In this session, we are going to cover APP coding, documentation, and reimbursement. My name is Nicole Knight, and I am the director of MedAxium Revenue Cycle Solutions and a senior consultant. We're going to start off with our disclaimer. This presentation is intended for general information purposes. Since we are covering reimbursement and coding guidelines, we will offer references at the end of the presentation. This presentation does not constitute legal advice, and you should rely on your compliance plan, laws, regulations, and coverage that are nationally recognized. We're going to cover the terminology, supervision, Medicare, and other payer coverage guidelines, and resources as related to APPs. When we talk about APPs, there are several acronyms that are used. APP stands for Advanced Practice Practitioner. In our world, in cardiovascular, we normally refer to APPs that are PAs, which are physician assistants, and NPs, which are nurse practitioners. Medicare, from a reimbursement perspective, is known as CMS, the Center for Medicare and Medicaid Services. Their references to APPs are NPPs, which is the non-physician practitioner. So when you see APP or NPP throughout this presentation, we are referring to physician assistants or nurse practitioners or certified nurse specialists within our practices. When you look at Medicare guidelines, providers are reimbursed as Part B providers. There are specific recognized provider types by Medicare who can obtain a Medicare billing number. This is an example of the NPPs that are considered suppliers, and as mentioned from my abbreviation overview, nurse practitioners, physician assistants, certified nurse specialists are the common ones that we will see. From a credentialing standpoint, to obtain your Medicare CMS number, you're designated a specialty code. These are self-designated codes that describe the kind of medicine physicians, non-physician practitioners, or other providers are going to practice. These specialty codes help reduce inappropriate allocations and improve the quality of your utilization data that is reported through claims data from charges submitted. From an NPP perspective, nurse practitioners have a specialty code of 50, and physician assistants have a specialty code of 97. For physicians in cardiovascular, they have subspecialties. They can be recognized as a cardiovascular disease physician, which is considered a non-invasive physician, for example, an interventional cardiologist, or an EP physician. From a nurse practitioner or PA standpoint, you are not able to subspecialize by interventional EP or cardiovascular disease. So when you are a nurse practitioner or physician assistant working within a group practice, you are working in tandem with the specialty for which your collaborating physician or your supervising physician would be designated as. Supervision requirements. As we talk about the billing requirements for APPs, there are some supervision requirements from Medicare that are necessary to determine how these are being met within an office setting and a hospital setting. Direct supervision is considered a physician is in an office suite and readily available to assist or take care of anything as necessary. General supervision means that a physician must be in attendance in the room during the performance of a procedure. General supervision means it's under the overall direction of the physician. It's important to note that the supervision requirements refer to physician supervision. When looking at what your state scope of practice entails for your APP credentials, it is important to understand what you are able to provide services for from a supervision standpoint. This is also regulated by CMS or Medicare in determining if you can or cannot supervise staff, diagnostic testing, et cetera. When talking about nurse practitioners and PAs, when you're looking at supervision from a CMS standpoint, when you look for the diagnostic testing guidelines, it specifically talks about that a nurse practitioner, clinical nurse specialist, or physician assistant are not defined as physicians in according with the supervisory act. Therefore, you cannot function as a supervising physician under the diagnostic testing benefit. However, if a nurse practitioner or PVA personally performs the diagnostic tests, then this does not apply. Again, it's important to reflect on your state scope of practice laws and meet the state requirements for your state and your physician supervision or collaboration. What are the CMS NPP qualifications? For NPs, you're required to be a registered professional nurse authorized by the state to furnish services to practice as an NP in accordance with your state law. You've obtained Medicare billing privileges as an NP. You're certified by a national certifying body. You have a master's or a doctorate degree in nursing. The coverage criteria from a Medicare perspective is that you're legally authorized and qualified to furnish services in the state where you perform the services. These services must be reasonable and necessary and are performed in collaboration with the physician. Physician at surgery services can be furnished by an NP and are covered by the CMS reimbursement. What are some of the required qualifications of a PA, physician assistant? Again, you must be licensed by the state that you are going to practice in, have graduated from an accredited school, and also have passed a national certification exam. For the coverage criteria for PAs, it's important to note the difference between PAs and nurse practitioners. The criteria is the same as far as you're legally authorized and qualified to perform the services in your state. They meet the medical necessity requirements, but also these services are performed under general supervision of a medical doctor. If the physician or designee, they don't have to be physically present when this service is furnished, but they can be contacted by state law or regulations otherwise. In your specific state, from a PA perspective, you're required to have a supervising physician. From a nurse practitioner standpoint, you have what's considered a collaborative agreement. In the state in which you reside, these regulations can be different based on what your state allows from a licensing perspective as a physician assistant. Physician at surgery services can be furnished by a PA and are also covered and reimbursed by Medicare. What are some of the CMS billing options as a non-physician practitioner? So this would be a PA or nurse practitioner as we've discussed. The billing options from a Medicare Medicaid perspective are that you obtain your own provider number. You provide services within your state scope of practice and those are reimbursed at 85% of the Medicare physician fee schedule allowed amount. This would be you functioning independently as according to your state scope under your supervising or collaborative physician. The second option is to bill an incident to service. This service is billed under a supervising physician provider number. It only applies to an office setting, which is Places Service 11. It does not require a face-to-face service by the physician. It is not allowed for new patients, new problems, or a change in the current treatment plan. So we are going to go through some examples of what meets an incident to service. When an incident to service is provided by an NP or PA and it's billed under the supervising physician, it is reimbursed at 100% of the Medicare physician fee schedule. The third concept is a split shared visit with the physician and it's billed under the physician provider number. In this instance, it only applies to a hospital setting. Some examples of a hospital setting would be Places Service 21, which is an inpatient setting, Places Service 22, which is outpatient hospital setting. This does require a face-to-face by the NPP and the physician with the patient and it is applicable to hospital initial visits, subsequent, and discharge visits. When you bill a split shared service in the hospital setting under the physician provider number, it is reimbursed at 100% of the Medicare physician fee schedule. We will review some examples of the split shared services. What are the private payer differences? Private payers, somewhat like the state scope of practice, vary by state. Some do not recognize NPP providers and require you to bill under your supervising physicians. So some payers might only ask that state laws followed for delivering care as opposed to credentialing and providing a billable provider number to an NPP. It's important to query private payers to see what their rules are. So let's dive into the Incident to Services. You can find the guidance for Incident to Services in the CMS Benefit Manual. So what is the Incident to Regulation? Services Incident to a Physician's Treatment is the definition. It's an integral part to the normal course of the physician's treatment. They must have direct supervision, which is in an office suite, and direct financial expense to the practice, meaning you have to have some sort of employment relationship with the practice. So what are some of the elements that are required? To bill Incident to, you must have direct personal professional service furnished by the physician to initiate that course of treatment for which the service is being performed by the non-physician practitioner incidentally. So when a physician sees a new patient, establishes a treatment plan, and has the patient follow up with the non-physician practitioner incidentally, this may be billed as Incident to under the supervising physician in the office suite providing that service. There also must be subsequent services by that physician at a frequency that reflects active participation in the management and care of that patient. So the physician may see that patient initially establish the treatment plan, then the patient will see the non-physician practitioner as an Incident to visit, and the physician would have their own follow up or established schedule within a time frame that would reflect that active participation. What is not considered an Incident to service? From a CMS perspective, there are several local Medicare carriers by state. They do publish their own guidelines, so CMS issues these overall guidelines, and the Medicare administrative contractors, the MACs, take these guidelines and they do determine their own spin on these at times. So again, you're looking at state laws, you're looking at state Medicares. So what is not considered Incident to? A visit where the APPNPP changes the plan of care. Because remember, Incident to is for an established patient with an established plan of care. Another instance would be if the physician or no physician is present to meet the supervision requirements of direct supervision. A new patient does not meet the Incident to criteria. An established patient with a new problem also does not meet the criteria. One that is important to remember is that Incident to does not apply to the hospital setting. So if services are provided in an inpatient hospital setting or an outpatient hospital setting, those do not meet the Incident to requirements. It's important that you understand within the practice where you are participating in the office, is that practice designated as an outpatient hospital facility or is it designated as an office? If it's designated as an office, place of service 11, you may bill Incident to if the requirements are met. If you're designated as an office setting, but you're billing as an outpatient hospital facility, Incident to does not apply and cannot be billed in that setting. The CMS definition of a new patient is an individual who has not received any professional services, E&M service, or other face-to-face service from the same physician or physician group practice, same specialty and subspecialty, within the previous three years. So when you're looking at your Incident to guidance in an office setting, it's important to understand what the definition is of a new patient. So what are some things to ask yourself when determining if Incident to? Was the place of service an office or physician-directed clinic? Was there direct supervision by a physician in the office suite? Did the physician personally perform an initial service and develop a care plan? Was a new problem documented or a change in the treatment plan? These four questions are very important when determining if you're meeting the Incident to requirements. What are some of the documentation recommendations? One thing that is looked at is who performed the Incident to service, meaning who was the physician providing that direct supervision within the office? The documentation should link that there was a supervising physician within the office and also that this was an incidental service. So did the patient have an established condition and an established treatment plan linked to a previous visit by a physician? Split-shared services. What is the definition of a split-shared visit? Split-shared visits are medically necessary encounters with the patient where the physician and a qualified NPP each personally perform a portion of an evaluation and management visit face-to-face with the same patient on the same date of service. It's important to know that this can only occur within a hospital place of service. So this could be outpatient hospital, inpatient hospital, ER, et cetera. What do they consider a portion of the E&M visit? Well, when you look at what the requirements are for an evaluation and management visit, history, examination, and medical decision-making. CMS defines that simply signing off on an NPP's note by a physician does not meet the criteria for a split shared visit. That visit has to include the documentation that's going to support a face-to-face visit and portions of the evaluation and management service. The physician and NPP both must be in the same group practice or employed by the same employer. So what applies to encounters and settings for split shared services? The NPP is employed by the physician or that same employer. The encounter is a face-to-face visit with the patient by the physician and the NPP on the same date. It's not applicable to medical students, nurses, or residents, and it also is not applicable to consults, procedures, or critical care services. So what do split shared visits apply to from a coding and billing perspective? Initial hospital visits, which are our initial HNP or admissions. Subsequent hospital visits, which are our rounding visits. Discharge management services. Any observation care or emergency department visits. And the big thing to remember is any hospital office-based visits. So again, if your office is billing at place of service, 22 or 19 as a provider-based practice or an outpatient hospital facility, the split shared service requirements may apply. What are some examples of unacceptable documentation? So we talked about that the physician and the nurse practitioner or PA should document portions of the visit to substantiate that they both had the face-to-face visit, seen, treated the patient. So if just documenting agree with above, signed by the physician, seen, examined, and agreed, or I have personally seen, examined the patient independently, reviewed the PA's history, examined medical decision-making, and agree with the above, no comment at all by the physician and just a signature, none of these meet the split shared requirement. So what are they looking for in split shared services is not just a can statement and a signature. This is very important because several physicians work with teaching facilities as well as NPP providers. Teaching guidelines, which apply to a resident or fellow, are not the same as the NPP guidelines. So agree with above, signed by the physician, for example, may be acceptable with teaching physician guidelines, but from an NPP perspective, this is not acceptable documentation. So we're looking for the physician to support a face-to-face service. When you look at what CMS clarifies as a face-to-face service, they're generally looking for some exam findings and also that the physician performed and documented the ultimate medical decision-making. So when looking at the statements that we said weren't acceptable, if your physician chooses to use those statements and they document a portion of the exam and also the assessment and plan along with that statement, that could substantiate a split shared service. Cosigning the note does not qualify when it's only cosigned. So what are some points to remember? Split shared services may be billed by the physician or the non-physician practitioner. These are paid at 100% if billed under the physician by the Medicare physician fee schedules. These services could occur jointly or separate times of the day. There is no supervision requirement because there is a face-to-face visit by both the physician and the non-physician practitioner. Critical care services and procedures cannot be split shared. Critical care services are a time-based service and therefore time cannot be split shared by the providers and bill. Procedures as well are reflected based on their supervision requirements on who may or may not be able to perform them as well as your state scope of practice. The split shared service is in the hospital setting only. Moving on to signature requirements. So in our world, electronic signatures are generally what we see on documentation. There are still some handwritten signatures and there are guidelines to support what's required from a handwritten signature. We're gonna cover what's required from an electronic signature perspective. The electronic signature must contain a date and time and include an acceptable statement. Some of these acceptable statements are electronically signed by, reviewed by, confirmed by, finalized by, and then they all are accompanied with that physician's provider name. The handwritten or scanned digital signature is also acceptable. However, having the provider's name typed under that and authenticated by or authorized by is very important. If the signature requirements of a note are not met, CMS deems that service as a non-billable service and therefore it is not reimbursed. When we look at the NPP guidelines from CMS, there are several requirements around signatures. Palmetto GBA is a local Medicare contractor who puts out a table of what are the unique signature situations. And these are in reference mainly to NPP providers. There are several other Medicare carriers who put out some of this same information. So if the situation is Incident 2 and it's performed by an NPP, it may be signed by the NPP or the supervising physician. There are some Medicare carriers that would say an Incident 2 service must be signed by an NPP and a supervising physician. Palmetto says may. However, when you're thinking about substantiating your Incident 2 service and linking that supervising physician, generally that is easily done in my experience with a signature by the physician who was supervising that Incident 2 service for that NPP within the office setting. Split shared service in the hospital inpatient, outpatient or emergency department. And it's performed by both the NPP and physician to meet the split shared requirement. These must be signed by the billing provider. If the service is billed under the physician, the physician must sign the record. Additionally, the documentation must include a statement that a billing provider had a face-to-face contact with the patient and performed a portion of the E&M visit. And it would include one of the three elements we discussed, history, exam or medical decision-making. Again, when we look at split shared services in the hospital setting, in my experience, the non-physician practitioner and the physician would generally sign this documentation showing what the NPP has done and what the physician has done in order to meet that split shared requirement. It's important to note that in a scribe circumstance, it is generally not recommended that a licensed Medicare provider, such as a nurse practitioner or PA, are performing scribe duties. In this particular reference by Palmetto, it references ancillary staff providing scribe services. Ancillary staff could be a medical assistant, a registered nurse, an LPN. It does say that for scribing, a signature is not required, however, the billing provider must sign. It's important to note that this is just signature requirements for the scribe. There are overall requirements for a scribe that involve that the physician must attest to utilizing a scribe within that documentation. If a nurse practitioner or PA is functioning as a scribe, they must meet the scribe requirements. The scribe requirements basically entail acting as a living recorder. So the physician and the scribe would be seeing the patient at the same time, and the scribe is transcribing exactly what the physician is advising them to. The scribe cannot make any clinical judgments or any contribution to the assessment and plan of that patient. This is why it is difficult for a nurse practitioner or PA to perform as a scribe. Also, it is not the best utilization of their time when they could be providing incident to, independent or split shared services, which are billable services. So what are some of the frequently asked questions? Can a resident and a teaching physician render a split shared service? No, a split shared service occurs between an NPP and a physician. Per the teaching physician service guidelines, that physician cannot be a resident or fellow. Would you consider a shared split service if the MD's documentation was listed as an addendum on the NPP's note? A lot of the split shared service documentation depends on your workflow. So it's important to note from a documentation perspective within your facility, does the physician have to document an addendum or are the NPP's note and the physician's note independent? The answer from National Government Services, which is a local Medicare carrier, says a split shared service in the hospital setting requires performance by both the billing physician and NPP. The only way for a physician or NPP to describe his or her own professional contribution to the service is to document an addendum. The only way for a physician or NPP to describe his or her contribution to the service is to document an individual note describing the portion of the service performed. An example would be, I've seen and examined the patient with the PA and agreed with the assessment plan and physical exam findings. And then a summary of the items and data already listed by the PA. The physician is indicating his or her participation and the NPP is indicating that he or she is not participating. This would be adequate to support the physician's participation. So what NGS is saying is, whether or not your workflow is that the physician does an addendum to the NPP note or if they're able to document on the same NPP note, it is accepted as long as the split shared requirements are met. The NPP must personally see the patient when services are performed incident two. So incident two services in the office, how often should the physician or NPP see that patient? It only tells us that they must personally see the patient often enough to assess the course of treatment, the progress and where necessary to change the treatment plan. The NPP also has a specific timeframe as to how many times the physician or NPP should see that patient. In my experiences, most physicians see the patient every other visit. That way they're active in the participation and progress of that patient's treatment and care plan. Can a critical care service be performed from a nurse practitioner perspective in any setting? No, split shared services cannot be performed for nursing facility services, critical care services or procedure. Remember, these are time-based services and time cannot be split or shared between a nurse practitioner, PA or physician. A new or an established problem. An established patient previously seen by the doctor with the history of AFib. Patient is seen today by the NPP while the doctor is present in the office suite. The chief complaint is a new symptom of claudication and the NPP orders a lower extremity ultrasound. The MD does not see the patient on this day. Can this visit be billed under the MD's NPI number? Was incident two met? In response to this scenario, the patient was not seen by the physician. However, the physician was present in the office suite. The direct supervision requirement was met. But the patient has a new symptom of claudication in which the NPP is ordering additional testing. This would mean that this scenario would not qualify for an incident two service in the office based on the patient with a new problem and treatment plan. Will this scenario meet the split shared requirement for a subsequent or rounding E&M visit? The NPP makes morning rounds and sees a patient who is hospitalized for congestive heart failure exacerbation. The NPP performs the HPI and the exam. The physician from the same practice comes to the hospital after office hours and sees the patient, reviews the NPP's note, does a brief exam, writes orders for labs and makes medication changes. The physician cosigns the notes and documents what he or she performed, including exam elements and comments on the assessment and plan. Can this visit be billed under the MD's NPI number and was split shared services met? The answer is yes. This may be billed under the physician's NPI number and reimbursed at 100% because split shared was met based on the documentation and the patient being seen face-to-face on the same day by the physician and the NPP. The following are references to obtain additional information on all of the content that we discussed today. CMS provides in the Benefit Policy Manual several references to both Incident 2 and Shared Services. They also publish a MedLearn Matters article specific with examples on Incident 2. Additional references include the Claims Processing Manual, which actually give specific billing instructions and scenarios based on if you were meeting the requirements of Incident 2 split shared services or billing under your individual NPP number. Thanks for listening to our session. If you have any questions, please contact us.

APP coding

reimbursement

NPPs

Medicare

billing options

signature requirements

electronic signature statements