IN NOVEMBER 2021, the Centers for Medicare and Medicaid Services (CMS) set off a bombshell with new rules governing how physicians and NPs/PAs can bill split hospital visits. The rules took effect this Jan. 1, just two months after they were finalized.
Groups with physician-NP/PA teams were left scrambling to figure out how to implement the new rules. The group led by Sushamma Brimmer, MD, regional hospitalist medical director for the Northeast Texas Region of CHRISTUS Health, with two campuses, is a case in point.
“For us, it’s still a work in progress,” says Dr. Brimmer, speaking in mid-December. “Right now, I’m working with the finance and coding departments to try to figure this out, and I’m not sure there’s a best way to handle it. But I do know that we have to come up with something that won’t terribly affect our workflow.” Like hospitalist leaders and administrators around the country, Dr. Brimmer spent the last weeks of 2021 in meetings with her physicians and NPs/PAs, trying to figure out options to meet the new rules.
“We have to come up with something that won’t terribly affect our workflow.”
~ Sushamma Brimmer, MD
Those options may come down to having doctors spend more time performing (and documenting) split visits with NP/PA teams or letting NPs/PAs bill more visits at 85% of the physician fee schedule. Some group members don’t much like either option.
What the new rules say
For years, physicians and NPs/PAs have been submitting bills for split (or shared) visits under physicians’ names and ID numbers for 100% of the allowable physician fee—as long as doctors perform a “substantive portion” of the visit. (Otherwise, NPs/PAs bill under their own names and ID numbers at 85% of the allowable fee.) Medicare, however, has never provided any real oversight of that billing. Further, it’s never spelled out what a “substantive portion” of a visit really means, other than saying that doctors can’t just rubber-stamp the care that NPs/PAs provide and capture the visit at 100%.
That’s now changed. In its proposed rule last year, the CMS said “substantive” would consist of having to perform more than 50% of the time it took for the entire visit; only the provider spending that 50+% time could bill it. But in response to very loud concerns—after all, tracking time in the hospital has been used only for critical care and prolonged services, never for admissions and subsequent inpatient care or ED visits—the CMS in its final rule decided to make 2022 a transitional year.
For this year only, doctors and NPs/PAs can determine who bills a shared visit by using either that more-than-50% time gauge—or physicians will be considered to be providing a substantive portion of the visit if they perform one of three key visit components (history, exam or medical decision-making) in its entirety.
“More transparency and visibility for NPs/PAs could be a good thing.”
~ Michael L. Powe
American Academy of Physician Assistants
That “entirety” language is also brand new. Up to now, doctors and NPs/PAs have both been able to contribute to all visit components and still bill at 100%. As for 2023, when this transitional year ends? As the final rule currently stands, the CMS will crack down and allow only time of more than 50% to determine billing.
Another change this year and going forward: Previously, the CMS had no idea if a visit being billed at 100% under a physician’s name was actually provided by two different clinicians. Now, all shared visit bills must come with a new modifier—FS-Split—to tip the agency off and allow it to track those claims.
A move toward more transparency
What’s behind the changes? According to Michael L. Powe, vice president, reimbursement and professional advocacy for the American Academy of Physician Assistants, Medicare has come to recognize that, in certain encounters, NPs/PAs may often perform the lion’s share of the care. If that’s the case, the CMS would rather pay only 85% of charges, not the 100% that groups may have been billing up until now.
Also, says Mr. Powe, the CMS is looking for transparency about physician-NP/PA teams, as well as the ability to collect data (through the new modifier) on visits NPs/ PAs contribute to.
“We never know with these visits who does what and how health care teams contribute to quality, patient satisfaction and care outcomes,” he says. “We’re never able to track the productivity of NPs/PAs or the revenue they generate because of billing mechanisms like shared billing.” When visit claims don’t accurately reflect the actual level of care NPs/PAs provide, he adds, NPs/PAs can look less important to their organizations.
“At what point will doctors decide they no longer want to work in a team pair?”
~ Heather Miles, CPC
St. Dominic Hospital
“If you don’t really understand their impact in health care,” says Mr. Powe, “you can’t determine how to most efficiently utilize the members of health care teams going forward.”
Mr. Powe is also waiting to see what changes this transitional year brings. “More transparency and visibility for NPs/PAs could be a good thing,” he says. He also believes that, given the new visit component requirements, some doctors may choose to bill fewer shared visits—and NPs/ PAs in the hospital may start submitting more bills at 85%.
Making team care less attractive?
In Jackson, Miss., Heather Miles, CPC, is the practice administrator for the hospital medicine department at St. Dominic Hospital. She also administers the billing and documentation of her hospital’s neurology and palliative care departments, both of which utilize NPs/PAs.
In their current model, the NP/PA-hospitalist teams at St. Dominic share documentation, with physicians billing on more acute cases and NPs/PAs managing less acute care. “It’s the physicians’ call on how often they want to add an addendum and capture the charge,” Ms. Miles points out. “That’s the benefit of a true ‘split-share’ environment in which the team shares the work.”
Like Mr. Powe, she thinks the revised rules could spur more non-split NP/PA bills at 85%, and she worries about that potential hit to her hospital’s revenue.
But she has other concerns. Two years ago, the hospital medicine department decided to change the NP/PA contracts so those advanced providers could share in the productivity bonuses the physicians receive when they meet their RVU threshold on split visits. Currently, the bonuses are divided 75%-25% between the doctors and the NPs/PAs.
“It makes more financial sense for physicians to see new patients of their own instead of doing several split visits.”
~ Timothy Capstack, MD
“That provided a great deal of satisfaction for our advanced practice providers,” says Ms. Miles. Now, she worries that generating more bills at 85% will drive competition over RVUs between the doctors who work with NP/ PA teams and the NPs/PAs themselves.
Or if physicians working with NPs/PAs want to continue billing 100% and safeguard a higher number of RVUs, they may have to do more work during shared visits than just providing an appropriate addendum.
“At what point,” Ms. Miles asks, “will doctors decide they no longer want to work in a team pair?” Currently, only 40% of the physicians in her group choose to work on a team with an NP/PA. In response to the new billing rules, she’s concerned that the ranks of hospitalists who want to work solo may grow, even though the hospitalists rely on their NP/PA teams to help manage their census.
The case for practicing autonomously
Hospitalist Timothy Capstack, MD, was the lead author of an influential study on how groups use NPs/PAs that appeared in the October 2016 issue of the Journal of Clinical Outcomes Management.
In that research, Dr. Capstack found that his private group in Maryland—compared to an employed hospitalist group working in the same hospital—had the same outcomes with lower costs by using what the article called an “expanded PA” care model. Compared to the other group, his program relied on a much higher PA-to-physician staffing ratio, with physician-PA pairs seeing considerably more patients per day than its comparator.
Dr. Capstack’s group has now rebranded as Adfinitas Health, a private hospitalist group with about 200 physicians and 200 NPs/PAs serving in 15 hospitals and 50 post-acute care settings across six states. (Dr. Capstack is partner and clinical integration director.) Given that the group’s number of NPs/PAs has kept pace with that of doctors, it’s clear that NPs/PAs are still key to the program’s care model. Because the group relies on their ability to practice autonomously, NPs/PAs undergo extensive training and onboarding when they’re hired.
The extensive use of NPs/PAs is a selling point for hospital clients, Dr. Capstack says. “We’ve found a receptive environment,” he points out. “We’re more affordable because our salary needs are so much lower than groups staffed entirely by physicians. Hospitals have to offset less of our costs.”
Sometimes, doctors in his group do find it medically necessary to split a visit with an NP/PA, and “we’ll of course spend as much time as we need to,” he says. But many NP/PA visits are billed at only 85%, which Dr. Capstack says makes sense for his group.
“It takes a fair amount of time for the physician to earn that additional 15%,” he notes. “If it’s not clinically necessary, it makes more financial sense for physicians to see new patients of their own instead of doing several split visits. We don’t count on split visits for a big chunk of our reimbursement.” While the new billing rule will have some impact on him and his colleagues, he adds, “it probably won’t get to us as much as it might affect other groups that have different billing structures.”
How to assign RVUs
Alissa M. Clough, MD, is president of Inpatient Physician Associates, a private hospitalist group in Lincoln, Neb., that covers two Bryan Health hospitals. To figure out what her group wants to do to get ready for the revised rules, Dr. Clough has put in hours with representatives of her group’s billing company as well as her hospitals’ director of medical informatics and operations director.
Until now, her group—with 38 physicians and 30 NPs/ PAs—has billed about 90% of its claims for NP/PA team care as split visits at 100%. Going forward, she’s not sure how many of those claims may start being billed at only 85%, or what impact that change could have on group revenue. (See “An opportunity in open ICUs?“)
“The physicians may just go see more patients” as in Dr. Capstack’s group, Dr. Clough says. “In the end, we may not worry about the 15%.”
But that raises logistical and accounting challenges, she says, such as how to make sure the RVUs being billed at 85% under the NPs/PAs get assigned to the physicians who supervise them. That RVU assignment for physicians is also top of mind for Dr. Brimmer in Texas.
“One option may be to put all the RVUs generated by NP/PA billing at 85% into a bucket, then divide them among all the physicians who work with NPs/PAs,” says Dr. Brimmer. “That would assume that all those doctors use NPs/ PAs pretty evenly.” She adds that productivity accounts for as much as 25% of physicians’ income in her group.
In Nebraska, Dr. Clough and her colleagues are also trying to figure out what EHR and documentation changes are needed to accommodate the new billing rules. “Most of our shared billing right now is for admissions,” she points out. To meet the new rule’s component requirements for billing a shared visit at 100%, her group is reviewing how best to document in attestations that physicians are indeed providing the substantive portion of medical decision-making or of whichever component they choose to complete.
“Our physicians already do this, but has that been documented in a manner that complies with this new rule?” Dr. Clough says. “We’re working on adding some Epic SmartPhrases and a hard stop to make sure doctors document the assessment and plan within the attestation.” She also thinks that “physicians will have to do a bit more documentation and be more diligent about making sure the assessment and plan are on every attestation we do.”
Weighing component options
According to Dr. Capstack in Maryland, the visit component that doctors opt to complete to meet the new rule will be based in part on the particular patient they’re treating. (Again, according to the new rules, physicians’ ability to document a note component in its entirety and bill a split visit will no longer be an option in 2023.) But in terms of being efficient with physician time in split visits this year, “I’m guessing that documenting the interval history might be the way to go,” he says. “That would be less cumbersome than medical decision-making, which makes up the bulk of the progress note.”
In Texas, Dr. Brimmer is also weighing options around the various visit components. While she is certainly sensitive to physicians’ time and productivity needs, she’s also concerned about NP/PA job satisfaction.
“If we have to structure split visits in a way that NPs/PAs can’t bring anything to the table in terms of their clinical thinking, I’m worried they’ll feel like a scribe,” Dr. Brimmer says. “That concerns me. I definitely respect and value our advanced practice clinicians, and the last thing I want to do is lose them.”
For at least the first quarter this year, Dr. Brimmer adds, she and her colleagues may not make major changes. Instead, “we may just let the chips fall where they may, then make whatever changes we need.”
Mr. Powe from the AAPA points to another unknown: what definitive guidance Medicare administrative contractors (MACs) might put out about the revised rules and how much variation among MACs there will be. In the meantime, his biggest concerns are about 2023, when the rules are slated to change—and split billing may be based exclusively on time.
If that’s the case for 2023, “it may be necessary for the CMS to have some discussions with various professional groups about that,” he says. Dr. Clough in Nebraska agrees.
“We’re going to take this a year at a time,” she says. As for the drastic changes slated for 2023, “I’m going to hope that the Society of Hospital Medicine and other groups will continue to work toward solutions that benefit all parties. I worry about the strain on groups from only time-based coding for all shared visits.”
An opportunity in open ICUs?
WHEN IT COMES to the CMS’ revised rules for split billing, the possible impact on billing new and subsequent inpatient visits—and on hospitalist workflow—are getting most of the attention. But the new rules include other changes that should be on hospitalists’ radar.
“Shared critical care billing could have some advantages.”
~ Alissa M. Clough, MD
Inpatient Physician Associates
For one, NPs/PAs and physicians for the first time can now submit split bills for some services in skilled nursing facilities. That change may not have much of an impact because two providers aren’t usually engaged in SNF visits.
But here’s another first: Physicians and NPs/PAs can now submit split bills for critical care services, and that’s a big deal for hospitalists who work with NPs/PAs in open ICUs. Inpatient Physician Associates in Lincoln, Neb., a private hospitalist group that covers two Bryan Health hospitals, does just that, says president Alissa M. Clough, MD.
“Shared critical care billing could have some advantages, and I’m excited about it,” Dr. Clough says. “Now, we’ll be able to get credit for both physicians’ and NPs/PAs’ time, which should boost our payments.” While her group’s NPs/PAs may start billing additional non-critical care services at 85%, the gains or added RVUs that group members may see in split critical care billing could offset that lost revenue.
Critical care services, of course, are billed according to time, so the new split billing rules in the ICU pose some logistical and template challenges. According to Dr. Clough, she and her colleagues aren’t sure yet how to best capture the time element for each provider.
But “we may have to revise the critical care note—and we’ll need some kind of pop-up or alert to make sure physicians enter both their time and that of the associate,” she says. Her group plans to lean on its Epic resources to make documenting time spent providing critical care for split bills more seamless.
How many NPs/PAs bill independently?
It remains to be seen how new CMS rules on split billing that took effect Jan. 1 may change the number of hospitalist NPs/PAs who are billing independently.
For an idea of what billing statistics have looked like up to now, the “2020 State of Hospital Medicine Report” published by the Society of Hospital Medicine offers a great snapshot. For hospitalist groups that treat only adults, 83.3% reported employing NPs/PAs, a percentage that varies widely by region. Close to 94% of groups in the East, for instance, use NPs/PAs, but that’s true for only a bare majority (50.8%) in the West.
As for how those programs bill the work of their NPs/PAs, 17.4% said that NPs/PAs bill independently, while almost twice as many—31.6%—bill their work as shared services under a collaborating/supervising physician’s provider number. However, an even larger percentage—42.9%—use a combination of both independent and shared services billing. A much smaller group (8.1%) reported that NPs/PAs don’t provide billable services or at least don’t submit service charges to payers.
Other stats from the 2020 report on NPs/PAs:
• Among different employment models, 88.3% of multistate hospitalist management companies said they employ NPs/PAs, which is true for only 40% of private multispecialty or primary care groups.
• Private multispecialty/PCP groups have the highest percentage of NPs/PAs billing services independently: 26.7%.
• Among NPs/PAs employed by hospitals, health systems or integrated delivery systems, only 10.5% of NP/PA services are independently billed.
Published in the January/February 2022 issue of Today’s Hospitalist