ACEP ID:

Shared/Split Services Sample Letter

Date

To: MAC Medical Director Name

RE: Review and Verify for Split/Shared Visits

The American College of Emergency Physicians (ACEP), representing 40,000 emergency physicians, and the Emergency Department Practice Management Association (EDPMA), representing about half of the 146 million patient visits to U.S. emergency departments, request that based on the updates from CMS that you update your policy regarding the documentation for a Split/Shared service between a physician and a nurse practitioner (NP) or physician assistant (PA).  We are asking for a uniform implementation of the below CMS rules and for certain attestations to be acknowledged as acceptable.

The Medicare Claims Processing Manual, chapter 12 page 38 states:

When a hospital inpatient/hospital outpatient (on campus-outpatient hospital or off campus outpatient hospital) or emergency department E/M is shared between a physician and an NPP [Non-Physician Practitioner (NPP), including Nurse Practitioner (NP), Physician Assistant (PA)] from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number.

The 2021 Final Physician Fee Schedule on page 125 states:

…we note that we are reiterating what we finalized in the CY 2020 PFS final rule, that any individual who is authorized under Medicare law to furnish and bill for their professional services, whether or not they are acting in a teaching role, may review and verify (sign and date) the medical record for the services they bill, rather than redocument, notes in the medical record made by physicians, residents, nurses, and students (including students in therapy or other clinical disciplines), or other members of the medical team. We emphasize that, while any member of the medical team may enter information into the medical record, only the reporting clinician may review and verify notes made in the record by others for the services the reporting clinician furnishes and bills.

From the above, it seems clear that CMS intends for the physician to use their time caring for patients as opposed to re-documenting what other members of the medical team (NPs and/or PAs) have already documented in the medical record.  In the years prior to this CMS update, some Medicare Administrative Carriers have had policies that require the physician to re-document in the medical record some part of the History, Physical Exam and/or Medical Decision Making for a Split/Shared service.

  • National Government Services (NGS) 2017: Acceptable example: “I have seen and examined the pt. with the PA and agreed with A/P and physical exam findings (and then a summary of items/data already listed by the PA,” link
  • Palmetto GBA 2018: Not acceptable example: "I have personally seen and examined the patient independently, reviewed the PA's History, exam and MDM and agree with the assessment and plan as written" signed by the physician link

Since the CMS rule making update, both Celerian Group Company (CGS) and WPS Government Health Administrators (WPS GHA) have updated their documentation policies regarding how to document a Split/Shared service to allow for an attestation of a face-to-face by the physician without any further patient specific information documented by the physician.  They list the following attestations as acceptable:

  • CGS 2021 Acceptable example: "I have personally seen and examined the patient independently, reviewed the NPP’s Hx, exam and MDM and agree with the assessment and plan as written" signed by the physician. link
  • WPS GHA 2020 Acceptable example: “I have personally seen and examined the patient independently, reviewed the PA’s Hx, exam and MDM and agree with the assessment and plan as written” signed by the physician. link

We agree that attestations that do not clearly describe the personal involvement of the physician in patient care should not be acceptable such as “Patient seen” or “Seen and examined”.  However, in alignment with the new CMS rules, attestations that clearly describe a physician’s personal performance of a face-to-face interaction and a clear review of the information entered by other members of the medical team (NP and/or PA) should not also require the re-documentation of information already placed in the medical record.

ACEP and EDPMA want to ensure that the physician’s time is spent caring for patients as opposed to re-documenting information in the medical record.  We are asking for you, based on the above information, to update your current Split/Shared documentation policies to come into alignment with CMS, CGS and WPS by allowing the attestation “I have personally seen and examined the patient independently, reviewed the PA’s Hx, exam and MDM and agree with the assessment and plan as written” signed by the physician, to be acceptable without any further patient specific information.

Sincerely,

Mark Rosenberg, DO, MBA FACEP, President
American College of Emergency Physicians   

Bing Pao, MD, FACEP, Chair of Board
Emergency Department Practice Management Association (EDPMA)

 

Federal Register December 28th, 2020 (Vol. 85, No. 248) page 125

https://www.federalregister.gov/documents/2020/12/28/2020-26815/medicare-program-cy-2021-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part

Date accessed: April 30, 2021

Medicare Claims Processing Manual July 25th, 2019 Chapter 12 page 38

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