Oncology & Hematology Coding Alert

Important: The application of this rule to the facility setting, which changed on Jan. 1, 2022, means “you can use split/ shared visit rules if your physician performs services in the emergency department [ED], for example, because that’s an outpatient service performed in a facility,” according to Catherine K. Delli Carpini, BSN, RN, in her webinar, “2022 CMS Evaluation and Management Updates.”

What Services Can You Bill as Split/Shared?

In addition to ED and inpatient services, the split/shared coding rules also apply to observation, prolonged services, and consultations as of Jan. 1, 2022. “Admission and discharge can also be split/shared, and critical care can be split/ shared,” according to Delli Carpini.

But “an admission cannot be done solo by a PA or NP unless the facility’s rules allow that person to have full admitting privileges. However, if a physician with admitting privileges is responsible for that admission, he or she can split/share that with a PA or NP, but the PA or NP can do it on their own only if they have admitting privileges,” Delli Carpini pointed out.

Who Gets Paid When the Service Is Split?

This is where split/shared billing gets complicated. Medicare states that “payment is made to the practitioner who performs the substantive portion of the visit,” which sounds simple enough. However, the definition of substantive is somewhat more complex and, confusingly, will also change in the future, though the exact date for it doing so is still up in the air.

The current policy: This year, 2022, “the substantive portion can be one of the three key E/M visit components (history, exam, or medical decision-making (MDM)), or more than half of the total time spent by the physician and NPP/APP performing the split (or shared) visit,” according to Medicare. The Centers for Medicare & Medicaid Services (CMS) further elaborates that if both practitioners use one of the key components, and you use that element as the substantive portion, the billing practitioner must perform the level that element required to select the visit level billed.

Remember: For critical care services, since services are coded based on the time as documented, the substantive portion can only be determined by identifying the provider who spent more than half of the total time.

Reimbursement reminder: Medicare, and payers following Medicare rules, currently reimburse 85 percent of the MPFS for the service if an NPP/APP furnishes the substantive portion. But that does not mean you should always bill such encounters with the physician’s provider number to capture the higher reimbursement.

“Billing incorrectly in order to retain 100% reimbursement can cost much more than what is earned in capturing 100% of the Physician Fee Schedule,” if your claim is deemed fraudulent by the payer, cautions the Ohio Association of Advanced Practice Nurses (OAAPN) (https://oaapn.org/2020/08/split-shared-encounters-explained/). So, it is vitally important that you make sure your documentation matches your billing for the service.

When Will the Policy Change?

In the 2022 MPFS final rule, Medicare intended for the new definition of substantive portion, which eliminated the three key E/M visit components in favor of the “more than half of the total time” definition, to go live in CY 2023.

Instead, in the 2023 Medicare Physician Fee Schedule (MPFS) proposed rule, Medicare is advocating that “clinicians who furnish split (or shared) visits will continue to have a choice of history, physical exam, or medical decision making, or more than half of the total practitioner time spent to define the substantive portion, instead of using total time to determine the substantive portion” (www.govinfo.gov/content/pkg/FR-2022-07-29/pdf/2022-14562.pdf).

If Medicare does finalize the 2023 proposed rule, the change will finally take effect in 2024, and the substantive portion of a split/shared visit will be then only calculated by who spent more than half the total time performing the split/shared visit. This could have a significant impact for providers commonly working in tandem as a team pertaining to both workflow and revenue. Planning and awareness will be key for a smooth transition.

How Do I Document a Split/Shared Visit?

This is important, as documentation will determine who gets paid, and how much. The two people who are splitting or sharing a service should be clearly noted in the documentation, according to Delli Carpini. In addition, the individual providing the substantive portion has to sign and date the medical record. The best practice from a medical review standpoint is to have each contributing provider document their portion of the service, including time spent if the service is time-based, Delli Carpini added.

“Remember that the record has to be able to support the fact that there were two people contributing here,” she said. “What did each person do, who were those people, and how much time did they spend doing it? So, although the guideline that’s definitive from CMS is saying the substantive person has to sign and date the record, we would encourage you to have your providers have both folks who are contributing sign and date so that you can support that record in the event of a medical review,” Delli Carpini said.

Don’t forget: You must use modifier FS (Split (or shared) E/M visit) on claims for split/shared visits to identify that the service was split or shared. But as split/shared visits are only recognized by Medicare or payers that follow Medicare guidelines, you will only be able to bill them modifying the service code with FS.