Non-physician providers (NPPs) continue to integrate and gain credentials offering collaborative billable services in a hospital setting. Yet to this end, the professional side of coding has several gray areas that MAC guidelines don’t address clearly. For the purposes of billing Medicare Part B, medical record documentation must satisfy a few criteria found in the Internet-Only Manual (IOM).
One of these metrics is the employment arrangement requiring that both the attending physician and the NPP be a part of the same group practice, either through direct employment or a lease arrangement. Another requirement is meeting the relevant Centers for Medicare & Medicaid Services (CMS) definition as it pertains to documentation.
The IOM states:
An inpatient Split/Shared Evaluation and Management (E/M) service is an E/M service "shared between a physician and an NPP from the same group practice, and the physician provides any face-to-face portion of the E/M encounter with the patient." Additionally, the CMS IOM states that "a split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision-making key components of an E/M service." (Centers for Medicare & Medicaid Services IOM Publication 100-04, Chapter 12, Section 30.6.1B).
At first glance, this may look very similar to the “incident-to” guidelines applicable to NPPs and physicians for outpatient services. Understand that these are not the same, however, and documentation requirements for inpatient billing have very different supervision provisions.
From an audit perspective, the “face-to-face” portion of shared services often is performed yet not clearly documented, which creates vulnerability, not to mention a huge incentive for MAC providers to reduce payment to 85 percent of the physician’s allowable sum. Another common misconception is that all inpatient services can be shared between an MD and NPP; however, this is absolutely not the case. Per CMS, shared services are applicable to admissions (OBS and I/P), ER, hospital discharge and hospital prolonged visit services. Shared services are never applicable to consultations, procedures or critical care. CMS has not changed the consultation guidelines, even with the elimination of the code series back in 2010. This often is coded and billed incorrectly by facilities.
So let’s focus on the IOM definitions of “substantive” when applied to local MAC clarifications. Depending on where in the country you live, this may affect how transparent your carrier is when defining how much of an E/M element is required. Take, for example, WPS Medicare, covering Wisconsin, Illinois and Minnesota. In an August 2012 medical review memorandum, it published examples of what would be inadequate documentation under shared services. Some included:
- "I have personally seen and examined the patient independently, reviewed the PA's Hx, exam and MDM, and agree with the assessment and plan as written," signed by the physician.
- "Patient seen" signed by the physician.
- "Seen and examined" signed by the physician.
- "Seen and examined and agree with above (or agree with plan)," signed by the physician.
- "As above" signed by the physician.
- Documentation by the NPP stating that "the patient was seen and examined by myself and Dr. X., who agrees with the plan," with a co-sign of the note by Dr. X.
- No comment at all by the physician, or only a physician signature at the end of the note.
Although this supplements the IOM to some degree, it still does not outline precisely how much E/M documentation is sufficient to pass medical review. Other MACs, such as Noridian, have provided similar communication. In a Sept. 14 inquiry, Noridian responded to the following;
GCS: For an inpatient shared service between a NPP and MD, how does Noridian define “substantive” for purposes of medical decision-making? If both NPP and MD see the patient face-to-face, the NPP documents the note and the MD documents portions of the A/P, would this qualify as substantive?
Noridian: I reviewed your questions with our Medical Review (MR) department. If the patient is seen face-to-face by both the nurse practitioner (NP) or physician assistant (PA) as well as the doctor, the NP or PA may document the note and the doctor may document the portions of the assessment and plan. Also, if this is indeed a shared service, it should be documented that it is a shared service. MR suggested that you review this evaluation and management fact sheet: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Evaluation_Management_Fact_Sheet_ICN905363.pdf.
Under the current set of guidelines, providers should be advised that more is better when qualifying E/M components along with face-to-face time.
The final loophole, which deserves a separate article to explain properly, relates to PATH (physicians at teaching hospitals) criteria applicable to teaching providers. If your physicians are participating as a teaching attending, require them to review CMS transmittal 2303, dated Sept. 14, 2011. This transmittal provides several relevant examples of best-practice documentation for physicians. Shared services regulations are not applicable to students or residents in an inpatient setting, and they should be separated clearly for coding/billing education.
As a compliance measure, check with your local MAC and your billing department to validate guidelines, as the RACs are always on the lookout for new revenue opportunities.
About the Author
Jana B. Gill, MA, CPC, is a product engineer and developer of Regulatory and Reimbursement software suites for Wolters Kluwer. Jana also is the principal of Gill Compliance Solutions, LLC which specializes in physician compliance, developing internal auditing programs, government appeals (RAC/CERT), coding risk assessments, due diligence for physician/hospital integrations and revenue analyses of hospitalist services.
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