Despite another delay in the implementation of the Centers for Medicare & Medicaid Services’ (CMS’s) rule change for billing split/shared evaluation and management (E&M) inpatient visits, it is important that health systems, hospitals, and provider practices begin planning now for the impact the change will have on operational processes, documentation requirements, and billing procedures for hospital visits.
The new regulation requires action by provider practices, hospital-based provider groups, hospitals, health systems, and physician services organizations to determine how the new requirement should be implemented and monitored from a compliance perspective.
In part three of our continuing series on split/shared billing, we outline key operational and practice considerations organizations should review in preparation for full implementation of the new requirements, now planned for January 2025.
Who Bills for What?
When the new rule goes into effect, a shared hospital patient visit will have to be billed by the physician or advanced practice provider (APP) who performs the “substantive portion” of the visit.
Under the interim rule, providers bill for the visit if they complete the history and physical exam and/or complete medical decision-making on the date of service. Beginning in 2025, “substantive portion” will be defined as more than half of the total time spent during the visit. Providers will need to document the total time spent face-to-face with the patient and time spent on other activities that support medical decision-making, including:
- Reviewing lab or diagnostic study results.
- Evaluating the patient’s response to medications and treatments.
- Discussing the patient’s care with nurses or other providers.
- Discussing diagnostic findings and the plan of care with the patient.
- Documenting the patient’s medical history, physical exam findings, and progress notes.
- Order entry.
EHR documentation should account for how each provider spent their time on behalf of the patient; however, only the provider who spent more than 50% of the total documented time may bill for the visit.
Operational and Practice Considerations
Given these changes and traditional APP care delivery models, many provider practices and hospital-based provider groups will need to evaluate and modify team roles. Here are a few operational and practice considerations as your group plans for the rule implementation:
- Ensure that any planned changes to APP job roles are supported by state laws, nonphysician collaborative practice plans, and job descriptions.
- Ensure that medical staff bylaws accommodate the role of APPs as a rendering and rounding provider.
- Plan collaboratively within your group, and empower administrators, physicians, and APPs to jointly develop and implement a successful strategy for high-quality patient care, top-of-license practice, and billing compliance.
- Since the time requirement will define which provider may bill the visit, consider whether both the APP and the physician in the group need to see the patient. It may make more sense to divide and conquer, with physicians seeing all new consults and dividing rounding lists based on patient need and acuity.
- Assess and modify compensation plans to reflect shifting responsibilities and allocation of productivity.
- Evaluate the impact on practice revenue related to shifting some portion of billed visits to APPs.
- Develop and provide clear messaging to patients, referring providers, and inpatient team members regarding care delivery changes.
Edited by: Matt Maslin
Published August 25, 2023
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