An Egregious Piece of Misinformation from a MAC

NGS needs to retract its wildly inaccurate instructions about split and shared visits. A client recently reached out to me trying to understand whether it is permissible for non-physician practitioners (NPPs) to perform hospital admissions or discharges.

They shared a link to the NGS website on split, shared, and incident-to services.

This misinformation in the link (Evaluation and Management FAQs – NGSMEDICARE) is truly appalling. 

The second question is “please provide a guideline for MDM (medical decision-making) documentation by the substantive provider.” The first paragraph is just fine. It says:

“The medical record must reasonably support the work relative to the MDM. This may include commentary on the findings documented by the other contributing provider or may include additional findings or details not previously noted by the other contributing provider, all of which played a part in establishing MDM and a plan of care. The substantive/billing provider must sign and date the medical record for the service.”

This is perfectly accurate and completely consistent with the regulation found at 42 C.F.R. § 415.140. That regulation includes a documentation requirement, something generally rare in Medicare:

“Medical record documentation. Documentation in the medical record must identify the physician and nonphysician practitioner who performed the visit. The individual who performed the substantive portion of the visit (and therefore bills for the visit) must sign and date the medical record.”

The regulation requires a signature and a date, that’s it. Now, let’s explore the plethora of misinformation from NGS. 

Their FAQ continues:

“In support of the physician’s role as the substantive provider, documentation of the physician’s findings and conclusions in developing the MDM are expected. The physician’s documentation must be robust enough to substantiate that greater than fifty percent of the medical decision making was performed by the physician.”

Note that the regulation imposes no obligation on the physician. The physician need not document anything except a signature and a date. NGS apparently doesn’t understand that. 

The errors continue in question 12:

“For a subsequent inpatient split shared visit, do the NPP and the physician have to do two separate notes, or can they document their own face-to-face encounters on the same note?

Answer: Each provider should document his/her contribution to the service, with both notes indicating the service was ‘performed in conjunction with (NPP or MD).’”

I suppose that the answer says “should,” not “must,” so technically, one can argue that it is accurate because it isn’t imposing a requirement. But everyone will read that as an instruction. 

But wait, there’s more. Here is question 13:

“Would you consider a shared/split service if the MD’s documentation was listed as an addendum on the NPP’s note?

Answer: Split/shared services in the hospital setting require performance of MDM or greater time spent by both contributing providers.” (I am going to interrupt the quote at this point to note that this text says both professionals have the “greater” time. That is obviously impossible. Back to the quote.) “The only way for a physician and NPP to describe their own personal contribution to the service is to document an individual note describing the portion of the service performed.

In order to bill the service as the ‘substantive’ provider, the physician’s documentation would need to describe the physician’s work as exceeding the NPP’s work in formulating MDM or in spending more than half of the total visit time.”

This is so troubling. I mean, the split/shared regulation is short and clear. The individual who performed the substantive portion of the visit must sign and date the medical record. If what NGS said was true, the regulation would say “each professional must document their own work.” 

That is not what it says. Super sloppy work.

The bottom line is that after correctly observing that the doctor just needs to sign and date the record, NGS has three wildly inaccurate statements suggesting that the physician has to write his or her own note. This is particularly annoying because there is another regulation, 42 C.F.R. § 410.20(e), that very explicitly clarifies that anyone can do the documentation: 

“Medical record documentation. The physician may review and verify (sign/date), rather than re-document, notes in a patient’s medical record made by physicians; residents; nurses; medical, physician assistant, and advanced practice registered nurse students; or other members of the medical team including, as applicable, notes documenting the physician’s presence and participation in the services.”

This is a great reminder that you should not blindly rely on information from a Medicare Administrative Contractor (MAC). They can and do issue statements that are clearly inconsistent with regulations and statutes.

This particular issuance is particularly inaccurate.