Basics of Shared Visit
Nurse practitioners (NPs) or physician assistants/physician associates (PAs) and physicians sometimes ‘share; patient visits. A shared visit which is also called a split visit is one where both types of clinicians participate in evaluating and managing a patient on a given day. The Centers for Medicare & Medicaid Services (CMS) defined shared visits in the 1980s and issued rules on how to bill shared visits. At that time and ever since, CMS has held that their rules on billing shared visits have applied only to hospital inpatient visits, hospital outpatient visits, and emergency department visits. A different set of rules applies to shared office visits, the billing for which is known as ‘incident-to billing. Recently CMS proposes to change how shared visits are billed. If proposed changes are finalized in November, the new rules would go into effect from January 1st, 2022.
Who Spends the Most Time?
Under a proposed rule, CMS would mandate that the clinician who spends the most time with the patient bills the visit. Here is how the proposed rule directs practices and clinicians to make the decision about who should bill a visit:
- If the nonphysician practitioner (NPP) i.e., an NP, PA, clinical nurse specialist, or certified nurse-midwife, first spent 10 minutes with the patient and the physician subsequently spent another 15 minutes, the total individual time spent would equal 25 minutes. The physician would bill for this visit because they spent more than half of the total time (15 of 25 total minutes).
- If the physician and NPP met together for 5 additional minutes (beyond the 25 minutes) to discuss the patient’s treatment plan, that overlapping time could be counted only once for purposes of establishing the total time and who provided the substantive portion of the visit. The total time would be 30 minutes, and the physician would bill for the visit because they spent more than half of the total time (20 of 30 total minutes).
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What Count as Time Spent?
CMS has identified the activities that may be counted as time spent. For visits that are not critical care, the following activities may be counted, regardless of whether they involve direct patient contact:
- Preparing to see the patient (for example, review of test results)
- Obtaining and/or reviewing the separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering medications, tests, or procedures
- Referring and communicating with other healthcare professionals (when not separately reported)
- Documenting clinical information in the electronic or another health record
- Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- Care coordination (not separately reported)
The following activities may not be counted as time spent:
- The performance of other services that are reported separately
- Teaching that is general and not limited to discussion required for the management of a specific patient
Regarding the added burden of time-keeping, CMS says: We recognize that this policy would necessitate the practitioners’ tracking and documenting the time they spent for these visits. However, we believe that practitioners are likely to increase the time of their visits for purposes of visit level selection independent of our split (or shared) visit policies, given recent changes to the CPT E/M Guidelines, and the fact that critical care visits are already timed.
Here are additional changes that CMS is proposing:
- Shared visit billing will be applicable to visits in nursing facilities unless regulations require a visit to be conducted entirely by a physician.
- The rules on shared visits would apply to new patient visits and established patient visits.
- The rules would apply to critical care.
- Documentation must identify the two individual providers. The billing provider signs and dates the note.
- Claims would include a modifier to indicate a split/shared visit.
Please note that the rules on incident-to billing will remain unchanged. Incident-to billing allows a practice to receive 100% of the Physician Fee Schedule rate, whereas if a visit is billed under an NP’s or PA’s name, the practice receives 85% of the Physician Fee Schedule rate. Incident-to billing allows a physician to bill under their own name for an office visit provided by an NP or PA.
For your reference, we shared these proposed changes to shared visit billing. We will share new rules also as soon as it gets finalized and ready to implement from 1st January 2022. MedicalBillersandCoders (MBC) is a leading provider of medical billing and coding services. Our billing and coding expertise over various medical specialties ensures quick and accurate insurance reimbursements.
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