Revised Billing Guidelines For PA/NP Billing

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Revised Billing Guidelines For PA/NP
Billing
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Revised Billing Guidelines For PA/NP Billing
CMS recently introduced guideline changes to its
Medicare reporting rules that impact physician
assistant (PA) and nurse practitioner (NP)
billing. These changes could require practices to
modify how they report split/shared services.
Previously, shared services were frequently
reported in the name of a physician. Now, new
rules determine who can report the services.
Failing to comply with the new CMS rules will
create compliance risks for physician practices.
Lets understand revised billing guidelines for
physician assistant (PA) and nurse practitioner
(NP) billing. Revised Billing Guidelines for PA/
NP Billing Split/Shared Billing Split/ shared
visits are now defined as evaluation and
management (E/M) visits in the facility setting
that are performed in part by both a physician
and nonphysician practitioner (NPP) in the same
group. According to CMS, a facility setting means
an institutional setting this could apply to
inpatient hospital locations, outpatient hospital
locations, observation, the ED, or a skilled
nursing facility for selected services. Chapter
12 of the Medicare Claims Processing Manual no
longer includes an office/clinic example. CMS
reiterated that if a split/shared visit is
performed in an office/clinic setting,
incident-to criteria must be met. Office/clinic
settings are not all treated the same for billing
purposes. Private practices typically report
office services using place of service 11
(office), which is not a facility setting. As
such, those locations could use incident-to
reporting but are not allowed to apply CMS
split/shared rules. Hospital-owned or academic
practices may instead classify their offices as
place of service 19 (off-campus outpatient
hospital) or place of service 22 (on-campus
outpatient hospital).
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Revised Billing Guidelines For PA/NP Billing
These locations are not allowed to use
incident-to reporting but could apply CMS
split/shared rules. Substantive Portion The
physician and the PA/NP must each provide a
portion of the service with the patient on the
same day and document their respective work. The
service must be billed by the provider who
performs the substantive portion of the visit.
Previous guidelines also required that both
providers provide face-to-face service with the
patient on the visit date. The guidance for how
much work the physician was required to perform
to allow billing was not explicitly described
though. Counting Time CMS is using CPTs 2021
E/M guidelines for codes 99202-99215 to define
the activities that can be counted toward total
time when determining the substantive portion of
the visit, whether or not they involve direct
patient contact. This is another area where the
impact of two sets of CPT E/M criteria is felt
Although the CPT rules for hospital-used codes
such as 99221-99233 and 99281-99285 state that
unit/floor time can be counted toward visit time,
they do not explicitly use this list of
qualifying services to determine the level of
service. Since 2021, CPT has used this list to
determine the level of service for E/M codes
99202-99215, but now CMS has stated it can also
be used to determine the substantive portion of
other E/M categories.
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Revised Billing Guidelines For PA/NP Billing
Face-to-face Contact CMS now requires that only
one of the providers has face-to-face contact
with the patient it is no longer required of
both providers. Furthermore, it is not required
that the provider who performs the substantive
portion has face-to-face contact. Documentation T
he revised guidelines state that the
documentation in the medical record must identify
the physician and NPP who performed the visit,
and that the individual who performed the
substantive portion of the visit must sign and
date the medical record. We believe that it is
best practice for all providers to
authenticate/sign their documentation, even if
not required by CMS. New Modifier Beginning in
2022, split/shared services must be reported with
a new modifier, FS. Note that this requirement
does not apply only to split/shared services
billed in the name of the physician if a visit
is shared by a physician and PA/NP and the PA/NP
performs the substantive portion, CMS still
requires the use of modifier FS.
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Revised Billing Guidelines For PA/NP Billing
Prolonged Services During 2022, the CPT codes for
prolonged services will depend on the setting. In
all settings, the combined time of both
practitioners must meet the criteria for the
appropriate code, G2212 in the office setting and
codes 99354-99359 for other inpatient/outpatient
codes, and either method 1 or 2 can be used to
determine the substantive portion. In 2023, only
the time method will be used to determine the
substantive portion. Practices should apply
these revised guidelines only to Medicare
patients and should research both state-specific
Medicaid guidelines and payer-specific rules to
confirm how they compare to Medicares revised
guidelines. If you need any assistance in
Physician Assistant (PA) and Nurse Practitioner
(NP) billing contact Medisys Data Solutions at
info_at_medisysdata.com / 302-261-9187
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