Split Shared/Cnsulting Services t Split Share r Cnsult is the Questin HCCA Cmpliance Institute 2017 Natinal Harbr, MD March 27, 2017 Nicle S. Huff, DHA, MBA, CHC, CHSP Chief Cmpliance & Privacy Officer St. Luke s University Health Netwrk Bethlehem, PA Andrea Riccelli, CPC, COC, CHC, CPC-I Manager, Prvider Services Cmpliance St. Luke s University Health Netwrk Bethlehem, PA Disclaimer The views and pinins expressed during this presentatin are thse slely f the presenters and nt thse f any cmpany r entity with which they may be assciated. Objectives Discuss split shared and cnsulting E/M clinical case scenaris Review an audit plan Split/Shared r cnsulting services fr prviders in same specialty 1
Cnsult & Split Shared Effective January 1, 2010 Medicare n lnger recgnizes cnsultatin cdes regardless f what ther third party payers recgnize. New mdifier: AI Principal Physician f Recrd - used with inpatient hspital admissin cdes and initial nursing facility visit cde. Cnsult: Hspital vs. Office Hspital Admissin cde (99221-99223) Cannt bill cnsult cdes fr Medicare patients Office New patient cdes (99201-99205) Established patient cdes (99212-99215) Cannt bill cnsult cdes fr Medicare patients 2
New Patient Keep In Mind N prfessinal services received frm a physician r physician grup practice E/M Services Face-t-Face (i.e., surgical prcedure) N visits frm any prvider in same physician specialty Physicians in the same specialty and subspecialty. Fr, Medicare E/M services, the same specialty is determined by the physician's r practitiner's primary specialty enrllment in Medicare. Within previus three (3) years Established Patient Prfessinal services received frm physician/npp Physician f same specialty within grup practice Within previus three (3) years Setting f Service Office r ther utpatient setting Hspital Inpatient Emergency Department (ED) Nursing Facility Physician Specialty Cdes 01 General Practice 36 Nuclear Medicine 02 General Surgery 37 Pediatric Medicine 03 Allergy/Immunlgy 38 Geriatric Medicine 04 Otlarynglgy 39 Nephrlgy 05 Anesthesilgy 40 Hand Surgery 06 Cardilgy 41 Optmetry 07 Dermatlgy 44 Infectius Disease 08 Family Practice 46 Endcrinlgy 09 Interventinal Pain Management 48 Pdiatry 10 Gastrenterlgy 66 Rheumatlgy 11 Internal Medicine 72 Pain Management 12 Ostepathic Manipulative Medicine 76 Peripheral Vascular Disease 13 Neurlgy 77 Vascular Surgery 14 Neursurgery 78 Cardiac Surgery 16 Obstetrics/Gyneclgy 79 Addictin Medicine 17 Hspice and Pallative Care 81 Critical Care (Intensivists) 18 Ophthalmlgy 82 Hematlgy 19 Oral Surgery (dentists nly) 83 Hematlgy/Onclgy 20 Orthpedic Surgery 84 Preventive Medicine 21 Cardiac Electrphysilgy 85 Maxillfacial Surgery 22 Pathlgy 86 Neurpsychiatry 23 Sprts Medicine 88 Unknwn Prvider 24 Plastic and Recnstructive Surgery 90 Medical Onclgy 25 Physical Medicine and Rehabilitatin 91 Surgical Onclgy * list is nt all inclusive Office Split/Shared Split/Shared evaluatin management (E/M) encunter between a physician and a nnphysician practitiner Nurse practitiner (NP), physician assistant (PA), clinical nurse specialist (CNS) and certified nurse midwife (CNM) Service is cnsidered t have been perfrmed incident t if the requirements fr incident t are met and the patient is an established patient. If incident t requirements are nt met - bill under the NPP s UPIN/PIN and payment f 85% will be made. Incident-t billing is nt allwed fr new patient visits. 3
Incident T Services must be part f patient s nrmal curse f treatment. Physician persnally perfrmed an initial service and remains actively invlved in the curse f treatment. Dcument the essential requirements fr incident t service in patients recrds Direct supervisin is required. Physician desn t have t be physically present in the rm. Physician must be in the ffice suite readily available t render assistance, if necessary. Hspital Split/Shared Medically necessary encunter with a patient where the physician and a qualified nn-physician practitiner (NPP) each persnally perfrm a substantive prtin f an E/M visit, face-t-face with the same patient n the same date f service. A substantive prtin f an E/M visit invlves all r sme prtin f the histry, physical exam r medical decisin making key cmpnents f an E/M service. The physician and NPP bth must be in the same grup practice r emplyed by the same emplyer. Applies nly t selected E/M visits and settings Hspital inpatient, hspital utpatient, hspital bservatin, emergency department, hspital discharge, ffice and nn-facility clinic visits, and prlnged visits assciated with these E/M visit cdes. Des nt apply t critical care services r prcedures Bill under either the physician s r the NPP s UPIN/PIN number Understanding the Revenue Pitfalls 4
Office Visit Scenari 1 Referral fr Subspecialty Dr. A is primary specialty Cardilgy nly. Dr. B is primary specialty Cardilgy and subspecialty Electrphysilgy. Bth dctrs are in same grup practice If Dr. A refers patient t Dr. B fr subspecialty f Electrphysilgy, can Dr. B bill a new patient visit? Office Visit Scenari 2 Subspecialty Refers t Primary Specialty Dr. Wiseguy and Dr. GetItRight are bth rthpedic primary specialists in the same grup practice. Only Dr. Wiseguy has a subspecialty in sprts medicine. Can Dr. Wiseguy, wh treated the patient initially fr sprts medicine services, refer this patient t Dr. GetItRight fr surgery? Office Visit Scenari 3 Secnd Opinin Referral Dr. Suzie treats a patient but the physician wuld like fr the patient t receive a secnd pinin frm Dr. Q-Tip, wh is a partner in the same grup practice. Can Dr. Q-Tip bill fr a new patient visit? 5
Office Split/Shared Scenari 1 Mr. McGee, physician assistant (PA), is seeing an established patient in the ffice. Dr. Hw steps int examining rm with the PA t perfrm part f exam and review plan with patient. Is this a split/shared visit? Office Split Shared Scenari 2 Ms. Betty, certified nurse practitiner, is seeing an established patient in ffice lcated n first flr. Ms. Betty calls the physician t ask him/her t review the patient s prgress nte fr cllabratin. The physician dcuments additinal rders and plan f care. Is this a split/shared visit? Hspital Split/Shared Ms. Betty evaluates a 70-year-ld patient admitted fr chrnic bstructive brnchitis and prgressing shrtness f breath. Ms. Betty dcuments the service and prvides the attending physician with an update n the patient s status. The fllwing day, the physician makes runds and cncurs with the patient s current plan f care. Can the physician bill fr split/shared visit in a hspital setting? 6
Hspital Split/Shared Scenari 2 Ms. Cx, a hspital emplyed certified nurse practitiner, treats a patient n the telemetry unit in the mrning. Dr. Jeffery, an independent physician, runds the unit later that afternn and evaluates the same patient assigned t Ms. Cx. Hw des Ms. Cx and Dr. Jeffery bill fr treating the same patient n the same day? Hspital Cnsult Scenari Mr. Jnes was admitted t an inpatient unit t receive psychiatric treatment as the primary diagnsis. The patient als requires treatment fr his/her diabetes management. The psychiatrist is nt able t treat the diabetes. Therefre, psychiatrist cnsults with an internal medicine prvider. The internal medicine prvider evaluates and treats Mr. Jnes fr diabetes as an inpatient. Hw shuld the internal medicine prvider bill fr the diabetes management services? Audit Plan Identify risks Assign qualified auditrs t cmplete tasks Review external audit reprts Design audit tl/prcess t prevent inapprpriate claim submissins r billing errrs Review claim denials and appeals Onging educatin/training Data mining Trends High utilizatin f certain CPT cdes Cmmunicate audit results and crrective actin plans t senir management, physician leadership and thers 7
Nicle S. Huff, DHA, MBA, CHC, CHSP nicle.huff@sluhn.rg 484-526-3288 Cntact Andrea Riccelli, CPC, COC, CHC, CPC-I andrea.riccelli@sluhn.rg 484-526-3232 References https://www.cms.gv/regulatins and Guidance/Guidance/Manuals/dwnlads/clm104c12.pdf http://www.cms.gv/manuals/dwnlads/clm104c26.pdf http://www.wpsmedicare.cm/j5macpartb/departments/enrllment/sp ecialty_cdes.shtml Medicare Claims Prcessing Manual Chapter 12 Physicians in Grup Practice (Rev. 1, 10 01 03) https://www.cms.gv/regulatins and Guidance/Guidance/Transmittals/dwnlads/r178cp.pdf https://www.cms.gv/outreach and Educatin/Medicare Learning Netwrk MLN/MLNMattersArticles/dwnlads/se0441.pdf 8