to submit claims directly to the health plan, then while the provider is waiting to receive his or her NPI, his or her services are not eligible for reimbursement as incident two. OK, so basically what they're saying is they don't follow incident two in regards to nurse practitioners and PAs. They say, hey, if our health plan accepts a claim under that provider, you bill it directly under that provider. Their incident two policy is more for staff performing like, you know, a nurse administering an infusion. That's a very common example of an incident two service that GI performs. The doctor's not the one administering the medication. It's the nurses. The doctor's just there in clinic while that service is rendered. That's where Anthem follows incident two, but not in regards to APPs and physicians. OK, so just just know not everybody follows Medicare. And then they say the following services are not eligible for reimbursement as incident two. Services performed in a facility setting, ER, emergency services rendered by any provider who is eligible to directly submit those claims to them. OK, and this is in reference to Anthem's professional reimbursement policy number 32. Cigna, you've got Cigna requires that the APP be registered and will direct you to a form that is available on their website. They specifically state they will not credential, but will register these providers and will accept claims for these providers. They expect that the provider that performs the service be the billing provider. OK, so again. Not necessarily everybody doesn't follow Medicare. And unfortunately, we've been in audits situations and in practices where they the practice bills. The practice follows Medicare for incident two and then split shared and then all the commercial claims are just all billed under the doctor. And that is a no, no. You've got to know. We are not living in the 1990s anymore where nobody really had an APP in the practice. Now they're very common and they are billing providers. You have to keep that in mind. So tips for billing. Majority of payers will accept a claim under your nurse practitioner and physician assistant. Be sure to check each payer requirements. This is not just Medicare. Keep a spreadsheet on your top commercial payers. Include their policy. This may take reaching out to your provider reps. There are some things. So when Kathy and I look at payer policy, we get to Google it and we get a national policy. That's what we get to read. We are not a practice. I don't have a username and password to actually get into these insurance companies that you are contracted with. That is what you should be doing and reaching out to your provider representative to find policy if you can't. Understand your state supervision guidelines versus payer specific billing guidelines. This is important, guys. Don't confuse the two. Billing. Billing under a claim under the APP is completely different than supervision requirements. Supervision is state specific and it, you know, like 10 percent of records have to be reviewed by the physician or whatever your state requirement is. That is nothing to do with billing. If you have a specific payer that will not accept a claim under your NPP, report the services under their supervisor NPI number. So you are. I'm not saying you won't ever. You may have you may have a payer that requires you to bill under the supervising physician. And that's OK if that's their policy. That's completely OK. Remember, when you you're utilizing the APPs, make sure they're your APPs, they're in your practice, they're part of your group. And that is it. But again, more importantly, just making sure that, you know, they're all billing providers and we have to make sure we're following those requirements and billing under that appropriate provider.

split-shared billing

incident-to billing

advanced practice provider

payer-specific policies

healthcare compliance

billing accuracy