Making Sense of Shared Visits

CMS has deleted official guidance on the topic but promised that new guidance is still to come.

It was pure coincidence that I was going to write an article on shared visits when Ronald Hirsch, MD called my attention to the fact that the Centers for Medicare & Medicaid Services (CMS) pulled the shared visit language from the Manual on May 3. 

So, what is a shared visit, and what does this news mean? I can answer the first of those two questions. A shared visit is an encounter in the hospital wherein a physician and a non-physician practitioner (NPP) or a physician assistant (PA) both see the patient.

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. Some of the guidance from CMS, including the removed language, conflated the two terms. And intellectually, shared visits seem like a subset of “incident to” encounters. Making matters worse, there’s absolutely no statutory or regulatory reference to shared visits. They existed only in the Manual.

As we discussed just last week, manuals aren’t binding. In fact, that is the reason the language was removed. Someone submitted a petition to CMS asking them to delete the language because of the lack of regulatory support. It is true that the absence of regulation allows someone to claim that on some level, shared visits never existed. 

But with the language deleted, where are we? Well, at least one Medicare Administrative Contractor (MAC), WPS, has said that the removal of the language doesn’t change the fact that CMS intends to cover shared visits. If you have seen guidance from other MACs, please let me know! 

On a macro level, it is helpful to recognize that “incident to” is used in a clinic, and by “clinic” I mean a freestanding facility that has no associated facility fee. Shared visits are 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 under inpatient or outpatient status. (One quick side note: unfortunately, Medicare does refer to a wide variety of hospital services as “incident to.”

Regretfully, they have used the same term multiple times with a different meaning. But when CMS is talking about hospital services provided “incident to,” they are talking about services covered by the facility fee, not professional services. I know that is still confusing, but it’s a topic for another day. Just focus right now on the fact that we are talking about 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 make the billing work.  After all, Medicare policy permits only one evaluation and management (E&M) encounter per specialty per day. The result is the idea of a shared visit. When a physician and a NPP from the same group see the patient and the physician “provides any face-to-face portions of the E&M encounter with the patient,” the two visits are combined into one, according to now-deleted language in the Medical Claims Processing Manual, Chapter 12, Section 30.6.1. That section now says, “left intentionally blank for future updates.” Note that a different section of the Manual, also deleted, that discussed skilled nursing facility (SNF) visits, used slightly different language, stating that a shared visit required the physician to perform a substantive portion of the visit. It said that the physician must perform some element of the history, exam, or medical decision-making.  Note that “some portion of the face-to-face encounter” and an element of either the history, exam, or medical decision-making are different. You can provide medical decision-making without being present to perform some of the encounter face-to-face. There was a lot of really crummy writing here.  

So, what does it all mean? It seems appropriate to combine work by two professionals from the same group, as long as both of the professionals have actually physically seen the patient. That argument seems to apply even in the hospital. 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, there is still a pretty good argument to be made that you may bill for the combined effort of the NPP and the physician on one claim.

CMS has indicated that it will be issuing regulations on the topic.

We will all be eagerly awaiting them. 

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