# Critical Care vs. Split Shared Services



## abenet1 (Jan 11, 2019)

Good Afternoon,
     Here is a question for the group concerning billing critical care services. The scenario is: a mid-level sees the patient in critical care. The physician comes into the room at some point with the mid-level. He takes over the service, performing the all aspects of the 99291, documents, makes edits to the mid-levels documentation, adding his own and signs off. I explained the nuances of the split-shared visits and that you cannot bill critical care as a split shared visit. The response back was it is not technically split/shared as the physician, he is doing all the work, just not needing to re-document all of the aspects of the note. The time billed in support of the code is his time only. The question presented to me was why, if he is acting independently, performing the visit and noting only his time, can’t he bill the CC charge? The thought was perhaps there is an attestation that he might be able to use to clarify and support billing, by stating the visit was performed in entirety by the physician. i.e. “I personally and individually spent X amount of time with the patient performing………………..
    I presented the CMS guidelines. I need to be able to clarify for him why this does not or maybe there is a loop hole, I don’t know. If someone can tell me some helpful instruction to provide I would appreciate it. 

Thank you,

Andrea R. Altensey, RHIT, CPCO, CCS-P, CPC, CHAP 
Sr. Compliance Coding Auditor
Andrea.Altensey@tmh.org


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## coloradopa (Jan 14, 2019)

abenet1 said:


> Good Afternoon,
> Here is a question for the group concerning billing critical care services. The scenario is: a mid-level sees the patient in critical care. The physician comes into the room at some point with the mid-level. He takes over the service, performing the all aspects of the 99291, documents, makes edits to the mid-levels documentation, adding his own and signs off. I explained the nuances of the split-shared visits and that you cannot bill critical care as a split shared visit. The response back was it is not technically split/shared as the physician, he is doing all the work, just not needing to re-document all of the aspects of the note. The time billed in support of the code is his time only. The question presented to me was why, if he is acting independently, performing the visit and noting only his time, can’t he bill the CC charge? The thought was perhaps there is an attestation that he might be able to use to clarify and support billing, by stating the visit was performed in entirety by the physician. i.e. “I personally and individually spent X amount of time with the patient performing………………..
> I presented the CMS guidelines. I need to be able to clarify for him why this does not or maybe there is a loop hole, I don’t know. If someone can tell me some helpful instruction to provide I would appreciate it.
> 
> ...


There is no loop hole here. He is trying to use split/shared service documentation rules to justify his documentation. In critical care billing only the documentation done by the provider counts. So if they are using APP (advanced practice provider) documentation to justify their critical care billing then they are wrong. The other issue is they are leaving tremendous amounts of money on the table. Both providers can bill critical care as long as they do it separately and meet medical necessity. The APP can see the patient formulate a plan and write the note. The physician can then come along and change or modify the plan as well as provide any other input. The APP submits their bill the attending submits theirs. This is follow on care and clearly allowed by Medicare. In our fairly large Critical Care Center (15 ICUs) the APPs do around 60% of the billing.


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## abenet1 (Jan 15, 2019)

coloradopa said:


> There is no loop hole here. He is trying to use split/shared service documentation rules to justify his documentation. In critical care billing only the documentation done by the provider counts. So if they are using APP (advanced practice provider) documentation to justify their critical care billing then they are wrong. The other issue is they are leaving tremendous amounts of money on the table. Both providers can bill critical care as long as they do it separately and meet medical necessity. The APP can see the patient formulate a plan and write the note. The physician can then come along and change or modify the plan as well as provide any other input. The APP submits their bill the attending submits theirs. This is follow on care and clearly allowed by Medicare. In our fairly large Critical Care Center (15 ICUs) the APPs do around 60% of the billing.



Hi, I appreciate your  interesting response. Something I had not considered. Wouldn't it be difficult to meet the medical necessity for both providing the levels?


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## abenet1 (Jan 15, 2019)

coloradopa said:


> There is no loop hole here. He is trying to use split/shared service documentation rules to justify his documentation. In critical care billing only the documentation done by the provider counts. So if they are using APP (advanced practice provider) documentation to justify their critical care billing then they are wrong. The other issue is they are leaving tremendous amounts of money on the table. Both providers can bill critical care as long as they do it separately and meet medical necessity. The APP can see the patient formulate a plan and write the note. The physician can then come along and change or modify the plan as well as provide any other input. The APP submits their bill the attending submits theirs. This is follow on care and clearly allowed by Medicare. In our fairly large Critical Care Center (15 ICUs) the APPs do around 60% of the billing.



Hi, I appreciate your  interesting response. Something I had not considered. Wouldn't it be difficult to meet the medical necessity for both providing the levels?


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## coloradopa (Jan 31, 2019)

abenet1 said:


> Hi, I appreciate your  interesting response. Something I had not considered. Wouldn't it be difficult to meet the medical necessity for both providing the levels?


Not really. Critical care is ongoing and we routinely have 2 to 3 providers bill on a patient on a given day. Each provider needs to show that they are actively supporting an organ system to bill critical care but when you are weaning pressors or adjusting the vent thats pretty easy.


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