Split/Shared Visits - Q and A

Hello Mr. Weiss,
 
I read your article "Split/Shared Visits" and found it to very helpful . We recently added a PA to our surgical office and the rules for PA billing are extremely confusing and many times contradictory by payor. And the recent change by Michigan BCBS regarding PA's has totally muddied the waters with no resolution in sight.
 
I would appreciate clarification of one statement you made regarding the general requirements for these visits.  You state "If physician only participated in the service by reviewing the patient's medical record, then service may only be billed under the NPP's UPIN/PIN."   My understanding of the Medicare rules is that a PA can see a patient with the physician only reviewing the medical record and be billed as the physician as long as it's an established patient with a physician-established course of treatment for existing problems and the physician is in the suite at the time of the appointment. For most other payors, the "in suite" requirement does not exist  it's "per state rules" which in Michigan allows for phone calls, etc.  If it's a new problem, the physician must see the patient himself and provide clinical direction in order for the physician to be billed.  If the PA treats the new problem without direct physician interaction, then the visit must be billed as the PA.  Review of the medical record for new problems can not be billed as the physician unless s/he actually sees the patient.  Does your statement mean that the physician is supposed to be actually seeing every single patient that the PA sees in order to be billed as the physician?
 
Thanks for your ongoing articles in BC Advantage.  The information you provide helps keep me informed in a rapidly changing environment.
 
Sincerely,
Pam Trombley


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Hello Pam Trombley:

First I would like to thank you for submitting your question. Second, thank you for your kind words related to my articles. I am glad to know they have been of help to you and your staff! Now, on to the question at hand. When an established patient presents for follow-up with your PA and there is nothing new going on with the patient, they are simply there for the follow up of their chronic problem then under the general supervision guidelines of "Incident-To" provisions the services rendered may be billed under the the physician number. If that established patient comes back in presenting with a new problem and only the PA sees them and develops the treatment plan then the services need to be billed under the PA. If the patient is seen by the physician and the treatment plan is devised by the physician as well as having the "Key" components of the E/M service are performed by the physician then the services are billed under the physician. Below are some General Requirements for "Incident-To" services:

Supervising physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary.
Physician has performed initial service & subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment.
The professional identity of the staff furnishing the service must be documented and legible.
Note: A counter signature alone is not sufficient to show that the "incident-to" requirements are met.

Examples:

    1. NPP sees patients in the office with the physician in the same office suite, immediately available to rendera assistance, incident-to requirements are met  the physician or the NPP may report the service
    2. NPP sees patients in the office while the collaborating physician is providing inpatient services at the hospital, - the service must be reported using the NPP's UPIN/PIN.

Question and Answer:

For Incident-to:

Can the NPP visit be for a new problem to the patient (i.e., the MD saw the patient as a new patient with HTN one month ago. The patient comes back to the office one week later with Pneumonia. Will this still qualify as incident to? (The MD initiated the plan of care for HTN, but did not initiate the plan of care for treatment of pneumonia on this patient.)

Answer: No, If the presenting problem is a new problem not previously evaluated by the physician, the NPP cannot bill incident-to, but should instead bill under his/her own PIN. The service will therefore be denied as "Payment adjusted as not furnished directly to the patient and/or not documented."

Pam, I hope all of this information and the further explanation is of benefit to you. Again keep the questions coming!

Regards,
Sean Weiss


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