Medicare Guidelines: Critical Care with a Physician and NPP

Basically, if you’ve got two physicians in a group practice and they both provide critical care the same day, you can combine their time and bill it under one of the physicians because that’s what you're supposed to do. You're supposed to add their time together and bill it under one of the physicians. Read this expert medical billing training article for more.

However, you cannot combine physician time and non-physician practitioner time for critical care because the result is that each provider would have to fully meet the requirements of that code in order to bill that service. You wouldn’t combine them. So for example, if the physician did 30 minutes of critical care and the nurse practitioner did 30 minutes of critical care, you would bill the physician as 99291 and the nurse practitioner is 99292 under her own number.

If either one did less than 30 minutes, that portion could not be billed as critical care and just would not be billed. Our expert stated in a live billing conference that, however, with the physicians if one had 20 minutes and one had 25, you can add those times together.

Now, some people say, “Well, a non-physician practitioner can't do critical care anyway.” Yes, they can if it's allowed by their scope of practice.

Now, originally the policy on consultations was not in writing. So there was a lot of confusion even though we had a CMS official state that the shared visit policy could not be applied to consultations and some carriers allowed it. But Medicare did clarify that back in December of 2005.

But one of the things that you're going to find when you're pulling together all of these regulations for nurse practitioners and PA is that it's not all in one location. Some of it in the Medicare Benefit Policy manual, some of it in the Medicare Claims Processing manual is in different sections. So this regulation is actually in the section of consultation, not in the section on non-physician practitioners or incident-to or shared. So, consult cannot be shared.

Shared visits in the office

The regulation doesn’t say anything about shared visits in the office but what CMS has said is that, “Yes, you could have a shared visit in the office, but you would still have to meet incident-to guidelines first.” So if you’ve already met incident-to medical billing guidelines, really the only benefit to having a shared service in the office would be if both the physician and the non-physician practitioner provided some counseling to that patient and you could add your time together.

But really, that’s the only benefit. And the reason was they weren’t even thinking office. When they write the CMS policy on shared visits, they weren’t thinking office at all. They were trying to see how nurse practitioners and PAs could be used in a hospital setting. So, that’s why you don't even consider it in the office.

Now be careful not to confuse shared visit roles with teaching physician Medicare guidelines. With the teaching physician guidelines you have a teaching physician, you have residents in a graduate medical program. The physician has to go behind the resident in writing the attestation statement, that he has  seen the patient, discussed and agree with the language that Medicare recommends. It's not the same. It's not same for non-physician practitioners.

With the teaching physician, all he has to say is, “I have seen the patient and agree” or “I’ve seen the patient and discussed.” With shared visit, you want to see what the physician did. We have not had – this policy is not long-standing enough for us to have had many audits on shared visit services. So, it's really hard to see how it would apply on an healthcare audit setting, how an auditor would view it.

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