CERNER FLASH FROM ONE MCLAREN

 CMS 2022 Changes to Documentation Guidelines

2/1/2022 Split / Shared Services:

Impacted Areas: Physicians with NPs & PAs in hospital (POS [Place of Service] 21), outpatient surgical centers or hospital departments (POS 22), Emergency Departments (POS 23), Inpatient Psychiatric Facilities (POS 51), Inpatient Rehab (POS 61), Skilled Nursing Facilities (POS 31), and Provider Based Clinics

[POS 19 off- campus locations; POS 22 for on campus locations]

Non-Provider-Based Clinics are excluded (POS 11). Effective: 1/1/2022

CMS' 2022 Final Rule includes changes for documentation guidelinesfor Split / Shared Services as of 1/1/2022 and now has new clarification that requires adjustment to documented statements.

Resource link for details: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-  medicare-physician-fee-schedule-final-rule

Split/shared services are no longer supported by a basic physician attestation such as, “I have personally seen and examined the patient, reviewed the PA’s history, exam, and MDM and agree with the assessment and plan as written.”

CMS' 2022 Final Rules now requires:

• To bill Split/Shared under a Physician, the documentation must support one of the following:

 Physician performed more than 50% of the time of the visit. However, the government has now clarified this language and indicates that it is looking for the actual time involved in care by the NP/PA and the physician not just the statement that it is more than 50% of the visit time.

OR

• Physician performed any one of the following three components in its entirety: the history, exam, and/or medical decision making (MDM) o Level of service cannot be higher than the key component documented by the physician allows o For example, if physician documents detailed exam for initial hospital visit and this component is used to support a split/shared service, the level of service cannot be higher than 99221. (There are criteria for the level of exam, ROS, etc. for billing at each level per prior CMS guidelines which are still in place.)

o Details about key components for each level (and whether need detailed, comprehensive, etc.) can be found here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf o Billing provider (physician) must sign and date o New Modifier FS is used to identify split/shared services.

• When billing in Cerner, the modifier can be added to the billing code in a dropdown menu (see screenshot on last page).

 Recommend physicians document complete assessment and plan to support substantive portion of MDM (medical decision making).

• Physician signature and date will support a split/shared visit billed by the physician.

o You must document under your own login to capture documentation under the physician.

Split/Shared Physician Documentation Recommendations:

1. When documenting time for split / shared billing as the NP or PA:

NP and PA statement would use the autotext : .attestNP_PA_TimeCMS2022 ; "I have personally seen and examined the patient, performed the documentation and the assessment and plan as written. Number of minutes spent on the visit: [        ].”

When performing more than 50% of the visit and documenting time for split shared billing as the Physician (MD/DO):

"I have personally seen and examined the patient, reviewed the documentation and agree with the

assessment and plan as written.  Number of minutes spent on the visit: [           ].” In Cerner this can be inserted using autotext  .attestPhysicianNP_PA_TimeCMS2022

**Please note that the time would need to be documented by the NP / PA and by the physician separately in their documentation. The physician time would have to exceed the NP / PA time to meet the standard.

2. When performing history, exam and/or MDM in its entirety:

"I have personally seen and examined the patient and reviewed the documentation. I have performed the history /exam / MDM in its entirety per my documentation."

* Physician would include the history, exam and/or MDM as applicable when performed. Only one is required.

You can adjust the statement to reflect what you have done (delete the part of the phrase that you did not do). In Cerner this can be inserted using autotext  .attestPhysicianNP_PA_MDM_CMS2022

**Next year, in 2023, Medicare will move to time-based documentation ONLY to support split/shared visit billing. The billing provider will be the individual who documents the most time spent with the patient.**

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SOUTH/SOUTHEAST

BILLING BUZZ SPOTLIGHT

Hear ye, Hear ye!

Presenting the fabulous South/Southeast Chapter officers!! We are here and ready to serve our chapter and the MMBA with exciting meetings and interesting industry content to share.

Previous Meeting Topics:

• 2022 Telehealth Guidelines for BCBSM Confirmation
• Cosmetic Surgery- Gluteal Transfer
• Social Determinants of Health and HCCs

Upcoming Meeting Topic:

Credentialing with Gwen Davenport

Come & Join Us!!

Unintended Consequence  

By Jill Young, CPC, CEDC, CIMC

As a member of the WPS Medicare Provider Outreach and Education and Education Advisory Group (POE AG) I was made aware of some disturbing information during a recent meeting.  The concern has been a known issue in the past.  However, now with increased numbers of claims are being submitted by Nurse Practitioners or Physician Assistants, there is now a more widespread problem of rejections for these types of claims with no payments being made.  The problem occurs in large groups or hospital systems where there are multiple specialties under the same tax ID, and Nurse Practitioners and Physician Assistants that work for those specialties are involved in the care of the patients (predominantly in the hospital).

Previously when multiple services by multiple physicians of differing specialties were performed on the same date, the claims submitted were paid by Medicare.  They did not show as concurrent care because the specialty denotation of each physician Medicare had on file showed that the services were performed by differing specialties.   Looking at that same scenario where perhaps two of the specialties had billings under their Nurse Practitioners (NP) is now a problem because the specialty denotation for the NP is simply Nurse Practitioner (50).  There is no medical specialty associated with their number.  The first claim submitted in this example is paid, but the second one is not.  Medicare sees the second claim by the same provider type is concurrent care and rejects that claim.  To Medicare, providers of the same specialty under the same Tax ID are seen as one provider.  The same is true when looking at this  scenario for Physician Assistants (PA) whose specialty denotation is Physician Assistant (97).

In a large system that utilizes Non-Physician Practitioners (NPP) of this type, rejections for a particular patient’s claims submitted for a date of service can be significant, depending on the number of NP or PA provider specialties that are submitting claims on a particular date.

WPS Medicare has indicated that they cannot change policy, only CMS/Medicare can.  On the POE AG call several members indicated they had received multiple rejections on patients for dates of service when one of these two provider types (NPs and PAs) submitted multiple claims.  Again, this is one of these provider types submitting claims on the same patient on the same date of service (i.e. several NP’s of differing specialties) 

This type of rejection for overlapping services by Nurse Practitioners or Physician Assistants can happen anytime in a large system including office New Patients (when an NP or PA has seen the patient at another location and the patient goes to a different specialty practice in the system and is seen by the same provider type (NP or PA).  If the NP from the first practice bills a new patient visit when the NP from the second practice in the same system under the same tax ID bills a new patient visit, the Medicare claim will reject.  Again, this is because there is no specialty associated with the NP’s specialty number.  The same is true if both providers were PA’s as well.

Unfortunately, this is not to offer any solution, but rather bring to your attention a problem that already existed but is now exacerbated by CMS/Medicare’s redefinition of their Split or Shared Policy.  It is, perhaps an unintended consequence of the policy change that should be addressed.