Resident Attestations; Infusion Services and Physician Supervision

Resident Attestations

Q: Can I use the same attestation for a resident and a nurse practitioner (NP) in the hospital? Will that let me the meet the "split/shared" requirement in the hospital setting for an NP?

A: There are distinct sets of rules governing each situation. An attending physician's relationship with another physician in an approved residency program is guided by Medicare's teaching physician guidelines, while an attending physician's relationship with physician assistants (PAs) and NPs in the physician's employ is governed by either the incident-to guidelines or the split/shared collaborative guidelines.

The resident-style attestation is geared to describe the degree the attending physician participates in the services provided, in part, by the resident, and it has a minimum of allowed documentation and participation specified. This situation requires very specific language describing whether a patient was seen and examined, the case discussed, and the agreed findings.

The circumstances handled in the split/shared environment are not as clear. Here there is some amount of work performed by the PA/NP, and then some other work, potentially duplicative, performed by the attending physician. There must be a face-to-face service provided by the physician. There is a sharing of the total work, and there is no specified documentation minimum by the physician, other than noting that a face-to-face service was provided.

Although these situations are similar, they are not identical. Due to the proscribed language, it is immediately clear to an auditor if a resident-style attestation is used in a split/share circumstance, and vice versa. It also suggests that the physician is likely using a common attestation to cover shared work without distinction as to its collaborator. If the physician uses the "reviewed and agree" attestation, it does not meet the presence required of split/shared. If the physician uses the "seen and agree" variety of attestation, it has elements of the drive-by visit that the split/shared standard purports to exceed.

We know what the resident attestations need to look like. The safe play for split/shared is to have some standard language that clearly states that the physician performed the face-to-face service in conjunction with the PA/NP service - just document it.

The one-size-fits-all statement doesn't fit both scenarios equally well, and may suggest the cloning concern so prevalent in recent OIG warnings. Don't go there.

Infusion Services and Physician Supervision

Q: Does a physician need to be present in the infusion center, or in close proximity, during infusion of non-chemotherapy medication (Enbrel/Remicade/Rituxan)? At the moment these services are provided by home infusion services by trained infusion nurses or pharmacists.

A: The short answer is yes and no. The physician needs to be in the infusion center but does not need to be present in the treatment area the entire time. He does, however, need to be "available," if necessary, during initiation.

The Medicare Benefit Policy Manual 20.7 section on non-surgical extended duration therapeutic services (Rev. 169, issued March 1, 2013) states, "CMS designates a limited set of therapeutic services meeting specific criteria as nonsurgical extended duration therapeutic services ('extended duration services'), defined in 42 CFR 410.27(a)(1)(v). These are outpatient therapeutic services that can last a significant period of time, have a substantial monitoring component that is typically performed by auxiliary personnel, have a low risk of requiring the supervisory practitioner’s immediate availability to furnish assistance and direction after the initiation of the service, and that are not primarily surgical in nature. In the provision of these services, CMS requires a minimum of direct supervision during the initiation of the service which may be followed by general supervision for the remainder of the service at the discretion of the supervisory practitioner. ... For these services, direct supervision means the definition specified for all outpatient therapeutic services in 410.27(a)(1)(iv), that is, immediate availability to furnish assistance and direction throughout the performance of the procedure. General supervision means the definition specified in the physician fee schedule at 410.32(b)(3)(i), that the service is performed under the supervisory practitioner’s overall direction and control but his or her presence is not required during the performance of the procedure.

"'Initiation' means the beginning portion of the extended duration service, ending when the supervisory practitioner believes the patient is stable enough for the remainder of the service to be safely administered under general supervision. The point of transition to general supervision must be documented in the patient’s progress notes or medical record. The manner of documentation is otherwise at the discretion of each supervisory practitioner."

Confusing Coding Sequence

Q: I have some questions about a patient admitted into observation. See the dates and charges below for the sequence and coding. Our dilemma is how to bill correctly for the date of the eleventh. The same doctor discharged the patient and then admitted him four hours and 17 minutes later. From the dictation for the readmit, the patient had positive blood cultures for bacteremia and was brought back in for treatment. This is a Medicare patient. Can we bill the observation, discharge, and hospital admit on the same date?

• The tenth: Patient admitted to observation, billed a 99219;

• The eleventh: Patient discharged from observation at 1:30 p.m., billed a 99217;

• The eleventh: Patient admitted to the hospital at 5:47 p.m., billed a 99223;

• The twelfth: Subsequent inpatient day, billed a 99232; and

•The thirteenth: Patient discharged from hospital, billed a 99238.

A: Great question. I actually think that you should bill 99236 for the eleventh. That captures the RVU for both the admit and the discharge. The code states that it is for a patient admitted and discharged on the same day, it makes no distinction between the observation versus inpatient status, and it does not specify sequence. It's just not the order of discharge and admit Medicare would expect. Billing 99236 however, may cause you payment problems for the next day.

Or you could try the 99217 and 99223 as you have above. Either way, you'll surely need to send in the notes to support the codes. This is one of those cases that reminds us that all the coding guidelines and rules aren't going to cover every situation. The payer computer program that will try and sort this out won't understand what you are trying to tell it. The claim form only details the date of service, not times.

Facing a coding conundrum? We're here to help. Send your questions to coding expert Bill Dacey at billdacey@msn.com. He will help clear up the confusion, and you may even see your question featured in the journal.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years.

This article originally appeared in the March 2014 issue of Physicians Practice.