New Split/Shared Modifier Is Prelude to Audits; Policy May Affect Team-Based Care

Physician practices should brace for audits of split/shared evaluation and management (E/M) visits now that they must be reported with modifier FS. This raises the stakes for compliance and revenue even though Medicare billing policy on split/shared services is in flux.

Medicare administrative contractors (MACs) will start to track split/shared visits by physicians and advanced practice providers (APPs), said Valerie Rinkle, president of Valorize Consulting, at the American Health Law Association’s Institute on Medicare and Medicaid Payment Issues on March 23. Because of the modifier, MACs will recognize the APP was involved when a physician bills for a service and vice versa. CMS foreshadowed the audits by requiring the provider who performs the “substantive portion” of the E/M visit to sign and date the medical record, Rinkle said. “This is a level of transparency that applies only in split/shared, not incident-to billing, despite advocacy calling for it.”

There’s more to come with split/shared visits, an area of considerable angst since CMS changed and formalized the billing policy in the 2022 Medicare Physician Fee Schedule (MPFS) rule after years of authorizing split/shared billing only in the Medicare manual. But providers complain the new split/shared policy doesn’t jibe with the real-world version of billing and documentation. It’s also at odds with team-based care, said attorney Larry Vernaglia, with Foley & Lardner LLP, who spoke at the conference.

With split/shared billing, Medicare pays for an E/M service provided jointly by a physician and APP (e.g., nurse practitioner, physician assistant) at an institution (e.g., hospital, skilled nursing facility). They may be provided to new and established patients and include critical care and prolonged E/M services, Rinkle said. Split/shared visits are billed under the national provider identifier (NPI) of the physician or APP, depending on who provides the substantive portion of the services. As CMS explained in the 2022 MFPS rule, “the practitioner who spends more than half of the total time, or performs the history, exam, or MDM can be considered to have performed the substantive portion and can bill for the split (or shared) E/M visit.”

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