It may come as a surprise that only one of the providers in split/shared visits—the physician or nonphysician practitioner (e.g., physician assistant, nurse practitioner)—is required to see patients face to face. Other services, such as ordering medication, tests or procedures, may be performed for patients without seeing them, according to new rules on split/shared billing, which made their debut in the 2022 Medicare Physician Fee Schedule regulation and were crystalized in Medicare Transmittal 11181.^[1] What matters to CMS is who spends the “substantive portion” of the time, 50% or more, with or on the patient because that’s the provider who bills Medicare. If it’s the physician, the split/shared visit is billed at 100% of the physician fee schedule; otherwise, it’s 85%. There’s a different game plan, however, when the substantive portion is based on the exam, history or medical decision-making.

An unintended consequence here is that patients may see an unfamiliar provider’s name on their remittance advice because the billing provider may not have performed the face-to-face part of the split/shared visit, said Jean Acevedo, president of Acevedo Consulting in Florida. “Make sure your accounts receivable staff is aware that this might be the situation and handles it before we have a compliance risk where patients call the fraud hotline,” she advised.

The new rules on split/shared billing have providers scrambling because aspects of them aren’t in tune with the way providers operate, opening the door to billing and documentation snafus, Acevedo said. They also have to incorporate new modifiers. But the rules have an upside for providers, with CMS welcoming critical care and prolonged care services to split/shared billing.