COMMENTARY

Shared Visit Billing: New Rules Proposed by CMS

Carolyn Buppert, MSN, JD

Disclosures

August 26, 2021

The Centers for Medicare & Medicaid Services (CMS) proposes changes to rules on billing shared/split visits.

What Are Shared Visits?

Carolyn Buppert, MSN, JD

Nurse practitioners (NPs) or physician assistants/physician associates (PAs) and physicians sometimes "share" patient visits. A shared visit (also called a "split visit") is one where both types of clinicians participate in evaluating and managing a patient on a given day. 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.)

Here is an example of a shared visit:

An NP and a cardiologist both work for a cardiology practice. Both clinicians provide daily visits, at different times of the day, for a patient hospitalized for heart failure. The NP visits the patient in the morning and asks the patient about ease of breathing and other symptoms, takes vital signs, listens to heart and lungs, evaluates extremities, reviews ECGs or other test results, and orders intravenous fluids, diagnostic tests, medications, diet, and referrals. The cardiologist visits in the afternoon and reviews the results of the morning's labs, re-examines the patient, and writes additional orders. Both clinicians document their work in the patient's medical record.

Currently, the cardiology practice would bill both clinicians' work together, using the CPT code that best describes their combined work of history-taking, physical examination, and medical decision-making. The practice would bill under the name of the cardiologist. Medicare would pay the practice 100% of the Physician Fee Schedule rate. If the cardiologist left the visit completely up to the NP, then the visit would be billed under the NP's name. In that case, the practice would receive 85% of the Physician Fee Schedule rate.

CMS now proposes to change how shared visits are billed. If finalized in November, the new rules would go into effect on January 1, 2022.

Who Spends the Most Time?

Under a Proposed Rule issued on July 23, 2021, 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:

For example, if the nonphysician practitioner (NPP) — the term used by CMS to refer to 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, in the same situation, 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).

Which Activities 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 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 other 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

  • Travel

  • Teaching that is general and not limited to discussion required for the management of a specific patient

For critical care, CMS refers to the qualifying activities listed in the prefatory language on pages 31-32 of the book Current Procedural Terminology 2021. CMS is asking the medical community for input about whether there should be a special list of qualifying activities for emergency department visits.

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 increasingly time 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.

You can find the proposed rule here. The section on shared visits starts on page 100.

What About Incident-to Billing Rules?

The rules on incident-to billing will remain unchanged. Incident-to billing allows a physician to bill under their own name for an office visit provided by an NP or PA. 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. The incident-to rules say that a physician who employs or contracts with an NP or PA may bill a visit under the physician's name if the physician:

  • Has provided the initial service

  • Is in the office suite at the time that the NP or PA is seeing the patient

  • Remains actively involved in the care of the patient

Interested parties may submit comments on the Proposed Rule. The comments period closes at 5 PM on September 13, 2021. To submit a comment electronically, visit regulations.gov. The file code is CMS–1751–P.

Carolyn Buppert ( www.buppert.com ) is an attorney and former nurse practitioner who focuses on the legal issues affecting nurse practitioners.

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