July 16, 2021 | By David Glaser
On May 3rd CMS pulled the shared visit language from the Manuals. The government has increasingly recognized that only statutes and regulations can limit Medicare coverage, so when something in the Manuals is not contained in either a federal law or a federal regulation, it is not binding. CMS has created a mechanism permitting people to request deletion of Manual language that is not based on a regulation, and someone submitted a request noting that the absence of a regulatory discussion about shared visits. Medical Claims Processing Manual Chapter 12, Section 30.6.1, which used to contain the discussion about shared visits, now says “Left intentionally blank for future updates.”
So, what does that mean for shared visits? And what WAS a shared visit? Let’s start with the second question. A shared visit is an encounter in the hospital where a physician and a non-physician practitioner like a NPP or PA, both see the patient on the same day. It can be extraordinarily difficult to understand how Medicare differentiates between services that are considered “incident to” and shared visits. There is a good reason for the confusion. Medicare sometimes used the two terms interchangeably. Moreover, shared visits seem like a subset of incident to encounters.
On a macro level, it is helpful to recognize that “incident to” is used in a clinic, and by “clinic” I mean a free standing location that is not billing as a hospital and has no associated facility fee. Shared visits have been used in the hospital inpatient or outpatient department. There is a policy reason for the difference. Medicare has a regulation, 42 CFR 411.15(m), that specifically excludes a variety of services to hospital patients. Included in the list of services that are not covered in the hospital are “services incident to a physician service.” In other words, a physician can’t bill for services incident to the physician’s work when they are done in the hospital, either inpatient or outpatient. If this weren’t confusing enough, Medicare routinely refers to a wide variety of hospital services as “incident to.” Unfortunately, the same term has been used multiple times with a different meaning. But when CMS is talking about hospital services incident to, they are talking about services covered by the facility fee, not professional services. This is terribly confusing, but also a topic for another day. For our purposes we are discussing services both performed, and billed, by a physician.
Recognizing that there are times a physician and a non-physician practitioner might both provide services to hospital inpatients and outpatients, Medicare wanted to find a way to explicitly acknowledge the method for submitting the claim. The result was a shared visit. When a physician and a non-physician practitioner saw the patient and the physician “provides any face-to-face portions of the E&M encounter with the patient” the two visits were combined into one, according to the now deleted language.
It is worth noting that in another section of the manual, also deleted, that discussed SNF visits, used slightly different language to describe the minimum requirements for a shared visit. That text, which was quoted by some contractors and a Medical Learning Network article, said that a physician could bill when performing “a substantive portion of the visit.” A substantive portion was defined some element of the history exam or medical decision making. Of course, those two instructions are not consistent. You can provide medical decision making without having any face-to-face interaction. Moreover, that text appeared in a section discussing skilled nursing facilities, and the fact that shared visits couldn’t be billed there. In short, it was not a place one would naturally look for guidance on shared visits.
Despite the poorly written Manuals, I have historically believed it was appropriate to combine work by two professionals to see a patient in the hospital as long as both of the professionals have actually physically seen the patient. If the physician has done any portion of an exam or history, which really could extend to asking “how are you” or looking at the patient’s respiratory effort, you may bill for the combined effort of the non-physician and the physician on one claim, and at the higher reimbursement rate billed by the physician.
And while you can do basically the same thing in the clinic, and there it would be called billing “incident to,” in the hospital the term to describe it is a shared visit.
With the language being withdrawn what should you do? I wish I could give a 100% guarantee that you can use the principles articulated in the deleted shared visit language without fear of retribution. While I can’t, I would still use those principles. At least one Medicare administrative contractor, WPS, explicitly said they’re still allowing shared visits and CMS has indicated that they will be issuing formal rulemaking to permit them. The proposed 2022 fee schedule will likely be issued in July, and it is possible it will include information about shared visits. Of course, even if it does, this will only be a proposal, with nothing final before January 1st. But the main reason that I would continue to use the “shared visits” principles is that they seem logical, and I don’t believe that they are explicitly prohibited by any statute or regulation. There is a longstanding principle that when two or more professionals of the same specialty see a patient in the same day, only one E&M services is billable. Nothing in the statutes or regulations PROHIBITS the idea that the work of the two professionals may be combined. Because of 42 CFR 411.15(m) we can’t say that the visit is “incident to,” but we can still argue that we are still applying the longstanding principle of combining visits by two professionals in the same specialty into one bill. Therefore, I would be inclined to bill using the principles outlined in the deleted Manual language. In the event that the claim is denied, you have a reasonable basis for appeal.
The other option, of course, is to bill the service under the name and number of the non-physician practitioner and await further instruction from CMS. Hopefully more definitive guidance will soon remove the ambiguity that clouds these shared visits.