Medicare and Medicaid split visit policy questioned by providers

Providers want the Centers for Medicare and Medicaid Services to change the upcoming policy about paying for hospital visits when both doctors and non-physician providers see patients.

Latest CMS Organizing a doctor’s fee schedule It proposes deferring the requirement that time spent with a patient will determine which provider can bill a visit until 2024. CMS originally planned to start the policy next January.

Healthcare trade groups welcomed the delay, but urged CMS to use the extra time to figure out an alternative policy that would allow for billing based on which provider spends the most time with the patient, or who drove the medical decision process. Providers are concerned that the policy could lead to a 15% cut in facility fees.

“We continue to have significant concerns about this policy and therefore support CMS’s proposal to delay its implementation. We urge the agency to use this delay to re-examine this policy, including by working with stakeholders to develop an alternative proposal for billing for split or combined visits,” the Hospital Association wrote American in a comment letter to CMS.

Medicare pays more for physician services than other advanced providers, such as physician assistants and nurse practitioners. While physicians receive full Medicare payments for assessment and administration visits, non-physicians typically receive 85% of the Medicare rate.

In an office setting, providers can use “incident to” billing and charge a doctor visit when a non-doctoral provider sees a patient. However, accident-to-hospital billing does not apply in other hospital and facility settings.

Until last year, CMS relied on routing documents to organize billing for split or shared visits in a facility environment, and allowed clinicians to bill for co-assessment and management visits when the physician performed a significant portion of the service.

But the Trump administration ruling

In January 2021, the Department of Health and Human Services issued a draft regulation Which aims to crack down on policies set outside of setting notice and comment rules, which have brought the Joint Visitation Guidelines to the fore. CMS withdrew its cross-visit billing guidelines in May 2021, and announced that it would return to rule-making politics.

CMS ‘ Doctor fee schedule for 2022 Expanded when providers can bill joint visits, establish a codified definition of visits, and most importantly, use time to determine which provider did the essential part of the visit.

Providers expressed concerns about the policy in comments to the 2022 fee schedule. Mayo Clinic described time tracking as “extremely problematic” in a comment letter sent to CMS last year.

What would be considered a physician spends a ‘substantial’ amount of time in [evaluation and management] A visit may change when another [non-physician practitioner] From the same specialty see the patient later in the day. The [non-physician practitioner] He may be unaware of the amount of time each provider spends with the patient, especially if not all providers document time,” the Mayo Clinic wrote.

More than 40 commercial healthcare organizations sent another letter to CMS in March urging the agency to propose a joint visitation policy based on decision-making as well as time. The policy that was completed this year is suspended Team Based CareI wrote groups.

Although CMS finalized the changes last year, in July the agency proposed delaying the policy to use the time to determine bills. The additional year will give service providers time to get used to changes to assessment billing and other management, according to the CMS. The delay also gives CMS an opportunity to gather more feedback and see if the policy needs to be modified, the agency wrote in its proposed rule.

Providers praised the delay in comments on the latest fee schedule proposal, but continued to express concerns about the time being used to determine which provider could bill. The American Association of Nurse Practitioners said the policy could lead to more doctorless visits, which could lead to a sharp pay cut.

“Billing under the supervision of a doctor versus a nurse practitioner allows them to be reimbursed at a 15% higher rate than if the practitioner paid it. This is an acute problem in rural and underserved areas, where systems and facilities with limited financial resources may not be able to sustain a 15% reduction in payments, Although NPs provide the same service as their fellow physician,” the organization wrote to CMS.

Providers asked organizers to allow time and medical decision-making to determine which physician would administer the substantive portion of the visit.

“Time is not necessarily of the essence in patient care. Medical decision making is a critical component of patient care management. However, it does not usually require most of the time. Physicians are compensated for their ability to synthesize complex medical problems and take appropriate treatment actions,” the Association of American Medical Colleges wrote in message.

Emily Cook and Caroline Rignley, both partners at law firm McDermott Will & Emery, expect CMS to finalize the policy delay. But while Cook said she wouldn’t be surprised to see the agency allow billing based on medical decisions next year, Reignley is more skeptical. “CMS likes objective measures. I think time is more objective — medical decision making becomes fast,” Renly said.

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