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.