Updates Clarify Medicare Split/Shared Billing
- By Andrea Faber
- In Billing
- April 1, 2022
- 12 Comments
Know the facts for ensuring proper payment of these claims in 2022.
New policy for split/shared evaluation and management (E/M) visits (including critical care services and prolonged services) was finalized in the calendar year (CY) 2022 Medicare Physician Fee Schedule (MPFS) final rule. Knowing the new guidelines for billing split/shared visits performed in the facility setting is essential to getting these claims paid.
What Is a Split/Shared Visit?
Prior to 2022, split/shared visits were typically billed by physicians, and certain specific conditions of collaboration had to be met. For example, the service required a face-to-face encounter; had to contribute to the history, exam, or medical decision making (MDM); and could only be performed by physicians employed by the same group seeing the same patient on the same date of service.
According to the Centers for Medicare & Medicaid Services (CMS), refinements to the policy for split/shared E/M visits were needed to “better reflect the current practice of medicine, the evolving role of nonphysician practitioners (NPPs) as members of the medical team, and to clarify conditions of payment that must be met to bill Medicare for these services.” CMS also needed to align its policy with the 2021 CPT® E/M guidelines.
CMS clarifies who may bill split/shared visits in the 2022 MPFS final rule: “Split (or shared) visit means an evaluation and management (E/M) visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner who are in the same group, under applicable law and regulations such that the service could be billed by either the physician or nonphysician practitioner if furnished independently by only one of them.”
This doesn’t sound radically different from the previous policy, but a closer look at the final rule spells out some important changes providers and billing staff must know.
New Billing Guidelines for Split/Shared Visits
The latest policy revisions for split/shared visits answer key questions, including:
- In which core settings may split/shared visits be furnished and billed?
- Which practitioner should report the visit when elements of the visit are performed by different practitioners?
- Must a substantive portion of the visit be performed by the billing practitioner?
- Must practitioners be in the same group to bill for split/shared visits?
CMS provides the answers to these questions and many others in the 2022 MPFS final rule.
1. Allowable places of service
The concept of the split/shared visit only applies in the facility setting, where incident-to is not applicable. Facility settings include hospitals, skilled nursing facilities, and nursing facilities. Office visits are excluded, where incident-to applies. This is not new.
2. Providers who can bill split/shared visits
Physicians and NPPs may now bill Medicare for split/shared E/M visits when the service could be billed by either the physician or NPP. NPPs include:
- Nurse practitioners (NP)
- Physician assistants (PA)
- Certified nurse specialists (CNS)
- Certified nurse-midwives (CNM)
Services billed using the physician’s national provider identifier (NPI) continue to be paid at a higher rate than those billed by an NPP. Medicare reimburses services paid under the MPFS and furnished by NPPs at 85 percent of the rate paid when physicians furnish the same service.
3. Determine the substantive portion of a split/shared visit
Either the physician or NPP may perform the substantive portion of the split/shared visit and qualify as the billing provider. (Previously, the physician had to provide the substantive portion of the visit.) CMS proposed to define “substantive” as more than half of the total time but received some flak from the industry. To appease stakeholders, CMS made a concession:
- For 2022 only, if billing under the physician’s NPI for inpatient, observation, and/or nursing facility services, use either time or one of the key E/M components (history, exam, or MDM) to support the substantive portion. Either the physician must have spent greater than 50 percent of the total time, and time must be documented, or the physician must have documented one of the key components in its entirety.
- When using time, both clinicians must document their time so that it is clear which practitioner spent more than 50 percent of the total time.
- Beginning Jan. 1, 2023, the practitioner who spends more than half the total time will bill for the visit.
- Split/shared visits apply to prolonged services when determining the substantive portion of the visit based on time.
(Note: Critical care services are always based on time.)
A couple of notes:
- In accordance with the 2021 CPT® E/M guidelines, when two or more practitioners jointly meet with or discuss the patient, only one practitioner’s time can be counted toward total time.
- Non-facing patient time counts toward total time.
- Practitioners can still use MDM to select the E/M visit level when using time to bill a split/shared visit.
- Split/shared services can be billed for new or established patients, as well as initial or subsequent visits.
- One of the practitioners must have face-to-face contact with the patient, but it doesn’t have to be the billing practitioner.
Activities Used to Determine Time
CMS provides a list of qualifying activities that count toward time when determining who rendered the substantive portion of the visit (there is a separate list for critical care in section II.F.2 of the final rule):
- Preparing to see the patient (e.g., review of tests)
- Obtaining and/or reviewing a separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering medications, tests, procedures
- Documenting clinical information in the health record
When not separately reported:
- Referring and communicating with other healthcare professionals
- Independently interpreting results and communicating results to the patient/family/caregiver
- Care coordination
Providers may not count time spent on:
- The performance of other services that are reported and billed separately
- Teaching that is general and not limited to the discussion that is required for the management of a specific patient
4. How CMS defines a group
CMS did not define the meaning of a group in the 2022 MPFS final rule, so this is still up for debate.
5. Medical record documentation is essential
Documentation in the medical record must identify the physician and NPP who performed the visit. In addition, the individual who performed the substantive portion of the visit (and therefore billing for the visit) must sign and date the medical record.
Examples of appropriate attestations:
“I provided a substantive portion of the care of this patient. I personally performed the ______________ for this encounter.” (Insert history, exam, or MDM.)
“I provided a substantive portion of the care of this patient. I personally performed the ______________ for this encounter.” (Insert history, exam, or MDM, followed by documentation of the history, exam, or MDM to the extent needed to support the assigned E/M code.)
“I provided a substantive portion of the care of this patient. I personally provided more than half of the total time dedicated to the treatment of this patient.”
6. Applicable modifiers for split/shared visits
The new HCPCS Level II modifier FS Split (or shared) evaluation and management visit must be included on the claim to identify that the service was a split/shared visit for services furnished on or after Jan. 1, 2022.
A breakdown of these requirements for billing a split/shared visit is provided in Table A.
Get Everyone Onboard for Split/Shared Billing
There are steps you can take to ensure your practice or organization understands the changes to the split/shared policy. Focus on evaluating strategies and optimization of provider and NPP work allocations.
- All-in-one implementation or phased-in approach, utilizing CMS’ grace period for E/M
- Design a transitional plan.
- Educate on critical care, which is already in place.
- Identify target audience of physicians and NPPs
- Identify encounters that could be performed solo by the NPP and those encounters requiring physician involvement.
- Discuss compensation for physicians and NPPs to ensure financial and regulatory compliance
- Address the concerns of providers impacted.
- Track and monitor
- Design and implement an auditing program.
- Inform and educate based on audit findings
In light of the policy updates, providers who utilize the split/shared billing concept should review the changes and ensure that their split/shared billing policies and practices are consistent with the new regulations.
Resources:
CMS Fact Sheet: CY 2022 Medicare Physician Fee Schedule final rule. Nov. 2, 2021.
www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-medicare-physician-fee-schedule-final-rule
CY 2022 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies. Nov. 19, 2021. www.federalregister.gov/d/2021-23972
Code of Federal Regulations Title 42. www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-415/subpart-D/section-415.140
Medicare Claims Processing Manual. www.cms.gov/files/document/medicare-claims-processing-manual-chapter-12
2022 Medicare Physician Fee Schedule final rule. www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched
- Updates Clarify Medicare Split/Shared Billing - April 1, 2022
Excellent article but don’t forget (as indicated in the article) this new rule only applies in the facility setting. The split/shared rule for outpatient encounters, which is usually only relevant where a new problem arises in an otherwise incident-to encounter for an established problem) is unchanged.
We are researching in our office if the FS modifier can be applied to the 99024 (Post-op) visit and have not had much success finding any documentation to either say it can or can’t be applied. Can you tell me if the modifier can be applied or direct me to some documentation to research for that answer?
We bill Office Visits in Place of Service 19 and 22 for Outpatient Hospital locations. Can we not use the CMS split shared rules for these locations?
Hi Cynthia. We are unable to research such a specific question on the blog. Please post your question in our forums or utilize our Ask an Expert service.
Jennifer, it is appropriate for a place of service 19 and 22, as they fall into the allowable places of service, being they are outpatient hospital (facility) settings. For office visits, place of service 11 are excluded.
“When using time, both clinicians must document their time…” This was recommended but not required per the Final Rule.
Split (or Shared) Services Please see this clarification from CMS (came out after the date of this article)
https://www.cms.gov/files/document/faqs-split-or-shared-visits-and-critical-care-services.pdf
Q1. Under the new policies effective January 1, 2022, can a split (or shared) visit be billed
for visits furnished in a Nursing Facility (NF) setting?
A1. No, a split (or shared) visit cannot be billed for visits furnished in a NF setting. We revised
our regulation at 42 CFR § 415.140 to define a split (or shared) visit as an E/M visit in a facility
setting in which payment for services and supplies furnished incident to a physician or
practitioner’s professional services is not available under § 410.26(b)(1).
Just want to make sure all are clear ok at SNF for visits (not requiring physician specifically) but not allowed in NF in long term care from what this states.
If the substantive portion by the MD is not clearly identified by an addendum or a separate note, would the attestation alone verify the MD’s substantive portion? I provided a substantive portion of the care of this patient. I personally performed the ______________ for this encounter.”
You’ll want to check your payer policy. Novitas says, “Medical record documentation — Documentation in the medical record must identify the physician and nonphysician practitioner who performed the visit. The individual who performed the substantive portion of the visit (and therefore bills for the visit) must sign and date the medical record.” https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00081589
How does Medicare define medical necessity for split shared services? If services rendered are within the APPs scope of practice and patient acuity is low, but the MD still rounds on the patient and provides a substation potion of the visit, as defined, can there be a question of MD medical necessity for the visit?
Shaundria, Auditors will certainly look at documentation to determine medical necessity of both providers who split/share services. It will be important for the documentation to indicate what was done by both providers.
The Final Register appears to have removed “same calendar day” from the verbiage. I am unable to locate anything that indicates a calendar day. What happens when a NPP sees patient late evening, but MD doesn’t have finalize review of labs, notes, documentation, etc… after midnight? Seeing that “same calendar day” is no longer part of the definition, does this mean the provider doesn’t have to finalizing documentation for the encounter prior to midnight?