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. 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.
“The new requirements are more complex than they used to be,” Acevedo said at a Feb. 22 webinar sponsored by the Health Care Compliance Association.
Medicare pays 100% of the physician fee schedule for an evaluation and management (E/M) service provided jointly by a physician and nonphysician practitioner (NPP) in the same group at an institution when billed under the physician’s national provider identifier (NPI). Split/shared visits may be provided at nine types of facilities, including off-campus and on-campus hospitals, emergency departments, skilled nursing facilities, nursing facilities and psychiatric facilities, according to a bulletin from WPS Administrators, a Medicare administrative contractor. That includes provider-based departments, but not place of service code 11 (physician offices), Acevedo noted. And it applies to new and established patients.
Although split/shared visits have been around for a long time, CMS removed the guidance last year from the Medicare manual because it wasn’t rooted in a law or regulation after a petition was filed under the Good Guidance Practices rule. Now that split/shared billing requirements have been promulgated through notice-and-comment rulemaking, they look very different.
‘They Conflated the Requirements’
Effective Jan. 1, 2022, split/shared visits are billed under the NPI of the physician or NPP who provided the “substantive portion” of the services. As CMS explained in transmittal 11181, “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.” Next year providers won’t have a choice; they must determine substantive portion by time.
That’s where things get more convoluted, Acevedo said. With the exam, history or medical decision-making version of substantive portion, it’s an all-or-nothing proposition. As CMS explains in the transmittal, “When one of the three key components is used as the substantive portion in 2022, the practitioner who bills the visit must perform that component in its entirety in order to bill.” For example, if history is used as the substantive portion and both practitioners take part of the history, the billing practitioner must perform the level of history required to select the visit level billed.” The same goes for physician exam and medical decision-making.
In other words, the billing provider, whether it’s the physician or the NPP, has to perform the whole thing (e.g., exam, history or medical decision-making) “and that element must meet the level of the code,” Acevedo said. There’s a big problem with that, she said. “They conflated the requirements for selecting the level of code with determining what is a substantive portion of the visit so you know who to bill under. It doesn’t make any sense.” CMS in 2021 embraced E/M documentation requirements developed by the American Medical Association and baked into CPT codes. They eliminated history and exams from the selection of E/M services for office or other outpatient services. Although Acevedo emailed CMS about the irreconcilable difference, she got a nonresponsive answer.
Compliance risks are built into the new split/shared billing rules. A biggie: the billing decision depends on the substantive portion, which depends on who spends more time with or on the patient, at least starting in 2023 (or now, if providers use time). But physicians and NPPs don’t typically document down to the minute, and their electronic health record systems aren’t set up that way, Acevedo said. “I encourage anyone who practices in a facility—place of service codes 19 and 22—to start implementing how they will capture the time,” she said. “Some physicians, from a professional and almost emotional perspective, don’t want to do it, but in less than a year, it will be the only way to choose the substantive portion.” The time spent by the physician or NPP only applies to the “distinct” time. “We can’t double dip,” she said.
Acevedo also noted that providers must append modifier FS to the E/M code when billing for split/shared visits.
Door Opens to Critical Care as Split/Shared Visit
CMS for the first time is allowing critical care services to be billed as a split/shared visit. Because critical care is by definition a time-based service, “the substantive portion will be more than half of the total time,” the transmittal states. Acevedo noted that Medicare also will pay for critical care provided on the same day to the same patient as other E/M services if they were provided before the critical care and aren’t duplicative. That’s a good thing, but it may be a little pie in the sky to think physicians document the order of events. “Folks will have to think about how they make sure the documentation supports the hospital visit was provided prior to the critical care,” she said. The practice also must bill under the treating provider who performed the substantive portion of the critical care and ensure that person signs and dates the medical record.
CMS also now allows physicians and NPPs to bill separately for critical care provided during the global procedure if it’s unrelated to the underlying procedure. The modifier FT must be included on the claim for critical care services. “There’s a modifier 24 that has always been there to say critical care is unrelated to a procedure,” Acevedo said, and when to use the FT modifier vs. the 24 modifier “will be an area of confusion. I have yet to reach a solid conclusion.”
Next year, the split/shared billing door will be open to prolonged services. Until then, physicians are unable to count the NPP’s time in the total time for prolonged services, but that will change in 10 months.
Contact Acevedo at email@example.com.