Split (or shared) visits—the current term used by the Center for Medicare & Medicaid Services (CMS)—allow non-physician practitioners (NPPs) and physicians who work for the same employer/entity to share patient visits on the same day by billing the combined work under the physician’s National Provider Identifier (NPI) and receive 100% of the Medicare Physician Fee Schedule (MPFS), or the NPP’s NPI for reimbursement of 85% of the MPFS.
In the 2024 MPFS Final Rule, CMS revised the definition of “substantive portion” of a split (or shared ) visit to reflect the revisions made by the American Medical Association’s (AMA) Current Procedural Terminology (CPT) Editorial Panel.[1] CMS removed history and exam from the definition of substantive portion and adopted the determination of medical decision making (MDM) as defined by CPT as the provider who “made or approved the management plan.”
There are two ways for providers to meet the guidelines, and the billing provider is determined by the provider who performs:
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more than half of the total time, or
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a substantive part of the MDM as defined by CPT (except for critical care visits, which use time only and are not MDM).
The revised policy is somewhat unexpected, as CMS has several times delayed a proposed policy that “whichever of the providers who spends the most time” would bill the service.
While there are many articles for providers on how to be compliant going forward, for auditors and providers facing retrospective audits, things are a little bit more confusing—specifically for auditors working in the legal space who frequently perform audits based on the different guidelines in effect for the different dates of service. For example, an auditor may be asked to review evaluation and management (E/M) services where the scope also includes compliance with split (or shared) services from 2021 to 2024. This would be a challenge with the different guidelines for split (or)shared services with different rules based on 2021 and prior, 2022 to 2023 new policy and transition, and 2024 revisions. To complicate this further, AMA had major revisions to the CPT Documentation Guidelines for outpatient office visits (CPT 99202–99215) in 2021 and for the remainder of E/M services in 2023 that impacts how E/M services are documented and reviewed.
Background Medicare’s split (or shared) visits—2021 and prior
Prior to 2002, the role of NPPs and the appropriate billing practices related to the services they provided in the facility setting were not clearly defined. Typically, NPPs such as nurse practitioners and physician assistants—also referred to as qualified healthcare practitioners (QHP) by the AMA—would assist physicians in the hospital with rounding or seeing patients in the emergency room, and these services were billed under the physicians’ NPIs. While certain documentation requirements applied, they were not clearly defined and varied by payer.
In October 2002, CMS Transmittal 1776 introduced Medicare’s payment policy for split (or shared) E/M visits.[2] However, the full definition was introduced in Transmittal 808 in January 2006; it updated CMS Internet Only Manual: Medicare Claims Processing Manual (MCPM) Publication 100-04, Chapter 12, Section 30.6.1.H Split/Shared E/M Visit. (This section has since been removed):[3]
A split/shared E/M visit cannot be reported in the SNF [skilled nursing facility]/NF [nursing facility] setting. A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer. The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to consultation services, critical care services or procedures.
This allowed physicians to be reimbursed at 100% of the MPFS, although the NPP may have done most of the work if the physician performed and documented a face-to-face portion on the same calendar day.
These regulations remained in effect until CMS removed the MCPM sections related to split (or shared) E/M visits on May 26, 2021,[4] preparing for the revised payment rules, which were published in the 2022 MPFS Final Rule in November 2021.[5] It should also be noted that with the removal of the guidelines and until CMS published the final rule, CMS stated that “the agency will limit review.”
