New Medicare rules for split or shared and critical care, teaching physicians clarified

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I'm still reading the rule but here are some basics from a CMS fact sheet about the final physician fee schedule https://www.cms.gov/newsroom/fact-s...22-medicare-physician-fee-schedule-final-rule

Evaluation and Management (E/M) Visits

CMS is engaged in an ongoing review of payment for E/M visit code sets. For CY 2022, we finalized several policies that take into account the recent changes to E/M visit codes, as explained in the AMA CPT Codebook, which took effect January 1, 2021. We are also clarifying and refining policies that were reflected in certain manual provisions that were recently withdrawn. Specifically, we are making a number of refinements to our current policies for split (or shared) E/M visits, critical care services, and services furnished by teaching physicians involving residents.

Split (or shared) E/M visits

We are refining our longstanding policies for split (or shared) E/M visits to better reflect the current practice of medicine, the evolving role of non-physician practitioners (NPPs) as members of the medical team, and to clarify conditions of payment that must be met to bill Medicare for these services. In the CY 2022 PFS final rule, we are establishing the following:
  • Definition of split (or shared) E/M visits as E/M visits provided in the facility setting by a physician and an NPP in the same group. The visit is billed by the physician or practitioner who provides the substantive portion of the visit.
  • By 2023, the substantive portion of the visit will be defined as more than half of the total time spent. For 2022, the substantive portion can be history, physical exam, medical decision-making, or more than half of the total time (except for critical care, which can only be more than half of the total time). o_O
  • Split (or shared) visits can be reported for new as well as established patients, and initial and subsequent visits, as well as prolonged services.
  • A modifier is required on the claim to identify these services to inform policy and help ensure program integrity. :cautious:
  • Documentation in the medical record must identify the two individuals who performed the visit. The individual providing the substantive portion must sign and date the medical record.
  • Codifying these revised policies in a new regulation at 42 CFR 415.140.
Critical Care Services

For critical care services, we are refining our longstanding policies, establishing that:
  • Critical care services are defined in the CPT Codebook prefatory language for the code set.
  • The CPT Codebook listing of bundled services are not separately payable.
  • When medically necessary, critical care services can be furnished concurrently to the same patient on the same day by more than one practitioner representing more than one specialty, and critical care services can be furnished as split (or shared) visits.
  • Critical care services may be paid on the same day as other E/M visits by the same practitioner or another practitioner in the same group of the same specialty, if the practitioner documents that the E/M visit was provided prior to the critical care service at a time when the patient did not require critical care, the visit was medically necessary, and the services are separate and distinct, with no duplicative elements from the critical care service provided later in the day. Practitioners must report modifier -25 on the claim when reporting these critical care services.
  • Critical care services may be paid separately in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (e.g., trauma, burn cases). We are creating a new modifier for use on such claims to identify that the critical care is unrelated to the procedure. If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), the appropriate modifiers must also be reported to indicate the transfer of care. Medical record documentation must support the claims. 😩
Teaching Physician Services

The AMA CPT office/outpatient E/M visit coding framework that CMS finalized for CY 2021 provides that practitioners can select the office/outpatient E/M visit level to bill based either on either the total time personally spent by the reporting practitioner or medical decision making (MDM). Under our existing regulations, if a resident participates in a service furnished in a teaching setting, a teaching physician can bill for the service only if they are present for the key or critical portion of the service. Under the so-called “primary care exception,” in certain teaching hospital primary care centers, the teaching physician can bill for certain services furnished independently by a resident without the physical presence of a teaching physician, but with the teaching physician’s review.

CMS finalized and clarified that when time is used to select the office/outpatient E/M visit level, only the time spent by the teaching physician in qualifying activities, including time that the teaching physician was present with the resident performing those activities, can be included for purposes of visit level selection. Under the primary care exception, time cannot be used to select visit level. Only MDM may be used to select the E/M visit level, to guard against the possibility of inappropriate coding that reflects residents’ inefficiencies rather than a measure of the total medically necessary time required to furnish the E/M services. 🤔
 

smithca

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Is the new split/share guidelines only for hospital setting as it says facility?
 

jessicaparker1

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No, billing/payment is based on who performs the substantive portion of the visit. So, 85% if the NPP performs the substantive portion of the visit, 100% if the physician performs the substantive portion.
I was reading the Federal register (https://public-inspection.federalregister.gov/2021-23972.pdf) page 422 and it's only mentioning 85% not 100% for both providers. Where can I find that the physician will be paid at 100%? Sorry, I'm attempting to respond to an Attending and I'm triple checking my facts. Thank you in advance.
 
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Because the 85% paid to QHPs is in relation to the physician fee schedule rate. You may have to take the attending through the sections of the SSA listed below.

When the physician bills for such a split (or shared) visit, in accordance with section
1833(a)(1)(N) of the Act, the Medicare Part B payment is equal to 80 percent of the payment
basis under the PFS, which, under section 1848(a)(1) of the Act, is the lesser of the actual charge
or the fee schedule amount for the service. In contrast, if the physician does not perform a
substantive portion of such a split (or shared) visit and the NPP bills for it, in accordance with
section 1833(a)(1)(O) of the Act, the Medicare Part B payment is equal to 80 percent of the
lesser of the actual charge or 85 percent of the fee schedule rate.
 

csperoni

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I was reading the Federal register (https://public-inspection.federalregister.gov/2021-23972.pdf) page 422 and it's only mentioning 85% not 100% for both providers. Where can I find that the physician will be paid at 100%? Sorry, I'm attempting to respond to an Attending and I'm triple checking my facts. Thank you in advance.
I think you are misreading the link you provided.
"When the physician bills for such a split (or shared) visit, in accordance with section 1833(a)(1)(N) of the Act, the Medicare Part B payment is equal to 80 percent of the payment basis under the PFS, which, under section 1848(a)(1) of the Act, is the lesser of the actual charge or the fee schedule amount for the service. In contrast, if the physician does not perform a substantive portion of such a split (or shared) visit and the NPP bills for it, in accordance with section 1833(a)(1)(O) of the Act, the Medicare Part B payment is equal to 80 percent of the lesser of the actual charge or 85 percent of the fee schedule rate."
 

jessicaparker1

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I think you are misreading the link you provided.
"When the physician bills for such a split (or shared) visit, in accordance with section 1833(a)(1)(N) of the Act, the Medicare Part B payment is equal to 80 percent of the payment basis under the PFS, which, under section 1848(a)(1) of the Act, is the lesser of the actual charge or the fee schedule amount for the service. In contrast, if the physician does not perform a substantive portion of such a split (or shared) visit and the NPP bills for it, in accordance with section 1833(a)(1)(O) of the Act, the Medicare Part B payment is equal to 80 percent of the lesser of the actual charge or 85 percent of the fee schedule rate."
Thank you for your help! I have forward the information.
 
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