What exactly is split/shared billing?

CMS finalized a major change regarding services performed in a facility setting when both the QHP and physician make rounds with the same patient on the same calendar date—otherwise known as a split/shared visit. This occurs when a physician and a QHP of the same specialty/subspecialty perform an evaluation and management (E/M) service on the same calendar date; if these services are performed on a different date, it is not considered split/shared. This is demonstrated by who is performing the most work while rounding (greater than 50%); according to CMS’s definition of substantive portion, the greater than 50% must be in the form of MDM or time, which must be explicitly documented via the attestation written by the physician. The QHP typically does not bill for the work they performed, and the physician, in turn, bills for the service based on the appropriate attestation for their participation in patient care.

What has CMS changed when I bill split/shared services?

CMS changed how split/shared services are used effective January 1, 2022, and will change how the physician attests as well as what is supported when documented.^[2] CMS uses the term “substantive portion” to specify what should be documented when determining the substantive portion (greater than 50%), which is much different from years prior as it only required an attestation for the physician to receive a credit to bill. Now, CMS has changed its requirements dramatically.

Here is the breakdown of how split/shared services are reimbursed when billed by an medical doctor or QHP:

When a physician bills

• When a physician bills for split/shared services, the bill is paid at 100% of the Medicare Physician Fee Schedule (MPFS)

When a QHP bills

• When a QHP bills for split/shared services, the bill is paid at 85% of the MPFS

Other items to consider when split/shared services are billed

• An encounter is shared between a physician and QHP from the same group specialty/subspecialty

• The same employer employs both QHP and doctor (note that this would not apply to medical students or residents)

• When encounters are submitted to the bill, they are submitted with the modifier FS when performed in one of the following places of service:

  • Hospital inpatient

  • Hospital observation

  • Outpatient hospital outpatient departments

  • Hospital discharge services

  • Emergency department

  • Critical care services

  • Prolonged services

Examples of split/shared billing scenarios

Example 1: A nurse practitioner sees a patient at noon and writes a note to explain her findings and recommendations discussed with her collaborative physician; the physician then attests his note, documents his discussion and to the extent of MDM related to the patient as well as sign and date the attestation on the same day.

Rationale: In this instance, this example would be appropriate and does not demonstrate risk as the services and the requirements were documented correctly with the attestation signed by the physician on the same calendar date of the nurse practitioner’s note.

Example 2: Physician and physician assistant see the patient. The documentation of the care was discussed and detailed; however, the physician had to leave early for another patient and forgot to attest the note on the same calendar date they saw the patient. Here is what the physician wrote:

Attestation by the physician: I saw the patient on the (same calendar date); I agree with what was documented by the physician assistant.

Signed and dated by the physician.

Rationale: This example would not be accepted if CMS reviewed the note. Why, you ask? The attestation does not elaborate on what was discussed with the physician assistant, nor does it explain what was done to arrive at the plan of care documented.

Example 3: Nurse practitioner (NP), Amy Jones, sees a patient on Wednesday, October 9, at 10 p.m., and Dr. Smith sees the same patient the next morning and attests to the note the next day.

Rationale: This encounter, if sent on as split/shared billing, is not acceptable as it was not attested on the same calendar date as the nurse Jones’s note. To meet documentation requirements acceptable to CMS, the note must be attested on the day the patient was seen as well as on the same calendar date. If not, this would not be considered a split/shared service, and when reviewed, this would be recouped if any monies were paid post-review.

Example 4: The physician and the NP see the patient on the same calendar date, and the note is attested as the following: “I reviewed the QHP’s note and spent more than 50% of the time.” The encounter is billed out to CMS.

Rationale: This example would be questioned by CMS as it does not state specifically hhow much time was spent by each practitioner to demonstrate the substantive portion. When reviewed, this would require more scrutiny and could very well be recouped by CMS as this may not be supported. Whether MDM or time (which should be greater than 50% for the substantive portion), the activities associated with the time and the exact time need to be documented.

What does CMS mean by substantive portion?

CMS has determined the substantive portion for split/shared as more than half of the total time spent by the physician and QHP performing the split/shared visit beginning January 1, 2023.https://www.federalregister.gov/d/2021-23972/p-1260 In other words, for CY 2022, the practitioner who spends more than half of the total time or performs—in its entirety for that level—the history or exam, or MDM, can also be considered to have performed the substantive portion and can bill for the split/shared E/M visit. (See Table 1.)

Table 1: Table of Substantive Portion for E/M Portion Code Families in Split/Shared Billing

Documentation requirements

Substantive portion MDM/time levels of service tables – facility (initial/subsequent)

Table 2, titled “Hospital Billing Tables for Full Admission and Observation Services,” demonstrates the two types of visits in the inpatient setting (as well as time and MDM). The initial and subsequent visits for the categories of service performed in the facility. Keep in mind that the documentation requirements for such are related to split/shared services only. Any other type of billing related to professional inpatient services outside of split/shared services will still be billed as per CMS.^*

When reviewing the billing of split/shared services, Table 2 explains what should be billed and how the split/shared services would be viewed by CMS^* based on the inpatient service but not limited to.

Table 2: Hospital Billing Tables for Full Admission and Observation Services

Qualifying time‐based activities to bill split/shared services per CMS

• Physician/other QHP time includes the following activities (when performed):

  • Preparing to see the patient (e.g., review of tests)

  • Obtaining and/or reviewing separately obtained history

  • Performing a medically necessary QHP-appropriate examination and/or evaluation

  • Counseling and educating the patient/family/caregiver

  • Ordering medications, tests, or procedures

  • Referring and communicating with other health care professionals (when not reported separately)

  • Documenting clinical information in the electronic or other health record

  • Independently interpreting results (not reported separately) and communicating results to the patient/family/caregiver

  • Care coordination (not reported separately)

What language is used for the attestation?

When notes are attested, they should include who performed the substantive portion and by which means (time or MDM). If the note determines the substantive portion by MDM, then the note should demonstrate by which means by way of the assessment and plan. If it’s by more than half the total time, then it would need to say by how much and the qualifying activities used to bill based on time, as noted above. You should be monitoring very closely, and the query should the attestation be insufficient in determining the substantive portion.

Allow time to implement workflows

As CMS has revised split/shared services, you should allow workflow implementation. Work with your IT team to create attention and training on usage. After the attestation has been determined, the bill should go out with the newly created FS modifier to identify split/shared services used to bill. CMS has noted that they will monitor split/shared services closely and may pull medical records for additional review to ensure proper documentation related to reimbursement.

Takeaways

• Gage the documentation requirements and evaluate risk within your organization.

• Continually educate providers, so they clearly understand how to document their substantive portion.

• Query when the substantive portion is not clear upon review.

• Keep a close watch for likely offenders and reeducate when needed.

• Implement workflows for departments that practice split/shared services more frequently; this may prove effective for coders and communication when there are issues.

*Documentation requirements have changed based on the final rule Medicare Physician Fee Schedule published on November 1 for CY 2023 from CMS via the Federal Register (which is updated annually). Keep in mind that as these rules are produced, so may documentation requirements as of the date of this publication which may be effective the following year they are introduced and/or modified.