Practice Management Alert

Find out what an expert says about some shared billing FAQs.

Maryann Palmeter, CPC, CPCO, CPMA, CENTC, CHC, offered many insights on shared billing for evaluation and management (E/M) services provided in a facility setting during a session on shared billing at AAPC’s HEALTHCON 2022.

Here are her answers to some questions about shared billing (and for a glossary of related terms, see page 4).

Does Physician Outrank APP?

Question: The advanced practice provider (APP) sees the patient and documents a full note (including medical decision making [MDM]). The physician documents that the patient is seen with the APP and then documents MDM. Can the physician bill?

Answer: “If the physician performs the MDM to the level needed to bill the evaluation and management (E/M), then yes you may bill as a physician service, as long as the physician signs or cosigns the note. Let’s say the service performed is an established patient, outpatient hospital visit (POS 22) and the level of service is determined by MDM. The APP’s documentation supports a medically appropriate history and exam and a moderate level of MDM. The level billed would be a 99214. If the physician performs a moderate level of MDM, then the physician satisfies the substantive portion, and the service could be billed under the physician’s provider number as long as the physician signs or cosigns the APPs note. Append the ‘-FS’ modifier to indicate split/shared billing. The physician is not required to write a separate note, but your organization may choose to require that.”

Don’t Make More Work for Yourselves

Question: We’ve been telling our providers that just because the MD renders a component does not mean it is the automatically the substantive component. We have been advocating for our providers to think of substantive as “more” when determining claim credit. In 2023 it could be more time, but in 2022 it can potentially be who rendered the more complex component or who rendered more components. Do you agree with this approach, or do you think we should be looking at other elements?

Answer: “I think that your organization may choose to make the requirements more arduous than CMS requires if you want. Just keep in mind, any one of the three key components could be considered the substantive portion. Let’s say the service is initial inpatient hospital care. All three key components are required for billing. If the APP takes a comprehensive history and performs a comprehensive exam, and performs a moderate level of MDM, then 99222 could be billed by the APP at 85 percent of physician allowance. The physician only performs MDM of straightforward complexity.

“In order to bill 99222 under the physician, the physician would need to perform MDM of at least a moderate complexity. Since the physician only performed a straightforward level of MDM, the physician does not satisfy the substantive portion as the physician did not perform the level of MDM necessary to support the billable level of the E/M service. Keep in mind that it may be difficult to determine exactly what the physician performed if the physician is only required to sign the APP’s note. I suggest you make it very clear to the physician that signing the APP’s note means they did at least satisfy the requirements for the substantive portion of the encounter.”

Does Physician’s Signature Mean They Get to Bill?

Question: In cases where the APP documents all of the history, exam, and a portion of the MDM, and the provider documents the MDM and just notes ‘agrees with the history/exam,’ does the APP get the service?

Answer: “Yes, because by adding that type of note the physician isn’t really saying they performed any part of the service, just that they reviewed the APP’s note and agreed with it. Unfortunately, with CMS’ guidelines, the physician must perform the substantive portion to the level that supports the service billed but is not required to personally document as such. The physician’s only documentation requirement is to sign the note. Again, I suggest you make it very clear to the physician that signing the APP’s note means they did at least satisfy the requirements for the substantive portion of the encounter.”