Hi, everyone, we'll get started shortly. We're going to give everyone some time to get dialed in. All right, we're going to go ahead and get started with our housekeeping slides. Welcome everybody to our webcast. We're going to focus on coding and documentation guidelines for our advanced practitioners. My name is Nicole Knight, I lead our revenue cycle division and care transfer and work with our care transformation team. Happy to be joining. It's been a bit since I've done a webcast with you all. Right, so we have a QA tab for question and answers. If you type your questions in as we go through the presentation, we're happy to answer those. We'll also, if we have time at the end, we'll answer them and then we always answer, make sure that all questions were answered and upload the document of those questions after about a week or so on the Academy. Also in the chat is a link to the presentation. So you can download and save that presentation, print out those slides and have reference to that as well. You also have access to that in your Academy login, but you can download those from the chat link as well. We do have AAPC CEUs for coders. Those are available online in the Academy. Once the session is complete, usually they're there in about one to two business days and you can download and it also saves those for you and they're available to you as you need those. A screen that shows you where you, how you can claim your CEUs and what those look like. Once you claim your credits, like I said, your certificate will be available in your transcripts as well. I tell you, I like that feature because when I have to go back and fill out my AAPC CEUs, I just go back to the Academy and download all of those certificates or the numbers and then provide them. So that is available under that Academy platform. All right. So we're going to talk about the billing and documentation requirements for advanced practitioners. We're going to go over what are the options for billing for services, either independent incident to or split shared. And then we're going to go over some miscellaneous things such as scribe regulations, a few other things that come up along with an update on telehealth, where we're at today. And then a reminder about the add on complexity code for E&M services. So let's talk about some general information in regards to our advanced practitioners. So there are many acronyms that are used with our advanced practitioners. CMS uses the acronym NPP for non-physician practitioners. So when we cover the Medicare information, you'll see NPP listed. We often refer to our nurse practitioners, physician assistants, nurse specialists as advanced practice providers. You may also see APC. Used to a long time ago, we would use mid-levels. We don't use that term as much anymore. But here are some examples of our advanced practice providers. One of the things I want to call out here is CPT, which is our coding resource that's written by the AMA. They have terms in there that are around a QHP or a qualified health professional. From a CPT standpoint, these are considered our advanced practice providers. So when you think about who's not considered an advanced practice provider, that would be our RNs, LPNs, medical assistants, ancillary staff. And they are also by CPT not considered a qualified health professional that can bill for services. So often in our CPT descriptions, you see physician or qualified health professional. When they reference that in our coding, that references our advanced practitioners and what are those designations as an advanced practitioner. So as we go through these guidelines, I don't think you're going to hear anything new, maybe just some updates, focus areas, and what we see across the country. But we always like to remind everyone, it's not just about the billing requirements. So there are many considerations to our advanced practice providers. It depends on your payer mix in your organizations. So if you have Medicare payers, which we know are a large portion, Medicare, Medicare Advantage, they follow the CMS guidelines. For your commercial payers, your Blue Cross, United, Aetna, all of the ones we have, in each area, region, they have different requirements. So it's important to know what those requirements are. For credentialing, what payers can your advanced practitioners be credentialed with? What are the state licensure requirements, the scope of practice in your state? Then also, what does your hospital facilities grant privileges for for your advanced practitioners and what are their bylaws and guidelines in regards to advanced practitioners? Also, depending on services rendered and where those services are located drives that billing. So we have to take into consideration, I can tell you a lot of times we talk about what do you need to bill for your advanced practitioners? And you'll hear us caveat things with, well, you need to check your state scope of service or your state licensure, those types of things. And that's very important. But I would say when it does come to billing for Medicare services, the Medicare guidelines are not overridden for billing purposes by the state guidelines. So what do I mean by that? Interesting enough, recently we had something that one state said that, you know, a physician assistant can practice under the supervising physician agreement in their state, which is yes, that's true. They took that potentially as that meant they didn't have to follow Incident 2. Well, Incident 2 is a billing guideline, not a licensure guideline. So it's important as you look at that, that you understand what's considered my state licensure requirements, the hospital privileges, the location, and then of course, get to the billing requirements. As with any of our documentation, it's important that medical necessity is the overarching criteria of that service. And just with all of our other positions and our advanced practitioners, we want to be sure that our documentation supports the level of service for the date of that encounter. So when we talk about E&M services, and we look at what the documentation supports for that day of service, so E&M, meaning our visit services, whether it's the office of the hospital, whatever's reflective in that encounter note for that date of service is what has to support the level of service being reported. So we always want to remember that medical necessity is that overarching criteria, and then whatever's in the documentation, if it's not in there, then it's not supported. So when we talk about all of our services, this is not just in relation to our advanced practitioners, we want to remind everyone about copy and paste, or what Medicare refers to as cloning. We see this particularly with our rounding visits, where we'll see each rounding visit copied over each day, and only some aspects of the note changed. It's important, if you haven't looked at your Medicare carrier, and looked for any updated policies on copy and paste, that you go out and look at that, and be sure they haven't published anything recently. There's been a few probe audits where we've seen some information about cloning or documentation and the misrepresentation of medical necessity. So it's important to remember, if you do copy and paste, that you have to edit that information for each day. And as we know, our EMR systems are very good at identifying what has been copied and pasted. And I will tell you, interesting enough, I recently was involved with one of the Medicare target audits for high-level services, and they actually requested the audit trail for the notes that were submitted. So we know that this information is stored in our electronic health record. And I see here, it always, when we're doing our slides, it always corrects EHR to HER. So I see we have that typo there. We'll make sure we get that corrected. But it's important to know, how does your EHR record the information being documented in your note? What does that look like if you have to send that in with your documentation to your medical carrier? I also heard that a Blue Cross in one region did the same thing and requested a review and also asked for that audit trail of who created the documentation and what was copied forward, those types of things. So it's out there. It's nothing to be afraid of. This is not meant to scare anyone or to make you shy and copy and paste. But you just want to make sure that you are updating that information and that it supports the service that's distinct for that date of service. When we look at the definition of a new or established patient, this comes up often with our advanced providers. So the definition of a new patient under CPT and Medicare is it's an individual who's not received any professional service from a provider or another provider of the same specialty who belongs to the same group within the previous three years. And an established patient is one that has received service within the past three years. The guidelines make no distinction between you and your partners of the same specialty. So it's important when we talk about physicians, they do have subspecialties in cardiology. We have cardiology, interventional, EP, and heart failure. Those are our designated subspecialties. For our advanced practitioners, they do not have designated subspecialties. So their particular specialty is designated either as a physician assistant, advanced practitioner, nurse practitioner, whatever their credentialing is versus their specialty from a CMS perspective. And they are not subspecialized according to the credentialing of Medicare. So you want to be sure that you know when the patient, if it's medically necessary that the patient sees one of your heart failure docs and one of your EP physicians, so not your advanced practitioners, we'll talk about that in a little bit, on the same day, both are billable by the guidelines. However, payers vary. So we see across the country, some payers will reimburse both specialties on the same day. Some of them will deny it and you have to appeal it. And it's really about what occurs in your region, your particular Medicare carrier, your advantage plans and your commercial plans and what that looks like. But Medicare does recognize the subspecialties for physicians. So a couple of insights when we talk about our advanced practitioners. We already said CMS does not currently assign subspecialty designations to our nurse practitioners and physician assistants. As an example, if you're a 50 specialty type, you're a nurse practitioner, if you're 97, you're a physician assistant. In addition, if the patient's been treated by a provider of the same subspecialty within the three year periods, the claims will deny. And because you're not subspecialized, it's hard if you're working with multiple specialties within your group. Now interesting enough, over the last two years, and I did look this up on some of our Medicare carriers, there are some references to some guidance around if you have advanced practitioners working in multi specialty clinics. Now by multi specialty clinics, CMS says a multi specialty clinic is a clinic that has specialties across the board. So they may have primary care, orthopedic, internal medicine, cardiology, podiatry. So they're truly designated as their NPI number as a multi specialty clinic. So that's what this refers to. So if you're a designated multi specialty clinic, and they've had WPS as an example, Noridian has an example as well, where they specifically talk about for multi specialty clinics, that you can populate on your claim form box 19 with a subspecialty. So you're going to build that claim under your nurse practitioner as the provider of service, but they have guidance if you're a multi specialty clinic, that you can in box 19 identify if it was EP, cardiology, one of the recognized specialties. Now the caveat here is this is designated for only multi specialty clinics, I could not find anything around if you're designated as a group practice or a hospital based provider, those types of things, but you may want to check your Medicare carrier. But I do think that this is a step in the right direction. In the future, we may see more payers adopting this, I wanted to bring it up because inevitably when we talk through this, someone brings up, well, we've been putting in box 19, you know, and it truly depends on if you're designated as a multi specialty clinic. So if you want to find some more information on that, there's some links here and then you can look on your Medicare carriers if they have provided you those insights. Some guidance on Medicare for scribes. So particularly around scribes, all scribes, whether they're an advanced practitioner, a medical assistants, a RN, they have to function as a living recorder that's documenting in real time what the physician is doing. So what I say all the time is it's like you're in their lab coat pocket, you are side by side by them with them, and they are telling you, this is the exam on this patient, you know, heart regular rate rhythm, lungs clear, and you are scribing that information. The scribe cannot act independently. The scribe are not providers of items and services, and they cannot make medical decisions. This becomes very important if you're using your advanced practitioners, and remember I said CMS refers to them as NPPs. If you're utilizing your NPPs as a scribe, they cannot make independent medical decisions. They have to be that living recorder, and they cannot independently act in that encounter. So it has to be clear in the documentation if you're using advanced practitioners as scribes that you are documenting this in the documentation, and you're following the specific requirements for your Medicare payer for documentation of the scribe. Now I will tell you, obviously we do not advocate for advanced practitioners to be scribes because we believe obviously they can function independently, be an active member of the care team providing services, and all of that team-based care approach. However, we do see at times where they are being utilized, and often they're not being utilized appropriately because they aren't acting as that living recorder. They're acting more as making independent decisions. So it's important that you follow the guidelines around scribing. Also look at how your encounter comes out when it's finalized, so print off your visit that you would send to the payer, and what does that visit look like? Does it show what the advanced practitioner documented? Were they scribing? Were they not scribing? Does it just have two signatures on it? What does that look like? Also it's important to know that the rules vary, we talked about by our facility bylaws and accreditation, like our joint commission, those types of things. A lot of time in our healthcare facilities, so if we have advanced practitioners rounding with our physicians, some facilities require that the physician see the patient and sign the documentation, even though the advanced practitioner can independently perform that service. So remember, you've got to separate what are my bylaws, facility requirements, and what's truly required from my billing compliance standpoint. All right, so from a diagnostic testing standpoint, when you look at this act, and I have this in here because a lot of times I'm asked for the specific verbiage, diagnostic testing are distinct from the incident to benefit category. So diagnostic tests do not need to meet the incident to requirements. So what does this mean? So we have an updated policy by Medicare that has expanded the list of provider types who, an example, would be authorized to supervise a diagnostic test. And this comes up all the time on the listserv, we'll see, well, my advanced practitioner cannot supervise the stress test, they have to perform it. This actually was changed in 21. It started in the pandemic, and then they did finalize the policy. And there's a link here where you can pull that policy. So previously, our advanced practitioners had to perform the diagnostic test under fee for service, with certain exceptions, because the definition was physician supervision. In 21, they changed that to where the individuals performing the supervision can be nurse practitioners, physician assistants, certified nurse specialists, etc. If your state scope of practice allows it, and if you are able to be credentialed in your facility allows it. So this is important when we talk about diagnostic tests, we'll see sometimes the question about supervision of stress tests, which yes, your advanced practitioners can supervise stress tests and bill for that supervision. The other one is, is what if an EKG is done as a visit and the advanced practitioner is seeing that patient independently? Well, an EKG is a diagnostic test. So depending on your process in your organization, that that advanced practitioner can interpret that EKG and document it and bill the EKG under their provider number, it is billed at 85%. If the physician is interpreting that EKG and doing the actual interpretation and signing that interpretation, then it can be billed as a under the physician and reimbursed at 100%. So when you think about diagnostic testing, the supervision requirements have been updated to include our advanced practitioners, but each diagnostic test on the fee schedule has a different level of supervision. So depending on that particular test, procedure, etc, you have to look at the fee schedule and determine what level of supervision is required for that particular CPT code to bill, and then who is meeting that requirement and who should we be billing that under. So very important as you think about your diagnostic test as well, because these are not covered under incident two. All right, so let's dive into our Medicare advanced practitioner guidance. So this is Medicare, which we know is adopted by Medicare Advantage plans. I mentioned before about your commercial payers, and that is variable, there's no way that we can capture what each payers doing in each state. We're pretty safe when we talk about Medicare and Medicare Advantage plans. However, when you get into certain blue crosses, for example, I've been in areas where they absolutely will not recognize incident two. So they do not allow incident two to be provided in an office setting, which means either the nurse practitioner has to bill independently, or the physician has to bill independently, and follow those documentation and billing guidelines. That can vary by state to state, it can vary by plan to plan. So we are not going to be able to help you figure that out with your commercial payers. But we are going to go through each of these categories, including billing independently, the definition of incident two and of split shared services. Right. So for our advanced practitioners who bill independently to Medicare, they would independently see the patient, it is applicable to all places of service, they can do their complete documentation and bill directly under their provider number if credentialed with the payer, and then it's reimbursed at 85% of the Medicare physician fee schedule for your traditional Medicare and then your contracted rates as they are done or negotiated for your Advantage plans, we see generally 80 to 85% of the Medicare physician fee schedule. So this would be the advanced practitioner solely acts independently sees the patient does all the documentation and bills directly under their provider number for a payer that their credential. And that is totally accepted. So incident to services, let's talk about incident to incident to is only applicable for places service 11 places service 11 is an office based practice. So this is not a hospital outpatient, if you're billing your E&M services visits in the office as a hospital incident to doesn't apply. This would be if you are billing your office services as places service 11. So some of our organizations that are owned by hospitals do bill places service office still for their E&M visits, their diagnostic testing may be hospital based. And then we have some who have converted all of their service to hospital base. So it's important you understand how are you billing for office visits patients that are seen in your clinic, if it's places service 11 incident to is an option for your Medicare services for your advanced practitioners, but there are certain guidelines that are required. First of all, the advanced practitioner has to be employed by the physician or the clinic group. So there must be an employment arrangement, a physician has to provide direct supervision for the service being provided by the advanced practitioner in the office. Now that direct supervision can be provided by their supervising physician if they are physically present in the office suite, when the advanced practitioner seeing the patient, or it can be provided by physician in the clinic group that's providing the direct supervision. However, whoever's providing the direct supervision is the billing physician. So that's where this gets a little tricky. So first things employed and you have a physician providing direct supervision. The patient has to have a course of treatment initiated and reflects continued physician participation and management. So what does this mean? We're going to dive into this a little deeper. But what this means is you cannot bill incident to for evaluation of a new patient, or an established patient with a new problem that requires a change in their treatment, or their plan of care. So incident has multiple definitions, and all of these requirements that have to be met. So if you if you meet that you're employed, and you have direct supervision, you still have to meet that the patient has an established treatment plan. And it has to reflect the ongoing participation of the physician. If you meet those three, then you can build a visit under the physician providing the direct supervision and be reimbursed at 100%. If those things are not met, then it has to be billed under the non physician practitioner advanced provider and reimbursed at 85% of the Medicare physician fee schedule. So incident to applies to place of service 11. All right, so here's some of our payer guidelines. So Novitas, which is a local Medicare carrier, they have specifics on their website that tell you exactly what they expect to see for documentation requirement, they expect to see in the medical record who rendered the service, who provided who was the physician providing that direct supervision. Oftentimes, that's documented by the advanced practitioner, you'll see something in there, it says, Dr. Smith was present in the office during the visit, those types of things. They also expect to see that the physician initiated and has continued involvement in treatment, and that it meets, of course, our medical necessity, the overarching criteria. Now they actually say what is evidence that of the link to a physician's care plan to the provider being in the office. So this they'll tell you a co signature is required of both the advanced practitioner and the physician on the documentation. So that's required by Novitas that can differ across payers. And they also say consider documentation for other dates of service that for example, link the initial visit or established treatment plan between the two providers. So they're looking for that this patient does not have a new problem, and that they have an established treatment plan that's being followed by the advanced practitioner when incident to requirements are met and being built. This is from NGS. Also, when you look at this, they reference some of the same things you'll see this across many of your Medicare payers. It says the NPP is following the plan of care set forth by the physician. And it says visits with established patients who are experiencing new problems require active physician participation and cannot be billed on an incident to basis. So again, they're calling that out. And then they also say it's expected that the physician performs and documents intermittent services at a frequency that reflect active participation in the course and treatment for a specific problem. So what we see in cardiology in regards to that if you have patients in your clinic that and you have advanced practitioners and physicians will often see where they either have a two to one or one to one visit scenario, meaning the nurse practitioner, the physician sees them, the nurse practitioner sees them once or twice, then the physician sees them again, you want to be sure that there is a cadence. If you have patients that have not seen a physician in two to five years, and they've only been seen by a nurse practitioner and you're billing incident to that definitely is something if you think about how we bill under our MPI numbers, and what that looks like, and if they do a review that they could tell if they're having that active participation. Now a nurse practitioner or a PA can independently see a patient and bill. But remember this incident to concept for office requires that interaction with the physician and active participation in their course of treatment. So again, just something you may want to look at if you do have both in your clinics. Also, I thought this was interesting, because this is a question that I would tell you we probably get if not weekly every two weeks around incident to for medication adjustments. It is clear with many of our Medicare carriers. So this is NGS, they actually have this under their FAQs. It says a physician, a physician's initial plan of care may include prescription management that may require adjustment on subsequent visits. The need for medication adjustment does not represent a new problem. These visits may be billed as an NPP is incident to to the original plan of care when the physician includes that obstruction in the original plan. So that's the key, right? They have an established plan of care. And the physician has that documented. So here's an example, have have page I started the patient on Lusartan. His blood pressure is 160 over 90. He's returning two weeks for follow up dosage may be adjusted by my nurse practitioner on follow up visits. That is documented in the plan of care. Therefore, if that patient comes in, they have an established plan of care. If their blood pressure is elevated, and their medication requires titration or new medication, or any type of adjustment, then that could fall under incident to if the physician had documented this on their original plan of care. Okay. Documentation does have to support the link. This is just another reference to that when it's not just a co signature. And in the office, it's not just a statement that says the physician agrees with the above because split share does not exist for place of service office. That's for our facilities services, which we're going to talk about. But you want to be sure that you've done some documentation improvements to assist with incident to if you are still billing incident to. So some options for advanced practitioners, if they're seeing a patient who does not meet incident to, obviously, that advanced practitioner can see the patient address their plan, their treatment, their problem, and bill independently and be reimbursed at the 85%. If you want to bill incident to, and the patient does have a new problem, or a new treatment plan that wasn't linked to the physician's previous treatment plan, the only other option you have, then the advanced practitioner billing independently is that the supervising physician takes over the visit and the documentation so that that physician that's providing the direct supervision, sees the patient does the documentation performs an assessment establishes the plan of care for the new problem. documentation supports the level of service billed by the physician and it's reimbursed at 100%. There's no in between that's addressed by Medicare in this situation for our office based patients. So it's important if you are following incident to that you are meeting all of those requirements. So here are some potential example statements that I wanted to provide for incident to that I've seen on some actual documentation. So this is a way that this would be that the physician is documenting this when they're initiating their plan of care. So I'll tell you, you know, these are for you if you want to use them or provide them as an example. But this third one is probably one I see pretty often based on the patient's medical history and current symptoms and collaboration with the advanced practitioner, we will manage follow up medication management to ensure compliance with the treatment plan. Now, oftentimes we'll see, you know, specific to the problem like we did in that hypertension example. But again, that physician is establishing the treatment plan, and the advanced practitioner is following that treatment plan as they continue that patient's care. And this is if they are billing incident to for office patient. All right, so split shared services, let's talk about split shared services. So split shared services, these are different from incident to and they are applicable to our hospital places of service such as 1922 2123, etc. So it's outpatient or inpatient hospital services, the patient can be new established, it can be an initial visit. It also includes critical care and certain skilled nursing facility services. Excuse me. The requirements for split shared from a billing perspective or whoever performs the substantive portion of the medical decision making that's MDM, or more than half the total time determines the billing provider. So this went into effect a few years ago. It's been readdressed every year in the final rule where they've tried to push this to time only. It wasn't even mentioned in the 25 final rule. So hopefully that's under the radar at this moment. But as of today, and and continuing through this year, split shared is determined by who performs the substantive portion of the medical decision making, or spends more than half the time that determines the billing provider, it's filled with a modifier FS, and it's reimbursed at 100%. Otherwise, it's billed under the advanced practitioner and reimbursed at 85%. So what does that mean? So what is the definition of a substantive portion? Interesting enough, CMS, originally and CPT had some differences in their interpretation of split shared visits, or the AMA rules were a little different, but in 24, they actually have aligned on that. So when you talk about medical decision making of that substantive portion for CMS, each practitioner performs certain aspects of the medical decision making, but the billing practitioner must perform the substantial part, they expect that whoever performs the medical decision making and subsequently bills the visit would appropriately document the medical decision making in the medical record to support billing of the visit, meaning the level of service bill, the AMA and CPT, officially, they updated and aligned in 24. So from an AMA perspective, you'll see as well that definition is quantifiable in two ways, based on the majority over half of the total clinical time invested in the visit, or by the substantial portion of the medical decision making. So when you look at CPT guidelines, they do require that the physician has to approve or create the management plan for the patient and assume responsibility for the plan. This would be if your billing split shared at 100% under the physician, where they are accepting inherent risk of the complication, this qualifies the physician as having fulfilled two of the three key elements. So you're gonna say, what does that mean, Nicole, I'm going to tell you what we see with that sometimes. And then it's important, this piece is the part that I think is most important. CPT does state this and CMS also has adopted this policy in the final rule 24, that medical decision making scoring the physician does not need to interview the independent historian personally, or must order the test review the test or external documents. However, the physician must personally perform any inter independent interpretations, or external discussions when these are in determining the report of the E&M level. So what this means is basically, you can't count if the advanced practitioner has an external discussion with the hospitalist, if you're billing under the physician, the physician has to document that they to discuss this with the hospitalist, or if they independently look at a chest x-ray, and they do their interpretation of that chest x-ray, the physician has to independently do that and document that in their note, the advanced practitioner cannot document those elements, because those are required by the individual who performs them. Okay. So understanding that revised shared service and substantive portion is only the definition, because again, it goes by a couple of other things. So let's talk about a few examples here. So if you're billing based on time, the key to this, as you see this, and I'm not gonna read all this to you, is basically the advanced practitioner spent 10 minutes, the physician spent 15 minutes, and then they spent about five minutes collaborating together, okay? And we'll talk about that as well. So if you meet together for that additional five minutes in this example, so you have 10 minutes by the advanced practitioner, 15 minutes by the physician. The physician spent more time. The physician can also count the five additional minutes as well. The key is only one provider, and usually it would be the billing provider, should count the time for the discussions together. So the nurse practitioner and the physicians both can't count that five minutes that they spent together. So you can't have overlapping time. Any overlapping time can only be counted once for the total time of the visit. So in this particular example, the total time would be 30 minutes if we take their five minutes added to the 25, and the physician would bill for the visit since he spent more than half of the total time on the visit and it's billed under the physician and paid at 100% for hospital service only. All right. So for split share guidance for critical care, this was also expanded. Critical care can be furnished as a split share visit. Again, it goes back to overlapping time. So you can only count your own time on that calendar day, and then whoever spends the substantial portion of the time can bill critical care services under that provider with the FS modifiers. The big thing is you have to meet all of the requirements of critical care services. Then you have to meet the requirement for the split shared service in order to bill it at 100% under the physician. So remember when we bill critical care, it's the definition of critical care, it's the treatment of critical care, and it's the total time of that critical care. All three of those have to be met. Then if you have a situation where you have split or shared services and the physician is spending the majority or substantial portion of that cumulative time on that day, then it can be billed split shared with an FS modifier. This is an example of a note where we, this is an actual note that we saw where they did, the physician performed a substantial portion of the medical decision-making. Obviously the note included a complete note by the advanced practitioner. And then the physician, this is just the snippet, came back and said, you know, they agreed, and then they went through the plan of care to support the care of that patient. And, you know, when we talk about the physician can't just say, I agree with the above and sign, and that meets split shared. When they have to document a substantial portion of the medical decision-making, then you would expect to see something like this. We see it in an addendum sometimes. Sometimes we see it in a separate note. None of that matters. What matters is, is that you're able to tie those notes together and understand who performed the substantial portion of that medical decision-making, who's the billing provider and the FS modifier that's needed. All right. Here are some example statements as well for split shared services that I see. So I performed a substantial portion. This is the physician. This would be if they're meeting all the requirements of being in a facility, those types of things. I performed the substantial portion of the medical decision-making during the visit. I evaluated the patient. I made and approved the management plan and acknowledged the risk and complications. I independently interpreted X. I did the management and test interpretation of such and such or if they talk to someone, they add that in. So we have seen that. This is another one. I provided the substantial portion of the care of this patient. I personally performed the MDM and they are documenting components required of that MDM to support the substantial portion. So this would be something that the physician is documenting as an addendum or an attestation to a nurse practitioner or a PA's note for that facility visit. So remember, they can't just say like residents, teaching facilities are totally different than when you're using an advanced practitioner. You cannot just say, I agree with the above and sign. I've also seen where folks will tell me, well, I edit the note of the nurse practitioner or PA and then I just put, I agree and made changes above. The key is if you print that note out to send to Medicare, does it show what the physician documented and changed or made on the assessment and plan or medical decision-making? Does it show what the advanced practitioner did? So you wanna consider those things because you may have a good process in place, but that note that you send in to the payer is what is reviewed to support the level of service billed on that encounter and if the requirements for split shared were met. So let's get into a couple of miscellaneous things and then we'll take some time for some questions. Diagnosis coding, not just particular to advanced practitioners, but wanted to remind everyone our diagnosis coding on our encounters is very important. So how are those diagnosis codes listed? A lot of times you have to remember whatever you're coding for your visit services may not be being reviewed by a coder. They may automatically get billed to the payer, which is something we see commonly. So do you have the primary diagnosis that was responsible for the encounter? Is that in your number one position that's gonna get billed on the claim? Are all diagnosis that are being coded addressed within your encounter? Or are you just pulling over an inconsistent problem list that has some conflicting information? Resolved conditions should not be coded. Relative status condition should be. So for example, in a lot of cases we'll see where if a patient has coronary artery disease and they're not having any angina, or they've had previous cabbage, or they've had a previous stent or angioplasty, you wanna be sure to code that, particularly if you're ordering a stress test. Because a lot of our carriers require not just the CAD, but that status post condition as well in order to support the medical necessity of that test. So what do we mean by addressed? It's important for every diagnosis that you list that you have to either monitor, evaluate, assess, or treat that condition and document it. So it has to be easily tied in your documentation. If you list four problems, I have to be able to say for that coronary artery disease, you see patients not having any chest pain, they're doing well. Hypertension, they're on their biostolic, their pressure's controlled. I'm addressing it, I'm evaluating. Hyperlipidemia, their LDL shows X, they're gonna continue their Lipitor, we're gonna get their lipids repeated in X. Three problems being addressed. If I just have a problem listed and nowhere within that note that it's being monitored, evaluated, assessed, or treated, then it cannot be counted towards your medical decision-making, and it also cannot be coded as a diagnosis on your claim form. So it's important on that data service that you include not only the diagnosis that you wanna code and bill on your claim, but also the documentation to support that you monitor, evaluate, assess, and or treat those conditions in order to support, one, the medical necessity, and that diagnosis being coded on your claim, and to support your medical decision-making in order to level your visit of service that day. All right, telehealth, couple of reminders on telehealth. I wish I had a crystal ball, I do not. There is a temporary extension through March of 25. I will tell you as of yesterday, I did see some guidance that there's a draft, and I say draft because there's nothing finalized, that's gonna extend this even further potentially to September for telehealth. However, that is not final. It's in draft in Congress or the house or wherever it lies. So that is something we're seeing for the telehealth piece that that could be extended. More to tell by the end of March, we should know probably in the next couple of weeks if this will be extended. But as of now for telehealth in 2025, you must specify clearly if you're using audio or video, the physician should have access to a secure platform to provide the audio and video service. If the patient is unable to use video, you must document that the patient is unable to use video. The telephone only codes were deleted in 25. The commercial payers have varied because some of them have accepted the new CPT codes that were created. And those new codes are being reimbursed. I'm told by a couple of our members by some commercial payers, however, Medicare does not recognize that. So when you bill audio video, the provider has audio video access and it's billed as your E&M service with the correct place of service. If it's audio only, the guidance has been that you document that the patient is unable to be on video and that you bill the E&M visit for that day with a modifier to indicate it was audio only. It's important to document where your patient is located. The consent for telehealth does have to be documented. And again, you want to have documentation to support the level of service for that medical decision-making for audio video unless you're billing based on time for your E&M visit, it would be that time that's related to the E&M visit if you're not using medical decision-making, okay? So lots of confusion in telehealth right now. I'm actually surprised, you know, FaceTime went away in 23. So the secure platform is not anything new for this year. You have always had to be on a secure platform since 23. So you want to be sure for your telehealth services as we continue to go through, you stay tuned to see what happens. Like I said, there was a draft extension that was put forth. I believe it's till the end of September for telehealth to continue. We don't know when that'll be finalized, when or if, but we will put it on the listserv. Also, as you continue, if you're continuing telehealth services in your organizations and you have commercial payers and you're having things come up, please share on the listserv. We can all learn something in the different areas for this with our payers and then trying to keep up with this. But remember, telephone only codes are deleted in 25. And if you do audio only, the physician has to have audio video access, has to document the patient is unable to be on video, and it has to be billed with a modifier with the regular E&M visit. Right. So our add-on complexity code G2211. This was something that was approved in January of 2024. So it has been around and it's continuing to be reimbursed this year. This G code for your Medicare patients can be added on to a visit in the office setting. And this supports that the patient has ongoing care related to a single serious or complex condition and that you have a longitudinal relationship with the patient. The caveat to being able to bill for this in your office setting with your E&M is that your E&M visit cannot be billed with a modifier 25. Modifier 25 is billed on an E&M service when a test is performed normally in the office that is variable by carrier. So you wanna check with your revenue cycle folks on if you're doing testing the same day as your visits, you may not be able to bill this G2211, but if you're not billing your E&M service with a modifier 25, and you're supporting the definition of the G2211, you may bill it. It has no time limit. It's not only for higher codes or certain conditions. It does have a work RBU value of 0.33, and it's reimbursed anywhere from about 15 to $25. Some I've heard it's like $42 to $48. This would not be relative if your relationship is discrete, routine, or time limited in nature. Medicare does have a published MedLearn Matters article that says there's no specific documentation requirements that they would expect that that longitudinal relationship and ongoing care is documented in your medical decision-making. However, some organizations are using a statement that they're providing longitudinal care or ongoing complex care, and they're adding that to their assessment and plan that supports it. That is not required, but we are seeing that in some documentation. But this is an opportunity, and largely I believe is underutilized in our office settings, because many of our cardiology patients do meet that serious complex condition, and you're providing that ongoing longitudinal relationship and care. The key is around depending on your processes, and if you're having to bill your visit code with a modifier 25, and the only way to know that is to check with your local coders, revenue cycle folks, because it's variable by payer and state. This just shows kind of the reimbursement around that G2211 in relation to that. I do believe that them continuing this in 25, it'll be interesting to see how this G code continues to evolve over the next couple of years for reimbursement, but this is something that has been in effect since 24. All right, so some key takeaways. Your documentation should be consistent. Do not have conflicting documentation. If you have conflicting documentation, that documentation cannot be counted towards your medical decision-making. So if you have statements in your HPI, and then you have a different statement from that in your assessment and plan that contradicts that, we're not able to count that towards your medical decision-making. Use caution with copy-paste. Be sure you have a policy on copy-paste and that that's being followed, and that's something that you continue to provide education on and insights and feedbacks to your providers. Diagnosis cannot be inferred from physician orders, nursing notes, lab, or diagnostics. Diagnosis need to be in the chart, in the medical record and documenting. That's where we get into our meat, where we manage assessing, treating, and is that documented within that note? And it should be that the medical necessity is the overarching criteria, and the treatment and evaluation would be consistent with the nature of that condition or presenting problem on that day. All right, there's a couple of references in here as well. And also Ginger on our team has worked with the MedAxiom team to create, they have the 24 APP Advanced Practitioner Compensation Survey available on our website as well. They have good information in there, not only about compensation, but also around access and clinics and those types of things. So they have some really good information in there if you wanna check that out as well. All right, so let me see if I can take a couple of these questions. So someone was saying on the G2211, the add-on code and 25, they did add that if you have a modifier 25 on a preventative service, such as immunization or an annual wellness visit, a modifier 25, then you can build the G code, but that did not go away with diagnostic testing. It's only for particular preventative services, which I know in many of our cardiovascular programs, we don't bill for immunizations and annual wellness visits. Some do, but I don't see that generally. But if you do, they did expand that in 25. So you are correct in that question. When a nurse practitioner sees a patient in the hospital in the morning, and then the doctor sees the patient in the same day in the hospital in the afternoon, are we able to bill for both the nurse practitioner and the doctor? Well, first of all, is the nurse practitioner and the doctor in the same group? If they're in the same group, then you bill one E&M for the day. If they're in a different group and not part of the same clinical practice, then depending on what specialty designation, group tax ID, multi-specialty clinic, they could potentially bill separate. But if you're within the same group, then you're billing for one E&M on the same day. Clarification on independent interpretation, are advanced practitioners allowed to independently interpret? I know in order to give the physician credit for the independent interpretation, the MD has to do the independent interpretation. It truly depends on an APP, an advanced practitioner, depending on your state's scope of licensure and requirements, if you can interpret an EKG, for example, or a stress test. That would be more involved in your licensure and your scope of practice versus billing. Because from a billing perspective, we saw Medicare does recognize advanced practitioners for certain diagnostic, most of our diagnostic studies as billable providers. However, you wanna be sure, what are the requirements for supervision? What are the requirements per code? But largely, depending on your scope of practice and if it's allowed, an APP can independently interpret, for example, an EKG, if that's allowed in their state scope of practice. Someone's asking about the slides. They are available in the chat or either under your Academy login as well. We do not email out slides. They are usually, they are located within the Academy or from the link in the chat box. The doctor sees the patient in the outpatient independent office with an APP. What documentation is necessarily to bill 100% of Medicare? Is a simple phrase I've seen examine the patient with the mid-level and agree with the plan, okay? Or does the summary of the patient's care need to be made? Well, in our office setting, which is place of service 11, your options are either to bill under the APP independently or the physician independently or follow the incident to guidelines. There is no split share. So if you wanna bill 100% and they're seeing the patient at the same time together, then the physician would have to document or the APP would have to meet incident to requirements. A statement does not suffice as meeting incident to requirements in the office setting. So those are your only two options. Also, we would say with that team-based care, if they're both seeing the patients together, it's probably some inefficiencies and I would look into some documentation on Medaxi on how folks are doing that. But normally we see APPs who have independent schedules that are seeing patients independently or billing incident to the physician and they're seeing that patient. Because when you see a patient incident too as an advanced practitioner, if you meet the direct supervision, you meet the established treatment plan, no new problems, the physician doesn't have to see the patient. The physician just has to be in the office providing the direct supervision. So that's what we commonly see, but there is no phrase that we would tell you is gonna support billing a visit completely documented by an advanced practitioner in the office unless incident two is met or the physician sees them independently and documents independently. Let's see, incident two, a new problem or change in point of care leaves some room for subjective interpretation. Are there examples of things other than MAD adjustment where an AP visit, APP visit could still be billed incident two? An example, if the patient has an annual stress test and the APP orders an annual stress test for the years and sees the patient, can this be a continued plan of care? It is one of those areas that can be subjective, but what I would say is if your advanced practitioner is seeing them post-stress test, number one, if it's just to give results of the stress test, that doesn't support a separately visible E&M visit, however, if they're seeing them for their coronary artery disease ongoing management and they have an established plan of care for that coronary artery disease, then it could be considered incident two, they make the CLAIR plan requirements and that they have direct supervision. You can look on your Medicare carrier, there are not distinct black and white examples that say that it has to be, you know, not just MAD adjustment, not just an order. The order piece, if you're ordering a test, the key I always say is when the APP is seeing that patient, if they're ordering a test, is that patient having a new problem or are they having a change in their treatment plan that's leading to ordering that test? If so, it wouldn't mean incident two. So it truly depends on the scenario, I wish I could tell you some black and white things, but that is an area where, as you saw, it has to be tied to the initial plan of care by the physician, if you're meeting all of the other incident two requirements. Advanced practitioner and a physician see a patient as a split shared visit, neither puts an attestation about completing the substantial portion of the medical decision making, can either of them bill for the visit, the MD cannot because there's nothing showing he documented the MD requirement. Well number one, I would say, I wouldn't be having a talk about how this is being done. The attestation is not the key, it's who performed and documented the substantial portion of the medical decision making. So from that note that's being provided, can you tell who documented the substantial portion of the medical decision making? If you cannot tell that, then you have to go back to your providers and determine what that process is and who needs to be billing it. As we talked about, the physician in the hospital setting does have to either agree with the plan of the APP and then document their personal interpretation, conversations and portions of the medical decision making and accept responsibility. If that's not done, then it has to be billed under the advanced practitioner, that's the only plan of care that you have that supports the substantial portion of medical decision making. Can advanced practitioners put orders in at the direction of the physician while they are scribing, or does the physician have to put those in? What I would say to that is, is the order showing that the advanced practitioner ordered it, because if it shows, if the advanced practitioner puts the order in and it shows it was ordered by the advanced practitioner, which they can put in, they can order, then it cannot be considered scribing. So it would have to be orders that have documentation that the physician ordered them. Not sure how you get around that in the system, because if it shows that nurse practitioner X ordered it, and there's nothing saying that the physician directed that order through scribing, then not sure how that would meet scribing. A physician sees a new patient in the hospital, creates a plan of care with discharge order. The APT then sees the patient in the office as a hospital, follow-up and follows the discharge instructions. Can the APP visit be billed as incident two? I will tell you that I've seen this one done a couple of different ways. If the physician is the supervising physician or the physician within the group that's created the plan of care that works with the nurse practitioner and the advanced practitioner sees them in the office and follows that in follow-up, I would say that if you're meeting direct supervision, you have the ability to bill incident two. However, if the discharge is done by a hospitalist that's outside of your group, and the advanced practitioner is not following the established plan of care of the physician, group, or direct supervisor that she's working with, I'm not quite sure how that would fall into incident two if they did not develop that initial plan of care. Now, I will tell you there are some organizations that if a patient is discharged from the hospital, they cannot bill incident two for their advanced practitioners, and that's an internal policy, and we do see that sometimes as well. Depends on number one, who did the discharge, whose plan of care is the nurse practitioner following or PA following, and are you meeting and supporting that definition of no new problems, no change in treatment plan, those types of things. Some of you are asking about the modifier for audio only. I wish I could tell you that off the top of my head. Someone on my team, if you all could respond to that because I don't remember the audio only modifier for CMS. I should, but I don't bill those on a daily basis, so I don't know what those are. Someone was commenting, we need to be careful not to confuse incident two and split shared. I totally agree. Incident two only applies to place of service office, has different requirements than split shared. And someone just answered, it's modifier 93 for audio only. Thank you very much. I'm wondering if there's any element of these that can answer. Someone asked what's incident two, hopefully we answered that. Just to clarify, the conditions causing critical status of the patient or not the conditions being treated by the provider. Is the level of service based only on the documentation related to the conditions the billing provider is managing? Or can critical status treated by another special be used to determine the severity of the condition or risk of the treatment plan? That's a great question. So we see this sometimes. So many of our cardiovascular patients have, for instance, renal failure or they have diabetes. Obviously, cardiovascular is not, may not be treating those conditions. But the physician takes those into consideration for the medical decision making of that patient in a visit, as an example. And they document diabetes, the patient is on insulin, managed by their PCP, their A1C is stable. They're meeting that they're addressing that condition, and they're utilizing that treatment, the management of that condition for supporting those, that diagnosis can be coded. The ones we see that are not relative or not counted towards that, if you just say managed by PCP, can't just count that. You have to say something about that condition. Is it stable, controlled, worsening? If you reference blood work, if you reference treatment, you have to document something about that condition, and then it can be used to determine the severity and coded as part of the risk adjustment, those types of things. But you do have to address that condition, and not just say managed by another provider. I think that is all I have. If there are a couple of other questions here, we'll definitely answer those offline. I appreciate everyone's attendance. I know this is a hot topic. We always have great attendance for this. If you have any direct questions, my email is on here. You can also email revenuecyclesolutions at MedAxiom.com, and that will get you to us as well. But we appreciate any feedback. And please remember to always share anything you have going on with payer coding cardiovascular with your peers on the listserv. It's always good when you're seeing something that may be happening in your organization, and we can share that across our membership. That's the power of having the 500-plus organizations we have. So we appreciate your time today. And if you have any other questions, please reach out to us. Thank you.

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Incident-to Billing

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Medical Necessity

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