shared visit and critical care

What does it mean when Medicare says you can't have shared visits for critical care?
Currently have NPP & MD see pt. NPP does most of documentation. MD will write something including critical care time. OK to bill under MD?

Comments

  • NO



  • edited May 2017
    No the MD has to spend the 30 minutes, provide critical care and document their own time. The NPP note can be used to support the patients condition as critical but the NPP time cannot be included.

  • Todd's right that they can't share the time at all. Split/shared means the MD and NPP are working together to treat the patient. If the NPP is credentialed, the doctor doesn't need to do anything; the NPP can bill critical care under their own NPI...if it's allowed under their state scope of practice where the service is being rendered. Otherwise, the doctor needs to do the service him/herself, document their own documentation of it (unless they have a scribe) and then bill under their own NPI.

    You can find the rules here for critical care in Medicare Claims Processing Manual Pub 104, Chapter 12, Section 30.6.12, Critical Care Visits and Neonatal Intensive Care, and specifically subsection D. titled Critical care Services and Qualified Non-Physician Practitioners (NPP): https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf and here's the Medlearn Matters Network (MLN) article on critical care: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm5993.pdf

    Hope this helps.

    Kris

    Kris Cuddy, CPC, CIMC
    Healthcare Compliance Analyst
    Compliance Office
    Michigan State University HealthTeam
    East Lansing, MI
    Ofc: 517-355-4547
    Fax: 517-353-5292

    -----Original Message-----
  • Do you mean that nothing can be billed? Or is it ok to bill 99233 (requirements are met)?

  • If the MD did not provide 30 mins of Critical care then the NPP can bill the
    critical care if they have documented their time.

    If the MD did not provide 30 mins and the NPP did not document their time
    then you would bill the appropriate E&M code supported by combining both
    notes for a shared service.

    TT


    Todd
  • What's making this difficult, is that critical care is based on time. So although the MD documents that he spent 30 minutes, because the NPP documents history & exam-we cannot bill critical care time under the MD.
    (they are not sharing the time but are both involved in the care of the patient.)

  • For the one you presented, the NPP would need to bill the critical care. There's no split/shared allowed in for critical care and incident to is not allowed in the facility setting.

    Hope that helps to better clarify.

    Kris

    Kris Cuddy, CPC, CIMC
    Healthcare Compliance Analyst
    Compliance Office
    Michigan State University HealthTeam
    East Lansing, MI
    Ofc: 517-355-4547
    Fax: 517-353-5292


  • If the MD spends and documents of 30 mins of critical care you can bill
    critical care. You cannot combine MD and NPP times to reach 30 mins.

    So in your case the MD documented 30 mins of time so you can bill critical
    care. The fact that the NPP participated in the case does not prevent you
    from reporting critical care as long as the codes assigned are based only on
    the MDs documented time.

    TT

    Todd
  • Todd,
    What do you think of this statement in that MLN article on critical care?

    Other Critical Care Issues
    There are some specific rules about physician services and time that you should know:
    1.
    "Only one physician can bill for critical care during any one single period of time. Unlike other E/M services, critical care services reflect one physician's (or qualified non-physician practitioner's) care and management of a critically ill or critically injured patient for the specified reportable period of time. You cannot report a split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) as a critical care service. The critical care service reported should reflect the evaluation, treatment and management of the patient by the individual physician or qualified non-physician practitioner and not representative of a combined service between a physician and a qualified NPP."

    Just acquired a practice that uses Advanced Practitioners in Critical Care. They document most of note. Physicians write their time. Wanted to be sure what "critical care can't be shared" meant since it is a time based code.

    Thanks,
    Michele

  • That statement means that you cannot combine the MD time and the NPP time to
    determine a total billed CC time.

    Just because the NPP participated in the case and/or wrote their own note
    does not negate the fact that the MD provided critical care.

    TT


    Todd
  • In my education, that's exactly what it means, it is not a split/shared visit. A physician cannot bill for critical care when they did not do all the work themselves. If it's shared work with the NPP, the NPP must bill for the service.

    "H. Split/Shared E/M Visit
    A split/shared E/M visit cannot be reported in the SNF/NF setting. A split/shared E/M visit is
    defined by Medicare Part B payment policy as a medically necessary encounter with a patient
    where the physician and a qualified NPP each personally perform a substantive portion of an
    E/M visit face-to-face with the same patient on the same date of service. A substantive portion
    of an E/M visit involves all or some portion of the history, exam or medical decision making key
    components of an E/M service. The physician and the qualified NPP must be in the same group
    practice or be employed by the same employer. The split/shared E/M visit applies only to
    selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation,
    emergency department, hospital discharge, office and non facility clinic visits, and prolonged
    visits associated with these E/M visit codes). The split/shared E/M policy does not apply to
    critical care services or procedures."

    Taken from: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2282CP.pdf

    Is there some other directive that I'm missing that now allows this?

    Thanks,


    Kris

    Kris Cuddy, CPC, CIMC
    Healthcare Compliance Analyst
    Compliance Office
    Michigan State University HealthTeam
    East Lansing, MI
    Ofc: 517-355-4547
    Fax: 517-353-5292


  • Physicians and NPPs in a single specialty can indeed "share" the overall care of a critical patient in that they both bill for CC provided to that patient on the same day. CMS rules were changed in 2008 to allow this. What is actually restricted by CMS is a physician and NPP sharing any given CC code, which in reality means you can't mix physician and NPP time to support any given CC code. But a situation in which an ED physician bills 99291, an ED NPP bills the first 99292, and then an ED physician bills a second 99292 is possible as of 2008.



    Prior to 2008, you had to select a single representative of the specialty, either physician or NPP, to bill all CC provided by the specialty, but actually only for the CC provided by their own provider type.



    The 2008 revisions resulted in the following rules for this new CC billing method.



    * First, they state that the first CC code, 99291, must be supported by a single individual provider's time. So for that first code not only may you not mix physician and NPP time, you can't even mix the time of multiple physicians or multiple NPPs. One actual person has to support that initial CC code, meaning the first person to see the patient must be there for a minimum of 30 minutes before handing over to a colleague. Presumably CMS feels that a truly critical patient warrants continuous attention by a single person for at least a while, not sure.



    * Second, additional units of CC time billed with code 99292 may be supported by a single physician's time, a single NPP's time, or a combination of EITHER multiple physicians or multiple NPPs. Again, you can't mix physician/NPP time to support any given CC code.



    * Third, you cannot achieve more total CC reimbursements when billing for multiple provider types within a single specialty than if you had billed all CC under a single provider type. This is where I usually lose some people. It requires checking, before billing additional CC using units of 99292, two things: 1) if the total CC time would allow this unit of 99292 if all CC time would have been provided by a single provider type, and 2) just how much time has already been represented by prior CC codes billed.



    It also requires a higher understanding of CC codes. For example, CC code 99291 represents 60 minutes of CC. True, it is billable when at least half (30) has been provided, and the first "additional 30 minutes" 99292 code cannot be billed until at least half of the 30 stated in its description (15 add'l minutes above 99291's 60 represented minutes, so 75 total for the first 99292), are provided.



    This means the range in which 99291 will be the only billable code is 30-74 minutes, but this doesn't negate the fact that it actually represents 60 minutes of CC. Again, to bill CC provided by multiple provider types within a single specialty requires knowledge not just of the applicable minute billing range for a certain code, but the actual minute value that the code represents/reimburses you for.


    Seth Canterbury, CPC, CPC-I
    AHIMA-Approved ICD-10-CM Trainer
    Clinical Data Quality Education Department
    University of Florida Jacksonville Physicians, Inc.
    653 West Eighth Street
    Tower I, Suite 606
    Jacksonville, FL 32209






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  • edited May 2017
    With a regular E&M service, the work performed separately by the MD and the
    NPP is combined to report a "shared" E&M code.

    CMS does not allow this shared concept for critical care. Per CMS "The
    critical care service reported should reflect the evaluation, treatment and
    management of the patient by the individual physician or qualified
    non-physician practitioner and not representative of a combined service
    between a physician and a qualified NPP"

    This means we can only report CC time spent by the MD or CC time spent by
    the NPP. Their times cannot be combined to report a total critical care
    time by multiple providers.

    It does not mean that the MD is not allowed to report 99291 if the NPP was
    in the room to help with the patient, as long as the MD personally provided
    at least 30 mins of CC.

    These are the highest acuity patients, it is highly likely that a critically
    ill/injured patient will require an all hands on deck approach to managing a
    critical event. It would be silly to limit the MDs ability to report 99291
    because a mid-level provider was part of the encounter.

    TT


    Todd
  • That's what I thought-that only time couldn't be shared but I spoke to an educator/trainer at Novitas and she said they could not share the visit followed by this email:

    "Thank you for speaking with me today regarding additional clarification needed for critical care services.

    Split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) cannot be reported as a critical care service

    Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified NPP for the specified reportable period of time and shall not be representative of a combined service between a physician and a qualified NPP.

    Please consult the following link for additional information on critical care services.
    http://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00081590"

    Curious why they wouldn't allow this too.

  • I agree and that flows completely with Seth's response that's so wonderfully detailed.

    Kris

    Kris Cuddy, CPC, CIMC
    Healthcare Compliance Analyst
    Compliance Office
    Michigan State University HealthTeam
    East Lansing, MI
    Ofc: 517-355-4547
    Fax: 517-353-5292


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