The Center for Medicare and Medicaid Services (CMS) made changes to shared visit and teaching physician rules, physician assistant billing, and critical care, and took steps to increase telehealth billing for mental health services. The highlights of the final rule include:
Shared Visits
- The new guidelines change who can bill for evaluation and management (E/M) services performed as a shared visit between a physician and an advanced practice provider (APP) in a facility setting. “Facility settings” include provider-based clinics, the emergency room, and all inpatient facilities.
Specific Changes include:
1. A “shared visit” is now defined as an E/M visit provided in the facility setting by a physician and an advanced practitioner (APP) in the same group and same specialty. The visit is billed by the physician or APP who provided the “substantive portion” of the visit.
2. For 2022*, the “substantive portion” can be: a. The provider who documented one of the key elements (history, physical exam, or medical decision-making) in its entirety, (except for critical care, see below), OR b. The provider who rendered more than 50% of the total time of the visit on the day of the encounter.
*In 2023, the substantive portion of the visit will be defined only as the provider who contributed more than 50% of the total time of the visit on the day of the encounter.
3. Shared visits can be reported for new and established patients, initial and subsequent visits.
4. A new modifier (FS) will be required on claims to identify shared visits.
5. The final rule also allows an MD and APP in the same specialty and same group practice to combine their time towards billing critical care for the same patient on the day of the encounter. The billable provider is the provider who spends over 50% of the combined total time providing critical care.
Recommendation for January 1, 2022:
Additional steps may be required for providers who select the >50% approach (i.e., manually changing the billing provider). Therefore, we recommend the following approach to minimize workflow disruption for providers.
Recommended: Determine the substantive portion to be the provider who documented Medical Decision Making (MDM) in its entirety.
“In its entirety” means the documented plan by the billing provider meets the level of medical decision making for the E/M selected. Remember that MDM includes outlining the number and complexity of problems you are addressing, the amount and/or complexity of data you are reviewing, and the risk associated with patient management in your plan.
Compliance added to the APP/MD smartphrase (.MDAPPinvolvement) "my substantive plan includes***."
For providers who prefer to select the substantive portion to be based on >50% of the total visit time: Determine the substantive portion by the provider who rendered >50% of the total visit time on the day of the encounter. When using time- based billing, both the physician and the APP must track and document their individual time in the medical record. Time spent by the physician and the APP simultaneously can only be counted once. The shared visit time would be summed to determine the total time and who provided the substantive portion and therefore, who bills for the visit.
Compliance is actively exploring options within Epic to streamline the time-based workflows. We will keep you up to date on those enhancements as they become available. The activities that count toward time for the 2021 outpatient E&M codes are the same activities that count in a shared visit.
Append the “FS” modifier available in Epic to all shared visits.
As of January 1, 2022, providers will see the “FS” modifier available in Epic. Providers should add this modifier to ALL shared visits, regardless of place of service. YM has implemented a background edit that will remove the modifier when the site of service is a YM office. This will avoid the problem of providers having to understand where they are physically located (i.e., facility vs. office).
Compliance is updating existing training materials related to shared visits and developing new materials to support providers with these changes in 2022. Questions regarding shared visits can be directed to Medical Billing Compliance at https://yale-medicine.secure.force.com/compliance/askaquestion.
Critical Care
- Shared visits can be billed for critical care visits. The total critical care service time provided by a physician and an APP in the same group on a given calendar date to a patient would be summed, and the practitioner who furnishes the substantive portion of the cumulative critical care time would report the critical care service(s).
- CMS is adapting the prefatory language in the CPT with regard to the definition, CPT listing of bundled services, and the time guidelines for a single practitioner billing critical care.
- Critical care that is provided on a continuous basis and lasts past midnight does not reset and create a new first hour after midnight.
- Critical care visits may be furnished as concurrent care (or concurrently) to the same patient on the same date by more than one practitioner in more than one specialty (for example, an internist and a surgeon, allergist and a cardiologist, neurosurgeon and APP), regardless of group affiliation, if the service meets the definition of critical care and is not duplicative of other services.
- When critical care is furnished concurrently by two or more practitioners in the same specialty and in the same group to the same patient on the same date, the individual physician(s) or APP(s) providing the follow-up or subsequent care would report their time using the code for subsequent time intervals (CPT code 99292) and would not report the primary service code (CPT code 99291). CPT code 99291 would not be reported more than once for the same patient on the same day by these practitioners.
- When one practitioner begins furnishing the initial critical care service but does not meet the time required to report CPT code 99291, another practitioner in the same specialty and group can continue to deliver critical care to the same patient on the same day. The total time spent by the practitioners could be aggregated to meet the time requirement to bill CPT 99291.
- You may bill for an E/M service that was provided prior to a critical care service on the same date if at the time of the E/M the patient did not require critical care, the service is medically necessary, and the service is separate and distinct, with no duplicative elements from the critical care service provided later in the day. Practitioners must use modifier -25 on the claim when reporting these critical care services.
- Preoperative and/or postoperative critical care may be paid in addition to a procedure with a global surgical period if the patient is critically ill and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed. Modifier FT will be required when billing for unrelated critical care.
Teaching Physician Rules
- When total time is used to determine the office/outpatient E/M visit level, only the time that the teaching physician was present can be included. CMS clarified that only the time spent by the teaching physician performing qualifying activities listed by CPT (with or without direct patient contact on the date of the encounter), including time the teaching physician is present when the resident is performing those activities, may be counted for purposes of visit level selection. This excludes teaching time that is general and not limited to discussion that is required for the management of a specific patient.
Physician Assistants
- CMS has removed the requirement to make payment for PA services only to the employer. PAs may bill independently or may reassign their rights to payment for their services and may choose to incorporate as a group comprised solely of practitioners in their specialty and bill the Medicare program, in the same way that APRNs may do.
Telehealth
- Permits certain services (category 3) added to the Medicare telehealth list to remain on the list to the end of Dec. 31, 2023, to collect data to determine whether services should be permanently added to the telehealth list following the COVID-19 PHE.
Telehealth Services for Mental Health
- Removes the geographic location requirements and allows patients in their homes access to telehealth services for mental health services. Clarifies that the home could include temporary lodging and locations near the patient’s home.
- Requires an in-person visit within six months prior to the initial telehealth service and in-person requirement every 12- months thereafter. The in-person requirement may be met by another physician or practitioner of the same specialty and subspecialty in the same group as the physician or practitioner who furnishes the telehealth service.
- Permits payment for mental health services to patients via audio- only telephone calls from their homes. The provider needs to document in the medical record why audio only is the best treatment approach.
Note: CMS also added an exception to the in-person requirement. “If the provider and the patient together decide the burdens associated with an in-person visit outweigh the benefits, they don’t have to have that periodic in-person visit every 12 months." The joint decision making must be documented in the patient’s medical record.
The final rule can be accessed here: https://public-inspection.federalregister.gov/2021-23972.pdf