Wiki Shared Split Guidelines 2024

[kozy]

Hi everyone!
We had some questions presented to us by our physicians in regard to shared split. Since the face-to-face requirement is not needed for both providers anymore, would it be considered shared/split if the AP does the face to face but our Physician does the substantive portion of MDM by reviewing the medical record from a location other than where the patient is admitted. We have many inpatient facilities scattered throughout the area. The patient is admitted say at Facility A and that is where the AP did the face to face, but Physician is located at facility B and does a complete attestation and documents substantive portion of MDM wanting to claim their service. We can't find anywhere on CMS or Novitas website that this would not be allowed, and they had to be at the same location as the patient. Does anyone have any insight to this or guidelines supporting they need to be at the same location to perform and document MDM? This wouldn't be Telemid, this is shared split service with the AP doing the face to face at one location but the physician looking at the chart and determining the MDM (while documenting substantive portion) from another location. Appreciate any input!

 

[CBLENNIE]

I cannot find any documentation regarding whether visits can be billed as split (or shared) E&M visits when the providers are in different locations. The one thing that could be tricky is if the patient always remains at facility A, if the physician located at facility B bills for the E&M service, what would you document as the servicing location on the physician at facility Bs claim?

I work for a commercial insurance company (we also have MA plans) and we would question a physician's claim coming in with the servicing location that is different than the location where the patient is actually admitted. If we looked at the physician at facility B notes from the visit, what would your physician document as their location for the visit? This could cause the provider to be flagged for audit or pre-service claims review because of the discrepancy in the location of the patient and the physician. Additionally, this could cause an issue with benefits because the PA on file is going to be for facility A, it could also impact the patient's rights under the No Surprises Act.

Hypothetically if the both your AP and physician are out-of-network with the patient's health plan and the patient was entitled to in-network benefits because of the No Surprises Act because the patient is at an in-network facility (facility A) but receiving care from an out-of-network provider, if the claim comes in for physician B and the servicing location listed on the claim form is facility B, we would not apply the in-network benefits because it wouldn't match the facility we show the patient as being admitted.

All of that said, I couldn't find anything in the Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners section 30.6.18 - Split (or Shared) visits does not discuss the location of the providers and if they need to be in the same location or not. While CMS & Novitas are silent on this issue, it doesn't mean that it is allowed and if they decide it isn't it could come back to bite you in the backside if you've submitted claims and been reimbursed for these types of visits.

My suggestion would be to contact your Novitas for guidance, as well as any commercial insurance companies that you contract with to find out how to handle these types of claims.

Maybe someone else will respond to this post with the information you are looking for and you can avoid following up with Novitas and any commercial insurance companies that follow Medicare's policies and procedures.

 

[jkyles]

Hi there, I think the question is whether a physician can get credit for the substantive portion of the MDM by reviewing/attesting to the QHP's note. Based on this portion of the final 2024 Medicare physician fee schedule, I think the answer is no:

Although we continue to believe there can be instances where MDM is not easily attributed to a single physician or NPP when the work is shared, we expect that whoever performs the MDM and subsequently bills the visit would appropriately document the MDM in the medical record to support billing of the visit.

 

[CBLENNIE]

Hi there, I think the question is whether a physician can get credit for the substantive portion of the MDM by reviewing/attesting to the QHP's note. Based on this portion of the final 2024 Medicare physician fee schedule, I think the answer is no:

If you read the following statement the OP is specifically asking about the physician who is doing the substantive portion of the MDM can be in a different location than the AP.

Does anyone have any insight to this or guidelines supporting they need to be at the same location to perform and document MDM? This wouldn't be Telemid, this is shared split service with the AP doing the face to face at one location but the physician looking at the chart and determining the MDM (while documenting substantive portion) from another location.

 

[jkyles]

If you read the following statement the OP is specifically asking about the physician who is doing the substantive portion of the MDM can be in a different location than the AP.

According to CMS, the person who gets credit for the substantive portion must perform and document the MDM. In a case where the NPP performs and documents the MDM (performs the substantive portion) and the physician just signs off on the NPP's work, the NPP gets the credit. In other words, where the physician happens to be during the visit doesn't matter here. It's what they did (or did not) do.

 

[kozy]

I cannot find any documentation regarding whether visits can be billed as split (or shared) E&M visits when the providers are in different locations. The one thing that could be tricky is if the patient always remains at facility A, if the physician located at facility B bills for the E&M service, what would you document as the servicing location on the physician at facility Bs claim?

I work for a commercial insurance company (we also have MA plans) and we would question a physician's claim coming in with the servicing location that is different than the location where the patient is actually admitted. If we looked at the physician at facility B notes from the visit, what would your physician document as their location for the visit? This could cause the provider to be flagged for audit or pre-service claims review because of the discrepancy in the location of the patient and the physician. Additionally, this could cause an issue with benefits because the PA on file is going to be for facility A, it could also impact the patient's rights under the No Surprises Act.

Hypothetically if the both your AP and physician are out-of-network with the patient's health plan and the patient was entitled to in-network benefits because of the No Surprises Act because the patient is at an in-network facility (facility A) but receiving care from an out-of-network provider, if the claim comes in for physician B and the servicing location listed on the claim form is facility B, we would not apply the in-network benefits because it wouldn't match the facility we show the patient as being admitted.

All of that said, I couldn't find anything in the Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners section 30.6.18 - Split (or Shared) visits does not discuss the location of the providers and if they need to be in the same location or not. While CMS & Novitas are silent on this issue, it doesn't mean that it is allowed and if they decide it isn't it could come back to bite you in the backside if you've submitted claims and been reimbursed for these types of visits.

My suggestion would be to contact your Novitas for guidance, as well as any commercial insurance companies that you contract with to find out how to handle these types of claims.

Maybe someone else will respond to this post with the information you are looking for and you can avoid following up with Novitas and any commercial insurance companies that follow Medicare's policies and procedures.

Thank you! We had the same concerns with POS and claims. We did reach out to Novitas, and they gave us a " non-committal "Response. We sent another Query back with no reply. Seems they are tip toeing around the question.

 

[kozy]

If you read the following statement the OP is specifically asking about the physician who is doing the substantive portion of the MDM can be in a different location than the AP.

Yes that is what I am asking. Someone commented this " we expect that whoever performs the MDM and subsequently bills the visit would appropriately document the MDM in the medical record to support billing of the visit." Our Physician is appropriately documenting the shared split attestation as well as their substantive portion of MDM. They are just doing all that from a different location by pulling up the medical record in EPIC and having discussions with the AP who was with the patient for the face to face at the other location.