It’s easy as a nurse practitioner to go throughout your workday with knowing exactly how you get paid. Yes, you may understand your basic hourly or salary compensation structure but your employer wouldn’t hire you unless you were bringing revenue into the practice. The rules and regulations surrounding nurse practitioners and billing are quite complex.
Fortunately, Health Care and Business Attorney Alex Krouse is passionate about nurse practitioners (his wife is an NP, after all…) and is an expert in medical billing issues. He has generously volunteered to give us a crash course in shared billing, a practice that affects us all as NPs whether regardless of our level of understanding of the issue. I have asked Alex a few questions about shared billing to help us all better understand the topic.
1. What is shared billing?
Shared billing is also referred to as a split visit. In hospital settings, physicians are seeing patients but often nurse practitioners, physician assistants, and clinical nurse specialists are seeing patients as well. Historically, the physician would see the patient and bill for the services using an evaluation and management code. In setting where nurse practitioners and other practitioners are utilized effectively, hospitals are able to allow nurse practitioners and physicians to service patients together. Shared billing or split visits allows both practitioners to provide services and their cumulative services can be billed to Medicare. However, each individual’s services alone would be insufficient for reimbursement. The practical implication is that hospitals can utilize nurse practitioners and other non-physician practitioners (NPPs) more effectively while still maximizing reimbursement.
2. How do payments to providers differ for shared visits versus NP or MD only visits?
Payments for shared or split visits are desirable because the cumulative efforts of nurse practitioners and physicians can be reimbursed at 100% of the physician fee schedule. Normally, if the nurse practitioner or NPP performed the services alone, the reimbursement would equal 85% of the physician fee schedule. The current exception occurs for services provided by nurse midwives which is reimbursed at 100% of the physician fee schedule. If a physician were to perform all of the necessary components of an evaluation and management service, reimbursement would be 100%. However, hospitals can utilize nurse practitioners and other NPPs more effectively while still receiving 100% of the physician fee schedule.
3. In order for a patient visit to be billed appropriately, what information must be included in the medical chart?
In order for an evaluation and management service to be coded correctly patient history, physical examination, and medical decision making must be documented in the medical chart. Under a shared visit, a nurse practitioner or NPP would provide one or two of those components and the physician would provide the additional one or two components to meet those requirements. Hospitals and practitioners should be aware that documentation is becoming increasingly important with respect to shared visits. It must be evident that both the nurse practitioner or NPP and physician are providing a portion of the services to meet those requirements. Both practitioners must document and sign for the work they perform and be in the same group practice. Finally, in order for the service to be reimbursed at 100% of the physician fee schedule, the physician must document and show a face-to-face encounter occurred.
4. Are there any circumstances where a visit cannot be billed as a shared visit?
Absolutely. Often, one of the most overlooked areas is the requirement that the nurse practitioner or NPP and the physician must be in the same group practice or be employed by the same employer. A second and more problematic instance are situations in which these visits have not been documented correctly. Nevertheless, hospitals run into billing issues when the nurse practitioner is employed by the hospital and the physician is employed by the hospital’s medical group. Although it might appear to allow shared visits, in many cases it would not meet the requirement of the NPP and the physician being in the same group practice or being employed by the same employer.
5. Medicare sets most guidelines for shared visits. How does shared billing differ with commercial insurance providers such as Blue Cross?
Medicare has historically set the policy and standards for private commercial insurers. Nevertheless, it varies across the board. Part of the problem is that Medicare only allows such billing to occur in states in which nurse practitioners or NPPs are not practicing outside their scope of practice. Unfortunately, in Indiana it would be completely appropriate whereas in other states it may not be. The primary reason being that scopes of practice vary widely throughout the United States. Because of this, in some states shared billing for private insurers operates much like the general Medicare guidelines. However, in other states billing would be impermissible simply due to scope of practice laws.
6. What are the most common problems you deal with in your legal practice when it comes to shared billing?
Generally, one of the biggest concerns hospitals have is not understanding how to effectively use nurse practitioners and other NPPs. We have assisted hospitals and other medical providers with implementing effective use and operations of nurse practitioners and NPPs. This includes how to use these practitioners to adhere to state and federal law, and how to properly structure such relationships. For example, when a hospital employs a nurse practitioner and employs a physician in a separate hospital-owned medical practice, shared billing cannot occur. The second biggest issue we have seen relates to proper operation and documentation. For shared billing to work effectively, documentation needs to be a primary focus.
7. What advice do you have for NPs based on your experiences with shared billing?
Nurse practitioners and other NPPs should understand that knowledge of billing rules and regulations are extremely important to their practice. Often, a simple understanding of these laws can have a direct impact on the level of care patients receive. For example, by documenting services properly other practitioners will have a more informed understanding of the patient’s needs. In addition, by understanding shared billing practitioners can assist their organizations on front lines as it relates to these complex legal issues.
Alex Krouse is a healthcare attorney at Krieg DeVault, LLP. He regularly counsels health systems, hospitals, and medical providers on corporate, transactional, and regulatory issues. Please feel free to contact him by email at akrouse@kdlegal.com or by phone at 574-485-2003.
This article is provided for informational purposes only and should not be considered legal advice. if you have specific legal questions, please contact your attorney. In some jurisdictions, this article is considered attorney advertising.