Shared Services – Truth In Billing

By Jana Weis, Principal, Gill Compliance Solutions, LLC.

As consultants in the healthcare industry, we are asked all kinds of questions on a daily basis.  Yet, if I were to add up the number of times clients ask about shared services, it would likely be on the top of the list.  Shared services seem like an easy concept, two providers’ participation in the care of a patient, right?  Well, almost right. 

Let’s first take into consideration the CMS language surrounding shared services:

A split/shared E/M visit is defined as a medically necessary encounter with a patient where the physician and a qualified non-physician practitioner (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.

Just to emphasize, shared services is a Medicare concept, and typically does not apply to other payors, State or private.  Why?  Primarily due to the game of reimbursement specific to CMS.  As a physician (MD, DO) services are paid at 100% of usual and customary, where Advanced Physician Practitioners (APP or NPP’s) are paid at 85%.  CMS developed the shared services rule to allow for full payment if both providers collaborate in treating the same patient on the same day.   You might be thinking, this sounds a lot like an incident-to service.  These rules are similar for the end result (100% payment) but are very different in documentation requirements.  Incident-to, like shared services, require a collaborative effort, same day, between an MD/DO and an APP.  It is only applicable for POS (place of service) 11, office setting, and cannot be used in a provider based (POS 22) outpatient department.  Further, requirements are as follows and all must be met.

  1. Services must be provided by a caregiver who is directly supervised, and who represents a direct financial expense to the practice (such as a “W-2” or leased employee, or an independent contractor).
  2. Services must be provided under “direct” supervision meaning the MD/DO must be present in the immediate office suite to render assistance if needed.
  3. Diagnosis must be established by the provider (or group) with active involvement.  If diagnosis is new, the service should be billed under the NPP’s NPI, not the physician.

Not to dive to deeply into incident-to but simply draw a comparison to the requirement of a shared service.  The proof of incident-to would be based on the schedule (who was supervising and in the office) and the problem being an established diagnosis.  

Let’s turn back to the topic with the second part of the CMS guideline for shared services, which states the following:

  • The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital, office and non-facility clinic visits (incident-to), 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. A split/shared E/M visit cannot be reported in the SNF/NF settings.

So how are these so different?  First, shared services apply to inpatient services and not outpatient.  Secondly, and probably the most misunderstood part of the guideline ‘the physician and a qualified non-physician practitioner (NPP) each personally perform a substantive portion of an E/M visit face-to-face.  Right away, you might wonder what ‘substantive’ means as it relates to documentation.  Honestly, it’s been the center of multiple litigation cases due to the ambiguity of defining this one word.  

Take for example a teaching setting where residents are working with attending physicians. This environment is specific to ‘supervision’ and have separate documentation rules than shared services between an MD & APP.  Providers working in a teaching setting are used to pre-defined documentation requirements.  CMS publishes standards that provide examples of acceptable, minimal documentation.   

  • Admitting Note: “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”
  • Follow-up Visit: “Hospital Day #3. I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.”
  • Follow-up Visit: “Hospital Day #5. I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder, so I will obtain an echo to evaluate.”

As noted above, these scenarios are specific to teaching, supervision, and physician-to-physician.  Shared services are specific to collaboration between a physician and APP.  Let’s go back to that substantive portion of an E/M service.  If you dig deep into the MAC sites, you might find something like this:

  1. For an inpatient shared-service between a NPP and MD, how does Noridian define “substantive” for purposes of medical decision-making?  If both NPP and MD see the patient (face-to-face), the NPP documents the note and the MD documents portions of the A/P, would this qualify as substantive?
  1. I reviewed your questions with our Medical Review (MR) department.  If the patient is seen face-to-face by both the nurse practitioner (NP) or physician assistant (PA) as well as the doctor, the NP or PA may document the note and the doctor may document the portions of the assessment and plan.  Also, if this is indeed a shared service, it should be documented that it is a shared service.  MR suggested that you review this evaluation and management fact sheet.

This Q&A was posted from Noridian back in 2012.  As part of multiple litigation cases throughout the years, the interpretation of this, along with many other pieces of research, concluded that CMS is looking to see at least one area (history, exam or medical decision making) documented by the physician in conjunction with the APP note.  If ‘face-to-face’ was not transparent, the shared services were not allowed.  If statements, similar to those above (minimal documentation for a teaching setting) were documented, the shared services again were rarely allowed.  Based on the above, if APP’s were not credentialed and the provider did not meet the criteria for an E/M service, the entire visit was denied.  Yes, this was another case where a Hospitalist/Intensivist group hired APP’s, neglected to credential them, and was audited due to high-level visits coming into question.  The outcome was financially devastating to the group and the hospital. 

Take away tips:

  • Bulletproof your shared services notes.  Physicians must document at least one area of history, exam or medical decision making and show the visit was face-to-face
  • Check your payors outside of CMS to validate this is a valid billing rule
  • Develop written policies to help define the rules for Shared Services
  • Develop a gold standard example for providers to review for documentation expectations
  • Train all incoming physicians on your rules as they might have learned something different at another facility
  • Credential all your APP’s, if available, regardless of payor
  • Audit frequently to protect your practice and providers

References:

  1. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/...
  2. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1780B3.pdf
  3. https://content.findacode.com/files/documents/medicare/Evaluation_Manage...
  4. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/...

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