Billing for Shared Visits: What Group Practices Need to Know
In healthcare group practices, it is common for both physicians and non-physician practitioners (NPPs) to be involved in patient care, especially within facility settings such as hospitals and skilled nursing facilities. Though these shared visits bring many benefits to holistic care delivery, they create difficulties regarding correct and compliant billing processes. In fact, the rising role of NPPs in patient care requires healthcare practices to learn proper shared visit billing procedures to receive appropriate reimbursement while avoiding audits.
Healthcare providers must grasp all specified guidelines established by CMS and other insurance companies when performing shared visit billing operations. This includes recognizing who is responsible for billing based on the substantive portion of the visit, which is determined by factors like time spent or the medical decision-making (MDM) process. Incorrect billing results in reimbursement denials with payment errors and non-compliance challenges.
This blog will provide you with essential information about shared visit billing procedures, offering practical insight to establish precise and efficient practice billing protocols.
Billing for Shared Visits
During shared visits, both the physician and the NPP provide simultaneous medical care to patients within one encounter time. The provider who carries out the “substantive portion” of the visit holds the responsibility for billing the service to CMS. The substantive part of a visit has two methods to determine it:
Time-Based Billing: If the billing is based on time, the combined time spent by both the physician and the NPP is used to determine the correct CPT code. A provider becomes the substantive service provider after investing more than 50% of the total joint visit time with the patient.
Medical Decision-Making (MDM): For MDM-based billing purposes, the medical professional who takes the lead role in decision making should take responsibility for billing the service. This comprises all activities, such as developing a treatment plan and assuming responsibility for the ongoing care of the patient.
In shared visits, both time and MDM can be used to determine which provider performed the substantive portion of the service. For example, when patients receive attention from two providers, the one who dedicates lengthy periods to test result analysis and treatment plan modification will handle the billing responsibilities.
Key Considerations for Shared Visit Billing
Shared visit billing applies exclusively to services provided in facility settings, such as hospitals or skilled nursing facilities. In such facility settings, it is common for NPP and a physician to collaborate during patient care. This rule does not apply to services rendered in non-facility settings, such as private offices, where different billing guidelines may apply.
It is important for both the physician and the NPP involved in a shared visit to be part of the same group practice. This means that they must be employed under the same Tax Identification Number (TIN) to be eligible for shared visit billing. This requirement helps ensure that the services are considered part of the same organizational structure.
Documentation is key in billing for shared visits. This highlights the need to mention the contributions of both the physician and the NPP in the medical record. It should specify who performed each part of the visit, whether it was taking the patient history, performing the physical examination, or making the medical decisions. This level of detail is crucial to support the billing process and ensure that the right provider is reimbursed.
The procedure necessitates the correct CPT code in addition to the modifier -FS in shared visit claims submission. The modifier -FS demonstrates that clinical service was a split/shared visit, informing insurance companies about dual physician and NPP involvement in patient treatment.
The billing procedure for shared visits extends to critical care treatment services. The medical service should be billed by the physician or NPP who fulfills the substantial visit requirements during the visit or MDM considerations. Therefore, healthcare providers should bill the critical care service through CPT 99291 and use the add-on code CPT 99292 for extended periods.
Billing for shared visits requires careful attention to technical details, but group practices can achieve proper healthcare reimbursement by understanding the billing process guidelines. Proper billing requires evaluating the substantive portion of the visit, as this determination can happen through time spent or the medical decision-making process. In fact, clear documentation and appropriate modifier applications help practices simplify their billing operations while remaining compliant with rules.
As billing requirements continue to evolve, it is important for group practices to stay updated on the latest guidelines. If you are unsure about how to deal with these billing complexities or if you want to ensure your practice is billing accurately, consider reaching out to 24/7 Medical Billing Services. With their expertise, they can help optimize your billing process and offer valuable guidance through a free consultation.
Q1. Which billing code should be used for shared decision making as per CMS guidelines?
HCPCS code G9297 is used for shared decision-making when discussing conservative therapy before a procedure, as per CMS guidelines.
Q2. Can you bill for a follow-up visit?
Medical practitioners should bill follow-up visits using the appropriate E/M code (e.g., 99211–99215).
Q3. Explain how CPT code 99490 is different from 99439.
CPT 99490 serves non-complex chronic care management (CCM) sessions, whereas 99439 allows for additional 20-minute CCM sessions.
The practitioners can bill CPT code 99454 during each 30-day interval when the patient participates in remote patient monitoring for at least 16 days.
Q5. What is the billing code 99458?
CPT code 99458 can be used to bill RPM (Remote Patient Monitoring) services offered under Medicare guidelines.
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