- Shared or split services are Evaluation and Management (E/M) services performed jointly between a physician and a non-physician practitioner (NPP), in the same group, in a facility setting.
- Services may include both face-to-face and non-face-to-face activities, as defined by CPT.
- Services billed using the physician’s NPI are paid at a higher rate than those billed by a non-physician practitioner.
- CMS states that the service should be reported by the clinician who performs a substantive portion of the visit.
- New HCPCS modifier for 1-1-2022 FS- Split (or shared) Evaluation and Management service
See the Final Rule webinar for a review of CMS’s policy changes for shared services, modifiers for shared services and critical care, and telehealth policies for mental health services.
Overview of shared/split services rule changes
Services that can be reported as shared or split
E/M services may be billed as shared or split services when provided in a facility setting. Prior to 2022, they could be provided in an office setting if they also met the requirements for incident-to billing. CMS is no longer allowing shared services in an office setting, although incident-to services are still allowed.
Specifically, office and other outpatient codes 99202–99215 can be billed as shared services in a facility setting, that is, an outpatient department. Also, inpatient hospital services, observation services and emergency department visits can be billed as shared services. Beginning in 2022, nursing facility services can be billed as shared services, except for the mandated visits which must be performed by a physician in the nursing facilities participation of care rules. Beginning in 2022, critical care services can be billed as shared or split services.
CMS’s Final Rule uses the term “nonfacility” and “noninstutional” to describe place of service. However, it is really helpful to consider CPT place of service codes. As I interpret the rules, office and other outpatient services reported in place of service 11 office may not be reported as shared services. Office and other outpatient codes in place of service 19 or 22, outpatient hospital, may be reported as shared services.
The substantive portion
In the Final Rule, they note that withdrawn manual sections contained different definitions of the requirements. “For example, one section defined substantive portion as any face-to-face portion of the visit, while another section defined it as one of the three key components of an E/M service—either the history of the present illness (HPI), physical exam, and/or MDM.”[1] (Let’s leave aside the fact that the HPI is only one part of the key component of history.) In this section, the rule does say
“Given recent changes in the CPT E/M Guidelines, HPI and physical exam are no longer necessarily included in all E/M visits…”
CMS is setting different definitions of substantive for 2022 and 2023
CMS is requiring that the shared visit be reported under the provider number of the physician or non-physician practitioner who has performed a substantive portion of the visit. If the physician is not performing a substantive portion of the service, then CMS believes the rate of payment should be at the 85% rate, paid for NPP services.
For 2022, a transitional year, they are defining a substantive portion of the service as the practitioner who performed more than 50% of the time of the visit, or the practitioner who performed and documented in its entirety either the history, exam, or medical decision-making portion of the note. They seem to have forgotten here, that office and other outpatient services billed in outpatient departments use codes 99202—99215, and these do not anymore have a specific requirement for history and exam. “We are clarifying that 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.”[2]
Office visits in an outpatient department use either time or MDM. If the physician performs and documents all of the assessment and plan, then consider that the substantive portion. If the physician spends more than 50% of the time, consider that the substantive portion. If neither of those is true, bill under the NPP provider number.
The rule describes the old split/shared and incident-to manual sections and notes,
“This provision was generally interpreted to meant that split (or shared) visits cannot be billed for new patients.”[3]
This isn’t true. Incident-to services cannot be billed for new patient visits in place of service 11, office, because the physician has to have seen the patient at a prior visit and established the plan of care. So, shared services in the office setting could not be billed for new patient visits. But, shared services in an outpatient department (POS 19, 21) could be billed for new patients, because these did not have to also meet the requirements for incident-to. But, the rule now explicitly says that shared or split services can be provided for new or established patients (in a facility setting) or for initial and subsequent hospital, observation and nursing facility visits.
For emergency department visits, you must select the level of service based on the three key components. But you can determine the substantive portion either by the practitioner who spent to the most time, or the key components. If the physician documents in its entirety either the history, exam or MDM, bill under the physician’s NPI.
For inpatient, observation and nursing facility services, if billing under the physician’s NPI, use either time or one of the key components to support the substantive portion. Either the physician must have spent greater than 50% of the time, and time must be documented, or the physician must have documented one of the key components in its entirety. If using time, both clinicians will need to document their time, so that it is clear which practitioner spent more than 50%. Use the current activities listed in CPT.
In 2023 CMS will require that shared services be reported by the provider who provides more than half of the time of the service. They are proposing that all of the activities that are listed in the current CPT book as activities that can be included in the time of the visit can be counted in this calculation.
Documentation of shared services
If billing shared services, the documentation must identify the two individuals who performed the service. CMS points out that in prior years, they finalized a rule that
“any individual who is authorized under Medicare law to furnish and bill for their professional services, whether or not they are acting in a teaching role, may review and verify (sign and date) the medical record for the services they bill, rather than re-document notes in the medical record…” [4]
They say it may be helpful for each individual to document their own participation in the record, in order to determine the substantive time. They state that the record must identify the two individuals who performed the services, and “The individual who performed the substantive portion (and therefore, bills the visit) must sign and date the medical record.”[5]
Honestly, do you agree it is a case study in confusion?
Citations
- [1] CMS 2022 Physician Fee Schedule Final Rule, page 426
- [2] Final Rule, page 430
- [3] Final Rule, page 438
- [4] Final Rule, page 445
- [5] Final Rule, page 446
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