CMS’s 2023 shared or split services policy: document and report them correctly

What about 2023? CMS is extending the 2022 rules through 2023. When you watch this video, the rules for 2023 are the same as described for 2022.

• Medical practices need to know CMS’s split or shared services policy rules
• 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.
• 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.
• In 2023, the substantive portion may be based on time or one of the key components. In 2022, CMS said that looking forward to 2023, time alone would be used to determine the substantive portion. However, they are continuing the 2022 rules in 2023.
• Shared services may not be performed in place of service 11.
• HCPCS modifier for 1-1-2022 FS- Split (or shared) Evaluation and Management service

See also Medicare Incident to and Shared Services Coding Guide

Overview of CMS’s 2022 shared or split services rule changes

• Download split/shared quick reference sheet
• Download slides

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 in the office 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.  Inpatient hospital services, observation services and emergency department visits can also 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 jointly performed by a physician and a non-physician practitioner 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.  Office and other outpatient services (99202–99215) 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 2022, and still in effect for 2023.

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’s 2022 shared or split services policy is different than the rules for 2023.

CMS requires 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 2023, an extension of the transitional period, 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. Because these office and other outpatient visit codes do not have specific history and exam requirements, it makes sense to use MDM as the component for 99202–99215, if not using time. “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 using time as the substantive portion, each clinician should document the time they spent. If neither of those is true, bill under the NPP provider number.

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. Keep in mind that, inpatient/observation and nursing facility visits now use the 2023 revised guidelines of MDM or time. And that the ED visits also use the 2023 revised guidelines for MDM, but not time as time is not (and never has been) assigned to ED visits.

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 unit time,  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 2024 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. This is what they said in the 2023 Final Rule.

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]

Citations

• [1] CMS 2022 Physician Fee Schedule Final Rule, page 426
• [2] 2022 Final Rule, page 430
• [3] 2022 Final Rule, page 438
• [4] 2022 Final Rule, page 445
• [5] 2022 Final Rule, page 446

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