This column addresses changes to the split/shared policy including definitions, reporting rules, and information about new modifier FS to help surgeons and coders understand this revised policy.
The calendar year (CY) 2022 Medicare Physician Fee Schedule, which went into effect January 1, 2022, introduced changes to the Medicare split/shared visit policy. This policy applies when an evaluation and management (E/M) visit is performed by both a physician and nonphysician practitioner (NPP). The determination of whether the physician or NPP can bill for the E/M is important because Medicare provides a higher payment rate for E/M services that physicians provide than for services that NPPs furnish. This column addresses changes to the split/shared policy including definitions, reporting rules, and information about new modifier FS to help surgeons and coders understand this revised policy.
A split/shared visit is an E/M visit in a hospital or other facility setting that is performed in part by both a physician and an NPP who are in the same practice group. The Centers for Medicare & Medicaid Services (CMS) also has finalized that a split/shared visit can be provided to a new or established patient and for an initial or subsequent visit. Split/shared visits are not provided in the office setting.
No, split/shared visits apply to E/M visits in the facility setting and incident-to services occur in a nonfacility setting, such as a physician’s office. Different Medicare regulations govern incident-to situations, addressing instances in which an NPP works with a physician who bills for a visit in a nonfacility setting, rather than billing under the NPP’s own provider number.
Who is considered an NPP?
Medicare defines an NPP as a nurse practitioner, physician assistant, certified nurse specialist, or certified nurse midwife, all of whom may independently report E/M services if they are legally authorized and qualified to furnish an E/M service in their state. NPPs who care for Medicare patients must enroll in the Medicare Program.
CMS has yet to provide a definition of group. CMS has indicated that a physician and an NPP must work jointly to furnish all of the work related to the visit in circumstances when a split/shared visit is appropriately billed. If a physician and NPP are in different groups, the physician and NPP would be expected to bill independently and only for the services each fully furnishes.
TABLE 1: Facility Split/Shared E/M Visit Reporting Policies for 2022 and 2023
The physician or NPP who performs the “substantive portion” of the split/shared visit should bill for the visit.
For CY 2022, except for critical care visits, the substantive portion is defined as one of the three key E/M components (history, exam, or medical decision-making [MDM]), or more than one-half of the total time the physician and NPP spend performing the split/shared visit. If conducting a key component instead of total time is used to determine the “substantive portion,” the practitioner who bills the visit must perform that component in its entirety.
However, beginning January 1, 2023, the substantive portion will be defined only as more than one-half of the total time that both the physician and NPP spent performing the split/shared visit. CMS has allowed CY 2022 to be an adjustment period so providers can establish systems to track and attribute time for split/shared visits. The facility split/shared E/M visit reporting policies for 2022 and 2023 are summarized in Table 1.
If the person who provides the substantive portion is determined by time, is code level selection also based on time?
No, the time criteria for who reports the split/shared service is not necessarily related to the level of code reported. For example, an NPP may have spent 10 minutes related to a split/shared inpatient visit and the physician may have spent 25 minutes delivering the same service. In this instance, the physician would report the split/shared service because the physician provided the substantive portion of the service based on the definition of more than one-half of total time. However, once it is determined that the physician will report, the physician then can select the level of code to report using MDM or using total time of both the physician and NPP if more than 50% of the total service time was related to counseling and/or coordination of care.
TABLE 2. Split/Shared Visit Based on the Substantive Portion Concept
The time for the physician and NPP in the same group is summed and added to the time when both individuals work together. When two or more individuals jointly meet with or discuss the patient, only the time of one individual may be counted. See Table 2 for examples of who reports the split/shared visit based on the substantive portion concept.
TABLE 3. CPT E/M Guidelines List of Activities
CMS relies on the Current Procedural Terminology (CPT)* E/M Guidelines list of activities to determine what could count toward total time for purposes of determining who performed the substantive portion of a split/shared visit, as indicated in Table 3.
No, for all split/shared visits, only one of the practitioners must have face-to-face (in-person) contact with the patient, but it does not necessarily have to be the physician nor the practitioner who performs the substantive portion and bills for the visit. The substantive portion could be provided entirely with or without direct patient contact and will be determined based on the proportion of total time, not whether the time involves direct or in-person patient contact.
CMS states that MDM is not easily attributed to a single physician or NPP when work is shared because the elements of MDM are unquantifiable and can depend on patient characteristics, such as risk factors.
Documentation in the medical record must identify the two individual practitioners who performed the split/shared visit. In addition, the individual who performed the substantive portion, and therefore bills the visit, must sign and date the medical record. CMS has emphasized that, although any member of the medical team may enter information into the medical record, only the reporting provider may review and verify notes made in the record by others for services the reporting clinician furnishes and bills.
Yes, CMS requires that modifier FS, split or shared E/M visit, be appended to facility claims for split/shared visits, whether the physician or NPP bills for the visit. This modifier does not apply to incident-to office visits. CMS has stated that it is important for program integrity to have a way to identify who is providing split/shared E/M services and how often Medicare pays at the physician rate for services provided in part by NPPs.
Surgeons should be aware of these new policies because they will affect reimbursement for facility-based E/M visits and will require proper documentation. Surgeons should consider how they and their NPPs can track time in these circumstances to correctly bill for split/shared visits. Contact email@example.com with any questions.
*All specific references to CPT codes and descriptions are © 2021 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.