PA's rounding on patients

Advanced Practice Columnist / Guide · Oct 29, 2010

Critical care services refers to the activity not the place. You can bill critical care on the floor and bill E/M in the ICU. One of the cardinal points of critical care billing is that you rarely (almost never) bill critical care time on the day of discharge from the ICU. The point is that if they are stable enough to go to the floor then they are stable and don't qualify for critical care time. Essentially you only bill shared billing for the stable patients where you are billing E/M.
For example if I go to a code met and stabilize a patient then I can bill for my critical care time on the floor. Similarly if I have written transfer orders for a patient and they are waiting around for a floor bed they are obviously not critical and I would bill E/M for them. In reality probably 40-50% of our ICU players do not meet critical care guidelines. We have a lot of patients that come out late from the OR after big surgeries. They are watched overnight in the ICU and then transferred to the floor the next day. Endovascular aneurysm repairs (EVAR) are one item. We have an agreement with vascular surgery that all EVARS will come from the OR to the ICU. Most of them arrive with no issues and spend the night watching TV. Occasionally they act like the vasculopaths they are and do all of the things you would expect (NSTEMI, STEMI, Bleeding aortic aneurysm, renal failure, sepsis etc.). In the first case you do a hospital consult (really a hospital initial patient E/M since there are no more consults). Then E/M the next day. On the other hand if they come up in shock and you are resuscitating them for the next few hours you bill critical care time.
The other thing that you have to remember is that more than one person can bill critical care time, just not at the same time. For example if I am resuscitating a patient and I move to put in a central line (paid for outside of critical care time), then the attending can take over the resuscitation and bill for that time. When I'm done they can either continue to direct the resuscitation or let me take it back. In that case I would bill for my time and the procedure and they would bill for theirs.
Consider the trajectory of a mostly normal patient:
POD 0: Arrives status post ex lap for bladder perf with abcess S/P debridement. Resucitate treat the shock place the patient on the vent start pressors. CCM time 140 minutes.
POD1: Wean the vent, wean down the pressors, narrow the antibiotics as the cultures come back. CCM time 90 minutes
POD2: Continue vent weaning and off pressors. CCM time 70 minutes:
POD3: Off pressors SBT and extubate - depends on how much weaning you have to do. They no longer have life threatening condition but did at the beginning of the day. You can bill either way. Say a couple tries at SBT and long to wake up. CCM time 80 minutes.
POD4: PT stable. No pressors, extubated. Could D/C to floor but going to OR in AM for hip debridement and further washout. HV3 50 minutes.
POD5: PT back from OR extubated not on pressors. No volume issues. Observe overnight (not critical). HV3 60 minutes
POD6: Tx patient to floor HV3 55 minutes.
Over the course of 7 days I billed CCM for four days and Hospital follow up visit level 3 for three days. We have a program we use to bill and put in minutes for hospital days also so they can measure productivity.
Hope this helps.
David Carpenter, PA-C

Oh, I understand situations that call for a Critical Care Note and the requirement to indicate critical care time in the note itself. I also understand E/M codes in particular. I used to work in a facility where we (NP's) billed as part of the critical care service for all our procedures and notes. I am in a place now where we currently do not bill (university-affiliated major academic medical center with large training programs in the form or residencies and fellowships). The argument here is that shared billing for all E/M activities can not be used in critical care per CMS guidelines and that there isn't much of a difference in revenue among ICU's that have NP's bill and those who don't. It seems like the guidelines are clear that shared billing is not to be used in critical care. I used the article from "The Hospitalist" only as a point of reference to the guideline.

core0 · Oct 29, 2010

Oh, I understand situations that call for a Critical Care Note and the requirement to indicate critical care time in the note itself. I also understand E/M codes in particular. I used to work in a facility where we (NP's) billed as part of the critical care service for all our procedures and notes. I am in a place now where we currently do not bill (university-affiliated major academic medical center with large training programs in the form or residencies and fellowships). The argument here is that shared billing for all E/M activities can not be used in critical care per CMS guidelines and that there isn't much of a difference in revenue among ICU's that have NP's bill and those who don't. It seems like the guidelines are clear that shared billing is not to be used in critical care. I used the article from "The Hospitalist" only as a point of reference to the guideline.

I would label the argument that you can't bill E/M in critical care wrong. The problem is that people mistake what CMS means by service when they say critical care service. We use critical care service to mean the people that provide critical care. CMS uses it in a totally different way. When they say service they mean four very specific methods of billing. They are E/M, critical care, procedures, and (in 2005) consultation (which was a separate form of E/M). CMS very deliberately took consults out of shared billing in 2008. They left shared billing intact for E/M. The statement is that the service can be provided in any setting just like critical care. Here is the CMS guidelines for shared billing:

"Hospital Inpatient/Outpatient/Emergency Department Setting.--When a hospital inpatient/hospital

outpatient or emergency department E/M is shared between a physician and an NPP 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.

However, if there was no face-to-face encounter between the patient and the physician (e.g., even if

the physician participated in the service by only reviewing the patient's medical record) then the

service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate

physician fee schedule rate based on the UPIN/PIN entered on the claim."

Here is the AAPA brief on this:

Shared Visit Billing in a Hospital Setting - American Academy of Physician Assistants (AAPA)

Whether shared billing is worth the effort is going to depend on the payor mix and the staffing mix. I also work for a big university hospital with fellows etc. We have five ICUs with around 100 or so beds. One is staffed solely by NPPs and intensivists, three by residents and NPPs and intensivists, and one by residents and specialists. The unit that is staffed solely by NPPs has a lot of observation patients (ie not critically ill but have to be watched closely). They generate a lot of E/M time. They also have more (relatively speaking) NPPs and intensivists. In their model the intensivist goes around and sees all the patients in the AM and discusses their plan. In our model we are expected to move any patients we can out before the intensivist rounds in the afternoon so they don't have to see them. In the first model the 15% probably adds $15k a month or so. In our model we could add another $2-3k per month but that would mean the physician would have to stay another 2 hours later per day. Since they are already there pretty late most days and up most of the night with phone calls its not worth their time. YMMV.

As far as not billing at all thats just money left on the table. We are looking at the billing for all of our units by RVUs as we ramp up our NPP staff (20 in the last year). Its a considerable amount over what the physicians were billing.

David Carpenter, PA-C

Advanced Practice Columnist / Guide · Oct 29, 2010

I would label the argument that you can't bill E/M in critical care wrong. The problem is that people mistake what CMS means by service when they say critical care service. We use critical care service to mean the people that provide critical care. CMS uses it in a totally different way. When they say service they mean four very specific methods of billing. They are E/M, critical care, procedures, and (in 2005) consultation (which was a separate form of E/M). CMS very deliberately took consults out of shared billing in 2008. They left shared billing intact for E/M. The statement is that the service can be provided in any setting just like critical care. Here is the CMS guidelines for shared billing:
"Hospital Inpatient/Outpatient/Emergency Department Setting.--When a hospital inpatient/hospital
outpatient or emergency department E/M is shared between a physician and an NPP 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.
However, if there was no face-to-face encounter between the patient and the physician (e.g., even if
the physician participated in the service by only reviewing the patient's medical record) then the
service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate
physician fee schedule rate based on the UPIN/PIN entered on the claim."
Here is the AAPA brief on this:
Shared Visit Billing in a Hospital Setting - American Academy of Physician Assistants (AAPA)
Whether shared billing is worth the effort is going to depend on the payor mix and the staffing mix. I also work for a big university hospital with fellows etc. We have five ICUs with around 100 or so beds. One is staffed solely by NPPs and intensivists, three by residents and NPPs and intensivists, and one by residents and specialists. The unit that is staffed solely by NPPs has a lot of observation patients (ie not critically ill but have to be watched closely). They generate a lot of E/M time. They also have more (relatively speaking) NPPs and intensivists. In their model the intensivist goes around and sees all the patients in the AM and discusses their plan. In our model we are expected to move any patients we can out before the intensivist rounds in the afternoon so they don't have to see them. In the first model the 15% probably adds $15k a month or so. In our model we could add another $2-3k per month but that would mean the physician would have to stay another 2 hours later per day. Since they are already there pretty late most days and up most of the night with phone calls its not worth their time. YMMV.
As far as not billing at all thats just money left on the table. We are looking at the billing for all of our units by RVUs as we ramp up our NPP staff (20 in the last year). Its a considerable amount over what the physicians were billing.
David Carpenter, PA-C

Good to hear your perspective. I actually had the impression that shared billing was allowed in critical care (at least in my past job) but now I'm getting mixed information in this current job. I also agree that allowing NPP's to bill does increase revenue. It's an agenda some NPP's here are pushing for but in a cautious manner obviously.