Understanding qualified services is first step to reimbursement
by Carol Pohlig, BSN, RN, CPC, ACS
In response to internal and external pressures to minimize length of stay, adhere to limitations on the maximum number of admitted patients, focus on evidence-based care, and improve outcomes of care, hospitalists have incorporated nonphysician providers (NPPs), such as acute-care nurse practitioners (ACNPs), into their group practices.1 HM groups employing these practitioners must be aware of state and federal regulations, as well as billing and documentation standards surrounding NPP services.
Consider the following common hospitalist scenario: A nurse practitioner evaluates a 67-year-old patient admitted for chronic obstructive bronchitis and progressing shortness of breath. The nurse practitioner documents the service and provides the attending physician with an update on the patient’s status. Later in the day, the physician makes rounds and concurs with the patient’s current plan of care.
The above scenario represents a shared/split service in which two providers from the same group perform a service for the same patient on the same calendar day. The Centers for Medicare & Medicaid Services (CMS) allows these visits to be combined and reported under a single provider’s name if the shared/split billing criteria are met and appropriately documented.
The shared/split billing option only applies to services rendered by the attending physician and specified NPPs: nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives. Both the attending physician and the NPP must be part of the same group practice, either through direct employment or a leased arrangement that contractually links the two individuals. The “leased” relationship often occurs when the facility directly employs the NPP but arranges for the NPP to provide services exclusively for the physician group. It is imperative that the bills for the NPP services are captured and reported by one entity—the hospitalist group.
Several other NPPs (e.g. clinical psychologists or certified registered nurse anesthetists) are recognized by CMS but are ineligible for shared/split billing and must report their services under a different Medicare billing option. Additionally, shared/split services do not apply to physicians in training (interns, residents, fellows) or students.
Medicare reimburses services that are considered reasonable and necessary and not otherwise excluded from coverage. From a clinical perspective, NPPs might provide any service permitted by the state scope of practice and performed under the appropriate level of supervision or collaboration as depicted in licensure requirements. These typically comprise visits or procedures rendered by ancillary staff or considered a “physician” service.
Alternatively, shared/split billing regulations limit the types of services that can be reported under this methodology, recognizing only evaluation and management (E/M) services provided in explicit facility-based settings: EDs, outpatient hospital clinics, or inpatient hospitals. Critical-care services and procedures are excluded.
The NPP and the physician must have a face-to-face encounter with the same patient on the same calendar day, and there are no constraints on which provider should perform the initial encounter of the day.2
The extent of each provider’s involvement is left to provider discretion and/or local Medicare contractor requirements. Some contractors refer to the physician performing a “substantive” service but do not elaborate with specific service parameters, leaving the physician to determine the critical or key portion of his/her service. A corresponding, detailed notation alleviates any misconceptions of physician involvement.
Documentation by the attending physician should include an attestation that unequivocally demonstrates their personal encounter with the patient—for example, “Patient seen and examined by me.” Additionally, both the NPP and the physician should document the name of the individual with whom the service is shared/split—for example, “Agree with note by ____.” This allows for better charge capture; alerts coders, auditors, and payor representatives to consider both notes in support of the billed service; and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.
Each provider must document their portion of the rendered service, date and legibly sign their corresponding note, and select the visit level supported by the cumulative encounter—for example, “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR.”
Only one claim can be submitted for a shared/split service. The services might either be reported with the physician’s NPI or the NPP’s NPI. Reimbursement is dependent upon this designation. The physician NPI generates 100% of the Medicare allowable rate; the NPP NPI limits reimbursement to 85% of the allowable physician rate.
The shared/split billing policy only applies to Medicare beneficiaries. Due to excessive costs of NPP credentialing and enrollment, most non-Medicare insurers do not issue NPP provider numbers.
Effective June 1, 2010, Aetna began to enroll and reimburse NPP services, but it has not yet outlined a policy that parallels Medicare’s shared/split billing policy. However, lack of payor policy does not preclude payment for shared NPP services; it necessitates additional—and initial—efforts to obtain recognition and corresponding reimbursement.
After determining which insurers have applicable shared/split billing policies, develop a reasonable guideline to offer those payors who do not recognize the billing option. Alert the payor, in writing, that policy implementation will take place in a predetermined timeframe unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option:
This can be performed for any of the NPP billing options and is not limited to shared/split billing. Be sure to obtain payor response before initiating the shared/split billing process.
NPPs are involved in numerous services within the hospital, and often share/split services with hospitalists. Successful reporting requires understanding of and adherence to federal, state, and billing guidelines.
It is important to identify NPP employment relationships, the NPP’s role in the provision of services, the state supervisory or collaborative rules, and local payor interpretations to prevent misrepresentations, misunderstandings, or erroneous reporting. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.
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