Optimizing Shared Care and "Incident To" Services in 2024

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Solving the Mysteries And Changes Around Shared
Care 2024 Incident to
Jan Rasmussen PCS, ACS-OB, ACS-GI, ACS-EM

Professional Coding Solutions janrpcs_at_aol.com
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Objectives

• Explore the difference between shared care and
  incident to services.
• Recognize changes to shared care in 2024
• Review specific guideline for each service
• Understand reimbursement issues
• Define QHP providers versus clinical staff and
  services they can provide
• Understand which services require orders
• Look at how other payers view these Medicare
  policies

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Basics

• All physician groups that employ QHPs may be
  faced with billing Medicare for their services.
• The key issue is differences in reimbursement
  based on who reports a service
• Services billed using the physicians NPI are
  paid at a 100 of the PFS rate
• Services billed using the QHPs NPI are paid at
  85 the PFS rate
• Huge compliance issue
• Failure to comply with the shared care and
  incident to rules can lead to issues ranging
  from
• Claims denials
• Overpayments /paybacks
• Future pre- and/or post-payment review
• False claims liability
• Lookback or statute of limitations of up to ten
  years).

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QHP/NPP

• A QHP/NPP is a licensed health professional
• Recognized by Medicare as able to
  evaluate/diagnose, treat and be paid for
  medically necessary services on the Part B
  physician fee schedule
• Qualified by education and training
• QHP must meet eligibility requirements to be
  credentialed by Medicare and bill independently
• Examples nurse practitioner, physician
  assistant, clinical nurse specialist, certified
  nurse-midwife

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Clinical Staff

• Person who works under the supervision of a
  physician or other QHP professional
• Allowed by law, regulation and facility policy to
  perform or assist in the performance of specific
  professional services
• 99211 or specific code based on TOS
• Service billed under physician/QHP name
• Includes medical assistants, licensed practical
  nurse, etc.

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Split/Shared Care

• Shared or split services are Evaluation and
  Management (E/M) services performed jointly but
  not concurrently between a physician and a
  non-physician practitioner (NPP/QHP), in the same
  group, in a facility setting.
• May not be performed in office setting (POS 11)
• Services may include both face-to-face and
  non-face-to-face activities.
• QHP/NPP is employed in the same group practice by
  the physician or employed by the same employer
• Work must be performed on the same date of
  service
• Rounds at different times of day
• If a physician saw the patient in the morning and
  his partner sees the patient later in the day for
  the same problem they would bill one E/M service
  but they may combine the complexity of their
  services and bill for the level of the joint
  visits.
• CMS requirements for split shared care in 2024
  were supposed to be based on total time to
  determine the substantive portion.

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Split Shared Care

• Significant change in CPT and under the 2024
  final rule.
• Substantive portion now either 50 of the
  total practitioner time or substantive portion of
  medical decision making.
• History and physical exam no longer considered
  for substantive portion of visit.
• Medical decision-making has 3 components
• Number and complexity of problems addressed
• Amount and/or complexity of data to be reviewed
  and analyzed
• Risk of complications and/or morbidity or
  mortality of patient management
• Based on CMD as the substantive portion a
  provider would have to document all or 2/3rds of
  CMD to qualify as substantive portion.
• CMS feels MDM is not easily attributed to a
  single physician or NPP when the work is shared,
  it is expected that whoever performs the MDM and
  subsequently bills the visit would appropriately
  document the MDM in the medical record to support
  billing of the visit

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CPT Split Shared Care

• For the purpose of reporting E/M services within
  the context of team-based care, performance of a
  substantive part of the MDM requires that the
  physician(s) or other QHP(s) made or approved the
  management plan for the number and complexity of
  problems addressed at the encounter and takes
  responsibility for that plan with its inherent
  risk of complications and/or morbidity or
  mortality of patient management. By doing so, a
  physician or other QHP has performed two of the
  three elements used in the selection of the code
  level based on MDM.
• If the amount and/or complexity of data to be
  reviewed and analyzed is used by the physician or
  other QHP to determine the reported code level,
  assessing an independent historian's narrative
  and the ordering or review of tests or documents
  do not have to be personally performed by the
  physician or other QHP, because the relevant
  items would be considered in formulating the
  management plan.
• Independent interpretation of tests and
  discussion of management plan or test
  interpretation must be personally performed by
  the physician or other QHP if these are used to
  determine the reported code level by the
  physician or other QHP"

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Split/Shared Care

• Activities that may be considered as part of
  substantive time
• Preparing to see the patient (for example, review
  of tests)
• Obtaining and/or reviewing separately obtained
  history
• Performing a medically appropriate examination
  and/or evaluation
• Counseling and educating the patient/family/caregi
  ver
• Ordering medications, tests, or procedures
• Referring and communicating with other health
  care professionals (when not separately reported)
• Documenting clinical information in the
  electronic or other health record
• Independently interpreting results (not
  separately reported) and communicating results to
  the patient/family/caregiver
• Care coordination (not separately reported)

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Incident to Requirements

• Performed in physician office
• Physician provides direct supervision
• Physician must be present in the office
  suite and immediately available to furnish
  assistance and direction throughout the
  performance of the procedure.
• Supervising physician can be any physician in the
  clinic
• Does not have to be same physician that initiated
  care
• If auxiliary personnel perform services outside
  the office setting, e.g., in a patients home or
  an institution (other than hospital or SNF),
  their services are covered incident to a
  physicians service only if there is direct
  supervision by the physician e.g., the
  physician must be physically present to oversee
  the care.
• PHE temporarily changed direct supervision rules
  to allow the supervising professional to be
  remote and use real-time, interactive audio-video
  technology, instead of requiring the physicians
  physical presence.
• Extended flexibility until December 31, 2024

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Documentation

• Identity of performing provider
•  Note indicating name of supervising/billing
  physician was in the office suite at the time of
  the service.
• Preferable to have physician order available that
  ordered follow up by QHP or ancillary service

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THE END
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