EM Coding Alert

Billing:

Find Clarification on Observation Care for Shared Billing

Published on Wed Jun 22, 2022

Hint: Remember that documentation establishes the patient’s medical narrative, too.

The updates to shared billing rules have thrown many for a loop. Check back in on your understanding of how to document and report encounters that are split or shared between providers.

Read on for five quick tips shared by NGS Medicare’s Catherine K. Delli Carpini, BSN, RN, during the Part B payer’s March 17 webinar, “2022 [Centers for Medicare & Medicaid Services] CMS Evaluation and Management Updates.”

1. Remember Split/Shared Visit Rules Changed for Facilities

Understanding how to report evaluation and management (E/M) codes appropriately is essential, particularly when they’re split or shared among providers, Delli Carpini said. “The bulk of services paid by the Medicare program are the evaluation and management codes.” She added that effective Jan. 1, 2022, split/shared E/M visit rules changed for services provided in the facility setting by physicians and nonphysician practitioners (NPPs) — including nurse practitioners (NPs) and physician assistants (PAs) — who work for the same group. But before you turn away from coding using this new strategy because you assume that the services your physician performs all occur as outpatient services, think again.

“Facility setting means that in any facility — inpatient or outpatient — split/shared visit rules apply,” Delli Carpini noted. “They do not apply in the office setting. In the office setting, incident-to rules apply, and they’re a bit different than the split/shared rules.” Therefore, you can use split/ shared visit rules if your physician performs services in the emergency department (ED), for example, because that’s an outpatient service performed in a facility.

2. Define ‘Substantive’ for Accurate Payment

Many providers have been confused by the word “substantive,” Delli Carpini said. “It simply means that of the two providers, the physician or the NP/PA, the person who performed the bulk of the work is considered the one who did the substantive portion of the visit,” she said.

“Payment is made to the practitioner who performs the substantive portion of the visit,” according to the Medicare Claims Processing Manual, Chap. 12, Section 30.6.18, A and B, which you can read here, www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf.

The substantive portion can be based on work performed around the history, the physical exam, the medical decision making, or (when applicable, such as with inpatient E/M coding), you can choose the code using more than half of the total time spent with the patient, she said.

“When you’re using time to assess that substantive portion, the provider who spent and documented the most time is considered the substantive or the billing provider,” Delli Carpini noted. “It really is relatively simple.”

3. Keep Modifier FS in Mind

If you’re reporting split/shared services, you must append modifier FS (Split (or shared) evaluation and management visit) to the appropriate E/M code, Delli Carpini advised. “Modifier FS applies to split/shared E/M services used in the inpatient and the outpatient setting. So all of your inpatient and outpatient codes used within a facility apply to the split/ shared idea that it can be performed collaboratively by a nurse practitioner, PA, and a physician. And whoever performs the most work is the substantive provider who will be the person under whose number the visit will be billed.”

4. Apply Split/Shared Rules to Observation, Critical Care, Consults

In addition to ED and inpatient services, the split/shared coding rules also apply to observation, prolonged services, and consultations this year, Delli Carpini said. “Up until this year, the guideline from CMS was that consultations could not be split/shared. As of January 1 of this year, CMS has confirmed consultations can now be split/shared. Admission and discharge can be split/shared, and critical care can be split/shared.”

When it comes to admission and discharge, you must be aware of which providers are permitted to perform particular services before you can evaluate whether the split/shared rules apply, she added. Just because these rules are valid in admissions and discharges, that doesn’t mean every admission/discharge code can be billed by an NPP.

“An admission cannot be done solo by a PA or a nurse practitioner, unless the facilities’ rules allow that person to have full admitting privileges,” Delli Carpini noted. “Now, if a physician with admitting privileges is responsible for that admission, he or she can split/share that with a nurse practitioner or a PA, but the PA or nurse practitioner can do it on their own only if they have admitting privileges. So there’s been a little bit of confusion around those points.”

5. Identify Those Who Split/Share Services in Documentation

The two people who are splitting or sharing a service should be clearly noted in the documentation, Delli Carpini said. In addition, the individual providing the substantive portion has to sign and date the medical record. Delli Carpini advised that best practice from a “medical review standpoint” is to have each contributing provider document their portion of the service, including time spent if the service is time-based.

“Remember that the record has to be able to support the fact that there were two people contributing here,” she said. “What did each person do, who were those people, and how much time did they spend doing it? So, although the guideline that’s definitive from CMS is saying the substantive person has to sign and date the record, we would encourage you to have your providers have both folks who are contributing sign and date so that you can support that record in the event of a medical review.”