Have you ever wondered how hospital prices became so irrational? As is often the case, things changed incrementally. Hospitals and healthcare systems have experienced years of inadequate inflationary update factors, often reduced by factors such as presumed over-coding under the federal inpatient and outpatient prospective payment systems.
CMS penalties have dramatically increased since the Price Transparency Rule was released, and providers must take heed before CMS and a legislative gauntlet arrive at their front door.
The 2022 Final Rule defines split (or shared) visits as evaluation and management (E&M) visits in the facility setting that are performed in part by both the physician and a non-physician practitioner (NPP) who are in the same group, in accordance with applicable laws and regulations. Additionally, split/shared visits are further defined as those that:
CMS has stated that limiting split/shared visits to institutional settings only, for which “incident to” payment is not available, would allow for improved clarity and clearly distinguish the policies applicable to such visits from the policies applicable to services furnished incident to the professional services of a physician. CMS further explained that they did not see a need to allow split/shared visit billing in the office setting, because the “incident to” regulations govern situations in which an NPP works with a physician who bills for the visit.
“Physician practices have been billing for split/shared visits in the office setting for many years now,” said Kathy Pride, Panacea Healthcare Solutions Executive Vice President for Coding and Documentation Services. “Most providers are focusing on patient care and do not necessarily read the billing regulations on a regular basis and may not be aware that the split/shared visit is no longer allowed in the office setting.”
CMS is also now including certain skilled nursing facility/nursing facility E&M visits under this definition, and for critical care, which were previously excluded from split/shared billing.
The practitioner who bills for the split/shared visit should be the practitioner who performs the substantive portion of the visit. The “substantive portion” is defined as “more than half of the total time spent by the physician and NPP performing the split/shared visit.” However, CMS is allowing one transitional year (2022) to include in the definition, noting that “the substantive portion of the visit can also be defined as one of the three key components (history, exam, or medical decision-making/MDM).” It is important to note that starting Jan. 1, 2023, time will be the sole basis for split/shared visits, and the substantive portion will be defined as “more than half of the total time.”
CMS also clarified that when one of the three key aforementioned components is used as the substantive portion in 2022, the practitioner who bills the visit must perform that component in its entirety. CMS has also clarified that only one of the practitioners must have a face-to-face (in-person) contact with the patient, but it does not necessarily have to be the practitioner who performs the substantive portion and bills for the visit. The substantive portion could be entirely with or without direct patient contact, and will be determined by the proportion of total time, not whether the time involves direct or in-person patient contact.
“A lot of the times, the guideline changes are slow to be adopted, due to the fact that the physicians are not getting the information in timely fashion,” Pride added. “Therefore, it is important that the compliance and coding leadership/education teams get the word out to the providers that the rules have changed.”
On Jan. 1, 2017, the Centers for Medicare & Medicaid Services (CMS) and Medicare Administrative Contractors (MACs) began requiring the use of the JW modifier. The JW modifier is appended to applicable drug HCPCS codes to report the discarded amount of unused injectable medication from a single-dose vial. The HCPCS code and JW modifier are reported on a separate claim line from the drug HCPCS code representing the amount that was actually administered. The modifier is not required for the claim line representing the amount of medication administered.
Do you and your team have a good process to readily identify and bill appropriately for self-administered drugs?
The Centers for Medicare & Medicaid Services (CMS) has had a longstanding policy excluding self-administered drugs (SADs) under the outpatient Part B benefit. Oral drugs, suppositories, and topical medications, for example, are easy enough to identify as self-administered, and medications normally administered by intramuscular injection are not usually considered self-administered. But what about drugs administered subcutaneously? Learn more
Compliance plans are critical to making sure your organization is mitigating risk. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recommends that you audit a minimum of 10 professional encounters per year, per physician – but if you’re not going above and beyond that by performing focused audits, you’re putting your practice at risk by ignoring everything else (not to mention, you may be missing opportunities by under-coding). Learn more
The chaos and confusion fomented throughout the American healthcare industry by the continuing COVID-19 pandemic has been bad enough in of itself – but when coders found themselves unable to accurately document what was even going on with patients, things got even worse. Learn more
Following the recent unveiling by federal officials of the 2021 Outpatient Prospective Payment System (OPPS) Final Rule, Panacea Healthcare Solutions has created a comprehensive Final Rule Summary highlighting some of the most salient looming changes facing healthcare providers nationwide.
The comprehensive diagnostic review includes analysis of CMS Price Transparency shoppable items and services to alert providers of risks and opportunities. Learn more
Designed for hospitals just starting on their consumer display and machine-readable file, this session will include an overview of the requirements, 10 things you need to know, data requirements, how to layout the machine-readable file, and 3 options to consider for meeting the consumer display requirement.
This session will cover:
Watch our complimentary webinar to hear Panacea executives, Greg Adams, Fred Stodolak and Henry Guitterez discuss the process of pulling the critical data and technology together to comply with the CMS Price Transparency requirements that go into effect January 1, 2021.
Watch the Q&A session from the workshop