Split-Shared Billing Challenges in Critical Care Service
Written by: Shannon O. DeConda, CPC, CPMA, CEMC, CEMA, CPA-EDU, CRTT
Effective collaboration between healthcare providers is vital in the fast-paced environment of Intensive Care Units (ICUs). Split shared services—where a physician (MD) and an Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA) jointly manage patient care—are increasingly common. However, billing for critical care services in such settings presents unique challenges concerning documentation and compliance with Centers for Medicare & Medicaid Services (CMS) guidelines. Understanding these complexities and creating effective documentation is essential to ensure accurate and compliant billing.
What Are Split Shared Services?
Split shared services refer to scenarios where two healthcare providers collaborate to manage a patient’s care during a single encounter. Typically, one provider takes the lead in direct patient management while the other supports through ancillary tasks. This collaborative approach creates efficiencies and increases patient care but introduces complexities in billing, especially for time-sensitive services like critical care.
The Critical Care Billing Puzzle
Critical care services are billed using time-based codes that reflect the intensity and duration of care provided to critically ill patients. According to CMS, to bill for critical care as a split/shared service, the documentation should reflect:
- A Minimum of 30 Minutes of Direct Patient Care: This involves face-to-face, direct patient interaction within a single calendar day.
- Perform Substantive Management: Both providers must engage in active management and decision-making beyond merely reviewing the medical record.
- Substantiate Medical Necessity: The critical care service, time, and substantive work of each provider must be validated on the basis of the patient’s condition and the complexity of the care as documented.
The Split Shared Billing Conundrum
Imagine a scenario where both an MD and an APRN/PA attend to a patient for critical care. The MD documents the required 30 minutes, meeting the time-based billing requirement. However, the APRN/PA does not include a time statement, nor does their work validate their personal contribution toward substantive management.
This gap in documentation can lead to significant compliance issues. CMS directs payment to the practitioner who performs the substantive portion of the visit. Without the APRN/PA documenting their time, it becomes challenging to verify who contributed most significantly to patient care. This uncertainty can trigger audits and potential billing discrepancies, putting your practice at risk.
Case Scenario: Critical Care Intervention by Nurse Practitioner and Physician
Let’s apply some hands-on learning.
In the Intensive Care Unit (ICU) of a busy hospital, Nurse Practitioner (NP) Jane Smith is managing a critically ill patient admitted with severe pneumonia. During her shift, Jane identifies that the patient is not responding adequately to the initial treatment regimen. She initiates critical care intervention, including administering vasoactive medications to stabilize the patient’s condition.
Later that day, Dr. John Green, the attending physician, rounds on the patient. He assesses the patient’s condition and notes that despite the initial interventions, the patient has become hemodynamically unstable, requiring immediate and intensive management. Dr. Green steps in to provide additional critical care. The cumulative documentation for critical care on that date totals 42 minutes.
Thought-Provoking Questions and Rationale
- Who Should Bill for the Critical Care Service: the MD or the Nurse Practitioner?
Rationale: According to CMS guidelines, billing for critical care services should be attributed to the practitioner who performs the substantive portion of the visit, defined as more than half of the total time spent. In this scenario, the total documented critical care time is 42 minutes. NP Jane Smith nor Dr. John Green document their contributed minutes to the total. It appears both providers performed substantive service to the patient, but there is no indication as to who spent the majority of time for billing purposes.
- Could the Coder Request That the Physician and Nurse Practitioner Review the Documentation and, If Possible, Provide an Addendum to Their Services?
Rationale: Yes, the coder can and should request that both Dr. Green and NP Smith review the documentation to ensure its accuracy and completeness. If there are any ambiguities or additional details that could clarify each provider’s contributions, an addendum should be added to the medical record. This collaborative review process helps verify that the documentation accurately reflects the services rendered by each provider. Additionally, providing an addendum can mitigate potential discrepancies during audits by demonstrating thorough and transparent documentation practices.
- If the Service Was Already Billed by the Nurse Practitioner, Is There a Compliance Risk with Keeping the Reimbursement?
Rationale: If NP Smith billed for the critical care services based on her documented 30 minutes, and this documentation is accurate and clearly supports that she performed the substantive portion of care, then retaining the reimbursement is generally compliant. However, considering that the NP’s reimbursement rate is 85% of the physician fee schedule, the billing may not precisely reflect the full value of the services rendered. This discrepancy doesn’t inherently pose a compliance risk, but it does underscore the importance of accurate and comprehensive documentation.
To minimize any compliance risks, especially if an audit occurs, it is essential to ensure that all critical care activities are thoroughly and accurately documented by both providers. If the documentation can be updated to more precisely reflect the services rendered by each provider, it should be done to enhance clarity and support accurate billing practices. Best practice involves updating the documentation, when appropriate, to reflect the exact nature and extent of each provider’s contributions to patient care.
Determining the appropriate billing provider requires an accurate account of each practitioner’s time and contributions to patient care. While billing through the Nurse Practitioner is compliant with CMS guidelines, it’s essential to recognize the difference in reimbursement rates compared to physicians. By addressing these thought-provoking questions and implementing best practices—such as updating documentation to accurately reflect services rendered—healthcare providers and coders can better navigate the complexities of critical care billing. This ensures compliance with CMS guidelines, minimizes financial and regulatory risks, and promotes the accurate representation of the high-quality care provided to critically ill patients.
Take Action Today
Ensure your critical care billing practices are accurate and compliant. Reach out to our billing specialists for personalized support in navigating split shared services between physicians and nurse practitioners. Enhance your documentation processes and maximize your reimbursements by partnering with our expert team. Don’t leave your billing to chance—Contact Us Now to review your ICU billing strategies today.
About the Author:
Shannon O. DeConda, CPC, CPMA, CEMC, CEMA, CPA-EDU, CRTT
Ms. DeConda has devoted her entire career to healthcare, starting as a front-desk receptionist and progressing through roles in medical assisting, respiratory therapy, practice management, billing and denials support, and in-office coding, auditing, and education.
In 2007, she founded the National Alliance of Medical Auditing Specialists (NAMAS)—the first organization to formally educate medical auditors and the original creators of the CPMA credential. Today, as President of NAMAS and as the VP of Regulatory Compliance with the parent company, DoctorsManagement, Ms. DeConda continues to elevate industry standards, providing essential resources and training to healthcare professionals nationwide.
