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The Business of Neurocritical: Understanding Split-Share Billing with APPs

By Currents Editor posted 07-20-2022 11:22


Ryan Hakimi, DO, MS, NVS, RPNI, CPB, FNCS

This series will be a running feature highlighting billing, coding, practice management, and other business aspects of neurocritical care.

Beginning on January 1, 2022, split-shared critical care billing with APPs is now allowed by CMS and commercial insurance carriers. With this change, physicians can get credit for critical care done by the APP and the physician in their group, thereby avoiding the 15% billing reduction incurred by APP billing. A group is defined as a collection of practitioners practicing the same specialty or subspecialty (where applicable) in a given practice. This is where having the correct taxonomy code ensures that attending neurointensivists count as neurointensivists (not neurologists) if they are part of a Department of Neurology, for example. APPs do not have specialty or subspecialty taxonomy codes, and thus they would be part of the group as long as they are credentialed to practice neurocritical care and are paid for by the group (as opposed to by the hospital).

From a practical standpoint, multi-disciplinary critical care with APPs can be thought of three periods of time:

  1. Time the APP spent providing critical care without the attending
    • Ex: Examining the patient, reviewing the electronic medical record (EMR)/medication list/labs, entering orders, documenting the critical care provided, etc.
  1. Time the APP and attending spent together providing critical care
    • Attending and APP go into a patient’s room and treat a patient in convulsive status epilepticus

  1. Time the attending spent providing critical care without the APP
    • Ex: Reviewing the MRI brain and identifying a cerebral abscess as the source of the patient’s hemiparesis, starting the patient on IV antibiotics, meeting with a family to discuss goals of care, etc.

If 2+3 are greater than 1, the attending bills the cumulative time of 1+2+3, and the group is eligible for 100% of charges within the constraints of the following CPT codes:

  • 99291 30-74 minutes
  • 99292 each additional 30 minutes

If 2+3 are less than 1, the APP bills for the cumulative time of 1+2+3, and the group is eligible for 85% of the charges.

To better understand the ramifications of this change and how it may impact staffing, rounding practices, and provider documentation requirements, see the following illustrative case.

Case Study

A 65-year-old male with hypertension, chronic atrial fibrillation, and uncontrolled type 2 diabetes with hyperglycemia has been admitted with aneurysmal SAH due to a ruptured anterior communicating artery aneurysm. His course has been complicated by obstructive hydrocephalus necessitating EVD placement, acute respiratory failure with hypoxemia necessitating mechanical ventilation, and cerebral artery vasospasm necessitating vasopressor therapy for induced hypertension. The patient is admitted to the NCC team with Neurosurgery following, as they have coiled the aneurysm

0700: The Neuro ICU APP reviews the patient’s data in the EMR, examines the patient and notes that their ICP is 25 in the context of their sedation being paused for a spontaneous breathing trial. The APP feels that the patient is not an extubation candidate due to copious secretions and thus places an order for the patient to be placed back on PRVC and to have the sedation turned back on. The APP orders a dose of mannitol, adds a second vasopressor to maintain the patient’s blood pressure within target range, and discusses the case (face-to-face) with the Neurosurgery Chief Resident who indicates that their team does not want to lower the EVD but supports the decision to add hyperosmolar therapy. The APP then documents a system-based progress note and indicates, “I personally provided 25 minutes of critical care time to this patient excluding any procedure related time or any non-face to face time.”

0915: The attending is conducting multidisciplinary rounds with the same APP, the respiratory therapist, the NCC pharmacists, the bedside nurse, and case management. The attending physician then goes in the room, examines the patient, finalizes the plan of care for the day making some minor changes to the insulin regimen, and answers all of the questions from the team members related to the care of the patient (not time spent teaching).

1130: The patient’s family arrives, and the nurse contacts the attending physician indicating that the family wants to have a goals of care discussion because they are concerned that the patient will never wake up or come off the ventilator, which would not be in line with his stated wishes. The physician meets in person with the family, summarizes the patient’s care to date, and indicates that there is nothing at this time that indicates that the patient will never wake up or come off the ventilator. In the interests of patient autonomy, the physician discusses options of care including maximal medical care, DNR, and comfort care with hospice. The family is relieved and optimistic that there is hope for a meaningful neurological recovery and thus elects to continue with maximal medical care.

1300: The attending physician documents the critical care that they provided without making any reference to the work done by the APP. The attending physician documents, “I saw and examined this patient on XX/XX/2022 on multiple occasions. Briefly, the patient is a 65-year-old man with HTN, chronic A-fib, and uncontrolled Type 2 DM with hyperglycemia who presents to the hospital with a severe headache. I personally reviewed the neuroimaging which revealed the patient to have an aSAH due to a ruptured ACOM aneurysm. The patient’s clinical course has been complicated by obstructive hydrocephalus due to IVH necessitating EVD placement, mechanical ventilation due to acute respiratory failure with hypoxemia, and cerebral artery vasospasm necessitating induced hypertension with vasopressors. On my examination, the patient’s ICP was noted to be 17 mmHg. The patient’s propofol infusion was paused and he was noted to localize with the left upper extremity and briskly withdraw his lower extremities. He would not follow commands. During my examination, the patient’s ICP went up to 30 mmHg. I had the nurse draw up 50 mg of IV propofol and I personally bolused the patient which resolved the ICP crisis. I also ordered q6hr mannitol for management of cytotoxic cerebral edema. Later in the day the family arrived and requested a goals of care discussion. We discussed continued maximal medical care, DNR, and comfort care with hospice. After much discussion, the family indicated that they wanted to proceed with maximal medical care. The patient remains at high risk for death due to obstructive hydrocephalus, acute respiratory failure with hypoxemia, and cerebral artery vasospasm thereby necessitating continued neurocritical care. I personally provided 55 minutes of critical care to this patient excluding any procedure-related time or any time spent on the telephone.”

Billing Dissection

  • The time spent by the APP is 25 minutes (A)
  • The time spent by the attending with the APP + the time spent by the attending without the APP (B +C) is 55 minutes
  • 55 + 25 minutes = 80 minutes and 55 is greater than 25, therefore the attending bills 99291 + 99292 X 1.

Document Dissection

  • Both the APP and the attending physician documented in the first person which demonstrates work that they individually did, indicated why the patient warrants neurocritical care, stated a specific numerical time that they spent providing critical care services excluding time associated with separately billable procedures or non-face-to face time such as time spent on the telephone.
  • The attending documented a brief history but used the term “with,” which makes the diagnoses active medical problems contributing to the medical complexity of the patient and therefore impacting hospital mortality rate, as opposed to “with a history of,” which makes all of these diagnoses historical and non-contributory, putting them in the same category as the patient’s history of tonsillectomy as a child which is clearly not relevant. The attending also indicates the medical necessity of the critical care being provided by stating why the patient requires continued neurocritical care.
  • Of course, the attending may also document a system-based note in place of the paragraph format above. However, one benefit of paragraph-based documentation is that it tells the story and is not usually subject to cloning whereas the use of the copy-forward function within the EMR puts one at risk for cloning, especially when the patient has a relatively static condition.
  • All documentation must be done in the hospital on the same date of service to allow the documentation time to be included in the critical care time. If the documentation is done at home or in the hospital on a different day, the time spent documenting does not count.

It is important to note split-share billing with APPs is still prohibited for procedures that the APP is credentialed to perform. Therefore, if the physician supervises an APP for a procedure that the APP is credentialed for, the physician cannot bill for the procedure. In contrast, a physician may supervise an APP who is not credentialed to perform a procedure, as long as the supervision is part of a plan for the APP to become credentialed to perform the procedure independently and the physician documents: “I personally supervised APP XXX as she/he successfully performed central line placement in her/his attempt to become credentialed to perform the procedure independently.”

In conclusion, allowing split-share billing in critical care offers the opportunity for greater physician wRVU generation and physician billing, thereby benefiting the group as a whole. However, it is important to note that each institution should consider how this change would impact their APPs’ compensation model and potentially consider appropriate modifications as revenue generation and work attribution is shifted from APPs to physicians. Clear communication and frank discussion with APP colleagues is key to ensuring that APPs do not feel undervalued as a result of this change, but rather understand that what was non-billable work in many instances can now be captured, thereby adding to their value and position within the team.


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